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Breaking the Cycle

Back pain is the most common type of chronic pain problem, and is the most prevalent medical disorder in industrialized societies. Not surprisingly, individuals with chronic back pain problems frequently report significant interference with sleep. In a recent study, it was found that approximately two-thirds of patients with chronic back pain suffered from sleep disorders. Research has demonstrated that disrupted sleep will, in turn, exacerbate the chronic back pain problem. Thus, a vicious cycle develops in which the back pain disrupts one's sleep, and difficulty sleeping makes the pain worse, which in turn makes sleeping more difficult, etc.

Pain diminishes both sleep quantity and quality
The term "insomnia" includes all types of sleeping problems, such as difficulty falling asleep, difficulty staying asleep, and awakening earlier than desired. Of all medical conditions, pain is the number one cause of insomnia. With chronic pain problems, difficulty falling asleep is one of the most prevalent types of sleep disruption. However, awakening during the night and awakening earlier than desired are also frequent problems. Research surveys of those with chronic pain problems have found that 65% report that they are awakened during the night due to pain and 62% report waking too early due to pain. In addition, many patients with chronic back pain problems do not feel "refreshed" in the morning when they awaken, a sleeping problem termed "non-restorative sleep."

Difficulty Falling Asleep

Chronic pain can impact sleep in a number of ways. To understand how a pain problem can make it difficult to fall asleep, it is helpful to think about the process associated with going to sleep for the night. In getting ready for bed, it is common to try and eliminate all distractions or other influences in an effort to "relax" and begin to fall asleep. This may include quieting the room, turning off the lights, eliminating any other noises, trying to get comfortable, and beginning to try and fall asleep.

However, this "quieting" of one's environment can cause problems for the chronic back pain sufferer since the only thing left for the brain to focus on is the experience of the pain. Patients will often report that one of their primary pain management tools during the day is being able to distract themselves from the chronic back pain problem by staying busy with other tasks (e.g., reading, watching television, engaging in hobbies or crafts, working, interacting with others, etc.). When trying to fall asleep, however, there are no other distractions available to focus on except for the pain. In many cases, one's perception of the pain actually increases when attempting to fall asleep. The longer falling asleep is delayed, the more stressful the situation becomes.

Chronic Pain Cycle

Difficulty Sleeping Through The Night

In addition to difficulty falling asleep, chronic pain patients also report awakening frequently during the night. Research has demonstrated that individuals experiencing chronic lower back pain may experience several intense "micro-arousals" (a change in sleep state to a lighter stage of sleep) per hour of sleep, which lead to awakenings. Thus, the chronic pain problem can be a significant intrusion into a night's sleep and disruptive to the normal stages of sleep. This problem is often the cause of "non-restorative sleep." Individuals with chronic pain often experience less deep sleep, more arousals and awakenings during the night, as well as less efficient sleep. Thus, the quality of the sleep is often light and unrefreshing. This non-restorative sleep pattern can then cause diminished energy, depressed mood, fatigue, and worse pain during the day.

Pain and Sleeping Problems Need To Be Treated Together

A sleeping disorder associated with chronic back pain should always be addressed as part of a multi-disciplinary, chronic pain treatment approach. As with any symptom of a chronic pain syndrome, one should not attempt to treat the sleep disruption in isolation without taking into account proper treatments for the chronic back pain problem that is part of the cause of the sleeping problems. Many behavioral and psychological approaches to chronic pain treatment will also help with the symptoms of sleep disorder, and one should not be too quick to rush to medication solutions for insomnia.

Behavioral approaches can be quite effective in helping improve the quality of one's sleep when they are practiced on a consistent basis. Certainly, these methods should be attempted first since they are safe and without adverse side effects. If they are not completely effective, then it may be appropriate to consult with a physician about medications as an adjunctive measure. When choosing a medication to help with sleeping problems, it is important for patients to talk with their doctor about other medications that they are taking for the chronic pain problem as well as other medical conditions.

Treating a sleep disorder involves attacking the situation from a number of different standpoints, including:

  • Pain and other physical symptoms. Addressing the source of the pain
  • Sleep hygiene. Practicing behavioral techniques that can help improve an individual's sleep
  • Psychological approaches. These may include techniques such as relaxation training, hypnosis, and deep breathing
  • Sleep medications. Appropriate medications specifically designed to help with sleep
  • When addressing a sleep problem associated with chronic pain, it is important to be sure that the patient is getting the best possible treatment for their back pain and within a multidisciplinary approach. Many of the treatments aimed at improving a chronic pain sufferer's sleep-wake cycle can also be helpful in the treatment of the chronic pain overall, and vice-versa.

Another step in improving sleep is to thoroughly investigate other possible medical problems (other than the pain) that might be contributing to the sleep disorder. Some of the common medical problems associated with poor sleep include:

Sleep apnea, where a person stops breathing for about 10 seconds or has reduced airflow hundreds of times during the night. The brain arouses the person from sleep in order to resume breathing, causing severely fragmented sleep and daytime sleepiness.

Restless legs syndrome, where a person has an extreme urge to move the legs, usually caused by uncomfortable sensations in the legs. The person may also experience involuntary jerking of the limbs during sleep and sometimes during wakefulness. These symptoms may cause difficulty in falling or remaining asleep, causing daytime tiredness or fatigue.

Successfully treating sleep disruption begins with working closely with a physician in addressing the chronic pain problem, as well as investigating any other medical conditions that might be disrupting the individual's sleep.