Sleep problems occur frequently in people with chronic pain. Common difficulties include having difficulty going to sleep at night, waking up a lot in the night, waking early, or sleeping too much. You may find that you always feel tired.
If you are unhappy with your sleep, you may find the following information will help to improve your sleep quality.
Factors which can lead to poor sleep:
- An irregular sleep pattern
- Reduced activity in the day
- Daytime napping
- Drinks or food containing caffeine
- Your bedroom environment
- Worrying, anxiety and stress
This leaflet aims to help you understand sleep and improve your sleep habits. When practised regularly over time, these changes can improve sleep quality.
If you have any further questions, please ask the healthcare professional who gave you this guide.
What is sleep?
Many people struggle with sleep difficulties. Research shows that inaccurate beliefs about sleep can contribute to insomnia as they can drive stress when people do not sleep as well as they would like. The first part of this leaflet aims to give you an understanding of sleep as a process which can be reassuring when we are struggling with sleep as well as providing a foundation for the sleep strategies described.
Sleep is a complex and active process. The chart on page 4 is taken from a machine that records electrical activity that is produced in the brain during sleep at night. It shows the pattern of electrical activity in an average person.
The peaks on the graph are times of increased electrical activity and the dips are times when the brain is less active. These peaks and dips occur throughout the night with each ‘sleep cycle’ lasting about 90 minutes. We normally experience 4 to 5 sleep cycles per night.
As you can see, falling asleep is not like an ‘on/off’ switch where you are either awake or asleep. Rather, falling asleep is more like a dimmer switch because of changes in brain activity:
When we first ‘drop off’ into stages 1 and 2, the brain is still fairly active but starts to slow down. This is light sleep where we can be easily woken. There is a lot of research that shows that we often think that we are still awake when in fact we were in light sleep.
As the slope dips on the chart showing brain activity slowing even more, we move into stages 3 and 4 deep sleep. Although our brain activity is very slow, the rest of our body is busy.
As we go into these deeper stages of sleep, the body releases chemicals to repair the ‘wear and tear’ from the day. It is very difficult to wake someone from stage 4 deep sleep.
After deep sleep, brain activity begins to increase again. We move back into light sleep and the cycle finishes with rapid eye movement sleep (REM) sleep. This is the black area on the chart.
During REM, our brains are very active, similar to when we are awake, and our bodies are relaxed. We dream and our eyes move around quickly, hence the name. REM sleep is related to mood and emotions and helps us to ‘process’ stressful things going on in our lives.
Some sleep facts
Fact 1
Different people need different amounts of sleep. We generally need less as we get older. A recent study looking at sleep and health in over 1 million adults showed that 6 to 8 hours is typical, but that quality rather than quantity is important.
Thinking that you need 8 hours every night is a myth that can lead to worry! You can, in fact, get by with much less sleep.
Fact 2
Although stressful, it is not harmful to lose sleep for several nights running. We can manage on less sleep than we think. If you have not slept well your brain automatically catches up by entering deep sleep more quickly. Look at the chart and you may notice that deep sleep (stages 3 and 4) takes place at the start of the night.
This is because the brain wants to ensure it is getting enough of this. Even if sleep is broken as the night goes on, you are likely to have got enough deep sleep at the beginning of the night.
Fact 3
Periods of waking are normal during the night. Brain activity readings taken in sleep studies always indicate 1-2 minutes of waking which people can’t remember. This is shown by the two highest peaks on the graph.
You are more likely to remember waking if you are in pain or are stressed. Pain and stress can then make it difficult to get back to sleep.
Understanding that waking up is normal and having strategies to help get back to sleep can be useful.
Fact 4
People who have sleeping difficulties often believe that they haven’t slept all night. However, sleep is a different state of awareness so our judgements about sleep can be wrong. Research asking people to rate how well they slept and comparing this to sleep machine charts always find:
- We tend to think we get less sleep than we actually do
- We tend to think it takes us longer to go to sleep than it actually does
- If our minds are racing with worry, 30 minutes of trying to sleep can feel like much longer
Improving sleep needs changes to bedtime habits. This leaflet offers a number of ideas which have been found to help improve sleep. They do, however, need to be practiced over a long period of time to work.
1. Practice good bedtime habits
Our lifestyle today often means that we get into bad sleep ‘habits’. The methods below will work best if applied over a long period of time.
Stimulants
Coffee, tea, energy drinks, fizzy drinks, chocolate and cigarettes are stimulants which affect our nervous system. If we have too much, it can take much longer to fall asleep. They can also reduce the amount of time in deep sleep.
Research has shown that caffeine can stay in our body for 8-14 hours and can interrupt normal processes in our brain that help us to fall asleep. It is recommended that we avoid caffeine after midday. Nicotine should be avoided within 2 hours of bedtime as this is a stimulant.
Alcohol
Although alcohol may help you fall asleep initially, it greatly affects sleep quality. Sleep studies show that people do not spend as much time in deep sleep or REM sleep so often feel sleepy the next day. Heavy drinking can also cause the opposite effect. As your body tries to process alcohol, you may wake early in the morning feeling very alert. Your body processes 1 unit of alcohol per hour. A small glass of wine contains approximately 1.5 units and a bottle of beer or cider contains 1.7 units. https:// www.nhs.uk/live-well/alcohol-advice has further information on units of alcohol.
Exercise
Exercise helps you to fall asleep quickly and improves sleep quality. People who do exercise spend longer in deep sleep, especially if the exercise is done earlier in the day. The body becomes more alert during and immediately after exercise so exercising too close to bedroom may keep you awake. Avoid intense exercise for 4 hours before bedtime.
Diet
Eating a heavy meal before bedtime can keep you awake as the body focuses on digesting food, rather than sleep. Leave at least three hours between eating and sleep. Include carbohydrates in your evening meal as this can help with neurotransmitters (chemicals in our brain) that facilitate sleep.
A glass of warm milk may have a similar effect.
Preparing for sleep
You should aim to do relaxing activities 60-90 minutes before you go to bed. Anything that helps you to ‘switch off’ and relax will help prepare your body for sleep. This can be activities such as having a warm bath or reading. With time, this helps our brain associate these rituals with relaxation and sleep, building better habits.
You may also want to practice relaxation. Avoid stimulating activities, which will keep you alert, such as exciting TV programmes or working on a laptop.
Lights down
Our body responds to light and dark. In a dark environment, the brain releases melatonin, a chemical which helps you fall asleep.
Dimming the lights an hour before bed will help this process. Staring at a laptop, TV or mobile phone screen will not.
It is recommended to avoid using digital devices (e.g. mobile phones/laptops) for 1-2 hours before bedtime for this reason.
Medication
When we’re desperate to get a good night’s sleep, it’s tempting to look for a 'quick fix from medication rather than the longer term sleep management approach outlined in this leaflet. Low doses of antidepressants that can also act as nerve pain killers are sometimes prescribed to help with sleep. They can be helpful with sleep for some people but can cause daytime sleepiness.
Stronger sleep medications such as diazepam and zopiclone are only prescribed for very short periods (1-2 weeks), usually for significant or acute stress. This is because long term use of sleep medications can lead to adverse effects such as unrefreshing sleep, rapid development of tolerance, dependence, withdrawal symptoms, daytime drowsiness, falls, memory loss and confusion.
The recommended treatment for long term insomnia based on available evidence is the approach outlined in this leaflet. If you are taking sleep medications and are concerned about their side effects or are finding it hard to stop them, you should speak to your GP. For other sleep problems, such as apnoea, sleep walking and narcolepsy you should speak to your GP about specific services that may be able to help.
2. Establish a good sleep pattern
Your sleep quality is at its best when sleep is ‘efficient’ and regular. You can change your bedtime ‘habits’ in a number of ways:
Help your body clock
Making changes to your sleep habits means working with your body’s natural rhythm or ‘body clock.’
Our body clock leads to natural changes in bodily systems including feeling sleepy or awake over 24 hours. The body clock is influenced by levels of light. We are therefore at our most sleepy and tend to have our deepest sleep at around 2am when it is dark. We experience feeling most awake from around 10am and tend to have our best reaction times mid-afternoon.
In addition to our body clock, our need for sleep ‘builds up’ during the day to accumulate sleep debt.
The graph below shows sleep patterns of someone with regular sleep-wake times (solid line) and irregular sleep times including daytime naps (dotted line). The solid line shows how sleep debt builds throughout the day and reduces at the night as we get our sleep. In the morning it resets and starts again. As you can see from the solid line, this follows the body clock and helps the person get regular sleep.
The dotted line shows how the build-up of sleep debt is interrupted by naps during the day. These naps then make it difficult to fall asleep at night as the sleep debt isn’t as big.
The person then falls asleep later and finds it difficult to wake up the next morning, maybe having a lie-in or a daytime nap. Over time this leads to poor sleep quality as the body clock gets out of synch and sleep debt isn’t building enough for bedtime.
To help link your body clock with a regular sleep pattern:
- Have a regular wind-down routine and go to bed when you feel sleepy. Then get up at the same time each morning. Doing this even after poor sleep helps to reset your body clock and may help get you into a better sleep routine if practiced regularly. Don’t lie in at weekends as this can undo a routine leading to poorer sleep quality.
- Try to avoid naps altogether if you can. If not, then restrict naps to before 3pm and for no longer than 20 minutes. Naps interfere with your body clock and sleep debt so that at bedtime you may find it difficult to fall asleep.
- Avoid trying to make up for a poor night’s sleep by going to bed early. Often, this is ‘out of sync’ with your body clock so you may lie awake anyway. This can lead to more worry about not being able to drop off. This worry can then stop you falling asleep.
3. Build a positive relationship between being in bed and being asleep
Lying in bed awake for hours builds a negative association between going to bed and falling asleep. This can mean that getting into bed suddenly leaves you feeling wide awake! A ‘sleep friendly’ routine can help you to fall asleep more quickly when you go to bed but may be difficult at first.
- Go to bed when you are sleepy.
- Do not read or watch TV in bed as these are waking activities. So are laptops, TVs and mobile phones. These activities also weaken the link between bed and sleep by keeping our brains engaged in daytime activities
- Only use your bed for sleep and sex. If reading helps you to relax, do this before going to bed and away from the bedroom. Do not choose a book you can’t put down as this will increase your level of alertness.
- Turn the light off straight away.
- If you’re not asleep within 20 minutes go to another room and sit and relax until you feel sleepy again. If this is not possible, at least sit up at the end of your bed.
- REPEAT step 5 as often as is required, and also if you waken for long periods during the night.
Remember!
This approach is not an overnight fix and can be really hard to do as insomnia may get worse before it gets better. If you can stick to this, you are likely to notice a significant improvement in sleep within a week.
4. Coping with daytime tiredness
While it is tempting to cancel all plans to catch up on sleep, it is important to continue with your day as planned. Cancelling activities can lead to more fatigue as it focuses attention on missed sleep and results in tension.
Often people think of energy levels as similar to a ‘mobile phone battery’ which is used up throughout the day. However, lots of things affect energy levels:
- The time of day
- Our body clock
- Our activities (e.g. how interesting/challenging the task is)
- Our mood
- What we have eaten
It is more helpful to think of energy as ‘rechargeable’ that we can ‘generate’ with simple activities.
To try this out, compare taking a brief walk outside rather than staying in chair when you are feeling sleepy. This shows how some activities can help you feel more awake.
Continuing with activity also reduces worry about missed sleep and provides a distraction. You can use strategies such as pacing, relaxation and energy generating activities to help you cope with tiredness. In the past, you may have experienced an energy boost from going to the gym after a tiring day at work – this is how activities can be ‘energy generating’.
If this sounds hard to believe, it can be helpful to ‘test’ both strategies separately. Try limiting activity on one day and continuing as normal on another by doing energy generating activities. Rate your tiredness throughout each day out of 10, perhaps every hour. It is likely you will feel more tired on days when you stop activities compared to days when you continue as planned.
5. Change unhelpful thinking about sleep
We need to be relaxed in order to fall asleep. Lying awake and worrying triggers the body’s stress response making it difficult to get back to sleep. These worries may be about general stress or about sleep.
General Stress
Tackling stress during the day using problem solving techniques can help with waking at night. Practising relaxation will help to make getting back to sleep easier when awake in the night.
It may be helpful to set aside 20 minutes earlier in the day for 'worry' or 'problem solving' time. This can help to disrupt worry cycles that stop people from ‘switching off.’ It can be helpful to use a notebook to write down how the day went and plan for tomorrow:
- What went well
- What did not go well
- Write a ‘to do’ list that will help tie up any loose ends from the day
- Write a ‘to do’ list that will help plan tomorrow
It is helpful to close the book at the end of this and keep a pen and paper by your bed to write down anything that pops into your head during the night. That way, once it is written down, you may be able to go back to sleep more easily.
Worries about missed sleep
Worried thoughts tend to focus on the worst possible outcome of missed sleep. Thoughts such as, 'I won’t be able to function at all' or 'I’ll feel exhausted all day' lead to an increase in anxiety.
It can help to think about how well you managed the last time you had a poor night’s sleep. Often, we manage better than our anxious thinking predicts.
Alternatives to anxious thoughts may be:
“I can usually get on with the things I need to, even if I have a bad night’s sleep”
"Even with a small amount of sleep, I will have had some of the deep sleep I need"
“My body can naturally catch up on missed deep sleep”
By taking this information into account, you may be able to focus on more helpful and realistic thoughts based on previous experience.
Stop clock watching
Checking the clock when you cannot sleep is very unhelpful. It can actually keep you awake as it can trigger anxiety about getting enough sleep, which can lead to thoughts about how you may or may not manage tomorrow. Turning the clock around so you can’t see it helps to limit this anxiety. A study found that ‘clock watchers’ had higher anxiety levels and were more likely to misjudge the amount of sleep that they got compared to people who read if they woke up.
Sleep references:
BMJ (2022). Best practice guidance: Insomnia.
Harvey, A.G. (2002): A cognitive model of insomnia. Behaviour Research and Therapy 40(8): 869-93.
NICE (2022). Clinical Knowledge Summaries: Managing long term insomnia. https://cks.nice.org.uk/topics/insomnia/management/ managing-long-term-insomnia-greater-3-months/
Selvanathan, J., Pham, C., Nagappa, M., Peng, P.W., Englesakis, M., Espie, C.A., Morin, C.M. and Chung, F. (2021). Cognitive behavioral therapy for insomnia in patients with chronic pain–a systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 60, p.101460.
Sleep self-help resources:
Espie, C. (2021). Overcoming Insomnia 2nd Edition: A self-help guide using cognitive behavioural techniques.
BBC Radio 4 - Just One Thing (2022). Sleep Well with Dr Michael Mosley - My five tips to help improve your sleep (see below).
Video podcasts: https://www.bbc.co.uk/sounds/series/p0d65hdd
What can I do to improve my sleep?
Date of Review: December 2024
Date of Next Review: December 2026
Ref No: PI_M_1484 (Salford)