Dr David Cunnington discusses an clinical approach to assessment and management of sleep in people with persistent pain.

As I’ve written about in other posts, on thinking and behaviour around sleep and lifestyle factors and medications, sleep problems are very common in people with persistent pain. However, it’s often not as simple as just managing the pain and expecting sleep to sort itself out. Much like in other forms of insomnia, once people begin to develop sleep problems, they can get a life of their own. In that case, my approach is similar to how I approach sleep problems caused by a range of other conditions. Trying to break it down in to the 3 main systems involved in sleep regulation, circadian, arousal and sleep systems. Then looking at behaviours and thoughts relevant to that system, together with the physiology, and planning treatment to address each of those areas.

Video Timeline:

  • 00:00 – 02:33 Clinical assessment & framework
  • 02:33- 03:44 Circadian rhythm
  • 03:44 – 05:03 Waking / arousal system
  • 05:03 – 06:33 Sleep homeostasis
  • 06:33 – 07:10 Summary

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So I would like to talk about how I approach sleep in someone who has got persistent pain. In actual fact, I use a similar approach in other co-morbid conditions when people have sleep problems.

In part, when people have got sleep problems, the way I’m trying to conceptualise it is, “Do they have a problem with the circadian clock?” which is the overarching regulatory process involved in regulating wake and sleep as well as lots of other human functions. Do they have a problem with the wake system? That’s the arousal system, the more sympathetic nervous system, adrenaline system. You know, lots of terms to describe that and the most common problem is difficulty without switching off. Or is the problem with the sleep system? So that sleep homeostatic system sometimes called sleep depth or sleep drive is another term that’s commonly used for that.

So these are the three main systems involved in sleep-wake regulation and in trying to manage people, it is a helpful concept when you’re thinking about symptoms, behaviour, medications. and how each of these three systems are functioning.

When I’m listening to people talk about both their behaviour and sleep and their thinking about sleep, I’m also thinking for each of these three systems, how are they behaving around sleep, around their sleep timing, around shutting off and winding down, around being active enough during the day to generate that sleep depth. How are they thinking about sleep? Are they over-thinking sleep and anxious about sleep? Are they really averse to feeling tired? So spending too long in bed, really sort of wishing for sleep and not got enough sleep drive. I think about the physiology as well. Are they on medications that are going to suppress circadian function? Medications that might actually be a little bit agitating that cause problems with wake drive or medications that may be sedating and causing augmentation of the sleep drive and affecting daytime functioning.

Conceptualising things in this way allows me to plan an approach in terms of strategies that can help people manage their symptoms and generally those strategies then follow those same patterns.

So I’m looking at things that are going to enhance circadian function. How can I change behaviour, thinking and the physiology? So it may be medications to change the physiology. What can I do to change waking function? Again, behaviour, thinking and maybe medications. What can I do that’s going to impact on sleep drive?

Now in terms of the circadian function, common things that will be impacting on circadian function are loss of that daily rhythm and that daily routine. So the important inputs to the circadian system are light and activity, and often people with persistent pain actually withdraw a bit from those stimuli. So it can get into a bit of a routine where they just feel about the same every hour of the 24-hour period. So they feel neither sleepy at night nor alert during the day and medications can also affect that. Opiates in particular can flatten out that circadian rhythm.

So if I think that’s more of the problem, the behaviours I will be looking for is more exposure to light, more routine, more engagement in regular activities, to cure the body clock into, hey, there is an intrinsic cycle and we do want to be switching off wake drive, switching on sleep drive at night and in the morning switching on wake drive and switching off sleep drive.

I will also sometimes manage the physiology by again light exposure but also then adding in melatonin at night to help to augment that shutting off and turning on the – shutting off the wake drive, turning on the sleep system at night.

Common symptoms of the wake system, not switching off appropriately, that people describe, “I lie down in the bed and the mind is just racing. I’m aware of a busy mind,” or during sleep, restlessness, sweating, noticed to be moving a lot, a sense of just constant rumination, going through the mind. These are all symptoms of the wake system not appropriately switching off.

The type of behaviours I will put in place to manage this is ensuring there’s appropriate winding down before going to bed, so not too much stimulating activity too late; also not too much light in the evening because that can make it more difficult for that wake system to shut off.

Thinking is really the big one here because often that wake drive is a conditioned anxiety response around sleep. If people have had trouble sleeping, they get this conditioned response almost of getting into bed feeling a little more anxious than they were before they got into bed.

A nice clinical question to sort that out is – you know, people are nodding off watching television on the couch, but then get into bed and find they’re hyper alert and you know then that’s this conditioned response.

That responds well to cognitive therapy, challenging thinking around sleep, as well as using the behavioural strategy of breaking that conditioned response using something like stimulus control.

Some of the problems with the sleep system and the most common thing I see with pain is people often using bed for rest and really not getting enough physical activity. So they’re not actually generating enough sleep drive for sleep to work well or they may have unrealistic expectations about how much sleep they’re going to get, so expecting long periods of sleep because they’re needing long periods of rest and sort of mix up equating that sort of rest and sleep.

So again the behaviour change I will use for problems with this part of the system is trying to better match the amount of time people are spending in bed with how much sleep they’re actually getting or how much sleep they actually need. Separating out that, “I need to lie down and rest because I’m fatigued,” or tired or sore from, “I need to actually be in bed and sleeping,” because often those two things get mixed up.

I will also work on the thinking. So, some of that is about expectation about sleep. How much sleep should I be getting? I wish for ‘X’ amount of hours of sleep. I’m feeling tired during the day. If only I could get a bit more sleep, I wouldn’t feel so tired. So spending too long in bed or not being active enough during the day, because sometimes it’s about fear or about what – if I do this activity, what impact or repercussion is it going to have for my pain?

That’s important to manage that. Sometimes with the physiology, we will be trying to augment the sleep system and that’s GABA agonists that can augment that sleep homeostatic drive and that’s a strategy I will sometimes use.

So hopefully that has given you a bit of a framework of how to approach people who have problems with pain and sleep. In terms of conceptualising it, it’s the control mechanisms involved in sleep and then some strategies in these three domains to be able to help people manage their symptoms.

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