Nonpharmacologic Treatments for Patients With Sleep Disorders and Pain
Many pain management practitioners realize there is a critical connection between pain and sleep. “Most people in pain don’t sleep well. You roll over, you hurt, and you wake up.” Kern Olson, PhD, a clinical health psychologist and pain management specialist, said in an interview with Practical Pain Management.
The fact that most patients with pain also suffer from a lack of sleep often is overlooked, said Dr. Olson, who has a subspecialty in sleep. “Primary care doctors typically don’t get much exposure to sleep issues in medical school. If a patient isn’t sleeping well, it’s easier to give a prescription.” But Dr. Olson, who runs a private practice in Portland, Oregon, along with a growing number of sleep specialists nationwide, believes that drugs should be the last resort for the treatment of insomnia. “It’s important to remember that sleep is a natural state, and natural treatment options should be explored first,” he said.
How Pain Affects Sleep
To grasp the relationship between pain and sleep, it helps to understand the four sleep stages. In the light sleep of stage I, the brain is active with alpha, beta, and theta waves. These brain waves slow down in stage II. Deep sleep begins in stage III, when slower delta waves begin to appear. Delta waves are the predominant waves bathing the brain in stage IV. Meanwhile, rapid eye movement (REM) and non–rapid eye movement (NREM) stages of sleep cycle about every 90 minutes throughout the night. However, patients with pain may experience stage I and stage II brain waves—and then awaken. To make matters worse, when they fall back asleep, they return to stage I and restart the sleep cycle. That is why they often are still fatigued upon awakening, and their pain levels may be even higher than they were the night before. Some sleep medications, such as benzodiazepine hypnotics, add to the problem by disrupting sleep architecture, or sleep stages, by reducing the amount of REM sleep a patient receives.
In part to avoid such unwanted negative side effects, increasing numbers of patients with pain are turning to nondrug therapies to treat insomnia. PPM interviewed a number of sleep experts to explore some of these alternative treatments.
Cognitive-behavioral therapy for insomnia (CBT-I) is considered by many sleep specialists to be the gold standard of treatment. “It’s as effective as medication, and with few if any negative side effects,” said Arthur Spielman, PhD, a clinical psychologist and co-director of the Center for Sleep Medicine at the Weill Cornell Medical College in New York City. Dr. Spielman treats patients for various sleep disorders, including those with chronic pain. CBT-I treatment includes progressive muscle relaxation (relaxing one specific muscle group at a time), deep breathing techniques, stimulus control (using the bed only for sleep and sex), and keeping a sleep diary to analyze the quantity and quality of sleep.1
One of the toughest elements of CBT-I for patients to follow is sleep restriction therapy, in which patients limit how much time they spend in bed. Dr. Spielman advised one of his patients, a 101-year-old woman who was having trouble falling asleep, to go to bed at midnight instead of at 11:00 p.m. For a week, she forced herself to stay up for the extra hour by organizing old photo albums. “It was a struggle,” said Dr. Spielman. “But she stuck with it and got dramatically better—even at her advanced age. It was deeply gratifying,” he noted.
Most sleep centers provide CBT-I training along with testing and treatment of sleep disorders. Not all centers are created equal, so verify that the American Board of Sleep Medicine certifies the sleep specialist you provide for your patient.
This technique involves being monitored with an electroencephalogram or a probe that measures either temperature, muscle tension, or respiratory rate. Patients are given feedback to recognize certain states of tension and the various sleep stages. With practice, patients can learn to either avoid or repeat these changes voluntarily, which may make it easier for them to fall asleep.
Indeed, in one study, 17 patients with primary insomnia were randomly assigned to either a tele-neurofeedback (n=9) or an electromyography tele-biofeedback (n=8) protocol.2 Twelve controls were used to compare baseline sleep measures, noted the investigators from the Research Unit Biological Psychology, Vrije Universiteit Brussel, Belgium. A polysomnography was performed pre- and posttreatment. The investigators reported that sleep latency decreased pre- to posttreatment in both groups, but a significant improvement in total sleep time was found only after the neurofeedback (NFB) protocol. Furthermore, “sleep logs at home showed an overall improvement only in the NFB group, whereas the sleep logs in the lab remained the same pre- to posttraining. Only NFB training resulted in an increase in total sleep time,” the researchers concluded.2
Yoga and Tai Chi
There are a number of pilot projects looking into incorporating yoga—and, to a lesser extent, Tai Chi—into treatments for patients with sleep disorders such as insomnia, in the context of chronic pain, said Ashwin Mehta, MD, MPH, medical director of Integrative Medicine for the Sylvester Comprehensive Cancer Center, and assistant professor of clinical medicine at the Miller School of Medicine at the University of Miami.3-5
In one preliminary study, a simple daily yoga treatment was evaluated in a group of patients with chronic insomnia characterized by sleep-onset and/or sleep-maintenance insomnia and primary or secondary insomnia. Participants maintained sleep–wake diaries during a pretreatment 2-week baseline and a subsequent 8-week intervention, in which the participants practiced yoga on their own following a single in-person training session.
“For the 20 participants completing the protocol, statistically significant improvements were observed in sleep efficiency, total sleep time, total wake time, sleep onset latency, and WASO [wakefulness after sleep onset] compared with pretreatment values,” reported Sat Bir Singh Khalsa, PhD, of the Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston.3
Dr. Mehta believes that the most groundbreaking study under way is taking place at MD Anderson Cancer Center at the University of Texas in Houston. The center has a $4.5 million grant from the National Cancer Institute at the National Institutes of Health to incorporate yoga into the treatment plan of women with breast cancer and cancer pain.6 “The medical community is transitioning from a disease-specific focus to a more wellness-oriented model,” said Dr. Mehta. “And so we’re moving more toward studying the effects of certain modalities like yoga that can improve sleep, reduce pain, and positively affect the overall wellness levels of patients. So far, the research is very promising.”