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18 Articles in Volume 11, Issue #9
Pain and Sleep: A Delicate Balance
Management of Insomnia: Considerations For Patients With Chronic Pain
PPM Editorial Board Outlines Management Strategies for Chronic Pain Patients With Insomnia
Attention Deficit Hyperactivity Disorder And Patients With Pain
Dry Needling Offers Relief From Chronic Low Back Pain
Etiology of Chronic Pain and Mental Illness: How To Assess Both
Temporomandibular Disorder: Examining the Cause And Treatments
Highlights From PAINWeek 2011
Is Your Patient Using Heroin?
Medications For Low Back Pain
Nonpharmacologic Treatments for Patients With Sleep Disorders and Pain
Man With Constant, Daily Headache Pain, Photophobia, Phonophobia, and Nausea
Successful Nonoperative Treatment of Persistently Painful Knees Following Total Knee Arthroplasty—A Case Series
Insomnia in Chronic Pain Patients
What Is Going Wrong With Research? Finding the Right Answer
Testing Positive for Marijuana in Urine
Hydrocodone, Carisoprodol, and Alprazolam—A Most Lethal Combination
Pro-inflammatory Diet

Nonpharmacologic Treatments for Patients With Sleep Disorders and Pain

These treatments offer patients with pain a safe and effective alternative to medications for managing their insomnia and sleep disorders.

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
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.”

Cranial Electrotherapy Stimulation
The US Army is turning to cranial electrotherapy stimulation (CES) as a nonpharmaceutical way to help service members battle insomnia, among other ailments. “Our biggest customers in terms of sales outside of China are the US Army and Veterans Administration,” said Daniel L. Kirsch, PhD, chairman of Electromedical Products International, based in Mineral Wells, outside Fort Worth, Texas.

In CES, a low-level electrical current is delivered to the brain via transcutaneous electrodes, attached to the ears by clip electrodes, for up to an hour daily. Dr. Kirsch, who also is a member of the PPM Editorial Board, said the device works something like a tuning fork, seeking to activate relaxing alpha brain waves by sending out various electrical frequencies. The FDA allows the machines to be sold only with a prescription as a Class III medical device. Dr. Kirsch said that more than 50 studies have demonstrated the safety and efficacy of CES. He points to a pilot study at the University of North Texas that showed significant increases in alpha activity after a single 20-minute session of electrotherapy, which left users in an “alert yet relaxed” state.7

More studies are under way, including two by the US Army, which currently uses CES for treatment of insomnia at several of its medical centers. In a recent unpublished, Web-based survey conducted by Texas State University —San Marcos and Electromedical Products International, 72% of the 1,514 service members who were using Alpha-Stim, a CES device sold by Dr. Kirsch’s company, reported that their insomnia was improved to some degree.8

Acupuncture and Acupressure
Acupuncture involves the insertion of tiny needles into specific points of the body with the goal of improving health, whereas acupressure involves applying pressure to those areas. C. Norman Shealy, MD, PhD, president of Holos Institutes of Health, Fair Grove, MO, and a board member of PPM, recently conducted an acupuncture study on the treatment of insomnia using LifeWave patches. The patches are designed to stimulate acupuncture points using acupressure. Dr. Shealy said his small study of 25 individuals suffering from chronic insomnia found significant improvements in length and quality of sleep.9 “There’s a slight warming effect because the patches trap the heat from the skin. And you can certainly activate acupuncture points with heat,” said Dr. Shealy. “The nontransdermal patches also contain a small amount of amino acids that the company says reflect heat back into the body.”

Dr. Shealy said preliminary results of the double-blind study he completed in October showed that a year later, half of the study subjects who used the patches for a month were still sleeping well. The unpublished, noncontrolled trial is based primarily on patient-reported outcomes.9 “There’s not a drug in the world that works that well for that long—and with no complications,” he said.

More research is needed to prove the effectiveness of treating sleep disorders with acupuncture. According to a recent study, 10 systematic reviews of acupuncture used in the treatment of insomnia were published between 2003 and 2010. The report states, “The evidence…is plagued by important limitations, eg, the poor quality of most primary studies.”10

The Case for Sleep Medications
Dr. Spielman has his concerns about the effectiveness of acupuncture along with other nontraditional sleep disorder treatments such as acupressure, energy medicine, and cranial stimulation. But he does not rule out the possibility that they may help. “There are small studies and anecdotal evidence in favor of the alternative treatments, so I don’t doubt they can be useful for some patients,” he said. But he is not convinced that their effectiveness will be proven anytime soon. “Drug companies spend millions developing a drug, so they have a stake in getting them to market. But these alternative approaches don’t have huge companies behind them to fund big studies,” he added. “So, at least for now, there just isn’t evidence that shows these approaches are as systematically effective as many sleep medications or CBT-I.”

As to the argument against some insomnia medications because they reduce REM sleep, Dr. Spielman said it’s irrelevant. “The end point is for the patient to regain the restorative value of sleep and functional capacity. That’s what I’m aiming for.” He pointed out that it is possible to mitigate some of the other negative side effects of sleep medications by taking a lower dose or taking them earlier at night to avoid the “hangover” effect the next day. And he pointed out a disadvantage of certain behavioral treatments, such as CBT-I—learning them can involve much time and effort. “If you need help tonight, drugs will work the fastest.”

Depending on the patient, Dr. Spielman recommended taking 2 to 3 mg of eszopiclone (Lunesta), 5 to 10 mg of zolpidem (Ambien), 2 to 6 mg of doxepin, or 15 to 30 mg of temazepam—either nightly or up to three times a week. He said that some patients benefit from long-term drug therapy, whereas others may need treatment for only a month before they’re able to sleep well again.

Sleep Hygiene
Sleep experts seem to agree on one thing: the importance of practicing good “sleep hygiene,” or simple behaviors that may improve sleep. That means exercising moderately, reducing stress, setting a consistent bedtime, and sleeping in a cool, dark, quiet room.

Last updated on: December 16, 2011
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