Pain and Sleep
When thinking about the most prevalent and significant health problems, chronic pain is rarely the first thing that comes to mind. But the consequences of pain should not be underestimated: it burdens more people in the U.S. than heart disease, cancer, and diabetes combined.
Much of this pain is not simply a short-term or minor issue. Over 100 million people with pain in the U.S. find that it lasts for weeks or months, and more than 14.4 million people have the highest level of pain. Studies have estimated the total economic cost of pain in the U.S. to be at least $560 billion per year.
One way that pain can impact quality of life is by affecting sleep. Pain and sleep also have an even deeper connection: sleep disturbances can contribute to the onset and severity of pain. In fact, the impact of sleep on pain may be greater than that of pain on sleep.
In this guide, we’ll take a deeper look at what pain is, the types of pain, its causes, and how it may be treated. We’ll go in-depth about the relationship between sleep and pain and offer tips for sleeping with pain and as a result, enhancing sleep to prevent and reduce pain.
What is Pain?
Virtually everyone has experienced pain and can tell you what pain feels like: it hurts. Actually defining pain, though, can be a trickier task.
Pain is a signal or sensation. Specifically, it is an unpleasant sensation communicated through the nervous system to indicate an actual or possible injury. Given the complexity of the nervous system, this broad definition provides for a huge range in how pain can be experienced.
For example, pain can be generalized or affect a specific location of the body. Pain can be dull or sharp. It can be constant or wax and wane. It can be intense or mild. It can range from a light tingling to a disabling ache. Pain may take all of these forms and countless variations in-between.
The perception of pain can vary significantly from person to person which is why we often refer to an individual’s pain tolerance. Psychological factors influence how we experience and respond to pain, adding another layer of complexity to this already multifaceted issue.
What Are the Types of Pain?
As a result of this tremendous diversity in the manifestations of pain, it is typically described and classified into different categories.
Chronic and Acute Pain
|Chronic Pain||Acute Pain|
|Duration||Lasts more than 3 months||Diminishes quickly|
|Causes||Related to long-lasting medical conditions||Injury to tissue, disease, or inflammation|
|Persistance||Comes back intermittently over long timeframe||Recedes for good after initial cause has healed|
|Treatment||Long-term treatment and therapy required||Pain recedes with treatment of injury|
One way of classifying pain is by determining whether it is acute or chronic.
Acute pain starts suddenly and usually does not last for a long time. It generally happens because of injury to tissue, disease, or inflammation. The pain immediately after surgery is an example of acute pain. Acute pain normally recedes once the initial cause has gone away.
Chronic pain lasts over a long period of time, usually from months to years. Pain is considered to be chronic if it meets one or more of the following criteria:
- It persists for more than 3 months.
- It persists for more than 1 month after the initial cause has been resolved.
- It comes back intermittently over a long timeframe.
- It is related to a long-lasting medical condition such as arthritis or cancer.
A national study in 2016 found that around 20% of adults in the U.S. experienced chronic pain. About 8% had what is known as high-impact chronic pain, meaning that it limited them in at least one important life activity. According to the U.S. National Institutes of Health (NIH), chronic pain is the nation’s leading cause of long-term disability.
In some cases, acute pain can become chronic pain, especially if the cause cannot be resolved. In addition, people with chronic pain may experience breakthrough pain. Breakthrough pain feels like acute pain in that it comes on quickly, is more severe, and is not resolved by their pre-existing treatments for pain control.
Nociceptive and Neuropathic Pain
The designations of acute and chronic tend to focus on how pain is experienced, but another way to classify pain is based on its cause.
The majority of pain is nociceptive pain. This is pain caused by the stimulation of pain receptors that happens with injury to tissues of the body. Damage to skin, bone, muscles, and internal organs typically cause nociceptive pain. Examples include post-surgical pain, a broken bone, or a burn.
Pain receptors in tissue can function very differently in how they communicate with the brain. Some parts of the body, such as the skin, have more receptors, allowing the brain to better understand the location and type of damage. On the other hand, for internal organs, which have fewer receptors, there can be considerably less clarity with pain signals.
Neuropathic pain relates to problems related to the nerves, the brain, or the spinal cord. A pinched nerve is a straightforward example. It can be caused by a condition like diabetes that leads to widespread nerve damage. Another example, although much less common, is pain in a phantom limb that results from improper processing of pain signals in the brain.
Another term that may be used to describe some pain is referred pain. Because signals from different parts of the body may be communicated using the same network of nerves, pain may be felt in an area distinct from the location of the underlying problem. The heart and arm share a nerve pathway, which is why people who are having a heart attack often experience pain in their arm.
What Causes Pain?
Pain can come about because of a tremendous number of situations. It can be a direct tissue injury or damage to the nerves or nervous system. Some people may be more sensitive to pain, and over time, especially with chronic pain, a person’s pain receptors may become more sensitized through remodeling of nerve fibers.
While not normally a cause of pain on its own, psychology plays a role in determining what causes pain and how that pain is experienced. Fear may heighten a person’s sense of pain, and pain catastrophizing is when someone is hyperfocused on pain and feels helpless in the face of it.
Because of the complex and enormous range of conditions that can cause pain, we won’t try to cover all potential causes in this section. Instead, we try to introduce some of the most common and well-known sources of pain.
How is Pain Diagnosed?
The goal of the diagnostic process for pain is to identify, if possible, the underlying cause.
Diagnosing pain starts by trying to understand how that pain is being experienced including its location, sensation, severity, and duration. Doctors typically ask patients to describe the pain. They also conduct a physical examination including moving parts of the body to understand what movements induce pain.
Based on this evaluation, a doctor may order further testing to gather more information. Tests could include blood or urine tests, imaging tests (such as an X-ray, CT, or MRI), and/or tests of nerve function.
In some cases, this diagnostic process may not reveal a clear source for why a person is experiencing pain. Additional rounds of testing or follow-up visits may uncover the reason for the pain, but there are situations in which no underlying cause can be found.
How is Pain Treated?
Treatment of pain can operate on multiple levels. One level focuses on resolving the cause. A second level focuses on symptom relief or, in other words, managing the pain. Symptom relief can be done alongside cause-oriented treatments or alone if the cause cannot be identified or treated.
Specialists who focus on rehabilitation, such as physical therapists (PTs) and occupational therapists (OTs) can help a person reduce pain and improve functional abilities after bodily damage. PTs can assist with interventions and exercises to reduce swelling, increase range of motion, improve balance, and build muscle strength. OTs can work with patients to facilitate effective self-care and daily activities in ways that minimize or avoid pain.
Medications are frequently a component of a person’s treatment plan for pain. Medications to treat pain can come from several different classes of drugs. The strength of the medication is typically tailored to a patient’s pain level. Some drugs are available over-the-counter while many others require a prescription. The more well-known medications tend to better alleviate nociceptive pain than neuropathic pain. As with most medications, pain-relieving drugs can have side effects. Many can be habit-forming or can become less effective with time as a patient may build up a tolerance to the drug. As a result, it is important to work carefully with a doctor to understand the potential benefits and risks of any specific drug to treat pain.
Many people also use medical marijuana (cannabis) to manage pain. Research has indicated that cannabinoids, active compounds within the plant, may reduce inflammation and fight pain, and further research CBD is one cannabinoid that has received particular interest for potential health benefits, and research continues to improve scientific understanding of the role that cannabis can play in treating pain.
Counseling and psychotherapy can be a component of a pain treatment strategy as well. Through talk therapy, such as cognitive behavioral therapy (CBT), a patient may learn to change their response to pain or to better manage fear and anxiety associated with pain. One potential element of psychotherapeutic approaches to pain is the use of relaxation techniques.
Relaxation techniques can be used to try to reduce the impact of pain. One example of these techniques is biofeedback. Biofeedback uses sensors, known as electrodes, to gather information about the body. For instance, it may measure heart rate or blood pressure. Through guided imagery or other techniques, the patient attempts to control their body and achieve a target metric. Other types of relaxation techniques include distraction, hypnosis, deep breathing, tai chi, yoga, and similar types of mind-body medicine.
Acupuncture is a treatment that uses carefully placed needles to try to reduce pain or achieve other positive health outcomes. It comes from a history of traditional Chinese medicine. Research studies about acupuncture have had mixed results, but many patients find it beneficial. Massage and other types of manual manipulation are other types of non-drug therapies that may be beneficial in certain situations.
Electrical stimulation involves a number of methods for stimulating muscles or nerves for pain relief. Transcutaneous electrical nerve stimulation (TENS) applies a light electric current through electrodes placed on the skin. It is believed that this helps activate stimuli that reduce pain-oriented nerve signals. Other types of electrical stimulation include peripheral nerve stimulation, spinal cord stimulation, and deep brain stimulation.
Another way to try to prevent the transmission of pain signals is with nerve blocks. Nerve blocks often involve injecting anesthesia in or around a local area to blunt the pain from a damaged nerve. Nerve blocks of this type are commonly used in surgery. In other cases, a nerve that is causing pain may be destroyed via injection, freezing, or heating.
How Pain Affects Sleep
Doctors and researchers have long recognized a relationship between pain and sleep. Initially, this relationship was primarily understood based on the negative effect that pain can have on sleep.
Patient experience supported the presence of this connection. Sleeping problems are “perhaps one of the most prevalent complaints” of patients with chronic pain, and studies have found that 67-88% of these patients report sleep complaints.
Both acute and chronic pain can complicate the ability to get good sleep. When suffering from pain, especially acute pain, a person may not be able to settle into their normal sleeping position. In some cases, including with chronic pain, it can be difficult to find any comfortable position in which to relax and fall asleep. Falling asleep is only part of the problem. The predominant complaint of pain sufferers is interrupted sleep from repeated nighttime awakenings. With each awakening, the challenge of falling asleep with pain rears its ugly head again.
Anxiety can compound pain-related sleep problems. Anticipating pain or dwelling on pain, both of which can occur with pain catastrophizing, can burden the mind in a way that makes it harder to get a good night’s sleep. People with an anxiety disorder often struggle with sleep disturbances, and those may be exacerbated by the presence of acute or chronic pain.
That pain can disrupt sleep is only part of the story. Further research into the association between sleep and pain identified clear indications that sleeping problems can contribute to pain. In fact, the impact of sleep on pain may be greater than the impact of pain on sleep. As one review of existing research summarized, “assessed in broad strokes, sleep and pain may appear to be reciprocally related, whereas finer-grained analyses suggest that poor sleep may exert a stronger and perhaps more durable toll on the experience of chronic pain.”
This review found that the impact of sleeping problems on pain were multifaceted. People with sleeping problems were more likely to develop new cases of pain. They were also more likely to experience increases in daily pain levels and to have a worse long-term outlook for resolving pain. The reverse was also found -- that good sleep can help resolve pain -- which enhances the strength of the causal connection between sleep disturbances and pain.
Better sleep may also play a role in managing the psychological aspects of how pain is experienced. As lack of sleep can contribute to anxiety, increasing quality and quantity of sleep may help combat worries about pain including the preoccupations that are part of pain catastrophizing.
Further research is needed to continue to clarify the connections between sleep and pain. For example, there is a need to expand this analysis to include more types of pain. The research to date has focused primarily on chronic pain, specifically from headaches and musculoskeletal causes. Nevertheless, there is strong evidence that indicates that an emphasis on improving sleep can deliver meaningful benefits for preventing and managing pain.
How to Get Sleep When You Have Pain
Improving your sleep can play a useful role in a treatment plan for pain. Because pain can make it harder to get good sleep, though, it takes some planning and effort to get the most and best sleep that you can. This section reviews some steps to help you optimize your sleep and pain management.
Consult a Health Professional
If you have acute or chronic pain that is affecting your ability to undertake normal daily activities, it is important to see a health professional. A doctor or nurse can try to identify the underlying cause and recommend appropriate treatment, and this can be an essential component of achieving lasting reduction or elimination of pain.
A doctor may make referrals to other health professionals that can offer further help. For example, specialists in pain management or in specific kinds of pain, such as headaches or fibromyalgia, can give tailored suggestions to fit your situation. Referrals to physical or occupational therapists can help create a home program for exercises or stretches to do before bed or when you wake up.
A referral can be provided for a psychiatrist as well. Psychotherapy assists many patients in controlling their response to pain. Some psychiatrists have a background in cognitive behavioral therapy for insomnia (CBT-I), which has proven results in combating many types of sleep disturbances.
Sleep hygiene is an umbrella term that refers to creating the right context for sleep. That context is composed of your environment and your habits. Focusing on both can provide an avenue for addressing problems with both sleep and pain.
A good starting point for improving sleep hygiene is with your sleep environment. In this section, we’ll walk through some of the core elements of your sleep setting and how to improve it.
Mattress and Pillow
Where you sleep is central to how well you sleep. If you’ve ever had to sleep on a clunky pull-out sofa bed, you’ve likely experienced how a bad mattress can interfere with sleep and can cause you to wake up with aches and pains.
Choosing a great mattress and pillow helps achieve two key goals: increasing comfort and giving your body the support it needs. Comfort is subjective and relates to the firmness of a bed. Firmness is often described on a scale of 1-10 with 1 being the softest. For most people, medium firm, between 4-7, is the most comfortable; however, some people prefer a much softer or firmer bed.
Support refers to how well a mattress promotes the alignment of your body. Proper spinal alignment can help to prevent and resolve issues around waking up with pain. Typically, responsive mattresses promote alignment because they can provide extra cushioning at your main pressure points.
As an example, people wondering how to sleep with lower back pain and sciatica frequently find that a responsive mattress gives bolstered support in the lumbar area. People who have arm pain and numbness while sleeping are also likely to find that a responsive material, which has extra give at the shoulder, offers relief.
Extra pillows can add additional comfort and cushioning as well. A body pillow or a pillow between the knees can help take pressure off the lower back in side sleepers. Stomach sleepers often find that small, thin pillows can give needed cushion to the neck or abdomen. Extra pillows can be used to elevate part of the body to fight inflammation as well.
The characteristics of your mattress and pillows should be in concordance with your body weight and sleeping position. Most experts say that side sleeping is the best position, but the fact is that many people find it hard to elect a sleeping position. For that reason, it can be hard to say that there’s any best sleeping position for neck pain, headaches, joint pain, or other conditions. Instead, a well-selected mattress and pillow can give your body the support in needs in the position that you usually sleep in.
Once you have your mattress and pillow selected, the next step is to find bedding that is a match with your needs. Different types of bedding and sheets can be better for staying cool or staying warm. A quality comforter with the characteristics that you prefer can make your bed cozy and comfortable when you head to bed.
Setting Up Your Bedroom
It’s important to think about not just your bed but your entire bedroom. Making it comfortable, welcoming, and free of distractions plays an important part in sleep hygiene.
Choosing your routines wisely can make it easier to get great sleep. There are several sleep-related habits that can boost your sleep hygiene.
Learn More About Pain and Sleep
- The American Chronic Pain Association (ACPA). ACPA is a nonprofit organization that delivers information about chronic pain and tools for self-care and pain management. Resources about support groups are also available.
- The U.S. Pain Foundation. This organization advocates on behalf of people who suffer from chronic pain and provides information to better understand and cope with pain. The Pain Connection program organizes a network of support groups.
Government Research Initiatives
- The National Institutes of Health (NIH) Pain Consortium. The NIH Pain Consortium is an initiative to encourage research and collaboration in the field of pain across different disease-focused agencies within the NIH.
- The National Center for Complementary and Integrative Health (NCCIH). This government research agency focuses on non-traditional medical therapies. Their website is useful for people interested in mind-body medicine and the use of natural products, providing details of the known benefits and risks.
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). NIAMS is the lead agency of the U.S. government on arthritis and many other conditions that cause pain. Their website provides useful background and insight into new directions in research.
- The Arthritis Foundation. This nonprofit group works to educate and support people with all types of arthritis while promoting research and advocacy directed toward government, insurers, and employers.
- The American Migraine Foundation (AMF). This organization, a patient-focused offshoot of the American Headache Society, helps people who suffer from migraines to better understand how to cope with these headaches. A registry is available for patients who want to contribute to migraine research.
- The National Headache Foundation (NHF). The NHF website provides a physician-finder tool to help patients find specialists, describes ongoing research in the field, and offers educational materials, including webinars.
- American College of Obstetricians and Gynecologists (ACOG): Endometriosis. ACOG is the leading national organization of women’s health professionals, and this page offers information about the causes and treatments for endometriosis.
- The Endometriosis Foundation of America. The Endometriosis Foundation is a nonprofit group that strives to raise awareness about endometriosis and empower women affected by this condition through information and advocacy.
- American Diabetes Association. The American Diabetes Association promotes research, advocates for patients, and disseminates useful information for preventing and living with different types of diabetes.
Gastrointestinal Problems & IBS
- International Foundation for Gastrointestinal Disorders (IFFGD). IFFGD is a nonprofit group that works to bring awareness to GI disorders like IBS. They offer various programs for patient knowledge and support.
- University of Washington Medicine: Finding Solutions for Chronic Low Back Pain. This video featuring Dr. Mark Jensen explores some of the key issues in treating chronic lower back pain and directions for future research.
- Mayo Clinic: Tools to Manage Chronic Pain. This video describes different components of the Mayo Clinic’s approach to addressing chronic pain.
- ACPA: Consumer Guide to Pain Medications and Treatments. This series of videos from the ACPA delves into available medications to treat pain and the benefits and risks that accompany the use of them.
- Swedish Hospital: What is Fibromyalgia and How is it Treated? This video from Dr. Gordon Irving with the Swedish Medical System in Seattle gives an overview of fibromyalgia symptoms, treatments, and research.
- Harvard University: Sleep Health and Education. The Sleep Medicine program at Harvard operates a website with evidence-based information about an array of sleep-related issues.
- The National Sleep Foundation (NSF). This sleep-focused organization shares articles about sleep and has links to numerous resources for learning more about optimizing your nightly rest.
- Psychology Today: Cognitive Behavioral Treatment for Insomnia (CBT-I) Defined. This article by Allison Siebern Ph.D., a board-certified sleep psychologist and Assistant Professor at Stanford University, gives an introduction to CBT-I.