Why Poor Sleep Worsens Chronic Pain (And What to Do)

[00:00:00]So we have seen from the research that poor sleep is more predictive of worsening pain than worsening pain is of poor sleep. When we know that there are solutions to improving your sleep, there are researchbacked protocols, there are treatment plans, there are ways to improve your sleep so that you don't have such a strong impact from the poor sleep.

[00:00:30]My name is Dr. Medallia. I'm the founder and CEO of Dr. Lullabi. I'm a behavioral sleep medicine specialist. And today, what I want to try to do is instill some hope that um there is a lot that we know about the relationship between sleep and pain. And there is a lot we know about how and where to focus your time and energy to get the most relief in this relationship.

[00:01:03]All right. So, to kick us off, let's go ahead and talk about the science of sleeper and and how pain impacts sleep.

[00:01:12]So, I love to talk about this because something that most people don't know is that we sleep in cycles and wakeups are part of sleep. So, in particular, a lot of times our chronic pain patients, they tend to have a little bit lighter sleep and more frequent wakeups. And so, anytime there's a wake up, it's really, really frustrating. And then there's a fear about, oh my gosh, I'm not going to return to sleep. I woke up. This is bad.

[00:01:38]Here we go again. Here's another night like this. And so, I want to assure you, most people wake up during the night.

[00:01:44]Wakeups are part of sleep. So, I myself wake up two to three times during the night. I wake up, use the restroom, lay back down, return to sleep. It's about a five minute wake up. And the reason is is because we sleep in cycles. And so we start off in stage one and then we go into stage two. Then we go into stage three when we have those big delta waves, slow wave sleep, back into stage two and then into rapid eye movement sleep with the when we have more vivid dreams and then the cycle completes and we start it all over again. Now, when you complete a 90 to 120 minute sleep cycle, usually your brain waves shift from a stage of sleep into a stage of wake. Have that for about 3 seconds. And so if it's 3 seconds and your bladder is not full and there is no pain sensors that are um red flagging you to wake up and take care of the pain um and or um and and you're you might just turn your head and then return to sleep and start another sleep cycle and you might not even remember that 3se second cortical arousal the next day. So some people say, "I never used to wake up. It didn't start until the pain started." And I will tell you this, you did. You did always. You were always waking up. We all always wake up during sleep. It's just part of how sleep works. So now on from now on, moving forward, I want to just help you guys to reshift your mindset so that when you complete a sleep cycle, you can then say, "I woke up. That's okay. I learned wakeups are part of sleep. this is not a bad thing.

[00:03:20]Cuz if the reverse happens and you're like, "Oh no, this is bad. I just woke up. This is a problem. I'm never going to fall back." You're pathizing the wake up and then you're having a stress response. Your body goes into fight orflight mode and you're much less likely to have success with return to sleep.

[00:03:41]I do really want you guys to understand how pain impacts sleep. You know, it impacts sleep. And here's the why. It is really hard to get good quality sleep when you're dealing with chronic pain.

[00:03:55]I'm going to tell you this as sort of like it's kind of like bad news, good news. It is true. I'm just validating for you right now and I'm not telling you anything you don't know that it is really hard to come by adequate sleep quality because pain when your body is experiencing pain it is signaling to the brain that something's wrong and that even if you're asleep it is trying to support your wellness overall. So while you're asleep you're going to have more of that lighter sleep that stage one sleep. you're going to have less of the slow wave sleep, that deepest stage of sleep. And the reason is is because when you're going towards, remember we talked about going in that cycle. When you're going towards stage two sleep, you're you're going to end up having what we call sleep stage shifts. We can also refer to these as alpha intrusion or microarousals, sleep fragmentation, right? You're moved, kicked out from the deeper stages, from stage two, from stage three back into one because it's an alert. It's a signal. Your body is doing what it's supposed to and telling your brain something's wrong. And so that's the essence of what's going on and why we always hear our pain patients complain about sleep quality. And then, you know, we just tend to see that our pain patients as a result of having poor sleep quality to begin with. They tend to have this just more fatigue, increased fatigue, which I don't have to tell this audience that you all know and are likely experiencing fatigue. And I want you to understand a little bit about the why. Um, and because of this, when us sleep specialists see a pain patient and they have insomnia, they say, "It's taking me a really long time to fall asleep, which is so very common.

[00:05:36]I'm having a long prolonged nighttime awakening, so I'm waking up in pain and it's taking me a long time to return to sleep is very, very common. So when we see these patients have complaints like this, we know that it is very likely, I'm going to get into this in a bit too, that we can actually help them here. We can improve their insomnia. We see incredible results with our pain patients, too. And we can reduce their insomnia symptoms, increase their total sleep time if it's relevant, and have them falling asleep and returning to sleep faster even with the chronic pain.

[00:06:14]The fascinating thing about the pain and sleep relationship is that there is this birectional relationship. So we know that the worse your sleep is, the higher your sensitivity to the pain, the increased experience you have, the increased inflammation that you experience and the harder it is to inhibit the pain response. And so that's why we talk so so much about the value and importance of improving your sleep for every pain patient. So what's been really interesting to learn from the research is while there's a birectional relationship there is a one there's a a direction of the relationship that is stronger. So we have seen from the research that poor sleep is more predictive of worsening pain than worsening pain is of poor sleep. Now of course we still know that worse pain is going to predict or is going to predict poor sleep. It's just that the poor sleep is the bigger culprit and the power of that to empower you and get you excited about that news in a way. I mean maybe excited is the wrong word but to feel strength from that finding you know and we know that there are solutions to improving your sleep. There are researchbacked protocols. There are treatment plans. There are ways to improve your sleep so that you don't have such a strong impact from the poor sleep.

[00:07:49]And so I wanted to get to a couple of things that you can honestly start with tonight. Whenever I'm speaking to audiences at in 2026, it's like everybody knows kind of the basics, right? And where I want to focus for this group though is really about the two things that I think you can do that might move the needle the most. and that you could start tonight. One is calming your body if you can have if you can take the one hour before bedtime. And this really does start with giving yourself an assigned bedtime cuz what is the 1 hour before bedtime if you're just going to bed whenever you want to go to bed? We do always say it's extremely important for all people, even if you're not a chronic pain patient. All people in general, even myself, I don't I I I don't have insomnia per se. I just go to bed, wake up at the same time every day because I know that optimizes my sleep.

[00:08:52]That optimizes my energy level, my brain function, my health, my mood, my relationships. Everything feels better when I keep a consistent sleep window because it's in training my circadian rhythm. It's teaching my body when to be awake, when to be asleep, and it's optimizing my sleep pressure buildups.

[00:09:12]And so, when it comes to our chronic pain patients, what you do during the hour before bedtime also needs to target pain. It is ideal if you have pain support and pain relief during that hour before bedtime. That way, everything is kind of calmed down a little bit. Um, and and that in itself will help to support improvement of both insomnia and sleep quality. Our general rule of thumb is typically a nice hot bath or a hot shower. Epson salt a lot of our pain pain patients do. So a nice hot bath and some soft music and some light reading during that hour before bedtime is a beautiful thing. So you want to pick two or three things that are the most important to you when it comes to pain support and calming your minds and your body. That's that's something that I think can be extremely helpful to get into the habit of and even if it's the same genre of music every night. We talk about this for the babies and the pediatric sleep or we always tell our parents to pick one song and play it on repeat during the hour before bedtime. I also think that can't be a bad idea for adults because it just you get used to it even if it's the genre, right? I take Enya baths. I love Enya. So that's the station that I listen to during my pre-leep ritual. It's not that I'm listening to the same exact song, but that's the genre because it trains my mindset. It's classical conditioning, impaired associations. My brain knows when Enya comes on, there's just an instant calmed response to that and it's been repeated night after night. So that repeated hearing really trains your brain to expect and to go into a state of calm. Then there's this issue of protecting your space. Turn off your cell phone, your tablet, your laptop.

[00:11:00]And the reason is twofold. It is about the light, the light that projects from the screen so close to your face. And it's also that you know that blue spectrum light. We still do believe in that. Um that blue spectrum light is telling the brain to stop producing melatonin. And ideally, you want that pouring of melatonin to support sleep onset. It's also though, and maybe even more importantly, the engagement that's happening from those devices that really sets you into fight orflight mode. So, you texted somebody. What did they text back? How do you feel about what they texted back? What's your response there?

[00:11:37]There's an emotional reaction. There's a stress response. Social media, someone posted this, I want to post that. What's your There's an emotional response.

[00:11:46]There's emotional engagement. There's relational triggers that are happening there. Email, my boss texted this and my boss sent an email about this and I'm going to respond that, right? All of these things in the digital world, relational elements are a no no from my standpoint. I think we just want to stop the human interaction on the digital side and the inperson side. So family, if you're look, if you live with a spouse and kids, it's like we really need to make it clear that the hour before bedtime should be me time. That should be their time to just, you know, close the door to the bathroom and count it as they should think of you asleep already.

[00:12:32]So on the other side of the fence, there's also just well, what does help to alleviate the chronic pain? And when you look at the research, it's really interesting to see that CBTI actually is does come up across the board. So cognitive behavioral treatment for insomnia, meaning if you just treat the insomnia, that in itself is so supportive of reduced pain. So that's really lovely to see. And then exercise as well is considered to be one of the best first line pain treatments just where reducing inflammation and that in itself is helpful and supportive with sleep and then you know doing stretching, walking and yoga and um yeah these are just these are also coming up across the board in the literature as supportive for pain reduction as well as being supportive for sleep. And then kind of combining these movement movement approaches as with with sleep tools are you know really helpful and powerful as well when we see from the research what is truly evidence-based and then actually moving the needle with um with actual management of pain to improve your pain and then thereby improving your sleep.

[00:13:50]So we see all the time people can have a diagnosis of chronic pain and comorbid chronic insomnia. And what the research really does show is what when it comes to chronic insomnia, the American Academy of Sleep Medicine, the American College of Physicians, NIH, they all recommends cognitive behavioral treatment for insomnia as the first line treatment. And actually it's not medication. All of the research says that it should be CBTI first and only if you fail CBT only if only if it doesn't work well for you then should a sleeping pill be tried. So another thing to really screen for be aware of is sleep apnea. So sleep apnea is a breathing disorder. So during the night the hallmark symptom of sleep apnea is loud snoring that you can hear outside the bedroom. And you don't always have to hear the pauses if somebody is just loud snoring and sleepy during the day. Those two symptoms in themselves are enough to warrant a sleep study most of the time.

[00:14:50]Um, but we do typically see that when someone has loud snoring and excessive daytime sleepiness, especially if they also have chronic pain. I'd love to see them get a sleep study because we would like to not miss anything. If you have untreated sleep apnea and chronic pain, we see the research actually shows that those who have those symptoms are often more likely to complain about insomnia as well and they're going to have more of an impact on their pain symptoms. So, it does become really important to catch this this possible sleep apnea, check it, and treat it.

[00:15:30]Let's talk a bit more about what is cognitive behavioral treatment for insomnia. So like I mentioned when I first introduced myself, I'm a behavioral sleep medicine specialist.

[00:15:42]And so my whole career and specialty area, my whole team, all we do is focus on insomnia management and special unique types of insomnia management. So there is this formal protocol of using sleep hygiene, sleep restriction, stimulus control, relaxations training, cognitive uh cognitive restructuring. Uh it's usually about 5 to eight sessions the protocol itself and uh what you do is you're filling in sleep logs while you're working with a clinician and they're analyzing your data. They're able to see from your data what kind of sleep window is going to make the most sense for you. They're making recommendations about how to deal with the fatigue. So, there's customized care. A lot of times really helpful for chronic pain patients because they're tired during the day and if they have a flare up and they're in a lot of pain.

[00:16:38]Normally insomnia patients, we say don't take a nap. But with pain patients, we kind of let them off the hook. We tell them try to rest instead of nap if you can because if you take a nap, it does impact your body's urge for sleep at bedtime the next night and you're more likely to have more insomnia that next night. That being said, we make exceptions for our pain patients because we know how hard it is to avoid naps when you're in pain. So, we also are a little bit more gentle on what we call sleep restriction. Sleep restriction is when a sleep clinician analyzes your sleep data and they say, "Okay, during your baseline logs, you were in bed 9 hours on average, but you are only sleeping 6 hours." So based on that and your circadian tendencies, I'm going to assign you a sleep window of 12 to 6.

[00:17:32]And then if you're in chronic, if you have chronic pain, we might be a little bit more gentle. So we might maybe do 12 to 7. you make it a little bit easier because we don't want too much sleep restriction for a pain patient.

[00:17:43]Sometimes that can cause flare ups. So, you kind of have to figure out what makes sense for which patient and um work together to be get the best possible starting off point and then you gradually increase that sleep window to get to the ideal sleep window while you're working on other techniques and strategies. And again, always always always alongside pain management care team support. So, one of the big things you you might have read read online to try to, you know, get out of bed if you're not sleeping, which is definitely something that behavioral sleep medicine specialists preach about. We don't want you laying in bed in pain, frustrated with your pain, stressed out by your pain, saying, "Why am I having this? Why is this happening to me?" all of that experience, associating your bed with those negative thoughts, with that pain experience, with that stress response.

[00:18:37]It's teaching your brain to associate the bed with negative thoughts, pain experience, and stress response. So, autom ultimately when you get into bed, you can kind of go right into that state.

[00:18:50]Your brain says, "Oh, I know what we do here in this bed. We go into pain mode.

[00:18:54]We go into a stress response. We feel anxious and stressed." So that is something that we really try to work on breaking. And then relaxation strategies. So these also are in if you search in the curable app, you're going to be able to find some really good relaxation strategies. We tend to like diaphragmatic breathing, positive imagery, and progressive muscle relaxation. So you should be able to look for deep breathing imagery, muscle relaxation, and really get some great tools to try. And again, you can even start with using those tonight just to kind of even in your pre-le ritual just to get your body physiologically in the best most calm state before sleep. And then, you know, we work on just getting your mindset into the right place because we do tend to see that when patients have chronic insomnia and chronic pain, there can be this sense of hopelessness, the sense of helplessness.

[00:19:52]Oh my gosh, I'm never going to sleep again. And I'll show you an example here of, you know, this was one of our just insomnia patients that, you know, they're triggering moments. They wake up, they're thinking during the day about their insomnia from last night and their thought that they're having that negative thought is h I'm never going to sleep again and they're feeling anxious in response to that negative thought and then we kind of look we work through with the clinician like what are the facts that support that that statement is true that I'm never going to sleep again. How true is that? Let's just let's just get down to the bare facts here. Well, two nights last week it did take me 1 hour to return to sleep and 40% of the last 6 months I did have 3 weeks of insomnia, right? We're just being super factual and just looking at the data. And what are the facts that dispute the accuracy of this direct statement? Well, five nights last week I fell asleep and returned to sleep in 20 minutes. And 60% of the last 6 months I had no insomnia. And the first 10 years of my life before the pain started I had no insomnia. So the replacement thought might be something like this. I'm doing my best to improve my sleep and completing the first line treatment protocol. So even if I continue to have some poor nights, I am grateful that this is the worst of my problems. So then it's like, I mean, maybe it doesn't get rid of the anxiety completely. You might still feel anxious thinking about last night's insomnia. It's just that from a more level head, from a more balanced replacement thought, you're able to think in a less fortunetelling, overeneneralized, over negative way. Cuz we don't want to just sugarcoat it and say sleep is perfect right now. We also just don't want to go to the other extreme and say that it's so terrible that you are never going to get past this cuz that's not true either. So, we kind of come up with ways to get more balanced in your thinking.

[00:21:55]With a behavioral sleep medicine specialist, our approach is usually to make sure that there's a great modification knowing what a chronic pain patient goes through. Like I said, it's behavioral uh sleep specialists see so many pain patients like it's just a very very common thing. And so we try um like I was telling you um if we we're not necessarily being as extreme when it comes to setting the sleep window, we don't do too much sleep restriction. So that's a one of the big modifications we make. We do try to instead of well normally we are very strict with nap avoidance. We do sort of allow for rest time and we're gentler if you need to take a nap. We try to ask our chronic pain patients to track pain as well as sleep. So when we have sleep logs filled out, we want every day also in the morning when they're filling out their sleep from the night before for them to rate on a scale of 1 to 10 how bad was your pain so that we can track and see the coralates there and just that catastrophic thinking about pain and sleep. It is so important to get control over your mindset to make sure that you are very clear about how overgeneralized thinking and catastrophic thinking about your pain about your sleep is actually making things so much worse. So trying to get into this new healthier empowered mindset that there is so much I can do the research is showing there is so much hope for me. That's the kind of mindset that we want to have and shifting that mindset will directly already help with both things.

[00:23:42]Key action steps. Just understanding the connection that we were talking about that pain and sleep and pain fuel each other. really working on that hour before bedtime, protecting your calming your body, protecting your space and your me time, making sure that you always stay proactive with your pain management approach, whatever it is that is best in class for you and your unique pain situation. And tracking, using data to inform your decision, see what's working, see what's not. Making sure you're screening for more clinical conditions. lot of people that have sort of mild sleep issues and I think if you're just more on the mild side just make sure that you're searching and help and you know optimizing your sleep on your own make sure you're looking up these the Purle app has these relaxation strategy tools that are really great so make sure you look in the app search the app for these different tools and techniques and then yeah knowing that CBT for insomnia it actually helps not just with the insomnia but also has results with the