“I have so much trouble getting to sleep”
“I wake up 10 times a night, I can never get comfortable, and I just can’t get back to sleep”
“Since I had my kids, I forget what it’s like to get a good night’s sleep”
How many of you have either heard or uttered sentences like these? Well, you are not alone! There are hundreds of people who experience sleep difficulties for all sorts of reasons. Some because of pain, stress, emotional unrest, or digestive issues; while others because of recent life changes, like having a baby.
As a physiotherapist, my clients tend to come see me for their physical problems, but many also ask what can be done about their sleep concerns. Truth is, there’s quite a lot that can be done; and the goal of this discussion is to provide some answers to the most frequently asked questions related to common sleep problems that I see in my practice.
Why is Sleep Important?
First, we need to understand the tremendous importance of sleep. Sleep is a highly organized physiological behaviour that is mandatory for every living mammal on earth. It is governed by something called a circadian rhythm, which is a ~24-hour cycle of behavioural, physical, and mental changes that respond to variations in light, noise, stress, pain, emotions, and certain substances or medications (i.e., codeine, caffeine, nicotine). Although the need for sleep can change depending on age or stage of life, we know that a human being can only live for 10 days without sleep.
A typical sleep cycle will activate varying levels of brainwaves that eventually lead to deep sleep and then rapid eye movement (REM) sleep. It is during REM sleep that we may dream and our bodies do their best healing. Sleep deprivation at any stage of the cycle can cause problems demanding an even greater amount of sleep for total recovery. For instance, it will take approximately four hours of restorative sleep to catch up on one hour of lost sleep.
What are some Common Sleep Problems and their Causes?
Although there are many biological, psychological, and habitual causes of insomnia, it is beyond the scope of this discussion to delve into each and every one of them. Some of the most common sleep disorders that I see in my practice are as follows:
- Sleep Latency – Inability to get to sleep
- Fragmented Sleep – Going back and forth between sleep and wakefulness
- Early Awakening – Once awake, there is significant difficulty getting back to sleep
- Non-Refreshing Sleep – Not sleeping deeply enough to feel rested
But what causes these issues? The most common causes of poor sleep that I see in my practice are nocturia or the need to pee in the middle of the night, significant changes to lifestyle such as having a baby, or the presence of chronic bodily pain.
Nocturia, or the need to pass urine in the middle of the night, can be a very annoying problem. Having to repeatedly wake-up significantly disturbs the sleep cycle, which can ultimately prevent the ability to achieve deep or REM sleep. Truthfully, unless in the later stages of pregnancy or passed the age of 55, one should never have to wake up in the middle of the night to pee, and even then only once is acceptable.
It’s no secret that many new mums wake periodically during the night to feed their babies. They also have the added challenge of adapting to the notable body changes that accompany birth and postpartum recovery. Thus, many new mums report not sleeping deeply or having greater difficulty getting back to sleep after waking up in the middle of the night.
With respect to pain, studies have shown that 50-88% of people with persistent pain also experience insomnia. This may be due to pain- or injury-related preoccupation while trying to fall asleep, side effects from pain medications that interrupt the sleep cycle, or greater activation of certain nerve fibres that intrude upon the ability to achieve REM sleep. Evidence also shows that persistent pain has a very strong overlap with sleep apnea, which itself is worth fixing as soon as possible.
What are the Solutions to these Sleep Problems?
Before we get into the specific techniques that I use to help patients with sleep problems, let’s take a minute to discuss brain adaptation. It’s important to know that the brain has an incredible capacity to learn new things and adapt to changes placed upon it. Without describing the complex physiological processes of how the brain does this, just know that if we repeat the same behaviours over and over again, the brain will actually reform to build a solid memory of that behaviour, enabling it to become automatic. This phenomenon explains how our ability to walk as adults no longer requires conscious thought, whereas a toddler just learning to walk needs to focus all of the mind’s attention until the walking behaviour is practiced enough to become automatic. Keep this in mind (pun intended) as you read on…
The first step in improving sleep is to educate patients about the function and importance of sleep. In detail, we discuss how healing it is when the body and mind are allowed to go through all the stages of progressively deep sleep. We also discuss the unconscious and negative conditioning that occurs in the brain when we habitually practice poor sleep behaviours that eventually cause sleep difficulties. Then, I call in my big guns – tips for promoting good sleep hygiene! Since we know that the brain has an impressive capacity to learn new things, why not teach it well?
Ten Tips for Promoting Good Sleep Hygiene
- Avoid drinking anything approximately 2-3 hours before bedtime – this will help prevent having to wake in the middle of the night to pee
- Develop a routine for sleep preparation – approximately 1 hour before bed, start to dim the lights and begin your bedtime routine; this will help promote natural circadian rhythm and sleepiness
- Ensure that you always sleep in a darkened room with no electronics or lights on – again promoting natural circadian rhythm and sleepiness
- Keep the room cooler (i.e., 16-17 degrees Celsius) – during the second stage of sleep, body temperature drops; it is best to not overheat yourself into wakefulness during this stage
- Practice good relaxation techniques – meditation, Shavasna pose, or a warm bath can help you wind down into a peaceful rest
- Only go to bed when sleepy – this will ensure that your brain always associates bed and bedtime with sleep
- If you are unable to fall asleep after 7-10 minutes of being in bed, get up and go to another room – this will prevent your brain from negatively associating your bed and bedroom with wakefulness
- Stick to a consistent bedtime and wake-up time – this will provide input into the circadian clock and help build the drive for sleep
- Use your bed and bedroom for sex and sleep only – watching TV or reading in bed are behaviours that reinforce negative brain conditioning and promote wakefulness
- Understand sleep drive hindrances – certain things such as napping, sleeping-in, physical inactivity, and changing bedtimes can decrease sleep drive making it harder to fall and stay asleep
Any Other Suggestions?
Another very useful tool I use in clinic is sleep efficiency. Sleep efficiency is a calculation of the total time one spends asleep over the total time spent in bed, times 100%. Ideally, we want this number to be 90% or more, however, many of my patients tend to hover around 50-60%. A lower sleep efficiency number indicates that the brain is more likely to associate bed, bedtime, or the bedroom with sleeplessness or insomnia.
To fix this issue, I recommend a technique called sleep compression, which involves patients going to bed later and waking up earlier, thus better matching the number of hours spent in bed with the number of hours spent asleep. This will immediately boost sleep efficiency and allow the brain to develop a more positive association of bed, bedtime, and sleep. With sleep compression, it takes approximately 14 days to modify the circadian rhythm, and we may expand the number of hours spent sleeping as efficiency improves.
So there you have it – some basic information about common sleep problems and ways to fix them. If you have any specific questions regarding sleep hygiene, sleep efficiency, and/or sleep compression, please feel free to call or book an appointment today. Cheers!
Carolyn Vandyken, PT [Onsite Course] Pelvic Health Solutions
MacDonald S et al. Avoidant Safety behaviours and Catastrophiza0on: Shared Cogni0ve Behavioural Processes in Co-Morbid Pain and Sleep Disorders. International Journal of Behavioural Medicine 2008; 15: 201-210