The Relationship Between Sleep and Pain: Evidence-Based Strategies

Anyone who has lived with back or neck pain knows how the nights go. The pain makes it hard to get comfortable, the broken sleep leaves the body more sensitive the next day, and the next night is worse. Pain and poor sleep feed each other. Reviews by Finan and colleagues, and by Smith and colleagues, describe the link running in both directions: pain disturbs sleep, and short or broken sleep makes people more sensitive to pain.

That cycle can be broken from the sleep side. The European insomnia guideline recommends cognitive behavioural therapy for insomnia, known as CBT-I, as the first treatment for long-term insomnia, ahead of sleeping tablets, because its benefits last and its risks are lower. It is a structured programme, delivered by a psychologist, a trained GP or an online course, that retrains sleep habits and the worry that builds around sleep.

Does the mattress matter?

It can. In a Spanish trial of 313 adults with long-term low back pain, led by Kovacs and published in The Lancet, people given a medium-firm mattress had less pain in bed and on rising, and less disability, after 90 days than people given a firm one. The old advice that a hard bed is best for a bad back did not hold up.

Sleeping position is a matter of comfort. Many people with neck or back pain find lying on the back or side, with a pillow that keeps the neck level, easier than lying on the stomach.

What about the bedroom and routine?

A dark, quiet, cool room helps. Light, particularly from screens, delays the release of melatonin, the hormone that signals the body it is time to sleep. In a study by Cajochen and colleagues, an evening in front of a bright LED screen shifted the body clock and reduced sleepiness.

Keeping the bed for sleep, getting up at the same time each day and having a regular wind-down routine all help the body expect sleep. These habits are part of CBT-I.

Exercise improves sleep overall. A review by Kredlow and colleagues found regular physical activity helped sleep quality. Very hard exercise close to bedtime can make it harder for some people to fall asleep.

Do food and drink matter?

Caffeine lasts longer than most people think. In a trial by Drake and colleagues, caffeine taken even six hours before bed noticeably disturbed sleep. Alcohol can help people fall asleep but breaks up sleep later in the night.

A large meal late in the evening can cause discomfort and reflux. Drinking less in the last couple of hours before bed reduces trips to the toilet overnight, which are a common cause of broken sleep in older people.

Magnesium is a popular sleep supplement. A small trial in older adults with insomnia, by Abbasi and colleagues, found it improved some measures of sleep. The evidence is limited, and anyone with kidney disease should check with their GP first.

How can the mind be settled?

A warm bath or shower an hour or two before bed helps. A review by Haghayegh and colleagues found it shortened the time taken to fall asleep, probably because the body cools afterwards, which signals sleep.

Dimming the lights in the evening and using warmer-coloured globes reduces the effect of light on the body clock. Mindfulness and relaxation techniques, such as slow breathing and meditation, can calm the busy mind that keeps people awake. A small study by Ong and colleagues found the benefits of a programme combining mindfulness with CBT-I mostly lasted a year.

When should sleep problems be checked?

Long-term insomnia, loud snoring with pauses in breathing, daytime sleepiness that affects driving, or pain that wakes someone every night are all worth raising with a GP. Night pain that keeps getting worse, or comes with fever, weight loss or feeling unwell, needs prompt review. The low back pain guide covers the warning signs.

Where to start?

For someone caught in the pain and sleep cycle, the most useful first steps are the simple ones: a regular getting-up time, a dark room, less caffeine after lunch and a medium-firm mattress. For long-standing insomnia, CBT-I is the treatment with the best evidence.