Sleep

All sleep information is general in nature, and does not take into account your personal situation. You should consider whether any information is appropriate to your situation. This advice is not intended to replace the advice of a professional sleep expert or your doctor. Where appropriate you may wish to consider adding a sleep expert to your health care group.

The Importance of Sleep

Sleep is a significant part of your health profile. Poor quality sleep, or not getting enough sleep, can have negative impacts on your health. Injuries can take longer to heal, and pain levels can be perceived as higher among other things. Mental health can be affected - for example anxiety and depression can be triggered or worsened - and this in turn can create further sleep disturbance.

If you are not sleeping well, it is important to consider putting into place some strategies for improving your sleep, as part of your treatment for your physical pain. As there are a great number of reasons why sleep can be affected, information specific to you can only be discussed within the context of your treatment. However, there are some common issues listed below, which you may find of some help to get you started.

Sleep Hygiene

Sleep Hygiene refers to a series of lifestyle practices and habits that can help you get a better night's sleep. If you have difficulty getting to sleep, or don't get enough sleep, these things could help you.

Before bedtime

Avoid sleep altering substances before going to bed
Avoid caffeine - caffeine is a stimulant and will make it harder to get to sleep. Avoid caffeine for at least 6 hours before sleep (the half life of caffeine - the time it takes on average for your body to eliminate half of the caffeine - is five to seven hours).
Avoid nicotine - nicotine is a stimulant and will make it harder to fall asleep. By quitting smoking entirely you will have less carbon dioxide (CO2) and more oxygen (02) in your blood, which will also improve sleep quality.
Avoid alcohol - Although alcohol can reduce the time it takes to fall asleep, sleep quality in the second half of the night is reduced, and rapid eye movement (REM) sleep is reduced. REM is the mentally restorative part of sleep, meaning you can wake up feeling less restored, more drowsy, have poorer concentration and memory problems. You are also more likely to sleep walk, sleep talk, and suffer from sleep apnoea as a result of drinking alcohol, so reducing or eliminating it may improve these sleep issues to.

Avoid heavy meals within two hours of bedtime. Give your body time to digest the food in your stomach and for it to empty into the small intestines. This will especially help if you suffer from reflux, as a full stomach is more likely to cause issues than if you are upright for a few hours until things have digested before lying down. Hormones (e.g. insulin) which are part of digestion can affect your circadian rhythm and sleep, making it harder to sleep. Some foods can help sleep, such as turkey and warm milk.

Get regular exercise but avoid energetic exercise within three hours of bedtime. Regular exercise can help tire you out, but exercise that is too energetic close to bedtime can leave your sympathetic nervous system (SNS - also known as the "fight/flight response") revved high, making it harder to fall asleep. Relaxing activities to help wind down the SNS will make it easier to fall asleep, and allow the parasympathetic nervous system (PNS or "rest and relax / digest" response) to predominate.

Getting ready to sleep

Develop a bedtime ritual so that your body knows you are getting ready to go to sleep. Our mind and body are geared towards automatic activity (for example you will put the same shoe on first every time) unless we make a conscious effort to change. Forming a new habit takes on average 66 days (not 21!), but can range from 18 to 254 days¹ depending on what we are changing and how consistent we are (the more consistent the better!) among other factors. Doing different activities and going to sleep at different times each day (working late one night and trying to get an early night the next to make up for it) is poor sleep hygiene.
An example of a good bedtime ritual: Eat an early dinner, clean up, enjoy a home brewed hot chocolate* while watching a little bit of TV or reading a book on the lounge to unwind, have a warm shower and go to bed at the same time each night.

*Although cocoa does contain some caffeine, the amount is very small (cocoa has 7% of caffeine compared to instant coffee per weight²), in the same range as decaf. It also has high levels of theobromine, a chemical similar to caffeine, but which actually improves sleep³. Additionally the warm milk can help with sleep too.

Reduce extreme light, temperature and noise in your bedroom. 
Melatonin is a naturally occurring chemical (hormone) in the brain that builds in the evening as it gets dark helping us feel sleepy, and is broken down in the morning by light. This is why it is usually harder to sleep during the daytime or in brightly lit places compared to a dark room. Blue light from devices (phones, TV etc) can affect melatonin levels and make it harder to sleep. Particularly avoid any blue light in the bedroom (do not have a TV or keep your phone / iPad etc in the bedroom overnight). Melatonin can also be prescribed by your doctor to aid with sleep. You will need to contact your GP and arrange an appointment to discuss if this is appropriate for you.
Keep your bedroom at a cool temperature (16-20 degrees⁴). Extreme hot or cold will affect sleep (naturally!) but generally we sleep better if we are cooler, and our body temperature tends to go down when we sleep (and warms back up when we are ready to wake up).
Loud noises can keep us from falling asleep (again, naturally!) and may trigger the SNS, making us more wakeful and on edge until our nervous system calms down again. Avoid action/drama/horror movies right before going to bed! A calm and quiet environment is a much better sleep environment.

Include an hour of quiet time before bed such as reading, or listening to music. For some people watching TV can be quiet time, but be selective in what you watch, and do not watch TV in bed. This will help the PNS ("rest and digest") to have a chance to kick in and prepare our body for rest and sleep. The PNS and SNS work against each other, so if one is active it suppresses the other and vice versa. Quiet time lets us wind down and prepare to go to sleep.

Sleep time

Bedrooms are ONLY for sleep and sex. Our brains are great at making associations (habits). Pavlov demonstrated this by training a dog with food and a bell. He would ring a bell and feed the dog. After a time the dog would hear the bell and start to salivate expecting food. If you watch TV in bed for hours, after a while your brain will begin to associate the two. This can lead to getting into bed and not being able to sleep because the brain is expecting to watch TV. Avoid habitually using the bedroom for anything other than sleep (and sex) - for example, avoid keeping in the bedroom the home office / computer, any TV or devices, gym equipment etc. as these can form associations which can lead to poor sleep.

If you can't sleep after 20mins, get up and do something boring until you feel tired, then try again. This will reduce the likelihood of building an association between being in bed and not being able to sleep. It can be common in cases of insomnia that the original problem causing sleep difficulty is gone, but the brain is so used to lying awake in bed it just keeps doing it! Break the cycle (habit) by making sure you get up and away from the bedroom. Train your brain to think bedroom=sleep.

Keep your sleep times regular - same bedtime, same rise time. Aim for 8 hours of sleep each night. This is a way to use Pavlov's theory in a positive way; the body and brain get used to becoming tired at a certain time, falling asleep and waking up all in a predictable manner, making it easier to go to sleep each time. Those people who lie down and are out like a light? Maybe it's because they've had a lot of practice!

Remember everyone has nights where they can't sleep. The more you worry, the worse this worry can become. If you are concerned about your sleep contact your family doctor.

Sleep Apnoea

Commonly associated with snoring, sleep apnoea is a condition where a person stops breathing for a short period of time while they are asleep. Generally the breathing will resume, but the effects of not breathing can have some significant negative impacts on health. For example brain fog, tiredness and headache can be symptoms of the brain not getting enough oxygen during sleep. Waking tired, stiff and sore can be from all the muscles not getting enough oxygen.

Often the treatment of choice is a CPAP machine (continuous positive air pressure) - a mask and pump that pushes air into you while you are asleep.

Osteopathic treatment may involve treatment of the face (nose and sinuses for example), neck and throat, ribs and breathing to improve the function of the muscles involved in breathing and drain sinuses for clearer airways to make it easier to breathe. Treatment may also include dietary, lifestyle and exercise advice. You may be advised to lose weight if you are overweight, exercise more to strengthen the cardiopulmonary system (heart and lungs) so that your body works better at night while you are asleep, do breathing exercises and/or stretches, as well as many other possible options to improve your health, physical well-being and sleep, to reduce the apnoea or it's effects.

If you have a CPAP machine, you may experience neck or upper back discomfort from the face mask and/or the position you have to lie in through the night. If this is the case, these things can also be treated with Osteopathic therapy.


Teeth Grinding / Clenching

Teeth grinding is commonly associated with stress. Since it happens when you are asleep, it is usually another member of the household that will be the first to notice - in some cases the sound of teeth grinding can be very loud! However, in the case of clenching, where there is no grinding, there also may be no sound, and the problem can go undetected for a long time.

Short term there can be issues with tension and pain in the jaw and neck muscles. Long term grinding and clenching can result in chipped and cracked teeth, resulting in a lot of pain and expense. If you are waking up with a sore jaw or teeth, you may be grinding or clenching.

Treatment can help reduce the tension and pain in the jaw muscles, by working directly on the affected muscles. This treatment can be external; massage applied to the jaw muscles, or internal - a gloved finger inside the mouth to treat the muscles from inside the mouth and jaw. In many cases, the muscles of the neck and shoulders may also contribute to the problem, and require treatment.

It is typically necessary to combine physical treatment (Osteopathy) with some form of therapy for stress (psychology, counselling, meditation/mindfulness etc), and in most cases exercise will complement both physical and psychological treatment.


Resources

References
¹ Lally, P., van Jaarsveld, C.H.M., Potts, H.W.W. and Wardle, J. (2010), How are habits formed: Modelling habit  
  formation in the real world. Eur. J. Soc. Psychol., 40: 998-1009. doi:10.1002/ejsp.674
² (Cocoa dry ingredients) https://fdc.nal.usda.gov/fdc-app.html#/food-details/169593/nutrients
  (Instant coffee ingredients) https://fdc.nal.usda.gov/fdc-app.html#/food-details/789444/nutrients
³ https://criobru.com/blogs/news/what-is-theobromine-and-should-i-swapping-it-for-caffeine
https://www.sleep.org/articles/temperature-for-sleep/

Other resources
(Sleep and caffeine) http://sleepeducation.org/news/2013/08/01/sleep-and-caffeine
(Benefits of sleep) https://www.medicalnewstoday.com/articles/325353.php#sleep-recommendations

"People who say they sleep like a baby usually don't have one."
- Leo J Burke

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