Inability to sleep due to pain, a phenomenon dubbed “painsomnia,” is an all-too familiar symptom for those living with different kinds of arthritis. “Unfortunately, it’s an every night occurrence,” Lee Driscoll Dandan told CreakyJoints on Facebook.
“I’m woken and kept awake by pain most nights — it’s mentally and physically exhausting,” shared Damla Huss.
In a major 2012 National Institutes of Health study, insomnia was significantly higher among those with arthritis (all types), affecting 10.2 million people and 23 percent of people with arthritis. A recent study from this year found an even higher estimate of insomnia among osteoarthritis patients, at 34 percent; in a university of Pittsburgh study, one-third of rheumatoid arthritis patients reported pain-disturbed sleep three or more times a week.
Why Does Pain Seem to Get Worse at Night?
The answer is likely due to a few different factors. It could be that levels of the anti-inflammatory hormone cortisol are naturally lower at night; plus, staying still in one position might cause joints to stiffen up. Another explanation: The way you experience the same pain may actually change in the wee hours.
“It is not as much that the pain is worse at night, but rather that the perception of pain is more pronounced at night, or the pain thresholds are lower at night,” says rheumatologist Elena Schiopu, MD, of Michigan Medicine Rheumatology at the University of Michigan. “One explanation could be that stimuli that are abundant during the day, the distractors, are no longer present at night.”
In other words, you notice your pain more at night, so it bothers you more.
The Start of a Vicious Cycle
And once you start dealing with a lack of sleep, a vicious cycle can start.
“Poor sleep leads to daytime fatigue, which in turns leads to pain amplification,” Dr. Schiopu says. “When tired, the brain lacks the ability to dampen pain signals, also called anti-nociceptive pathways, so the pain is perceived to be worse.” Also, when you’re tired during the day you’re less likely to feel like exercising, which can help improve arthritis and its symptoms. Not keeping weight in check is also linked with sleep apnea, which causes further sleep problems. Tiredness is also linked to greater depression in arthritis patients, which is again linked to worsening pain.
It’s no wonder that painsomnia can seem almost inevitable with arthritis, but there are some steps you can take to make it better:
1. Practice good sleep hygiene
Do the things that can help everyone — with or without arthritis — get a better night’s sleep. “It is important to go to bed each night at the same time and wake up at the same time each morning, no electronics or screen time prior to bed, and no eating or any other activities unrelated to sleep before bed,” Dr. Schiopu says. Keep your room dark and at a comfortable temperature for you.
2. Exercise during the day
Moderate physical activity is an important part of your arthritis treatment plan, and it’s also associated with better sleep for arthritis patients. But if you’re someone who struggles with painsomnia, make sure to exercise earlier in the day, as opposed to after work or dinner, to keep from too much stimulation before bed, Dr. Schiopu says.
3. Try meditation or deep breathing
Any mental technique that can help you relax before bed is worth it. Arthritis patient Cindi Arnsdorff , a CreakyJoints Patient Council member, uses three go-to visualizations. “I close my eyes and picture myself on a Caribbean Island, lying in a downy soft bed with the doors open to the sounds of waves lapping on the beach outside my window,” she says. “Another trick is literally counting sheep: I visualize sheep jumping over a stump and count them in my mind. Never have I gotten to one hundred.”
Another exercise Arnsdorff likes is to visualize a flickering candle and to quietly chant “om” until her mind is cleared.
4. Create a relaxing pre-bed routine
If meditation isn’t your thing, find what works to calm your mind and body. “This can be highly individualized process,” says CreakyJoints community member Dawn Marie Gibson, who recently coauthored a paper about managing painsomnia that was presented at the 2018 American College of Rheumatology/Association of Rheumatology Health Professionals (ACR/ARHP) Annual Meeting in Chicago. “Soothing sounds like waves and fireplaces help me relax by taking the focus off my pain. I also enjoy crocheting when I feel up to it.”
Dr. Schiopu suggests a boring book to put you to sleep. In addition, Gibson says to eliminate anything that riles you up. “Reducing or taking something away may be as helpful as anything being added in,” Gibson says. “Less caffeine, less news, or less arguing on social media might make it easier to wind down and go to sleep.”
5. Consider CBT
Pain is partly psychological, which is why research shows that cognitive behavioral therapy (CBT) can help train your brain how to respond to pain. “Pain is the result of myriad electrical connections and a perfect communication between the peripheral and central neurons, with significant modulation via the vegetative nervous system,” Dr. Schiopu says.
Translation: Pain signals in your brain can get worse if they’re in a state of high alert and sensitivity. CBT with a licensed therapist can help you modify both your coping response to those heightened signals and the signals themselves. In addition, any mental health issues you’re experiencing, such as depression, should be treated in order to improve pain at night.
6. Use hot or cold therapy
A warm bath before bed may help calm sore joints and promote feelings of relaxation. “During colder months I pop my comforter in the dryer for about five minutes to warm it up before going to bed,” Arnsdorff says. “Then I use it like a cocoon to soothe my sore muscles and joints, and help me enter dreamland.” She also makes “sock buddies,” which are filled with dry rice heated in the microwave to put over sore hands. Or, you can try ice on swollen areas.
This may require some trial and error, Gibson warns. You don’t want to over-stimulate yourself before bed or risk any harm by falling asleep on the hot or cold object.
7. Make sure your bed is comfy for you
Check with your doctor or physical therapist, but in general, avoid a too-firm sleeping surface. “A soft mattress is very important,” Dr. Schiopu says. Although Arnsdorff says heavy blankets put too much pressure on her joints, Gibson says weighted blankets can help some people settle down, and they’re becoming more widely used among people with chronic pain, so see what works for you.
You can also experiment with “throw pillow therapy” to see what feels good — Arnsdorff says she uses many pillows to cushion sore joints.
8. Consider herbal remedies to help you snooze
With your doctor’s OK, “you could try melatonin or herbal teas, particularly those with calming properties,” Dr. Schiopu says.
9. Discuss your medication options with your doctor
If you’re experiencing painsomnia, consider tracking it with an app like ArthritisPower so you can talk to your doctor about the degree of your symptoms and correlate them with other factors, such as your medication regimen. Having good control of your arthritis with disease-modifying drugs is usually the first step, but other medications that can specifically help manage pain at night may be needed. These could include anti-epilepsy drugs such as Gabapentin, as well as muscle relaxers such as Tizanidine or Flexeril, says Dr. Schiopu.
In addition, it’s a good idea to review the other meds you take for your arthritis. Side effects like weight gain or higher cortisol levels (such as from corticosteroids) might be messing with your sleep. Talk with your doctor and pharmacist to make sure your regimen isn’t contributing to your painsomnia.
If you experience painsomnia, Gibson says to remember “sleep issues don’t make you a failure — sometimes our bodies just don’t do what we want them to.” Try different approaches, talk with your doctors, and see what helps.
And remember this good advice: “Take painsomnia seriously,” Gibson says. “You need and deserve your sleep and rest!”