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Sleep, Pain and Yoga

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May this new night of rest, repair the wear of time

John O’Donoghue



Not a day goes by in my clinic that I don’t meet people who are bone-deep tired. People in pain for whom sleep, especially consolidated sleep, is elusive, a thing of the past. The rest and restoration of sleep is something they can only dream of. As a mum of a 2-year old who still wakes regularly I have joined this tired brigade – it feels like an age since I’ve had more than a few hours undisturbed. And while it may seem like an unreachable goal, better sleep shouldn’t be the stuff of dreams. There’s a lot we can do to facilitate more restful sleep – in this article we highlight some of the key benefits Yoga can offer to improve our sleep, and in turn help our journey beyond pain.



Headspace


First, some core nuggets from the scientific world. Sleep and pain are beautifully and bitterly intertwined (1). Poor sleep is one of the biggest predictors of back pain (2) and whether poor sleep precedes pain or the other way around is actually still up in the air, with evidence for both sides (3). Nonetheless, improving sleep can significantly help pain (4-6).

Sleep has many influencing factors but the two main processes are Homeostatic Mechanisms and our Circadian Rhythm (7-10). Homeostatic mechanisms simply refer to a build up of metabolites as a result of being awake. You know that super tired feeling you get when you haven’t slept well, like when it’s mid afternoon and your eyelids are really heavy - that’s the result of a build up of these substances - it causes our ‘sleep drive’.

The Circadian Rhythm is our body’s natural master clock and many of our bodily processes have strong circadian rhythms. Our natural body clock is governed by many processes and chemicals produced in our body. ‘Masking’ of our body clock occurs regularly and for lots of reasons: caffeine, alcohol and other stimulants interrupt it, as do long haul flights across time zones, shift work, not enough exercise and exposure to bright lights late in the day.



A number of chemicals our body produces are also important for sleep (10). For example, melatonin is a hormone that is crucial for sleep. Its release is strongly influenced by light exposure. Exposure to natural daylight early in the day and limiting exposure to bright, artificial lights later in the day are two key ways we can optimize the release of melatonin to get a good night’s rest. Cortisol is another chemical that is heavily implicated in sleep and when disrupted can contribute to poor sleep. Often recognized as a stress chemical, cortisol is a corticosteroid (anti-inflammatory) and steroid hormone that’s involved in many of our body’s processes. It has a strong daily rhythm – it typically peaks early in the morning (when we’re more alert) and drops off in the evening (when we’re supposed to be slowing down), being at its lowest 1-2 hours after sleep onset. Lots of things can interrupt cortisol levels but key factors include stress, high levels of alertness and illness. Managing stress and ensuring a transition from our active, awake selves to a more restful state pre-bedtime are crucial to regulating cortisol levels, ensuring they don’t interfere with our sleep.



Five ways Yoga can help sleep and pain


1. Move mindfully… Asana practice (Yoga postures) can be used in a couple of ways to help sleep. First, exercise can positively regulate our body’s physiology, which can improve sleep particularly if it raises our core temperature early in the day. If practicing in the evening, a gentler practice is wise as vigorous exercise can be overly stimulating.


2. Breathe… Pranayama (meaning life force but often used to describe breathing practices), particularly slow deep breathing, can facilitate our parasympathetic nervous system – our rest and digest response (11). This can reduce our ‘stress’ response reducing cortisol levels as well as reducing sympathetic nervous system activity (lowering heart rate, blood pressure and respiratory rate), bringing a calmer, more sleep-inducing state. As well as helping us get off to sleep, regulating cortisol levels is one possible way to reduce wakefulness during the night.


3. Regulate your mind…. Focused attention (Dharana) and Meditation (Dhyana) again facilitate greater parasympathetic nervous system activity and like Pranayama, can reduce our ‘stress’ response. Meditation has also been shown to improve pain and one way it does this is by activating release of our natural endorphins (13).


4. Practice Yoga Nidra (Yogic Sleep): Yoga Nidra is probably the most perfect conduit for sleep – encouraging both regulated breath awareness and a deep meditative state that can be used during the day, before bed or during the night to help transition us into a more restful state.


5. Lean into the Yamas and Niyamas (principles of Yoga that encourage self-observance, self restraint and discipline) to guide us. Yoga is essentially the study of the Self – it’s about us tuning into ourselves, how we interact in the world and how we can evolve into our best selves. The Yamas have five categories and I think two of these are particularly helpful for sleep: (1) Ahimsa (non-violence/ non-harming) and (2) Satya (truthfulness). We often think about non-violence in how we interact with others but what about if we apply this to ourselves? Are our current habits conducive to sleep or are they actually standing in the way of us getting a good night’s rest? Here we lean on Satya (truthfulness) as we take an honest look at our sleep habits. Personally, I’ve had a prolonged history of pain from my mid-teens to my mid-30’s. Changing my sleep was pivotal to shifting my pain. But it wasn’t easy….. As I reflected on how my days ran and invited ‘Satya into the room, I realized how much I worked and exercised late into the evening, carried stress to bed with me, and really didn’t wind down. Even though I was really aware of the importance of sleep with my clients, I really wasn’t walking the walk!


Enter the Niyamas, again with five categories, two of which I’ve found very useful.

Eventually, I invited Saucha (cleanliness) and Tapas (self-discipline) to join Ahimsa and Satya to my sleep-improving party to enable me to clean up my evening routines and truly practice some non-harming towards myself by becoming more disciplined about my sleep habits and routines as well as unwinding and working on my stress levels. It wasn’t long before I reaped the rewards!


But I get it…. I really do…. with our days so overscheduled, it can be hard to find time to wind down. By the time you get home from work, eat supper and prepare for the next day, it can seem like the day is gone. Even family time or some exercise can feel like a stretch. And when we’re already tired, sometimes all we feel able for is a glass of wine and a half an hour in front of the TV or scrolling through social media. Yet, running around doing a million tasks to end in front of the TV may well be the last thing our nervous system needs to enable sleep. The science supports what we’ve probably known for eons - we need a good wind down routine to transition our nervous system from its active / stressed state to a more relaxed one.


As we as a family work on improving my daughter’s (and our own) sleep, the things that crop up time and again are all the things we know well. Dim the lights, turn off the TV, phone and other devices and do a puzzle, read a book then have a bath instead. Create a space that’s conducive to sleep – cool but comfortable, uncluttered if possible. Have a small evening snack but avoid alcohol, caffeine and other stimulants. Alcohol may feel like it relaxes you but it’s strongly associated with waking up during the night. Gentle yoga and meditation, particularly Yoga Nidra are perfect conduits to a good night’s sleep. Anecdotally, while my daughter still wakes me regularly, when I practice yoga before bed my sleep quality improves and it’s easier for me to get back to sleep during the night .…… a sharp contrast to the TV/glass of wine option, which can leave me wide-eyed in the middle of the night!


Out of the head and onto the mat

My two anchors for a good night’s sleep are a gentle asana practice with slow deep breathing and Yoga Nidra. You might like to try either or both.


Night-time Yoga

Select one or two easy sequences of postures that are easy for you to repeat several times. The trick is that you don’t have to think about the actual movements much but can gently couple easy movement with a slow breath, repeating the sequences for 10-15 minutes.

An example might be: cat-cow à downdog à cat-cow à child’s pose

And / or

Tadasana à upward salute àforward fold à table top à upward salute à tadasana


You could try performing he sequence a couple of times with a slow, 4-count breath, inhaling for a count of 4 and exhaling for a count of 4. If you wish, you could then try extending the length of your inhalation / exhalation, or adding a pause at the end of the inhalation and exhalation. I often practice with a ‘squared’ breath, inhaling for 4, pausing for 4, exhaling for 4, pausing for 4. Repeat.



Yoga Nidra

Lots of you will be familiar with Yoga Nidra and there are certainly lots of great recorded guides out there on apps e.g. Insight Timer. Below is a script you could use but honestly, listening to a guided version probably works best.


Set up: Choose to rest in a comfortable seated or lying position.

Breath awareness: Bring your attention to your breath, monitoring the inhalation and exhalation without judgment for a few rounds until you feel settled and ready to move forward with the practice.


Sankalpa: Create a Sankalpa, which is an intention or affirmation based on your deepest desire or wish for yourself. State this as a positive statement in the present tense, as though it’s already happening. For example, “I am comfortable and at ease in my body”. Repeat it to yourself at least three times as though it is already happening.


Perform a Body Scan: Begin to consciously scan your body, starting at the crown of your head or the tip of your toes. Slowly move your awareness throughout your whole body. You are simply noting, greeting, maybe acknowledging with gratitude or offering an exhalation of relaxation to each body area, without adding any judgments or questions. Take the time you need to gently scan your whole body.


Visualisation: Now bring your attention to the area behind your closed eyes. As though you are watching a movie or slides projected on a screen, allow the following images to appear for you.

· Blue sky with white drifting clouds

· A forest, with trees all around you reaching up to the sky

· A bonfire on a beach

· Waves crashing on the beach

· A tall mountain

· A candle in a cave

· Raindrops

· Crescent moon at night, crescent moon shining brightly against a starlit night

· A candle flame

*Note: you can use many various forms of visualisation, so feel free to choose options you feel comfortable with.


Continue watching the space of the mind, and observe the thoughts that arise. For the next minute or so allow these thoughts or feelings to come up, taking the role of the witness, and simply observe without engagement of hope or repression.


Return: Repeat your intention to yourself at least three times. Allow this Sankalpa to sink into your consciousness.

Now bring your awareness back to your body on the floor.

Notice your breath. Take some deep breaths noticing the movement of your body. Now bring your awareness back into the room; notice where you are; notice the sounds that are around you, reminding you of where you are. Bring your attention back to the here and now. Start to gently move your fingers and toes.

When you feel ready, start to gently move and stretch your body and open your eyes. Offer yourself a moment of gratitude for taking this careful time for yourself.


Namaste,

Niamh







References

1. Mathias, J.L., M.L. Cant, and A.L.J. Burke, Sleep Disturbances and Sleep Disorders in Adults Living with Chronic Pain: A Meta-Analysis. Sleep Medicine, 2018. 52: p. 198-210.

2. Parreira P, Maher CG, Steffens D, Hancock MJ, Ferreira ML. Risk factors for low back pain and sciatica: an umbrella review. Spine J. 2018 Sep;18(9):1715-1721.

3. Finan, P.H., B.R. Goodin, and M.T. Smith, The Association of Sleep and Pain: An Update and a Path Forward. Journal ofPain, 2013. 14(12): p. 1539-52.

4. Afolalu, E.F., F. Ramlee, and N.K.Y. Tang, Effects of Sleep Changes on Pain-Related Health Outcomes in the General Population: A Systematic Review of Longitudinal Studies with Exploratory Meta-Analysis. Sleep Medicine Reviews, 2018. 39: p. 82-97.

5. Tang, N.K.Y., S.T. Lereya, H. Boulton, M.A. Miller, D. Wolke, and F.P. Cappuccio, Nonpharmacological Treatments of Insomnia for Long-Term Painful Conditions: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes in Randomized Controlled Trials. Sleep, 2015. 38(11): p. 1751-1764.

6. Ho, K.K.N., P.H. Ferreira, M.B. Pinheiro, D. Aquino Silva, C.B. Miller, R. Grunstein, and M. Simic, Sleep Interventions for Osteoarthritis and Spinal Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Osteoarthritis Cartilage, 2018.

7. Pace-Schott, E.F., Sleep Architecture, in The Neuroscience of Sleep, R. Stickgold and M. Walker, Editors. 2009, Academic Press: San Diego.

8. Monti, J.M., The Neurotransmitters of Sleep and Wake, a Physiological Reviews Series. Sleep Medicine Reviews, 2013. 17(4): p. 313-5.

9. Minkel, J.D. and D.F. Dinges, Circadian Rhythms in Sleepiness, Alertness, and Performance, in Neuroscience of Sleep, R. Stickgold and M. Walker, Editors. 2009, Academic Press: San Diego.

10. Mullington, J.M., Endocrine Function During Sleep and Sleep Deprivation, in Neuroscience of Sleep, R. Stickgold and M. Walker, Editors. 2009, Academic Press: San Diego.

11. Pascoe, M.C. and I.E. Bauer, A Systematic Review of Randomised Control Trials on the Effects of Yoga on Stress Measures and Mood. Journal of Psychiatric Research, 2015. 68: p. 270-82.

12. Pascoe, M.C., D.R. Thompson, and C.F. Ski, Yoga, Mindfulness-Based Stress Reduction and Stress-Related Physiological Measures: A Meta-Analysis. Psychoneuroendocrinology, 2017. 86: p. 152-168.

13. Sharon, H., A. Maron-Katz, E. Ben Simon, Y. Flusser, T. Hendler, R. Tarrasch, and S. Brill, Mindfulness Meditation Modulates Pain through Endogenous Opioids. Am J Med, 2016. 129(7): p. 755-8.



Image: Thorsten Frenzel, Pixabay




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