I haven’t really spoken much about sleep because there’s a lot to what is enough sleep or what constitutes good sleep hygiene that I don’t quite understand enough.
With so much information about sleep on social media and at home — e.g. “why so late still haven’t sleep?” — how do we separate the facts from fiction?
The best place to start is probably the National Sleep Foundation.
I gave their Bedtime Calculator a shot and I was surprised to realise that if I wanted to sleep for seven hours and wake up only at 10.00am in the morning, I can afford to sleep at three in the morning!
Of course that’s just simple math. We are so conditioned to accept that sleeping early is better for us that I feel negatively about myself sleeping at 2am in the morning, even when I do get “enough” sleep every night.
Do I really need 8 hours of sleep?
We are starting to see that there are no hard and fast rules for most things in healthcare.
When it comes to exercising, we know that just walking for five minutes will benefit you.
However, official guidelines across international organisations agree that you should aim for 150 minutes of moderate intensity exercise and at least two days of strength or resistance training.
What they are not saying is that there’s no point to doing less or that doing less doesn’t benefit you!
When it comes to sleep duration, if you are between 18 to 64 years old, the recommended sleep time is seven to nine hours.
That is not to say you need eight hours of sleep.
What I really liked about the National Sleep Foundation is that they published the methodology that they used to arrive at their recommendations. In 2015, they assembled a panel of 18 experts across 12 organisations to evaluate the scientific evidence looking into sleep duration.
Based on their findings, they have compiled the current sleep time guidelines. If you are interested, do feel free to examine their data points!
How many hours do I really need to sleep?
If you are sleeping within the seven to nine hours window, good on you! You are most likely getting enough sleep.
But how many hours of sleep time do you really need?
I am not going to fit you into a round hole so here are a few lifestyle questions for you to consider:
• Are you happy?
• Are you productive at work?
• Are you able to stay awake through the entire day?
• Are you able to focus engaging the task at hand?
• Are you able to get through a day without caffeine or similar stimulants?
• Are you able to sleep through the night?
If the answer is no to any or a couple of the questions, perhaps it’s worth looking into increasing the sleep hours or the quality of sleep you are getting every night.
We are not trying to establish a causal relationship here — e.g. you are unhappy because you don’t sleep enough. Instead, we are exploring what would enough sleep look like for your individual self.
Are you living with chronic back pain?
When it comes to the interactions between sleep and chronic pain, we have some pretty interesting hard science.
Coming from the Trøndelag Health Study — also the The HUNT Study — one of the largest health research ever performed in the world. The study has collected data from over 230,000 people and more than 300 clinical studies are using this information for their research.
One of the studies published just last year looked at the relationship between sleep and lower back pain in a whopping 6,200 participants.
The researchers followed the lower back pain patients for ten years and found that patients who often experienced sleeplessness are less likely to recovery from low back pain.
In this study, “often” was defined as more than once per week. If you are experiencing poor sleep for two or more times per week, you may be at higher risk for recurrent back pain (over a ten year period).
The study specifically investigated three insomnia symptoms:
• Difficulties falling asleep
• Difficulties staying asleep (e.g. waking up too early and unable to return to sleep)
• Work performance/productivity being negative affected as a result of poor sleep
Such research is really meaningful both for myself as a chiropractor and for yourself as a pain sufferer. While we know that sleep is important and that poor sleep can affect our pain experience, what we don’t know is the extent of its influence.
From this paper, we learnt that there is a association between sleep and your chances of a successful recovery. As the frequency of sleeplessness AND the number of insomnia symptoms increase, the less likely you are to achieve full recovery from low back pain.
It is ominous, isn’t it?
Through science, we are able to confirm that there is some merit to the (perceived) trivial “better sleep early” or “better sleep more” advice that we have received since our teenage years.
The good news is that sleep is a modifiable lifestyle behaviour.
Sleep is a learned behaviour
You are probably going to hate me for saying this but sleep is a learned behaviour.
This means you can take proactive actions to change your sleep patterns, duration, or quality.
As adults, we find changing our sleeping behaviour challenging because it’s a hard change.
As parents, you may also find sleep training for babies challenging because of its … challenges. Regardless, you may decide to commit to it anyway because of the long-term benefits.
If a baby can change their sleeping habits despite not having the cognition to understand what is going on, it is likely that you can also change.
The question is, how?
Clinical guidelines for management of chronic insomnia
Okay, you may not have insomnia or be diagnosed as such. That’s totally okay!
We are looking at the practice guidelines published by the American Academy of Sleep Medicine in 2017 as a point of reference to what we can do sleep better.
First, we have to acknowledge that sleep disorder is huge. If you think your insomnia may be clinical, the best thing to do is to consult with an evidence-based professional for an evaluation.
Second, even in diagnosed insomnia patients, behaviour is acknowledged as a potential contributor to the development of sleep disorders.
In the guidelines, the authors noted that staying awake in bed for prolonged period of time may lead to increased efforts in getting to sleep. This is an experience most of us are probably familiar with.
The sleep has the tendency to elude us the night before a major exam, presentation, or life event (e.g. wedding). Not being able to fall asleep comes with its own frustration and anxiety, which leads to even more wakefulness and negative emotions.
Over time, repeated sleeplessness can result in distorted beliefs and attitudes when it comes to sleeping well.
This is where the problem begins. And where we can start with behavioural interventions.
Here are the five steps you can take to improve your sleeping habits:
Step 1: Identify the behaviours and thoughts that may be contributing to your current sleep situation.
Step 2: Recognise these thoughts and see if you can challenge them with more sleep-compatible beliefs.
Step 3: Use behaviourial approaches to minimise the amount of time spent awake in bed and promote a positive relationship between time spent in bed with relaxation and sleep.
Step 4: Establish a sleeping-waking up routine, healthy sleeping habits (e.g. pre-bed ritual to induce sleep), and an environment that is conducive for sleep (e.g. make sure there is no light).
Step 5: Use psychological or behavioural techniques to reduce arousal or anxiety towards sleep (e.g. relaxing stretches, meditation).
Behaviour change mechanisms for healthy lives
I think clinical guidelines are sometimes not accessible or difficult to apply to our daily lives.
What if we were to take a more generic behaviour change approach to poor sleep?
How can we apply the five-step process into our daily lives in less regimental way?
If you know what is important to you, that’s probably the best place to start. Have a think of what you want to achieve with your values in mind and draft out a little action plan that is consistent with your own values.
If you look at the behavioural change diagram above, you’ll see that to facilitate motivation you’ll need to adopt a positive mindset, set goals, and have a good social support in place. I highly recommend that you work on them in this order.
If goal setting is more intuitive for you, maybe switch that around with fostering positive/compassionate mindset.
Restructuring misconceptions is a bigger challenge because for that to happen, you’d need to be able to identify your current attitudes and beliefs towards sleeping.
I suggested an exercise to help increase awareness of physical sensation, unpleasantness of the sensation, and thoughts in my earlier post on Pain Neuroscience Education. You can use the same exercise to journal your pre-sleep experiences:
• What do you do before sleep?
• How did that make you feel (e.g. emotions, mood)?
• What were the thoughts that were going through your head during that time?
If you are open to keeping a journal, you should be able to notice patterns or gain some in sights two weeks or so into the practice.
If your chronic pain is a big part of your pre-sleep experience, you can also add what are the physical sensations you feel into the journal.
Does sleep hygiene work?
Yes, sleep hygiene works.
While practising good sleep hygiene may not immediately help you sleep better, it does involve you taking action to improve the relationship you have with sleep.
This is particularly important if we are looking to approach improving sleep from a behavioural modification perspective.
There are two aspects to sleep hygiene. The what-you-do-before-you-sleep part, which some people refer to as a pre-sleep ritual, as well as the changes you can make to your environment to promote sleep.
• Ensure your bedroom is dark during sleeping hours. Draw the curtains shut if possible to block out the light coming in from outside or passing vehicles.
• Ensure your bedroom is as quiet as possible during sleep time. Consider closing the windows and door so your sleep is not disrupted. If necessary, use ear plugs.
• Ensure the ambient temperature is ideal for sleeping. This usually means cool for most of us in warm and humid Singapore. You don’t want to wake up in the middle of the night from the heat or perspiration, especially if you have the windows shut.
• Mindfulness practice or meditation seems to help people relax so this is something you may want to consider. If you are uncomfortable with mindfulness exercises, try some breathing-relaxation exercises instead.
• Turn off as many lights as possible 30 to 60 minutes before sleep time.
• Avoid computer or mobile phone use 30 to 60 minutes before sleep time.
• Consider reading a book or taking a warm shoulder to induce sleepiness.
Lifestyle changes routine
• Keep a consistent sleep-wake cycle, even during weekends
• Reduce liquid intake in the evening so you don’t have to make bathroom trips at night
• As much as possible, avoid afternoon naps. If absolutely necessary, limit it to 30 minutes and and at least four hours before bed time
• Avoid stimulants (coffee, tea, alcohol*) before sleep. If you are caffeine-sensitive, you may want to restrict caffeine intake to mornings only
• If exercising in the evening, choose relaxing exercise (e.g. yoga) instead of high intensity workouts.
*In small doses (1 to 2 standard drinks), alcohol acts like a stimulant to help people “loosen up”
Remember, the benefits of good sleep hygiene isn’t just about helping you to fall asleep. It also includes improve your attitude and thoughts towards sleep as well as to promote better sleep quality.
If you are struggling with chronic pain and your work productivity or day-to-day mood has been negatively affected, you may want to consider looking into your sleep habits.
Improving your sleep duration and sleep quality can boost your general well-being and possibly reduce your susceptibility to pain.
Don’t forget, sleep is a learned behaviour. With the right actions, you will be able to overcome your barriers to sleeping well.
Do you need extra help with your chronic pain management? If you like my sustainable, whole-person approach to helping people find freedom from pain, book in for an appointment via the form below. I promise it will not be like anything you have experienced before!
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Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.
Our goal? To make our own services redundant to you.