When we think about recovering from pain or an injury, we often focus on things like exercise, stretching, strengthening and hands-on treatment.
But there is another important part of recovery that is sometimes overlooked: sleep.
Sleep is not simply a time when our body switches off. It is an active process that helps our brain and body recover. Good-quality sleep supports our mood, concentration, immune system and physical health. It also plays an important role in how our body manages pain and recovery.
In fact, sleep and musculoskeletal pain have a two-way relationship. Poor sleep can make us more sensitive to pain, while pain can make it harder to sleep (1).
This means if you’re dealing with ongoing back, neck, shoulder, knee or other musculoskeletal pain, improving your sleep will be an important part of your recovery.
What happens when we sleep?
Sleep happens in cycles throughout the night. There are two main types of sleep: REM sleep and non-REM sleep. Non-REM sleep includes several stages, with the deepest stage often called deep sleep or slow-wave sleep.
Deep sleep is particularly important for physical recovery. During this stage, your heart rate, breathing and blood pressure slow down, your muscles relax, and the body carries out important repair and recovery processes.
REM sleep is the stage most closely linked with dreaming. It also appears to play an important role in learning, memory and processing information. Again, disruption to sleep alters this and can be implicated in persistent pain (2).
Your sleep cycles change throughout the night. You usually have several periods of REM sleep, with these periods becoming longer towards the morning.
So, getting enough sleep is not just about the number of hours you spend in bed. The quality and regularity of your sleep also matter.
For most adults, around 7–9 hours of sleep each night is recommended, although the amount needed varies between individuals and age groups.
How common are sleep problems?
Sleep problems are very common and they can present differently for different people.
Sleep problems can include:
| Sleep Pattern Problems 🌙 | Sleep Disorders 🩺 |
|---|---|
| Difficulty falling asleep Waking frequently during the night Waking too early Poor-quality or unrefreshing sleep Regularly getting too little sleep Sleeping much more than recommended | Insomnia Sleep apnoea Restless legs syndrome |
People who work night shifts or changing shifts can be particularly affected because their work schedule can interfere with their natural body clock.
Lifestyle factors can also affect sleep. Caffeine, alcohol, smoking and some medications can change how long we sleep or the quality of our sleep.
What does sleep have to do with pain?
This is where things get interesting. We have traditionally thought about pain as something caused by an injury or problem with a particular part of the body. However, pain is much more complicated than that.
Your brain and nervous system are constantly receiving information from your body and deciding how much attention that information needs. Sleep plays an important role in this system.
Research now shows that poor sleep can increase the risk of developing ongoing musculoskeletal pain (3). At the same time, people who already have persistent pain are more likely to experience sleep problems.
This creates a cycle:
The good news is that this cycle can potentially be broken.
Why can poor sleep make pain worse?
There are several reasons why a lack of good-quality sleep may affect pain.
You can become more sensitive to pain
When we don't sleep well, our nervous system can become more sensitive. Research has shown that limited sleep can lower your pain threshold, in simpler terms, the volume on your pain system can be turned up. For example, something that normally feels uncomfortable but manageable may feel much more painful after several nights of poor sleep. This may help explain why your pain can sometimes feel worse after a bad night's sleep, even though you haven't done anything to physically aggravate the injury.
Your body's ability to control pain can change
Your brain has systems that help reduce or "turn down" pain. These systems are sometimes described as the body's pain-inhibition system. Good sleep appears to support these systems. When sleep is disrupted, the nervous system may become less effective at reducing pain signals. This is one reason why sleep and pain can become closely connected.
Sleep loss can affect inflammation
Deep sleep is important for the normal regulation of the immune system. Research has found that disrupting deep sleep can increase certain inflammatory signals in the body. Disrupted deep sleep promotes inflammation (4). Inflammation is closely linked with how our body responds to injury and pain. While inflammation is an important part of healing, changes in the body's inflammatory response may also contribute to increased pain sensitivity or prolonged inflammatory processes. So, poor sleep may affect pain not just because we feel more tired, but because it can change some of the processes that help regulate pain and recovery.
Your nervous system can become more reactive
Normally, our nervous system can get used to a repeated sensation. For example, if you put a watch on your wrist, you may notice it at first. After a while, you stop paying attention to it. This process is called habituation. Research suggests that ongoing sleep restriction can make this process less effective. The nervous system may become more reactive to repeated stimuli. This is one of several processes that may contribute to increased sensitivity in people with persistent pain.
Pain can affect your sleep too
Of course, the relationship works both ways. If you have back, neck, shoulder or knee pain, you may find it difficult to get comfortable in bed. You might wake when you roll over, struggle to find a comfortable position, or become more aware of your pain when everything around you is quiet.
You can then end up in a frustrating cycle, just like before
Poor sleep can also make it harder to exercise, concentrate at work and manage everyday activities. Over time, this can affect your confidence and wellbeing as well as your physical recovery.
What about back pain?
The connection between sleep and pain is particularly important for people with persistent lower back pain (5). Research has found links between sleep quality and how much back pain affects a person's daily life. Poor sleep can also be associated with greater pain-related worry and anxiety.
This does not mean that poor sleep is the cause of someone's back pain.
Back pain is complex and can be influenced by many different factors, including physical activity, strength, previous injuries, stress, mood, work, sleep and how the nervous system processes pain. While some of these things we cannot change, sleep is one that we fortunately can!
Can improving sleep help chronic pain?
Sleep is an effective treatment for persistent pain (6).
There is growing evidence that improving sleep can also improve pain in people with chronic pain (6). One approach that can be particularly helpful for ongoing insomnia is Cognitive Behavioural Therapy for Insomnia (CBT-I). This is a structured treatment that helps people change habits and thought patterns that may be keeping their sleep problems going (6).
Physiotherapy can also play an important role.
When assessing someone with persistent musculoskeletal pain, it can be useful to ask about sleep as part of the bigger picture.
We will ask in the assessment:
| About Your Sleep 🛏️ | About Your Pain and Energy ⚡ |
|---|---|
| How do you wind down before going to bed? How many hours are you sleeping? Do you wake regularly during the night? Your pillow and mattress. Do you feel rested when you wake? Are there other symptoms suggesting a sleep disorder? | Is pain waking you? Did your sleep change when your pain started? Are you too tired to exercise? |
If your sleep problems need further investigation, we may recommend speaking with your GP or another healthcare professional.
What can you do to improve your sleep?
You don't necessarily need to completely change your lifestyle to improve your sleep.
Start with the basics.
Keep a regular sleep routine
Try to go to bed and wake up at roughly the same time each day. A regular routine helps your body know when it is time to sleep. Use the bedroom for sleep. It is not a place to watch TV or share with pets.
Give yourself time to wind down
Try to allow some quiet time before bed. Moving from work, exercise, emails and screens straight into bed can make it harder for your brain to switch off.
Watch your caffeine and alcohol intake
Caffeine can stay in your system for several hours and affect sleep. Alcohol may make you feel sleepy initially but can reduce sleep quality later in the night.
Make your bedroom comfortable
A dark, quiet and comfortable bedroom can help create the right environment for sleep.
Keep moving
Regular physical activity can improve sleep and is also an important part of managing many musculoskeletal conditions.
Exercise doesn't have to mean going to the gym. Walking, cycling, swimming, strengthening exercises or other activities you enjoy can all contribute to better health and sleep.
Don't ignore ongoing sleep problems
If you regularly struggle to sleep, wake feeling exhausted, or have symptoms such as loud snoring, choking or pauses in breathing during sleep, speak with your GP or another appropriate healthcare professional.
These symptoms can sometimes indicate an underlying sleep disorder, such as sleep apnoea.
Sleep is part of the bigger picture
When you are experiencing pain, it is natural to focus on the painful body part. But your body doesn't work in separate pieces. Your muscles, joints, brain, nervous system, immune system, sleep, stress levels and general health all interact. Sleep is one of the basic processes that helps your body recover and helps your nervous system manage pain.
It isn't a magic cure for musculoskeletal pain, and improving your sleep won't necessarily make your pain disappear. But the research is increasingly clear that sleep and pain are closely connected. Getting better-quality sleep may help your nervous system regulate pain more effectively, support physical recovery and make it easier to exercise and get on with everyday life.
So, if you're trying to improve your pain, don't just ask:
“What can I do for my back, neck, knee or shoulder?”
Also ask:
“How well am I sleeping?”
Because sometimes, an important part of getting better starts the night before.
When should you seek help?
If persistent pain or poor sleep is affecting your everyday life, a physiotherapist can help identify the factors contributing to your symptoms and develop an individualised treatment plan. If you have ongoing or significant problems with sleep, it is also important to speak with your GP or an appropriate sleep-health professional.
| See Your Physio For 💪 | See Your GP For 🩺 |
|---|---|
| Persistent pain affecting everyday life Poor sleep affecting everyday life An individualised treatment plan | Loud snoring Gasping Pauses in breathing Ongoing or significant sleep problems |
And yes, we have pillows that we can recommend to you in our clinic display!
