Living a Healthy Life with Chronic Pain (9 page)

Chronic pain can drain your energy, making Spouses, family members, and friends some-fatigue a very real problem for people who expe-times do not understand the unpredictable way rience chronic pain. Fatigue, not just pain, can in which the fatigue associated with your condikeep you from doing things you’d like to do. tion can affect you. They may think that you are Unfortunately, fatigue is often misunderstood just not interested in certain activities or that by people who do not live with chronic pain. you just want to be alone. Sometimes you may After all, others cannot usually see your fatigue. not even know why you feel so tired.

To manage fatigue, it is important to understand that your fatigue may be related to several factors, including the following:

• Chronic pain itself.
  When a chronic pain condition or other illness is present, the body uses energy less efficiently. This is because the energy that could be consumed by everyday activities is instead being redirected to the parts of your body affected by your condition. Therefore, your brain may release chemical signals to conserve energy and make you rest more. Also some chronic conditions are associated with anemia (low blood hemoglobin), which can contribute to fatigue.
  

• Inactivity.
  Muscles that are not used regularly become deconditioned, lose strength, and are less efficient at doing what they are supposed to do. This can happen to all the muscles in our body, including the heart, which is made of muscle tissue. When the heart becomes deconditioned, its ability to pump blood is decreased. Your blood carries necessary nutrients and oxygen to other parts of the body. When muscles do not receive these nutrients and oxygen, they cannot function properly. Deconditioned muscles tire more easily than muscles in good condition.
  

• Poor nutrition.
  Food is our basic source of energy. If we eat poor-quality food, eat too much food, or improperly digest food, fatigue can result. Chronic pain can cause a change in appetite. Some people overeat and gain weight. Extra weight causes fatigue by increasing the energy we need to perform daily activities. Other people lose their appetites. Eating too little, being underweight, or eating the wrong kinds of food can cause muscle tissue to break down. Less muscle means less strength and less energy. This leads to fatigue.
  

• Not enough rest.
  Some people with chronic pain overdo activity and do not balance activity with rest. Others suffer from lack of sleep or poor-quality sleep. Either situation can result in fatigue. We discuss how to manage sleep problems in more detail later in this chapter, and we review ways to balance activity and rest in
  Chapter 6
  .
  

• Emotions.
  Anxiety, fear, boredom, and depression can all cause fatigue. It can be exhausting to deal with the ongoing stresses that can accompany chronic pain. Being bored and not having enough to occupy your mind can also lead to fatigue. Most people are aware of the connection between stress and feeling tired, but fewer are aware that fatigue is a major symptom of depression.
  

• Medications.
  Some medications, including those you may be taking for your pain, can cause fatigue. If you think your fatigue is related to your medication, talk to your doctor. Sometimes medications or dosages can be changed.
  

If fatigue is a problem, start by trying to determine the cause. Again, a journal may be helpful. Consider the possible causes of fatigue that are within your control to improve. Are you eating healthy foods? Are you exercising? Are you pacing your activities with rest periods? Are you getting enough good-quality sleep? Are you effectively managing stress? If you answer no to any of these questions, you may have found one or more of the reasons for your fatigue.

The important thing to remember is that your fatigue may be caused by things
other than your pain
. Therefore, to combat and prevent fatigue, you must address all the possible causes. This may mean trying a variety of self-management tools.

If your fatigue is the result of not eating well, such as eating too much junk food or drinking too much alcohol, then the solution is to eat better-quality foods in the proper quantities or to drink less alcohol. For some, the problem may be a decreased interest in food, leading to decreased food consumption and weight loss.
Chapter 13
discusses some of the problems associated with eating and provides tips for healthy eating.

People often say they can’t exercise because they feel fatigued. This misconception creates a vicious cycle: they are fatigued because of a lack of exercise, and they don’t exercise because of the fatigue. Believe it or not, motivating yourself to exercise and be more physically active might be the answer. You don’t have to run a marathon; just get outdoors and take a short walk. If that is not possible, walk around your house or try some gentle exercises like the Moving Easy Program in
Chapter 8
. See
Chapters 7
and
9
for more information about starting an exercise program.

If emotions are causing your fatigue, rest will probably not help. In fact, it may make you feel worse, especially if your fatigue results from depression. We talk about how to deal with depression later in this chapter on
pages 57
–
63
. If you feel that your fatigue may be related to stress, read the section on managing stress on
pages 65
–
69
.

Sleep problems are common for people with chronic pain. Two out of every three people with chronic pain, and almost everyone with fibromyalgia, report poor-quality sleep. They may have trouble falling asleep, wake too early and can’t get back to sleep, wake up frequently in the night, or wake up feeling tired and achy. Sleep and pain experts think that the neurochemicals that are low in people with chronic pain are critical for regulating sleep and mood. That may be one of the reasons why chronic pain, poor sleep, and depression often go together. The problem of sleep and pain is even more complicated because some prescribed pain medicines, such as morphine or codeine, can also fragment sleep.

Sleep is a basic human need, like food and water. Good-quality sleep makes you feel refreshed, rested, and reenergized, ready to face the day. When you sleep, the body heals and repairs your muscles and tissues and provides energy to your vital organs, including the brain. Sleep may also play an important role in regulating appetite. When we do not get enough good-quality sleep, we may experience a variety of symptoms. These include fatigue, inability to concentrate, irritability, increased pain, and weight gain. Of course, this does not mean that all these symptoms are always caused by a lack of sleep. Remember, the symptoms associated with chronic pain can have many causes.

Nevertheless, improving the quality of your sleep can help you manage many of these symptoms, regardless of their cause. In fact, because sleep is so important, sleep and pain experts suggest that
improving sleep quality should be a major goal of all chronic pain treatment
.

How much sleep do you need? The amount varies from person to person. Most people do best with about 7½ hours. Some feel refreshed with just 6, while others need 8 to 10 hours to function well. If you are alert, feel rested, and function well during the day, chances are you’re getting enough sleep. But if you get less good sleep than you require night after night, your mood and quality of life will suffer.

Improving your sleep habits is one of the key steps you can take to help manage your pain. The self-management techniques we offer here are clinically proven to improve sleep quality for most people. They are not quick fixes like sleep medications, but they’ll give you more effective (and safer) results in the long run. Allow yourself at least two to four weeks to see some positive results and 10 to 12 weeks for long-term improvement.

• Get a comfortable bed.
  Your bed should allow for ease of movement and provide good body support. This usually means a good-quality, firm mattress that supports the spine and does not allow the body to sink in the middle of the bed. A bed board made of 1/2- to 3/4-inch (1 to 2 cm) plywood can be placed between the mattress and the box spring to increase firmness. Heated waterbeds, air beds, or foam mattresses are helpful for some people with chronic pain because they support weight evenly by conforming to the body’s shape. If you are interested in one of these options, try one out at a friend’s home or a hotel for a few nights to decide if it is right for you. An electric blanket or mattress pad, set on low heat, or a wool mattress pad are also effective at providing heat while you sleep. If you decide to use electric bedding, be sure to follow the instructions carefully to prevent burns.
  

• Keep your hands and feet
  warm
  with gloves or socks.
  For painful knees, it may help to cut the toes off warm stockings and wear the cut sock as sleeves over your knees.
  

• Find a comfortable sleeping position.
  The best position depends on you and your condition. Sometimes small pillows placed in the right places can relieve pain and discomfort. Experiment with different positions and pillow placement. Also check with your health care provider for specific recommendations given your condition. One caution: do not prop your head up on a mountain of pillows. This will aggravate a neck or back problem.
  

• Elevate the head of the bed 4 to 6 inches (10 to 15 cm).
  Do this if you have a problem with breathing, heartburn, or gastric reflux. You can prop sturdy wooden blocks under the bed legs or purchase an adjustable bed to raise your head during sleep.
  

• Keep the room at a comfortable temperature.
  This may be warm or cool. Each of us requires different conditions to sleep better.
  

• Use a vaporizer if you live where the air is dry.
  Warm, moist air often makes breathing and sleeping easier. If you prefer cool air at night, use a humidifier.
  

• Make your bedroom safe and comfortable.
  Keep a lamp and telephone by your bed, within easy reach. Get rid of scatter rugs by your bed that may be a hazard and cause you to trip and fall. If you use a cane, keep it by the bed where you can reach it easily and use it when you get up during the night.
  

• Keep eyeglasses by the bed.
  This way if you need to get up in the middle of the night, you can easily put on your glasses and see where you are going!
  

• Do not eat before bedtime.
  You may feel sleepy after eating a big meal, but overeating is not an appropriate route to falling asleep quickly and getting a good night’s sleep. Sleep affords your body time to rest and recover. When it is busy digesting food, the body redirects valuable time and attention from the healing process. If you find that going to sleep feeling hungry keeps you awake, try drinking a glass of warm milk at bedtime.
  

• Avoid alcohol.
  You may think alcohol helps you sleep better because it makes you feel relaxed and sleepy, but in fact, alcohol disrupts the sleep cycle. Alcohol consumption in the evening can lead to shallow sleep and frequent awakenings throughout the night.
  

• Avoid or limit caffeine.
  Caffeine is a stimulant, and it can keep you awake. Coffee, tea, colas and other sodas, and chocolate all contain caffeine. If you drink caffeinated beverages, drink them early in the day. If you have significant sleep problems, eliminate caffeine altogether to see if this has a positive effect on your sleep. If you have been a regular caffeine user, don’t stop caffeine suddenly. This can cause withdrawal symptoms such as headaches and the jitters. Instead, keep a log for a couple of days that tracks the number of caffeinated drinks you have each day. Gradually reduce the number of drinks you have each day by switching to noncaffeinated beverages as much as possible.
  

• Stop smoking.
  Aside from the fact that smoking can cause complications for your chronic pain, falling asleep with a lit cigarette can be a fire hazard. Furthermore, the nicotine contained in cigarettes is a stimulant. Like caffeine, it impacts sleep. Quitting smoking may not be easy, but doing so will be a huge step forward in managing your chronic pain condition. For help to stop smoking, talk to your doctor or contact your local public health department or lung association.
  

• Do not take diet pills.
  Diet pills often contain stimulants, which may interfere with falling asleep and staying asleep.
  

• Do not take sleeping medication.
  Although sleeping pills may seem like the perfect solution for sleep problems, they are not a viable long-term answer. For one thing, sleeping medications tend to become less effective over time. Also, many sleeping pills have a rebound effect—that is, if you stop taking them, it is even more difficult to get to sleep or stay asleep than it was before you began
  taking them. Sometimes your doctor may recommend a short course of sleeping pills (a few weeks at most) together with improving your sleep practices, such as limiting your time in bed and using your bedroom only for sleep and sex and nothing else. (See the
  How to develop a routine
  list below.) This combination of short-use medication and sleep-friendly practices may be helpful for people with chronic pain who have significant sleep problems. Sleep specialists agree that these sorts of approaches, instead of sleeping pills, offer the best long-term solution to poor sleep. Other types of medicines prescribed for your chronic pain may also improve sleep (see
  Chapter 16
  ).
  

• Do not use or watch any blue-light emitting devices such as computers, TVs, tablets, cellphones, or some e-readers for about an hour before you go to bed.
  The light from these devices can disrupt your natural sleep rhythms.
  

• Avoid diuretics (water pills) before bedtime.
  If you are on diuretics, take them in the morning so your sleep is not interrupted by frequent trips to the bathroom. Unless your doctor has recommended otherwise, don’t reduce the overall amount of fluids you drink, as fluids are important for your health. However, you may want to limit the amount you drink right before you go to bed.
  

• Maintain a regular rest and sleep schedule.
  Go to bed at the same time every night and get up at the same time every morning. Even though you may feel tired on some mornings, getting up at the same time each day helps your body maintain its natural sleep cycle. If you wish to take a brief nap, take one in the afternoon but only for 10 to 20 minutes, no more. Do not take a nap in the evening after dinner. Stay awake until you are ready to go to bed.
  

• Reset your sleep clock when necessary.
  If your sleep schedule gets off track (for example, you go to bed at 4:00 a.m. and sleep until noon one day), you need to reset your internal sleep clock. To do so, try going to bed an hour earlier (or later) each day until you reach the hour you want to go to sleep.
  

• Exercise at regular times each day.
  Not only does exercise help you sleep more soundly, it also helps establish a regular pattern for your day. However, avoid vigorous exercise in the evening before bedtime.
  

• Get out in the sun every morning.
  Exposure to sunlight is important, even if it is only for 15 or 20 minutes. A regular dose of morning sun helps regularize your body clock and rhythms.
  

• Practice relaxation techniques at regular times each day.
  This doesn’t have to be complicated. Even 10 minutes of deep belly breathing can help. Just like regular exercise, this establishes a regular pattern to your day, and quiets your nervous system. To learn more about techniques that can help you relax as you prepare for sleep, see
  Chapter 5
  .
  

• Do the same things every night before going to bed.
  This can be anything from listening to calm music on the radio to reading
  a chapter of a book to taking a warm bath. By developing and sticking to a “get ready for bed” routine, you are letting your body know that it’s time to start winding down and relax.
  

• Use your bedroom only for sleeping and sex.
  If you have had pain for some time, you may have begun to use your bedroom for activities other than sleep. Awake activities such as watching TV or balancing your checkbook keep you alert. When you do these activities in your bed, being in bed becomes a signal for your body to be alert. So you cannot relax and fall asleep. If you carry out these activities in bed because you are in pain and need to recline, move to another room where you can relax comfortably and do all your awake activities there instead. Reserve your bedroom for sleep and sex only! If you find that you get into bed and you can’t fall asleep, get out of bed and go into another room until you begin to feel sleepy again. Keep the lighting low when you are awake at night no matter what room you are in—bright lights signal to your body that it is time to be up and about.
  

Many people can get to sleep without a problem but then they wake up with the “early morning worries” and can’t turn off their minds. This becomes a vicious circle, if they become even more worried because they cannot go back to sleep once they have awakened.

Keeping your mind occupied with pleasurable or interesting thoughts wards off the worries and helps you get back to sleep. For example, try a distraction technique to quiet your mind such as counting backward from 100 by threes or naming a flower or sports team for every letter of the alphabet. The relaxation techniques described in
Chapter 5
may also be helpful. If you still can’t fall sleep, get up, leave your bedroom, and do something—read a book, wash your hair, or play a game of solitaire (not on the computer). After 15 or 20 minutes, go back to your bedroom and go back to bed.

It can also help to set a “worry time.” Does a racing mind regularly keep you awake? If it does, designate a regular time well before bedtime during which you write down your problems and concerns, and then make a to-do list. You can relax and sleep well at night, knowing that you have some ideas to address your concerns. You may not solve your worries right away, but there will always be tomorrow’s worry time to come up with new ideas for your to-do list.

If you are tired when you wake up in the morning, even after a full night’s sleep, you may have a sleep disorder. People who have the most common sleep disorder, obstructive sleep apnea, often do not know it. When they are asked about their sleep, they respond, “I sleep just fine.” Sometimes the only clue is that others complain about their loud snoring. Sleep specialists believe that obstructive sleep apnea is very common and alarmingly under-diagnosed.

When people have sleep apnea, the soft tissue in the throat or nose relaxes during sleep and blocks the airway. This makes breathing an extreme effort. The person struggles against the blockage for up to a minute, wakes just long enough to gasp air, then falls back to sleep
to start the cycle all over again. The person is rarely aware that he or she has awakened dozens of times during the night. This, in turn, leads to symptoms such as fatigue and pain, because the body does not get the deep sleep needed to restore energy and help with the healing process.