Relaxation and sleep

Parasympathetic (rest/digest)

Sympathetic (fight/flight/freeze)

Transcript

It is useful to have a basic understanding of the autonomic nervous system when considering sleep and relaxation.

This system automatically controls functions in your body that you don’t have to consciously think about such as breathing (how fast, how deep, which muscles to use), blood pressure (how high, how low)

The autonomic nervous system has 2 sides and can be viewed as a pair of scales:

There’s Sympathetic, or “fight/flight or freeze” branch on one side

and the Parasympathetic, rest and digest branch on the other.

Both sides are essential for survival but as with many things, having a long-term imbalance can cause problems.

The stress of living with a long-term condition can mean that the fight or flight response is continually “on” meaning that the mind and body do no fully rest and recover.

• How tensed or relaxed do you feel overall right now?
• Tension – held in various parts of the body- Where do you feel it?
• How can you relieve the stress that is held in the body?
• In the next slide there’s a short video with a muscle relaxation exercise.

Transcript

Being aware of how our bodies feel is an important part of making changes to manage stress. Take a moment to think to yourself,

On a scale of 1-10 where 1 is completely relaxed and 10 is fully wound up, think to yourself, “how am I feeling at this moment?”. There is no right or wrong answer. Please write your score in your workbook or make a mental note to yourself.

Our bodies respond to stress in various ways. You may recall from session 3, “stress” hormones are released. Another way the body responds to stress is by creating tension as it is in the fight or flight mode.

Imagine that you are about to fight someone or run away from them.

Your muscles get ready for action, they tense up.

This tension, this energy, when not released can be held in various parts of the body.

Quite often you may feel it in your neck or shoulders, some people get tension headaches – Take a moment to scan your body. Are there any places you can feel tension? If so, write them down in your workbook

There are many ways to relieve this tension or stress. On the next slide is a short video with a muscle relaxation exercise.

We’ll now watch a short video on YouTube. Note – You do not have to lie down for this activity, and you can skip any bits that cause you pain or discomfort.

After the video, consider if your overall relaxation score has changed, or if you have noticed anything else in your body. Make a note in your workbook, if so.

Try and consider how tense you are feeling in body right after this activity, compared to before. Has your score changed?

There are other ways of relaxing muscle tension – including massage, temperature and touch.

Relaxation

• Eyes closed or open
• Awareness of the present
• Conscious breath
• Requires learning and practice
• Helps to regulate autonomic nervous system
• Can be learnt using different methods to access a relaxed state

Sleep

• Eyes closed; mostly in lying
• Lose consciousness
• Unconsciously controlled breath
• Intuitive
• Needed for survival
• Not under voluntary control

Transcript

• Relaxation and sleep are both important in restoring balance to the autonomic nervous system.
• They are not the same and the quality and quantity of one can affect the other.
• The table illustrates some ways in which relaxation and sleep are different.
• Both are essential for survival – When you have a lack of sleep, you notice the impact much more quickly.
• When you don’t relax enough, it can take days, months or years to realise.
• As you can see on the slide, the last row suggests that relaxation is a skill that can be learnt, with practise, over time.
• Although sleep is not something you can easily control,
• Sleep is something you can influence
• We will go through some strategies later in the session

The autonomic nervous system consists of:

• Parasympathetic nervous system (Rest and Digest)
• Sympathetic nervous system (fight/flight/freeze)

What we do in the day, especially the evenings, can help or hinder sleep at night

Using active rest during the night if having sleep issues can help calm the system too

Transcript

Earlier we talked about the 2 branches to the autonomic nervous system:

The Sympathetic side (fight/flight/freeze) and the Parasympathetic side (rest/digest).

Both sides can not be activated at the same time.

You can’t fully rest if your system feels under threat, whether the threat is real or perceived – your brain will constantly be scanning for danger within the body and in the environment around you.

You might have heard someone say as a joke or a threat, “oooh, you’d better sleep with one eye open!” How restful would that sort of sleep be?

What you do throughout the day, especially in the evenings, can help or hinder sleep.

Using active rest during than day may enable you to lower the level of threat perceived by your brain and allow you to sleep with both eyes closed.

If you struggle to sleep at night, using active rest or relaxation strategies can help calm the system too. Even if that doesn’t lead to you falling asleep, being able to rest well is still beneficial.

Deep sleep – physical repair and immune system

REM sleep – memory processing and emotional regulation

Quality as well as quantity is important

Sleep disturbance is common in some conditions e.g. Long COVID, Fibromyalgia, ME/CFS

Transcript

This image shows a “typical” night’s sleep.

It shows how we go through cycles of sleep through the night, the different stages of sleep within each cycle; from being awake, REM, light sleep and deep sleep.

Each sleep cycle lasts around 90 minutes.

The image shows that deeper sleep tends to occur earlier in the night or sleep cycle. Deep sleep has a role in physical repair and your immune system.

Issues with this are likely to lead to you feeling unrefreshed from your sleep.

REM sleep (rapid eye movement) occurs more later in the night or early morning

REM sleep helps with processing memory and emotional regulation, therefore

Issues with this phase can lead you to experience “brain fog” and emotional challenges.

So good sleep is not just about how much sleep you get, but also about the quality of sleep, and the stages of sleep.

Unfortunately, Sleep disturbance is common in some health conditions like Long COVID, Fibromyalgia, ME/CFS. It is still not known exactly why, however it may be linked to the fight or flight response staying active.

• Our body’s internal clock
• Roughly 24-hour cycle
• Governs essential bodily functions
• Impacted by light and darkness

Transcript

It is also helpful to be aware of something called the circadian rhythm.

This is our internal body clock that runs roughly on a 24-hour cycle.

It syncs internal processes with the day and night cycle and helps govern essential bodily functions, especially the sleep-wake cycle. Cues to it being time for alertness or sleepiness are strongly affected by light. Other things governed by the circadian rhythm include: Core body temperature, The immune system, metabolism, hormone release, etc.

For example, hormones such as Cortisol and adrenaline are naturally higher in the morning and when we wake up, so that we are alert and ready for action.

Melatonin is released when it gets dark, signalling it is time for sleep.

Individuals do have some differences in their body clocks of when they naturally want to sleep and this can also change as you age.

In “modern” society, constantly being in brightly lit environments or in front of screens can delay the release of melatonin and affect the ability to sleep.

The next slide will take us through some common strategies advised to help better sleep.

Strategies to promote good sleep

• Routines
• Exposure to natural light
• Physical activity
• Review medications and supplements
• Limit screen time
• Build in time to unwind
• Do what you find relaxing, not stimulating
• Keep the bed for sleeping, intimacy and relaxing

Transcript

Here is a check-list of things to consider that can help or hinder good sleep, commonly known as “sleep hygiene”.

For some people, making changes to these fundamental things can make a significant difference to their sleep. Many of you will have come across these before, but sometimes it is worth getting back to basics. For those of you who have children, especially younger children, or anyone who has ever been a child, some of these may be familiar – if you think of getting a toddler to sleep, you would tend to get them to brush their teeth fairly early and change into pyjamas, put the bedside lamp on, read them a bedtime story or sing them a lullaby…

As with sleep-training a child, maintaining a consistent routine is key – your body responds well to familiar patterns of sleep, activity, meals. Speak to your clinician if you are struggling to build or maintain a routine.

Exposure to natural light – Sleep hygiene strategies often focus on your evening routine, however what you do in the morning can be just as important.

Exposure to natural light early in the day helps to regulate your circadian rhythm, as little as 10-15 minutes can be effective. If you struggle to get outdoors, you may be able to achieve the same effect by looking out of a window. Some people find light boxes/SAD lamps helpful in darker months.

Physical activity – It is beneficial to have some physical activity during the day – this does not mean that you have to get kitted up and go to the gym or go out for a run. Even gentle movement can help to dispel some of the energy that may be stored up if your feeling stressed. Exercise can also release endorphins which help you to feel good. It is important to consider what type of activity and what time you do the activity.

Doing something strenuous close to bedtime can leave you overstimulated and unable to sleep. Overdoing activities can leave you in pain or feeling physically uncomfortable, preventing you from sleeping.

Medications – some medications can disturb sleep or can increase lethargy during the day. Sleeping tablets may be helpful in the short term, however the type of sleep experienced is more like sedation than true sleep.

A medication review is advised if you are having sleep problems and take medication. Always let the GP/clinician know what supplements or herbal remedies you are taking as they can impact on sleep too.

Screen time – blue light emitted from screens including TVs and mobile phones can block melatonin, the sleep hormone.

Try to avoid screen time for at least an hour before bed and consider leaving your tablet/mobile phone in another room.

Time to unwind – Put aside the concerns of the day before bedtime as best you can. Build in a buffer time between when you finish for the day and when you go to bed. Consider brushing your teeth and changing into nightwear before you settle in front of the telly. This way, if you start nodding off, you are less likely to accidentally wake yourself up by the brightness of the bathroom light or the cold water hitting your mouth.

If you can’t fall asleep, try to do something relaxing or calming, not stimulating, rather than remaining awake in bed. Get out of bed and go to another room that’s dimly lit.

Read a book – no screens/ phones and when you’re sleepy return to bed, Try meditating or breathing exercises.

Maintain positive associations with your bed if possible – Keep the bed for sleeping, intimacy and relaxing

• Noise
• Light
• Smells
• Temperature
• Mattress and bedding

Transcript

Try to create a good environment for sleep where possible – factors include

Noise levels –

If you live by a busy road, have noisy neighbours or a snoring sweetheart, wearing ear plugs may help. Some people find having white, pink or other colour noises helpful to play in the background, others like the sound of rain, listening to a non-stimulating podcast or audio book

Light – we have already mentioned avoiding screens and blue light before bed. You might also consider switching from using overhead lights to use lower-level lighting or lamps in the evening, where possible and if safe to do so. This mimics the level at which the light comes from as the sun goes down. Some people find wearing an eye-mask or having black-out curtains helpful. You can even buy eyemasks with inbuilt blue-tooth headphones so you can block out light and listen to sounds without disturbing your partner.

Some people may find certain smells or fragrances help them to relax and sleep. Lavender is a commonly associated with relaxation and sleep.

Temperature – your body temperature tends to drop ready for sleep.

Having a warm shower or bath in the evening can help with this.

Some people find a slightly cooler room easier to sleep in.

If you feel the cold a lot, consider a hot water bottle or wheat bag. Some people opt for electric blankets. Weighted blankets can also provide a sense of security as well as adding warmth– just make sure you go for the recommended weight for you.

Nightwear and bedding are also important to consider in achieving comfortable sleep temperature for you. This includes the type of material as some synthetic materials may cause you to sweat more. If your temperature fluctuates during the night, consider layering blankets so you can add or remove easily if you start to get too hot or too cold.

The type of mattress is important – is it too firm? Too soft? Do you need an Orthopaedic or Memory foam mattress? How may pillows you use and how they are positioned can also help or hinder. Please note down anything you wish to discuss with your clinician.

• Cut down on caffeine, alcohol, nicotine
• Good hydration but reduce before bedtime
• Healthy, varied, balanced diet including sugar levels
• Don’t go to bed hungry but avoid heavy, rich foods before bed

Transcript

Diet and Nutrition can have a significant impact on sleep.

Although it is important to stay adequately hydrated, some people are often woken up by their bladders through the night. If this affects you, try “front-loading” your fluids – more fluids earlier in the day and sips in the evening

Caffeine interferes with the process of falling asleep by reducing our sleep drive. It also prevents deep sleep. Try avoiding caffeine in the afternoon or consider switching to decaf

Alcohol may help you to fall asleep initially, but is likely to disrupt your sleep later on in the night. Try not to have alcohol within 3 hours of bedtime.

Instead, consider having a warm, milky drink or herbal tea in the evening.

Too much food or alcohol, especially late at night, can interrupt your sleep patterns. Avoid having a rich or heavy meal close to bedtime as your body has to work harder to digest this through the night and is less able to rest. Improving sleep can improve abdominal symptoms.

• Insufficient sleep (less than 6 hours a night) has been linked with obesity for many reasons.
• Food intake is increased when sleep is restricted
• Dietary changes to help manage weight are more likely to be effective with a good sleep routine.

Transcript

There is a lack of evidence about specific foods that are good for sleep.  However, eating a well-balanced diet during the day can help contribute to a good night’s sleep. Try to include food from all the food groups every day and reduce your intake of foods high in sugar and saturated fats

Feeling hungry or thirsty at bedtime can distract you from falling asleep and can wake you up during the night.

Research has found that food intake is increased when sleep is restricted.

Feeling “Tired but wired”

Tiredness vs. Sleepiness

Hyperarousal and circadian rhythms: both can affect the other

Transcript

Here we will take a brief look at hyperarousal. This is when your autonomic nervous system is extremely active, the fight-flight response goes into over-drive. When we are aroused, our body releases hormones and chemicals like adrenaline and cortisol. This may be a negative reaction like cortisol being released when we are stressed. It can also be a positive reaction, like adrenaline from doing something exciting. Both of these are important and useful under the right circumstances but are not conducive to sleep.

You may experience feeling “tired but wired”, feeling exhausted yet unable to sleep – like you’re too switched on (busy brain, racing thoughts, feeling restless). Feeling tired is different from feeling sleepy and it is important to recognise the difference between the two. It is usually straightforward to fall asleep if we are both tired and sleepy. However, when we feel tired but not sleepy, trying to force ourselves to fall asleep can leave us feeling more stressed and frustrated, making matters worse.

Being “wired” during the day can be hard to come down from in time for bed and sleep. Doing things you find calming, enjoyable, soothing, encourages the release of more helpful hormones and chemicals. One approach is using active rest, which we will consider in the next slide.

• Actively doing something to aid rest, relaxation and restoration.
• Topping up your battery, and calming your nervous system
• Not the same as sleep
• Not the same as doing nothing
• Active rest is key to help managing fatigue, brain fog, stress and other symptoms

Transcript

Living with constant pain and fatigue or dealing with the uncertainty of fluctuating symptoms can often result in chronic stress. Resetting the autonomic system scales may seem impossible. If you feel unable to reduce anything from the fight or flight side, it may be possible to add to the rest and digest side through active rest.

SO what is ACTIVE rest? How can you be active and resting at the same time??

Active rest is actively doing something to aid rest, relaxation, restoration. It’s individual to you. Examples of active rest may include being in nature, mindfulness, candle-gazing, relaxing music, doodling, etc. Please look in your workbook for further ideas, or speak with your clinician.

As mentioned near the start of the session, rest or relaxation is not the same as sleep

Active rest is not “Doing nothing”. Simply not doing anything does not actively boost your parasympathetic nervous system and it doesn’t top up your “battery”.

Active rest is not necessarily the same as doing something you enjoy as that takes up energy. That being said, it is still important incorporate some things we enjoy. Sometimes we have to weigh up how much enjoyment or energy we get out of an activity vs how much pain or fatigue we may feel as a result. Then we can decide if that activity is “worth it”.

Active rest is key to managing fatigue, brain fog, stress and some other symptoms

• I can’t fall asleep
• Snoring!!
• I’m in pain!
• I’m too hot
• I’m too cold
• I can’t stay asleep
• I need the loo!

Transcript

This list shows some Common sleep issues reported to us by patients.

Have a think if any of these apply to you or write down any other sleep issues affecting you.

Go back through the sleep hygiene check-list, advice on environmental considerations and diet. Would any of those help in these situations?

E.g. – I’m in pain – reviewing pain medication, using a heat pad, changing your mattress or using pillows and bolster cushions may help.

When applying sleep strategies, it is important to try them consistently for an adequate amount of time. Try not to give up after if you don’t get immediate results. However, if you find any of the strategies increases your insomnia or anxiety around sleep, stop and talk to your clinician or GP.

For some people, their sleep issues continue even with good sleep hygiene measures in place. Sleep itself can become a worry, making matters worse. Further support for this may be needed which can be discussed with your clinician after the course.

• Sleepiness during waking hours that is hard to resist
• Microsleeps
• Difficulty breathing/gasping for air
• Excessive snoring
• Recurrent nightmares
• Other conditions, including mental health conditions or concerns

Transcript

You should talk to your clinician or doctor if you notice that insomnia lasts more than a few nights and/or if it starts to affect your daily routine, tasks and activities. You should also talk to them if you notice the following:

Sleepiness during your waking hours that’s hard to resist.

Brief instances where you fall asleep during waking hours (these are known as microsleeps), especially if they happen while you’re working or driving.

If you have other conditions, including mental health conditions or concerns, that affect how much or how well you sleep. This could be difficulty breathing, recurrent nightmares, or other things.

Finally, Here are some links to useful online information and resources which you may wish to explore.

Sleep problems/mental wellbeing – https://www.nhs.uk/mental-health/self-help/guides-tools-and-activities/mental-wellbeing-audio-guides/

Pain good sleep guide- https://www.northerncarealliance.nhs.uk/patient-information/patient-leaflets/pain-service-good-sleep-guide

Pain service/relaxation- https://www.northerncarealliance.nhs.uk/patient-information/patient-leaflets/pain-service-relaxation-what-it-and-why-it-important

Sleep better sleep guide- https://www.sleepschool.org/

Hyperarousal- https://sleephub.com.au/what-is-hyperarousal/

https://my.clevelandclinic.org/health/symptoms/hyperarousal

Occupational Therapy sleep advice https://www.rcot.co.uk/learn-about-occupational-therapy/ot-advice/lift-up/sleep