Q&A Time: Why is Pain Worse at Night?

how true is this pic?

I saw the above picture a while back on social media, and thought it was really clever. Lately, enough patients, a few emails from clinicians and my own experience has made me think differently about what night means to a sensitive nervous system.

Think about pain and CNS vigilance, the hyper vigilant nervous system tends to be both peripherally and centrally sensitive. In other words, activities, movements, and prolonged positions tend to be inputs that add up to the summation of perceived threat. We have all seen patients that have trouble sleeping on their painful side shoulder or hip, yet obviously this is not dangerous, it's just the sensation of pressure or sidelying WB is now allodynia instead of relaxing.

Back to the above picture, you step on a lego during the day, it certainly may be uncomfortable, but your nervous system is filtering out all kinds of extraneous stimuli, sounds, colors, and other inputs/sensations. We are constantly being bombarded by stimuli, and it is being filtered under our conscious perception. That same lego at night may feel like stepping on a nail or being bitten by a rat.

Does your house really only creak at night?

At night however, the creaks and groans of a quiet house come out. Ever wonder why? Perhaps we are not so distracted by the day's schedule, our daily stresses, and the normal hustle and bustle of a commute.

I have known for a while that the low level tinnitus in my right ear, normally a 0-2/10 at most during the day is normally around a 7-8/10 at night. I tend to sleep with white noise to "drown" it out. Lately, I have noticed that my hands, which sometimes have eczema, are, to sound like a patient "a bajillion times" more itchy at night. Is this because my sheets have some sort of allergen? Or is my CNS now more acutely aware of mild skin irritation, but there is no more imminent threat or less noise to filter out?

For patients in pain, perhaps not only the constant mild pressure on a threatened area, but it's the lack of "other things to do" or be aware of that really flares up the pain at night. Next time the typical night roll and change of positions do not work for patients with night pain, try some pain science education, or have them watch a movie in bed or listen to their favorite album. See if it makes a difference.

PS. Bonus tip for Android users - use a blue light blocker like screen filter of you're watching on a phone/tablet at night so sleep quality is not affected! Sorry iOS users (unless you jailbreak).

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...