Why Better Sleep May Be Part of Your Pain Treatment
If you have ever had a poor night's sleep and noticed that your neck, back, shoulder, or joints felt worse the next day, you may not have imagined it.
Pain can make it difficult to sleep. But increasingly, research suggests the relationship also works in the other direction: poor sleep may influence how we experience pain and, over time, may be associated with the development or persistence of musculoskeletal pain.
In other words, your pain and your sleep may be talking to each other.
The Relationship Goes Both Ways
It is easy to understand how pain disrupts sleep.
A sore shoulder makes it difficult to find a comfortable position. Back pain wakes you when you roll over. Neck pain makes the pillow uncomfortable. You wake several times during the night and feel exhausted the following morning.
But the other side of the relationship is particularly interesting.
A 2024 systematic review and meta-analysis examined prospective studies involving 116,746 adults. The researchers found that people experiencing sleep problems were more likely to develop chronic musculoskeletal pain later on. Sleep problems were associated with an increased risk of chronic musculoskeletal pain in both the short and long term.
The researchers also found evidence in the opposite direction: having chronic musculoskeletal pain may increase the likelihood of subsequently developing sleep problems.
This doesn't mean poor sleep inevitably causes chronic pain, or that simply sleeping more will make pain disappear. Pain is much more complex than that.
What it does suggest is that sleep may be one meaningful part of the bigger picture.
Why Can a Bad Night Make Pain Feel Worse?
Think about how different your body feels after a genuinely restorative night's sleep compared with a night of repeatedly waking up.
Sleep is an active biological process. During sleep, multiple systems involved in recovery, immune function, learning, emotional regulation, and nervous-system function are active.
When sleep becomes consistently disrupted, our ability to regulate and tolerate sensory input may also change. Pain can feel more intense, recovery can feel harder, and everyday physical demands may become less tolerable.
There is even evidence that this relationship can occur from one day to the next.
A recent systematic review examining day-to-day relationships between sleep and chronic musculoskeletal pain found a bidirectional relationship: pain can affect that night's sleep, while sleep can influence pain the following day. Interestingly, sleep quality appeared to be a more consistent predictor of next-day pain than pain was of the following night's sleep.
That is an important shift in perspective.
Instead of always asking:
“Is my pain preventing me from sleeping?”
It may sometimes be useful to also ask:
“Could my sleep be influencing how my body is handling pain?”
The Pain–Sleep Cycle
For some people, a frustrating cycle can develop:
Pain makes sleeping difficult.
Poor sleep increases fatigue and may increase pain sensitivity.
The next day, movement and exercise feel harder.
Activity decreases.
Stress and frustration increase.
The following night's sleep may become difficult again.
Over time, these factors can begin reinforcing one another.
This is one reason persistent pain treatment sometimes needs to look beyond only the painful body part.
If someone has persistent shoulder pain, for example, assessing shoulder strength, mobility, movement, and loading remains important. But if that person is also sleeping four or five fragmented hours each night, that information matters too.
The same principle can apply to persistent neck pain, low-back pain, arthritis, headaches, TMJ disorders, and other pain conditions.
Does Improving Sleep Improve Pain?
This is where we need to be careful with the evidence.
Improving sleep is worthwhile, but we shouldn't promise that better sleep will automatically eliminate pain.
Research examining cognitive behavioural therapy for insomnia (CBT-I), for example, shows strong evidence that it can improve insomnia in people who also have chronic musculoskeletal pain. However, a 2024 systematic review found that although CBT-I substantially improved insomnia, its effect on pain intensity itself was not statistically significant.
Other reviews have found small improvements in pain alongside meaningful improvements in sleep.
So the most accurate message isn't:
“Fix your sleep and your pain will go away.”
It is:
“If sleep is a problem, treating it may remove one of the factors making recovery more difficult.”
That distinction matters.
Sleep Shouldn't Replace Rehabilitation
For most musculoskeletal conditions, improving sleep doesn't replace appropriate rehabilitation.
Depending on the person and condition, treatment may still involve:
progressive exercise and strengthening
restoring mobility
gradually increasing activity and load tolerance
education and self-management strategies
modifying aggravating activities
addressing work or ergonomic demands
managing stress and recovery
appropriate medical investigation when indicated
Sleep can sit alongside these strategies.
We increasingly think about recovery as more than treating one muscle, joint, tendon, or disc in isolation. The physical problem matters, but so does the environment in which that tissue and nervous system are trying to recover.
Start by Asking Better Questions
You don't need a perfect sleep routine.
Instead, if you're dealing with persistent pain, start by paying attention.
Are you getting enough opportunity to sleep?
Do you regularly wake because of pain?
Do you struggle to fall asleep even when you are exhausted?
Do you wake feeling unrefreshed?
Does your pain consistently feel worse after poor sleep?
Are stress, work schedules, caffeine, screen habits, medications, or your sleeping position interfering with sleep?
And importantly, has your sleep problem become persistent enough that it deserves treatment of its own?
Sometimes changing a pillow or sleeping position helps. Sometimes pain needs to be better managed so sleep can improve. And for persistent insomnia, simply being told to practise “sleep hygiene” may not be enough. Structured treatments such as CBT-I have substantially stronger evidence and may be worth discussing with an appropriate healthcare provider.
Recovery Is Bigger Than the Painful Area
One of the most useful changes in modern rehabilitation is recognizing that good treatment doesn't have to choose between treating the body and looking at the person as a whole.
We can do both.
If your knee hurts, we should assess your knee.
If your neck hurts, we should assess your neck.
But if persistent pain is occurring alongside poor sleep, high stress, reduced activity, fatigue, or difficulty recovering between demanding days, those factors deserve attention as well.
Your sleep may not be the reason you hurt.
Your pain may not be the only reason you're sleeping poorly.
But when one is struggling, the other may be worth asking about.
Sometimes helping recovery means looking beyond where it hurts.
References
Runge, N., Ahmed, I., Saueressig, T., Perea, J., Labie, C., Mairesse, O., Nijs, J., Malfliet, A., Verschueren, S., Van Assche, D., de Vlam, K., Van Waeyenberg, T., Van Haute, J., & De Baets, L. (2024). The bidirectional relationship between sleep problems and chronic musculoskeletal pain: A systematic review with meta-analysis. Pain, 165(11), 2455–2467.
Sun, Y., Laksono, I., Selvanathan, J., Saripella, A., Nagappa, M., Pham, C., Englesakis, M., Peng, P. W. H., Morin, C. M., Chung, F., & Wong, J. (2023). Comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain: A systematic review with network meta-analysis. Sleep Medicine Reviews, 73, 101867.
Salazar-Méndez, J., Viscay-Sanhueza, N., Pinto-Vera, C., Oyarce-Contreras, F., Parra-Vera, M.-F., Suso-Martí, L., Guzmán-Muñoz, E., López-Bueno, R., Núñez-Cortés, R., & Calatayud, J. (2024). Cognitive behavioral therapy for insomnia in people with chronic musculoskeletal pain: A systematic review and dose-response meta-analysis. Sleep, 122, 20–26.
