Sleep, pain & your body after service

Feeling on alert and anxious can make you more aware of sensations in your body, like pain or a racing heart. When pain came from the same event as a trauma, it can also be a reminder of what happened.

Nightmares, restlessness and discomfort can all break up sleep. That leaves you more tired and less able to cope with pain and stress the next day.

Avoiding trauma reminders and avoiding pain can both mean less time with people and less activity. Over time, that can lower your mood and make life smaller.

1. Pick one area: sleep, movement, or getting a check-up.
2. Choose one small step for this week.
3. Track it in the “My sleep & pain diary” worksheet.
4. Tell all your providers that you have both pain and stress or PTSD, so they can work together.

• Aim for at least seven hours of sleep, regularly
• Avoid caffeine, nicotine and energy drinks within six hours of bedtime
• Exercise regularly, finishing about two hours before bed
• Get natural light every morning
• Skip naps within seven hours of bedtime

• Avoid alcohol within two hours of bed
• Don’t go to bed while you are feeling strong anger, fear or worry
• Go to bed only when you feel sleepy
• Keep your room cool, dark and quiet
• Keep phones and TV out of bed

1. If you can’t fall asleep in what feels like 15–20 minutes, get out of bed.
2. Do something quiet and calm in low light.
3. Go back to bed when you feel sleepy.
4. If you still can’t sleep after another 20 minutes, repeat.

Keeping your bed for sleep and intimacy only helps your brain link bed with rest again.

Relaxation and mindfulness can lower stress before sleep. Free DoD and VA apps, like Mindfulness Coach, Breathe2Relax and Tactical Breather, guide you through breathing and mindfulness exercises.

• Loud snoring most nights
• A partner notices you stop breathing or gasp in your sleep
• Waking up tired, even after a full night
• Feeling very sleepy during the day

VA has expanded home sleep apnea testing and telehealth sleep care, including for veterans in rural areas. Ask your VA primary care provider about a sleep check.

VA’s free online Path to Better Sleep program includes a 5-minute Sleep Check-up questionnaire, and a section called BreatheEZ with videos and fact sheets on sleep apnea.

Research suggests that for people with both PTSD and sleep apnea, using a CPAP breathing machine may also help PTSD treatment work better.

CBT-I can be done in person, by video, or through online programs. Ask your VA provider or Vet Center whether CBT-I is right for you.

• BreatheEZ: information on sleep apnea
• Sleep 101: spot habits that get in the way of sleep
• Sleep Check-up: a 5-minute questionnaire that screens for possible sleep problems
• SleepEZ: digital CBT-I for trouble falling or staying asleep

The course is a helpful companion, but it is not meant to replace care from a health professional.

Insomnia Coach is a free app based on CBT-I, made for everyone, including veterans and service members. CBT-i Coach includes a sleep diary, exercises to build better sleep habits and guided muscle relaxation.

1. Pick one activity that matters to you, like walking the dog.
2. Find the amount you can do on a bad day without a flare.
3. Start there, even if it feels too easy.
4. Add a little every week or two.
5. Rest before you hit your limit, not after.

A physical therapist can guide you through exercises to keep and improve strength and mobility. Ask your VA provider for a referral.

“Push through it” helped in service, but it can backfire with chronic pain. Treat recovery like a training plan: clear goals, steady reps, rest days and checking progress.

The “cognitive” part looks at your thoughts, feelings and expectations about pain. The “behavioral” part teaches specific actions to respond to pain in more helpful ways. It is not about pretending pain isn’t real.

• Changing pain-related thoughts that block your goals
• Doing more social and recreational activities
• Handling flare-ups better
• Worrying less about more pain or injury

CBT-CP includes an assessment session and 10 skills-based sessions, ideally weekly, plus a follow-up session if helpful. You set goals together with your therapist and practice skills between sessions.

You don’t need to stop other mental health care while doing CBT-CP.

Some evidence shows trauma-focused talk therapy alone may improve how well people function with pain. Some providers treat both together, and treating one at a time is also an option.

Start a conversation with your VA health team about Whole Health. VA also runs introduction courses, including “Taking Charge of My Life and Health”, where you learn alongside other veterans.

• Acupuncture, including Battlefield Acupuncture in the ear
• Biofeedback, to learn to control muscle tension and stress responses
• Chiropractic care
• Massage therapy
• Meditation
• Tai chi
• Yoga

Some, like acupuncture, can be covered by your VA medical benefits when your care team finds them clinically necessary. Not every therapy is offered at every VA medical center.

• “What non-drug options do you have for my pain?”
• “Can I try CBT for chronic pain or physical therapy?”
• “Is acupuncture, yoga or tai chi offered here?”
• “Can I talk to someone about Whole Health?”

VA’s Progressive Tinnitus Management teaches veterans to use three kinds of sound: soothing sound, background sound and interesting sound. These can make tinnitus less noticeable and less bothersome.

Ideas

• A fan or soft background noise at night
• Music or a podcast while you wind down
• Nature sounds during quiet work

The program also teaches mindfulness, relaxation and cognitive behavioral skills. It aims to improve sleep, stress, attention and mood. Veterans who completed this kind of program reported less distress from tinnitus and lower depression.

Ask your VA primary care provider for a referral to audiology for a hearing and tinnitus check. Some VA facilities offer tinnitus programs by video.

• Ask what helps on a bad pain day, before one comes
• Join in gentle activity, like an evening walk
• Mention snoring or pauses in breathing calmly, and offer to help book a check
• Protect quiet, dark sleep time in the home
• Celebrate small wins, like a walk finished or a better night

Group classes like yoga or tai chi, where offered, and Whole Health courses where you learn alongside other veterans can add connection as well as movement.

• “I believe you. What would make today easier?”
• “Want me to come with you to the appointment?”
• “Let’s figure out a plan for nights when you can’t sleep.”

• Veterans Crisis Line: dial 988 then press 1, text 838255, or chat at VeteransCrisisLine.net
• Anyone in the U.S. can also call or text 988
• If a life is in danger, call 911

• Ask your VA primary care provider about a sleep check, CBT-I, CBT-CP or physical therapy
• Enroll in VA health care: 877-222-8387 (weekdays)
• Call the Vet Center Call Center, 24/7: 877-927-8387

• Path to Better Sleep online course
• Insomnia Coach app
• A Whole Health course or coach
• Keep your sleep & pain diary going

Path to Better Sleep and VA’s apps work anywhere with internet. For a crisis, use the Veterans Crisis Line chat, or find a free local helpline at findahelpline.com.