by Wendy McBrair, MS, BSN, CHES
Many people take a good night’s sleep for granted. If you are one of those lucky individuals who have no problem getting to sleep, staying asleep, or waking up rested, you may not appreciate how precious a good night’s sleep can be. There are many reasons people can’t get to sleep, from crazy schedules and noisy neighbors to more serious problems that require medical treatment. This article focuses mainly on how the pain, stiffness, and stress of arthritis or fibromyalgia can contribute to sleep problems — and how you can use the many strategies, devices, and medicines available to achieve the sleep you want and need.
Sleep is one of life’s necessities. Although there’s a lot that researchers don’t yet understand about sleep, they do know that people who don’t sleep well are at higher risk for a number of health problems. These include heart disease, diabetes, and depression. Not sleeping well has other consequences, too. For example, it increases pain and sensitivity to pain. It impairs the functioning of the immune system, making it harder for people to fight off infections. It interferes with the way the brain lays down memories and impairs learning, concentration, and judgment. It even appears to contribute to obesity.
Lack of sleep, then, or poor sleep, can affect both mind and body. Experts believe that most adults need 7–9 hours of sleep a night. Studies have shown, however, that most Americans often sleep less than 7 hours. Even when people sleep more hours, though, they may not get sleep’s full benefits. This is because sleep has several stages, and we need to complete all of them successfully to get a good night’s sleep.
There are five stages of normal sleep. One stage is rapid eye movement (REM) sleep, and the other four stages are non-REM sleep. (See "The Stages of Sleep" for more detail on the different stages.) Your body goes through these stages, taking between 90 and 110 minutes to complete the full cycle. These cycles occur 4–6 times each night, and the time spent in Stage 5 (REM) sleep increases with each cycle. REM and non-REM sleep are both important. A person who does not sleep long enough or whose sleep is disrupted, for whatever reason, will not get the right mix of REM and non-REM sleep and will not feel refreshed in the morning.
There are general principles for getting a good night’s sleep that apply to everyone. But if you have arthritis, ensuring that it is well controlled is the first step. Make sure you are seeing your doctor and working to resolve any problems related to your condition that are affecting your sleep. Your doctor may switch the medicines you are on or instruct you to take them at different times of the day. If pain is keeping you awake, it certainly makes sense to try and time your pain medicine so that it works for you at night. (The paradox is that while arthritis makes sleeping well more difficult, sleeping well can make arthritis easier to manage.)
But don’t leave the work of controlling your arthritis or getting to sleep to medicine alone. There are other strategies besides medicines for controlling nighttime pain. For example, taking a warm shower or bath before you go to bed can help to reduce pain and make sleep easier. If one joint is particularly bothersome, try using a warm, moist heating pad or ice pack for 15–20 minutes before bed. Doing gentle stretching, relaxation, or guided imagery exercises before going to bed can also help you get to sleep. In addition, exercising during the day can not only improve your arthritis, it can help you sleep better at night as well (though you should avoid exercising close to bedtime as it can make it more difficult to fall asleep).
A great bed. A comfortable bed is a must. Fortunately, many new mattresses and mattress additions that can make your bed more comfortable are now on the market. For example, using a bed board — a board placed under the mattress — can help make a soft and saggy mattress more supportive. This is especially important for people with back problems. Adding an inexpensive foam egg-crate pad or a more expensive pillow-top mattress pad can make a saggy mattress feel just like new. Of course, you can have a “be good to yourself moment” and buy a new pillow-top mattress or a Sleep Number mattress. You may enjoy the Sleep Number mattress because you and your partner can each adjust your own side of the mattress to your preference. The mattress is so easy to use that if you start feeling uncomfortable during the night, you can change the mattress’s firmness with the push of a button. Other people like mattresses that can change position at the head or knee. These adjustable beds are just like traditional hospital beds, and you can now buy them for the home as well. Note that the costs for all of these items can vary widely, so make sure you try the less expensive options first.
Perfect pillows. It is very important to find a pillow that is comfortable for you, so investigate the material, thickness, and firmness of any pillows you buy. However, you should not sleep with lots of pillows that bend your neck forward, as this will add to poor posture and possibly cause neck pain. If you have neck or back problems, consider a cervical pillow. A cervical pillow supports your neck as well as your head and allows your head, neck, and spine to remain in proper alignment, which can help to decrease pain. If you have lower back pain, lying on your back and placing one or two pillows under your knees so that they are slightly bent can help support your back. Or you can purchase a foam wedge that serves the same purpose. If you have knee problems, you should avoid sleeping with a pillow under your knees so your knees are bent. This may increase knee stiffness and make it more difficult for you to straighten your knees. You might find instead that it helps if you put a pillow under the entire length of the leg. Putting a pillow between your knees as you lie on your side helps maintain back alignment, which can reduce hip and back pain. Again, a special pillow is available for this purpose. Another helpful pillow is the dual position bed wedge, which can be used both for sleeping and, in a different position, for reading or watching TV. You can find specialized pillows at medical supply stores and on the Internet.
Bed equipment. Some people with arthritis or fibromyalgia are bothered by heavy covers that press down on their feet at night. An adjustable blanket support can keep covers off sore feet and ankles and make it easier to turn and change position without disrupting your sleep. These supports can attach easily to the sides or foot of a bed. Sheets made of satin or another smooth material can also make it easier and less painful to turn over in bed. Partial side railings that anchor by sliding under the mattress to keep them in place are made to adjust in four positions. You can use the railings to help you turn over more easily during the night.
Other strategies. The best environment for sleep is one that is cool, dark, and quiet. This is sometimes easier said than done. For instance, you may live where there is noise outside your bedroom, such as traffic, or you may sleep with a partner who tosses and turns or snores loudly. Earplugs or sleep machines can help with outside commotion and with noisy sleeping partners. (Sleep machines create “white noise” that drowns out other sounds.) A person can reduce snoring if he or she loses weight or avoids alcohol in the evening — alcohol contributes to snoring by relaxing the muscles in the throat. Some people like to use special tape on the nose to enlarge the nasal passages during sleep (though there is little hard evidence that this works). If your nasal passages are swollen because of allergies, ask your doctor whether it’s OK for you to take allergy medicine to reduce the swelling and thus help reduce snoring. And sometimes snoring is a symptom of a sleep disorder known as sleep apnea, discussed later in the article.
Another good strategy for getting good sleep is to go to bed at the same time and wake up at the same time every day (including weekends). Using your bed only for sleeping (instead of reading and watching TV) and for sex can also help. But if you are awoken by your partner’s noise or movement and can’t find any other way of dealing with the problem, consider moving to another room.
Some people have no trouble going to sleep but wake up in the middle of the night and can’t get back to sleep. If you are waking up to empty your bladder, try stopping your intake of fluids a few hours before bed — for example, by 7 PM. If you wake up and are upset or worrying, you can try to stop the upsetting thoughts by using a technique called progressive muscle relaxation, in which you relax each muscle in your body, one at a time. To do this, first tighten all the muscles in your face for several seconds and then release them. Work from top to bottom, tightening and relaxing the muscles in each area of your body until you reach your feet. Concentrate on the relaxation process rather than on the fact that you are upset because you are awake.
The medicines you take and the foods you eat can cause sleep problems or make them worse. Prednisone and other corticosteroid drugs, which people with inflammatory arthritis often take, can cause sleeplessness. Other medicines — such as decongestants and some blood pressure drugs — can cause sleep problems, too. If you think a drug may be causing your sleep problems, check with your doctor or pharmacist. Caffeine, nicotine, and amphetamines cause sleep problems, as they are all stimulants. Some people try reducing their intake of caffeine from coffee, tea, energy drinks, or sodas to one cup or glass a day, preferably before 5 PM. Others have to stop altogether. (Also note that some headache relievers, such as Excedrin, may contain caffeine.) You should also avoid alcohol before bed if sleep is a problem, because alcohol does more than make you snore — it can suppress deep sleep and REM sleep. And remember Mom’s warm milk. Heated milk at bedtime helps some people relax and get to sleep faster.
Sleeping pills. While the hope is that changes in your sleep habits, sleep environment, and behavioral strategies will do the trick, there are also medicines that can help you sleep. Most experts believe, however, that these drugs should only be used short-term or as a last resort, because they are not risk-free.
Some people try over-the-counter sleeping pills. These pills usually contain an antihistamine. They are not recommended for long-term use and can interfere with alertness during the day. They often reduce the quality of your sleep, and you may quickly develop a tolerance for them. Check with your doctor before taking these.
Sleep medicines your doctor might prescribe include zolpidem tartrate (Ambien CR), zaleplon (Sonata), and eszopiclone (Lunesta), all of which can be habit-forming. Another sleep drug, which works in a different way, is ramelteon (Rozerem). Tranquilizers such as flurazepam (Dalmane), temazepam (Restoril), and estazolam cause drowsiness. They tend to be effective for only a few weeks and can lead to drug dependence. Some antidepressants, such as trazodone, are used for sleep problems. The tricyclic antidepressants, which include amitriptyline, can, when taken in small doses, help a person obtain deep, restorative sleep. They are often prescribed for people with fibromyalgia. Benadryl, an antihistamine, can help people relax and is available over the counter, sometimes in combination with Tylenol (Tylenol PM). Most of these medicines are used to help with short-term sleep problems, but some people do take them regularly.
If you and your doctor have tried all the strategies described here and nothing seems to help, it’s possible that not all of your sleep problems are caused by arthritis or the other common causes of sleep difficulties. You might have an underlying sleep disorder. Examples of sleep disorders are sleep apnea (in which you stop breathing temporarily while you sleep), narcolepsy (in which you skip the non-REM stages of sleep and go straight to REM sleep), and restless legs syndrome (unpleasant sensations in the legs while you are at rest). You might want to go to a doctor who specializes in sleep disorders or even to a sleep center, where doctors can observe your sleep to better diagnose your problem.
Last Reviewed on March 9, 2011
Wendy McBrair spent 30 years as a health-care professional in the fields of rheumatology and orthopedics, where she specialized in patient and community service, patient education, and advocacy.
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