Techniques for Improving Sleep
“[…]for sleep is that golden chain that ties health and our bodies together.” —Thomas Dekker
For people such as Trish Engleton, getting a good night’s sleep is an elusive goal. “It’s horrible!” says the mother of three who has been dealing with rheumatoid arthritis (RA) for the past 10 years. “Even though I feel tired, it can take an hour to settle down and get comfortable. When I’m finally asleep, if I roll over, the pain in my right ankle and hip jerks me awake. This goes on all night long…and then I’m exhausted and don’t feel like walking or swimming the next morning.”
Trish is not unique in her complaints. Individuals diagnosed with arthritis are about three times more likely than individuals without arthritis to experience sleep problems, such as not being able to fall or stay asleep, feeling exhausted during the day, or sleeping less than six hours per night.
Why does sleep matter?
As Thomas Dekker suggests, good sleep is a crucial component of optimal health. When you sleep, your body produces human growth hormone, which is vital to tissue and muscle repair and bone and collagen replacement. However, all sleep is not created equal. A person needs to cycle through the different stages of sleep to reach the deep sleep state that triggers the greatest production of human growth hormone. Impaired sleep may also cause the release of damaging inflammatory chemicals, which can speed up tissue and bone deterioration. Without the benefit of deep sleep, Trish’s damaged joints do not have what they need for adequate renewal and repair. She also has decreased energy and a further weakened immune system.
The link between sleep and arthritis pain
Trish’s experience of the vicious cycle of pain and impaired sleep is common for individuals with arthritis. Research suggests that people with arthritis who sleep poorly due to chronic pain report more frequent and more severe pain across time. It’s no surprise that people who are exhausted and in pain don’t feel like hitting the gym or taking a walk. But decreased activity makes things worse; not moving can lead to more stiffness and pain, worse sleep, and diminished health overall.
In addition to arthritis itself disrupting sleep, some arthritis medicines may impair sleep. Methotrexate, commonly prescribed for RA, can disturb sleep and cause daytime fatigue that may lead to decreased activity or napping. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen may cause ulcers, acid reflux, or heartburn, which can create nighttime discomfort and sleep problems. Steroids such as prednisone can be stimulating and make it difficult to fall asleep. Medicines prescribed for other conditions may also keep a person awake at night or cause him to wake up during the night. Diuretics (“water pills”), for example, can cause trips to the bathroom during the night.
Mood has a unique relationship with sleep; depression and anxiety may lead to sleep problems, and disrupted sleep may heighten symptoms of depression or anxiety. Constant worry about stressful life events, increased pain, or decreased mobility can keep you awake at night. On the other hand, fatigue after a poor night’s sleep may keep you from visiting friends or doing something fun, which in turn, can cause your mood to plummet.
The direct relationship between poor sleep and fatigue is obvious. However, the impact of disrupted sleep on other issues may be less noticeable. Chronic sleep problems can cause weight gain, which in turn can increase wear and tear on joints and cause additional pain. Fat cells release inflammatory molecules called cytokines, so putting on extra weight could also lead to additional inflammation.
Poor sleep may also cause problems with cognitive and physical functioning. People who are tired have a harder time paying attention and solving problems, and tend to make riskier decisions. If you are already distracted by joint pain, additional drains on concentration may make it difficult to start or complete projects, focus on conversations, or multitask. Fatigue can cause decreased motor coordination, leading to injuries or falls. Stubbed toes, tender bruises, and broken bones cause increased pain, additional sleep problems—and the cycle continues.
Treating sleep problems
The first step in treating sleep issues is to determine the cause of the problem. Many sleep problems have multiple causes that have built up over time, so finding a solution will likely not happen overnight.
One way to learn more about what’s preventing you from getting enough high-quality sleep is to keep a sleep–wake diary. Use paper, a computerized spreadsheet, or a smart phone app such as Sleep Cycle or SleepBot to track your sleep behaviors. Monitor what time you go to bed and wake up, how long it takes you to fall asleep, any changes in your mood, your levels of pain and fatigue at night and during the day, and your daytime activities. Examine these data for patterns related to both poor sleep and restful nights.
It’s also a good idea to schedule a checkup with your physician. Many different illnesses cause impaired sleep, including thyroid disorders, heart disease, and sleep apnea. Your doctor can help you determine whether any medical conditions besides your arthritis, or any medicines you may be taking are disrupting your sleep. Your physician can also screen for symptoms of depression, anxiety, or other mental health concerns, and refer you to a specialist for follow-up if necessary.
Getting better sleep
As you search for causes for your sleep problems, you can also develop a plan for getting better sleep. This may include changing your sleep environment and changing your behavior.
Environmental modifications. Changing certain aspects of your home, and of your bedroom in particular, can help you to sleep better. Here are some suggestions:
• At night, use soft, indirect lighting rather than harsh overhead lights in your home. Decreased brightness signals to the brain that it is time to sleep.
• Replace pillows or mattresses that are uncomfortable. Change the type, number, or position of pillows. Experiment with memory foam products, pillow-top mattresses, and whole-body pillows. Note whether your bed coverings are comfortable, and replace any that are too heavy or too hot.
• Ensure that your bedroom is a designated sleeping space. Avoid using your bed for activities such as watching TV, working, eating, or using electronic devices. (Using your bed for sex, however, is OK.)
• Use an electric blanket, heating pad, hot water bottle, or bed with electronic temperature controls to provide heat therapy before bed. You might also consider taking a warm bath or shower before bedtime to soothe your joints and muscles.
• Elevate or separate your legs while sleeping using a body pillow or foam wedge.
• Use blackout curtains or an eye mask to reduce the amount of light that reaches your eyes.
• Use ear plugs or a white noise machine to decrease or mask noise.
• Keep your bedroom well ventilated. Cool temperatures and adequate air circulation can help to promote sleep.
Behavioral modifications. In addition to changing your environment, it can help to change some of your lifestyle habits and routines.
• Establish a consistent bedtime routine. Go to bed at approximately the same time every night and get up at approximately the same time every day. Consider doing something relaxing every night before bed.
• Avoid naps, which may disrupt your sleep–wake cycle.
• Exercise. According to the National Sleep Foundation, exercise, even close to bedtime, can improve sleep. (Just don’t exercise instead of sleeping.)
• Eliminate stimulants such as caffeine—found in coffee, some teas, energy drinks, and chocolate (yes, chocolate!)—and nicotine in the late afternoon, evening, or during the night.
• Use alcohol in moderation only or not at all. If you drink alcohol, try not to do so close to bedtime.
• Avoid eating a big meal or drinking lots of fluids just before bedtime.
• Avoid reading stimulating or anxiety-provoking books, watching TV, or using electronic devices before bedtime.
• If you can’t fall asleep after about 20 minutes, move to another room for a quiet activity such as reading in dim light. When you feel sleepy, go back to bed. If you are having trouble sleeping, don’t watch TV or use another electronic device (even an electronic book reader). The light from these devices may actually make you more awake.
Mind–body techniques, such as visualization and cognitive-behavioral therapy, can help you relax. They may also reduce insomnia and chronic pain. Local health-care providers may be able to provide you with training in these techniques. A wide range of books, CDs, and smartphone apps offering instruction and guidance in mind–body techniques are also available.
Visualization. Visualization is a technique used to shift your focus toward calming or soothing images, and it may help improve sleep by decreasing anxiety, pain, and depressive symptoms. Visualization sessions often involve creating vivid mental “snapshots” of beautiful images, scenery, or animals. Visualization in combination with slow, measured, deep (diaphragmatic) breathing may be particularly helpful.
Meditation. Meditation can reduce heart rate and blood pressure, improve sleep, increase energy, and decrease pain. There are many different meditative techniques. In mantra meditation, for example, the meditator keeps his mind focused on a word or phrase. In mindfulness meditation, a meditator tries to become aware of himself in each moment, focusing on his breathing or observing his own thoughts as they come and go. You can practice for as long as you like as often as you like, though meditation sessions once or twice a day for 5–20 minutes at a time may be a good place to start. Quieting your mind can be difficult at first, but should become easier with practice.
Progressive muscle relaxation. Progressive muscle relaxation (PMR) involves the focused tightening and releasing of all different muscles to promote relaxation and decreased tension. This technique also trains you to recognize muscles that become tight and tense during the day and relax them. PMR sessions may start at the top of the body (the head and face) and move down to the feet or start at the feet and move up. As you move along the body, tense each muscle for about five seconds, and then relax it for about 30 seconds. Do this several times. If tensing muscles in a particular area is painful, stop and move onto another group of muscles.
Cognitive-behavioral therapy (CBT). Through CBT, people learn better coping skills and a more flexible, positive way of thinking about themselves, their environment, and their arthritis. CBT can focus on sleep problems directly, or it may be used to treat underlying depression, anxiety, or pain that causes impaired sleep. CBT usually takes place over 6 to 20 30-minute to one-hour sessions with a trained clinician who assigns homework and self-monitoring exercises between meetings.
Other options. Acupuncture, yoga, and massage therapy may also be used to increase relaxation, and decrease anxiety, depression, or pain that may make it difficult to get good sleep.
Certain hormones, herbs, and teas have been used as dietary supplements to improve a person’s sleep. These supplements aren’t regulated like prescription or over-the-counter medicines and don’t have to be approved by the FDA, so their strength and purity may vary. On the whole, large-scale studies of the supplements in people with arthritis have not been conducted, and it is unclear what doses of these supplements, if any, would be safe and effective. Supplements can also interfere with medicines you may already be taking, so consult your doctor before using them. If you and your doctor decide that trying a particular supplement may be right for you, look for the seal of a reputable, independent testing laboratory signifying that the contents of the supplement match what’s on the label. Reputable testing labs include the US Pharmacopeial Convention (USP), the National Sanitation Foundation (NSF), and ConsumerLab.com.
Melatonin. Melatonin is a hormone produced by the pineal gland in the brain. Melatonin appears to play a role in regulating circadian rhythm (the sleep–wake cycle), reproduction, metabolism, and body temperature. Disruptions to the circadian rhythm caused by jet leg, shift work, and pain can interfere with melatonin production.
Results are mixed, but limited research suggests melatonin therapy may be helpful for jet lag and sleep problems in the elderly, as well as for sleep problems associated with shift work and neurological conditions such as Alzheimer disease. However, there are no clear and consistent data to recommend using melatonin for arthritis-related sleep problems. Some studies have shown that melatonin may even increase the production of inflammatory proteins and decrease the effectiveness of corticosteroids. Depending on the timing of the dose, melatonin may also increase symptoms of depression, which (as discussed above) can negatively affect sleep. Other possible side effects of melatonin may include an irregular sleep–wake cycle, nighttime waking, nightmares and vivid dreams, sleepwalking, poor sleep quality, and insomnia.
Melatonin may also cause headache, drowsiness, and upset stomach. Allergic reactions to melatonin can cause hives, difficulty breathing, and swelling of the lips, face, or throat. Melatonin may also cause inflammation of the liver.
Melatonin may interact with high blood pressure medicines, immunosuppressant drugs, steroids, anti-anxiety drugs, drugs that cause sleepiness, St. John’s wort, NSAIDs, antidepressants, and warfarin (brand name Coumadin).
Valerian. Valerian is an herb sometimes used to treat anxiety and sleep problems. There are no clear and consistent data to recommend valerian for sleep problems.
Possible negative side effects of valerian include morning grogginess, excitability, nausea, uneasiness, dizziness, unsteadiness, low body temperature (hypothermia), anxiety, and restlessness. Valerian may require two to four weeks of use to create any noticeable improvement in sleep. If you start taking valerian, taper off the dose slowly rather than stopping abruptly.
Valerian may interact with benzodiazepines, such as alprazolam (Xanax); barbiturates; drugs to treat insomnia, such as zolpidem (Ambien); tricyclic antidepressants, and alcohol.
5-HTP. Available as a supplement, 5-hydroxytryptophan (5-HTP) is involved in the production of serotonin, a brain chemical associated with positive mood and the sleep–wake cycle. Research suggests that taking 5HTP as a supplement increases levels of serotonin in the body. Commercial 5-HTP supplements are produced from the seeds of Griffonia simplicifolia, a plant found in Africa.
A few studies suggest that 5-HTP may help people sleep more deeply, reduce fibromyalgia pain, and improve symptoms of depression and anxiety. However, there are no definitive data to recommend this supplement for sleep problems in individuals with arthritis.
Potential negative side effects from 5-HTP include nausea, vomiting, heartburn, muscle problems, stomach pain, sexual problems, and diarrhea. At high doses, 5-HTP may cause serotonin syndrome, a potentially life-threatening condition, symptoms of which may include confusion, fever, shivering, rapidly fluctuating blood pressure, increased heart rate, and coma.
5-HTP may interact with antidepressants, painkillers, cough syrups, and medicines for Parkinson disease and migraine.
SAMe. S-adenosylmethione (SAMe) is a compound produced throughout the body, but particularly in the liver, and has been shown to increase brain levels of serotonin in rats. People who don’t make enough SAMe naturally sometimes take manufactured SAMe as a supplement.
SAMe is used to treat a wide range of conditions, including depression, dementia, Alzheimer disease, fibromyalgia, osteoarthritis, bursitis, tendonitis, anxiety, heart disease, chronic lower back pain, chronic fatigue syndrome (CFS), attention deficit-hyperactivity disorder (ADHD), multiple sclerosis, liver disease, Parkinson disease, seizures, premenstrual syndrome (PMS), and migraine headaches. It is also used to slow the aging process and improve cognition. While there is limited evidence to support using SAMe to treat some of these conditions, there is no clear and convincing data to support the use of SAMe for sleep problems in individuals with arthritis.
Possible negative side effects of SAMe include insomnia, gas, nausea, vomiting, constipation, sweating, dry mouth, dizziness, headache, diarrhea, anorexia, and anxiety. SAMe may trigger a manic episode and increase the severity of manic episodes in people with bipolar disorder. SAMe may also make levodopa, a drug used to treat Parkinson disease, less effective.
SAMe may interact with antidepressants, cough syrups, and painkillers.
Herbal teas. Although there’s often little evidence to support their effectiveness, many different herbs that are mildly sedating and calming have been used for anxiety and sleep problems. Chamomile (Matricaria recutita, Anthemis nobilis, or Chamaemelum nobile), skullcap (Scutellaria lateriflora and others), hops (Humulus lupulus), motherwort (Leonurus cardiac and others), and oat straw (Avena sativa) can be used alone or in combination to enhance their calming effects.
These herbs are typically safe and do not cause side effects beyond occasional upset stomach. There may be a risk of allergic reaction with some herbal teas. Women who are pregnant or who may become pregnant may want to talk with their doctors before trying certain herbal teas. Motherwort may induce miscarriage, and traditional medicine has pointed to skullcap and chamomile as coming with a miscarriage risk. People with arthritis report varying success with using teas to treat sleep problems.
Prescription sleep medicines have been well studied in the general population, but there is little research on how well they work for people with arthritis specifically. Commonly prescribed drugs for sleep problems include benzodiazepines such as lorazepam (Ativan), temazepam (Restoril), and triazolam (Halcion); hypnotics such as eszopiclone (Lunesta) and zaleplon (Sonata); sedative–hypnotics such as zolpidem (Ambien); tricyclic antidepressants such as amitriptyline; and antipsychotics, typically used in lower doses than those necessary for antipsychotic effects.
Most prescription sleep medicines were designed for short-term use, and you shouldn’t use sleeping pills on consecutive days. If you use these drugs over a long period, you may develop a tolerance and require larger and larger doses to get the same effects. There is also the risk of dependence, which may make it extremely difficult or even dangerous to stop taking these medicines on your own.
Some people use medicines that cause drowsiness as a side effect to help with sleep problems. Examples include opioid painkillers, such as hydrocodone (Vicodin) and antihistamines, which are found in allergy and cold medicines such as diphenhydramine (Benadryl) and doxylamine succinate (NyQuil). However, these products do not create good-quality sleep, and they have the same risks of tolerance and dependence as other sleep medicines.
Be the key to better sleep
Getting restful sleep should be easy. But when getting a good night’s rest gets difficult, figuring out what’s wrong and taking action can help get you back into a routine of refreshing snooze. Talk to your doctor, explore your options, and experiment with changes big and small. Finding your way back to restful sleep lies in finding what’s best for you.