Sleepless with Arthritis

Having arthritis and sleepless nights can often go hand in hand. For nearly 20 years, Nikki Albert has confronted the daily pain of fibromyalgia. She was forced to leave her career in financial services and go on long-term leave. The 37-year-old not only struggles with muscle pain, tender joints and stiffness, but one of her toughest challenges is having inadequate sleep.

“Getting any quality sleep is the real issue,” says Albert, who has difficulty exercising and pursuing her personal interests. “I have problems getting to sleep certainly, but even when I do maintain sleep it is never quality sleep. So I’m always running on empty.”

When you are living with a rheumatologic disease, insomnia can be one of your biggest enemies. Insomnia affects about 20% of adults in the United States, but that percentage rises quickly among those with arthritis-related conditions. Chronic pain will keep many awake at night. Others discover that their joints are so painful and inflamed that falling asleep is hopeless.

Insomnia can lead to poor health and worsen arthritis symptoms. Sleeping issues often prevent people from getting the right amount of exercise and relaxation needed to stay in good shape. Difficulty sleeping becomes a vicious cycle for many in the arthritis community, resulting in constant fatigue, low energy and frustration.

Adults with normal sleep patterns get about seven to eight hours of shut-eye each night, according to the National Institutes of Health. Nearly everyone has occasional insomnia, which can include trouble falling asleep (referred to as sleep onset), staying asleep (referred to as sleep maintenance) or a combination of both. If a person regularly wakes up feeling unrefreshed in the morning, he or she probably suffers from insomnia, says Sairam Parthasarathy, MD, director of sleep disorders at the University of Arizona in Tucson and associate director of sleep and circadian sciences at the Arizona Respiratory Center.

Some cases of insomnia are short lasting and often are the result of life circumstances, such as not being able to fall asleep before a big presentation or dealing with bad news. On the other hand, chronic insomnia is considered disrupted or inadequate sleep that lasts at least three nights a week and lasts for about three months, affecting about 20% of Americans.

New normal for millions  

Coping with both arthritis and insomnia is very common among adults. In a survey by the National Sleep Foundation, 72% of adults ages 55 and older with arthritis complained of poor sleep, with 18% reporting that they had been diagnosed with a sleep disorder. The poll also revealed 15% of respondents reported sleeping less than six hours a night, and 18% reported daytime sleepiness.

The main culprit for sleepless nights is chronic pain. In a separate poll, the National Sleep Foundation discovered pain is a key factor in the gap between the amount of sleep Americans say they need and the amount they’re getting—an average 42-minute sleep debt for those with chronic pain.

“Clinicians and pain sufferers know that pain and sleep problems present together and aggravate each other. This poll confirms the relationship between pain and sleep,” says Timothy Roehrs, PhD, sleep research specialist at Henry Ford Hospital in Detroit. “Fortunately, it also shows that simple steps to improving sleep can be beneficial.”

The connection between pain and insomnia has been well researched. In online chat rooms, some people refer to it as “painsomnia.” Sleep researcher Vivien Abad, MD, does not use that term with her patients, but she fully understands that both conditions are undeniably intertwined. “It goes back to the belief that sleep is impaired by uncontrolled pain,” says Abad, adjunct clinical assistant professor at the Stanford Sleep Disorders Clinic in California.

Recent research also has found insufficient sleep can reduce a person’s pain threshold, meaning people will feel more pain if they don’t get enough sleep. Despite volumes of research on the link between pain and insomnia, there’s still a major gap in what people in the arthritis community understand and learn from their doctors and health-care teams.

“I came across the link a couple of years ago during a Google search, but my doctor never mentioned the connection,” says Sarah Murphy, 30, who lives with osteoarthritis and insomnia.

Consequences of sleepless nights

Inadequate sleep is associated with numerous health risks for those with arthritis symptoms. Partial sleep deprivation decreases the proportion of natural killer cells and lowers immune response. Proinflammatory cytokines—molecules involved in immune responses—and tumor-necrosis factor that is prevalent in RA and other related conditions are increased the morning after partial sleep deprivation.

At the University of Arizona, Parthasarathy and his colleague Stefano Guerra, MD, led a research team that found a significant link between persistent insomnia, inflammation and mortality. The NIH-funded team defined persistent insomnia as being present over a six-year period.

By analyzing data from a population-based study that spanned 40 years, the team found persistent insomnia compared with intermittent insomnia was associated with higher levels of inflammation in the blood as measured by a biomarker in the blood called C-reactive protein. Even more startling was the finding of a 58% increased risk of death due to persistent insomnia, specifically related to heart disease.

“This research shows that sleep is extremely important for the immune system to function,” says Parthasarathy. “Getting enough sleep may be an effective treatment for arthritis and other related disorders.”

Sleep dysfunction

Difficulty sleeping is common among people living with arthritis-related conditions. “With a higher number of musculoskeletal symptoms and tender joints, people living with these conditions are more susceptible to inadequate sleep,” says Abad, who studied the effects of insomnia across several rheumatologic disorders.

Conditions with significant insomnia issues include rheumatoid arthritis (RA), fibromyalgia, osteoarthritis, juvenile rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erthematosus, sarcoidosis and scleroderma. RA and fibromyalgia have been studied most extensively for their connection with insomnia. Sleep disturbance affects an estimated 30% of those living with osteoarthritis, but it’s those affected by fibromyalgia who have the highest rate of insomnia at 75%.

Albert, who was diagnosed with fibromyalgia about 20 years ago, has tried many approaches to treat her insomnia—from herbal remedies to OTC treatments and, ultimately, medication. She currently takes a sleeping pill called zopiclone. Says Albert: “I only get a moderate benefit because sometimes pain trumps sleeping pills. Also, I still wake up frequently, but I feel that I might fall back to sleep faster. So I get about five hours of sleep on the pill that is better quality than without.”

Among those living with RA, complaints about inadequate sleep and daytime sleepiness occur in an estimated 54% to 70% of people—about two to three times greater than found in the general population. There’s reason to be concerned if you have RA. Sleep loss further activates RA-related joint pain and increases overall pain and symptoms such as fatigue, depression and anxiety.

Researchers have shown a higher number of middle of the night awakenings is associated with more intense morning pain. In addition, RA sufferers are more likely to suffer from other sleep disorders including sleep apnea, restless leg syndrome and periodic leg movements of sleep.

But there is hope for those with RA. One study found people who followed a regular exercise program improved their sleep quality and reduced fatigue. The 12-week home exercise program included strengthening, stretching and walking programs developed in accordance with the American College of Sports Medicine. Study participants were given daily step count targets and advised on the level of exertion for which they should aim. For instance, doctors advised patients to be moderately out of breath on exertion and unable to comfortably hold a conversation while walking.

Exercise isn’t always within reach for many in the arthritis community. Murphy enjoys boxing and weight training, but during a flare up of osteoarthritis, she often has to skip exercise for weeks.

For Albert, the chronic pain makes it difficult to exercise, which is one of the key ways to manage her condition. She attempts to do routine exercises on a regular basis, but they are very low intensity. “There are days when I can walk for an hour and be in pain but manage it, but then there are days when I cannot even walk for 10 minutes. Planning any activity or holiday has to be very moderate, and I have to have the capacity to rest if needed.”

Paul Wynn, a writer based in Garrison, N.Y., has covered health-care trends for the past 20 years.

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