Sleep and arthritis

Non-REM sleep occurs in four stages (see Figure 1):

• Stages 1 and 2 refer to light sleep.
• Stages 3 and 4 refer to deeper sleep with slow brain waves.

Figure 1. The stages of sleep

These phases are repeated several times during the night, with each complete cycle lasting about 90 minutes. The proportion of deep sleep and dreaming sleep changes as we get older but the length of each sleep cycle stays the same. For example, babies dream for almost half the time they are asleep compared to an average of only 10% in adults.

Potential sleep problems can include the following.

• Some people have trouble getting to sleep, but then sleep through the night.
• Others wake frequently during the night or wake too early in the morning.
• Some people don't recall having disturbed sleep but don't feel refreshed when they wake (non-restorative sleep).
• People with a severely disturbed sleep pattern may suffer from all these problems. If this persists for a long period it can cause increased tension in muscles and can lead to muscular pain.

Sleep has a major effect on our mood. People who are depressed might have disturbed sleep because of their psychological illness. However, a poor sleep pattern over a period of time will often lead to anxiety or depression, or both. So it's sometimes difficult to know whether the sleep disturbance resulted from depression or was the cause of it.

Fibromyalgia is a rheumatic condition that causes generalized pain and stiffness associated with sleep disturbance and fatigue. Although it's likely that the fatigue is caused by a poor sleep pattern, it is also possible that pain and stiffness may be caused by sleep disturbance.

This idea is supported by the results of an experimental study that prevented volunteers from going into deep sleep. Within a few days all the volunteers developed widespread stiffness and muscle pains. And people with fibromyalgia often recall having disturbed sleep before the pain and stiffness began. The possibility that disturbed sleep could lead to the development of fibromyalgia makes it even more important to try and improve the quality of your sleep.

• Back pain or neck pain can cause problems getting to sleep or waking during the night. Having a pillow that is too firm, or a bed that doesn't give adequate support to the back, can make these problems worse.
• Pain from osteoarthritis occurs mostly when the joints are being moved but it can sometimes cause problems at night as well – surgeons often take this into account when considering whether a joint replacement is needed.
• People with rheumatoid arthritis are more likely to suffer disturbed sleep than people who don't have arthritis. Sleep disturbance is usually worse when the pain is worse, and the resulting fatigue also makes it harder to cope with pain and stiffness.

Severe snoring is sometimes a sign of obstructive sleep apnoea syndrome, a condition caused by intermittent obstruction of the upper airway during sleep. It's often associated with obesity and an increased neck circumference, and the risk is also increased in cigarette smokers, people with diabetes, and in those with chronic nasal congestion. It can cause long-term (chronic) fatigue and can only make matters worse if you already have fatigue associated with your arthritis.

Treatment for obstructive sleep apnoea syndrome includes weight control and avoidance of alcohol but, in addition, there are a number of specific therapies that may be effective, including positive airway pressure (a mask that is worn during the night), surgery to clear a blockage in the upper airway, and drug therapy.

The diary can include:

• the time of going to bed and waking up
• whether you got to sleep easily or not
• any causes of disturbance, such as your mood, pain or fatigue
• your daytime activities.

'Sleep hygiene' simply means things that you can do to improve your sleep.

• Avoid sleeping during the day because this can make it more difficult to get to sleep at night.
• Avoid caffeine – for example in tea, coffee and chocolate – after midday.
• Eat sensibly to prevent feeling hungry during the night but avoid eating and drinking large amounts just before bedtime.
• Avoid drinking alcohol if you experience significant sleep disturbance as it may affect your sleep.
• Don't smoke before bedtime or during the night.
• Take regular exercise during the day, but not within 3 hours of going to bed.
• Try not to use your bedroom for what may be stimulating activities, for example watching television, working or eating. It's best to make the bedroom a peaceful and pleasant environment, dark and quiet and at a comfortable temperature.
• Try to establish a relaxing routine, going to bed at the same time every day, ideally when sleepy. If you are unable to sleep after about 20 minutes, get up and return to bed when sleepy. Try also to get up at about the same time every day
• Taking a warm bath before going to bed may help if your joints are stiff or painful.

If your bed is old or uncomfortable you should probably consider replacing it or you could try putting a board under the mattress to make it firmer. Changing the number or position of pillows or choosing a soft or moulded pillow may be helpful if you have neck or upper back pain. Some people find it helpful to sleep in a narrow soft foam collar.

If sleep problems persist you should speak to your doctor, specialist nurse or therapist, who will be able to offer more advice and if need be prescribe suitable medication.

• Painkillers (analgesics) ­­– Taking paracetamol (with or without codeine) just before going to sleep can relieve pain symptoms for a time to allow you to get to sleep, but it is unlikely to last all night.
• Anti-inflammatory drugs – Slow-release formulations of anti-inflammatory drugs such as ibuprofen, naproxen or diclofenac reduce pain and stiffness throughout the night. Although these drugs have potential side-effects, they can be very useful if prescribed appropriately.
• Sedating antidepressant drugs – Some antidepressant drugs such as amitriptyline, dosulepin and trazodone have sedative effects (i.e. they make people feel sleepy) and may also reduce chronic pain. These drugs are not given as 'sleeping tablets' but may improve sleep as an added benefit. It is often advisable to take them a few hours before going to bed so that the effect has worn off by the morning
• Sedatives (hypnotics) – Temazepam, zolpidem and zopiclone are examples of drugs that are given specifically to help people sleep. They are sometimes called hypnotics. They help people to go to sleep but may not maintain sleep throughout the night. Doctors are often very reluctant to prescribe these drugs because of the risk of dependence. However, these drugs can be very helpful for short-term use, and in some cases long-term use of these drugs may be preferable to long-term sleep deprivation.

Many people experience painful muscle cramps during the night. Quinine sulphate can be a useful drug to reduce these pains, though it doesn't work on other types of pain.