2062 sleep and arthritis

8/13/2019 2062 Sleep and Arthritis

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Self-help and daily livingSleep and arthritis

Sleep andarthritisThis booklet provides informationand answers to your questionsabout sleep and arthritis.



A sleep problem can make thefatigue associated with arthritisworse and affect mood, memoryand concentration. If it carrieson for a long time, it may alsocause muscle tension and pain. This booklet will tell you aboutsome common sleep problemsand what can be done to help.At the back of this booklet you’ll nd a brief glossary ofmedical words – we’ve underlined these when they’rerst used in the booklet.

www.arthritisresearchuk.org

How can problems

sleeping affect me?



Arthritis Research UKSleep and arthritis

What’s inside?2 Sleep and arthritis at a glance

4 How can disturbed sleep affectmy health?

– What is a normal sleep pattern? – Sleep problems

– Sleep and pain – Sleep and arthritis – Restless legs – Snoring

9 How can sleep be improved? – Sleep hygiene – Drug treatments

12 Research and newdevelopments

13 Glossary

13 Where can I nd out more?

14 Further reading

16 We’re here to help



Painful conditions like arthritis can affectthe quality of your sleep, and poor-qualitysleep can in turn affect your general health.

What common sleep problemsare there?

Common problems include:• difficulty getting to sleep• waking up often during the night• waking too early in the morning• non-restorative sleep (when you don’t

feel refreshed when you wake up).

People with a severely disturbed sleeppattern may suffer from a numberof these problems. A sleep problem canmake the fatigue associated with arthritisworse and affect mood, memory andconcentration. If it carries on for a long

time it may also cause muscle tensionand pain.

How can I improve my sleep?

Try some of the following to help improveyour sleep:• Use a sleep diary to keep track of your

sleeping habits.• Avoid sleeping during the day.• Avoid caffeine after midday.• Don’t eat or drink large amounts just

before bedtime.• Avoid drinking alcohol if your sleep

is disturbed.• Don’t smoke before bedtime or during

the night.• Exercise regularly (but not within

3 hours of going to bed).• Keep the bedroom dark, quiet and

at a comfortable temperature.•

Check that your mattress and pillowsare comfortable.• Establish a relaxing routine – try to go

to bed and wake up at the same timeeach day.

• If you can’t sleep after about 20 minutes,get up and return to bed when sleepy.

• Take a warm bath before going to bed.

At a glanceSleep and arthritis

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What treatments are there?

Medications that might help include:• painkillers and anti-inammatories

e.g. paracetamol, codeine andibuprofen, but avoid types that includecaffeine as these may disrupt sleep

• quinine sulphate can help reducepainful muscle cramps during thenight, but it won’t work on othertypes of pain

• sedating antidepressant drugse.g. amitriptyline

• sedatives e.g. temazepam, zolpidemand zopiclone (doctors are oftenreluctant to prescribe these becauseyou can become dependent).

There are manydifferent things

you can try to helpimprove yoursleep, includingavoiding eating justbefore bedtime.



How can disturbed sleepaffect my health?Many people struggle to sleep atsome time in their lives, for examplewhen looking after young children. This doesn’t usually cause any healthproblems, although you may feel tired.However, some people with persistentlypoor or disturbed sleep may beginto notice their health getting worse.

Several biological functions areinuenced by sleep. Our body clockis regulated by our sleep pattern andmany different hormones in the bodyare affected by sleep. For example,steroid hormones produced by theadrenal glands are at their highest levelwhen we wake up in the morning andlowest before going to sleep at night.So taking steroid tablets later in theday can affect the body clock and maydisrupt sleep.

If these biorhythms are altered by achange in sleep pattern (for example,if you have jet lag), you may feelunwell. Fatigue, stomach problems andheadaches are common, and you maynd it difficult to think clearly, concentrateor carry out otherwise routine functionssuch as driving.

What is a normal sleep pattern?Sleep is essential for all animals, but theamount and pattern of sleep differsbetween animal species. The amountof sleep needed per day varies from20 hours in bats to 13 hours in domesticcats and 4 hours in horses. In humans,children need more sleep than adults.A baby will sleep for most of the day but

the amount of sleep we need reducesuntil we reach adulthood, when mostpeople need about 7–8 hours a day.

There are various stages of sleep, and thepattern of brainwaves differs in each stage(see Figure 1). They’re commonly referredto as non-REM (rapid eye movement) andREM sleep (dreaming sleep).

Non-REM sleep happens in four stages:• Stages 1 and 2 refer to light sleep.• Stages 3 and 4 refer to deeper sleep

with slow brainwaves.

These phases are repeated several timesduring the night, with each completecycle lasting about 90 minutes.

Most adults needabout 7–8 hours

sleep a day.

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The proportion of deep sleep anddreaming sleep changes as we get olderbut the length of each sleep cycle staysthe same. For example, babies dreamfor almost half the time they’re asleepcompared to an average of only 10%in adults.

Sleep problems

Sleep problems can take severaldifferent forms:• 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 havingdisturbed sleep but don’t feel refreshedwhen they wake (non-restorative sleep).

• People with a severely disturbed sleeppattern may suffer from all theseproblems. If this persists for a longperiod, it can cause increased muscletension and can be associated withmuscular pain.

Although most people need about7–8 hours of sleep each day, many peoplemanage quite well with less and sleepis really only a problem if you’re nothappy with the amount and qualityyou’re getting.

REM sleepDreaming sleep

• Faster brainwaves• Rapid eye movements from

side to side (REM sleep)

Non-REM sleep:stages 1 and 2

Light sleep• First phases of sleep

Non-REM sleep:stages 3 and 4

Deep sleep• Slow brainwaves

(called slow-wave sleep)• Gradually becomes

deeper until it changes intodreaming sleep

Figure 1 The stages of sleep

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Restless legsMany people nd their sleep is disturbedby restless legs – unusual and sometimesunpleasant sensations in the legs whichcreate a strong urge to move the legsto relieve the feeling. Restless legssyndrome (RLS) can occur at any timebut is often worse at night. A relatedcondition called periodic limb movement

disorder (PLMD) only occurs at night andcauses the arms or legs to jerk or twitch.

RLS and PLMD can affect anyone but arequite often associated with long-termconditions. They can also occur as aside-effect of some medications or asa result of iron or vitamin deciencies.You should see your doctor if restless legsare contributing to your sleep problems. Treatment may involve:

• changing your medications• taking iron or vitamin supplements• avoiding stimulants such as caffeine

and alcohol• stretching and massaging your

leg muscles.

If your symptoms are severe, your doctormay suggest treatment with a groupof drugs called dopamine agonists. These increase the levels of a chemicalcalled dopamine in the brain. Examplesof dopamine agonists include ropiniroleand pramipexole.

Snoring

Snoring is common and can be asymptom or a cause of sleep disturbance.Most people who snore remain perfectlywell and don’t feel sleepy during the day,but they may be more sensitive to theeffects of alcohol or sedatives.

Severe snoring may be a sign ofobstructive sleep apnoea syndrome,a condition caused by brief blockagesof the upper airway during sleep. It’s oftenassociated with obesity and an increasedneck circumference, and the risk is alsoincreased in cigarette smokers, peoplewith diabetes and in those with chronicnasal congestion. It can cause long-term(chronic) fatigue and can be diagnosedby measuring the level of oxygen in theblood during sleep.

Treatment for obstructive sleep apnoeasyndrome includes weight control andavoiding alcohol, but in addition there area number of specic therapies that maybe effective, including positive airwaypressure (a mask that is worn during thenight), surgery to clear a blockage in theupper airway and drug therapy.

Snoring is morecommon as we getolder. It has beenestimated that 45%of men and 30% ofwomen over 65 snore.

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How can sleep beimproved?A diary of your sleep pattern can bevery helpful in identifying the factorsthat help or hinder your sleep. The diarycan 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.

If your sleep is disturbed by pain,drug treatments may help. However,sleep disturbance is often causedby a combination of factors, which mayinclude pain but also fatigue, stress ordepression. This can be more difficultto deal with and health professionalswill usually suggest thinking about sleephygiene – things that you can do toimprove your sleep pattern.

Sleep hygieneSleep hygiene simply means things thatyou can do to improve your sleep.• Avoid sleeping during the day because

this can make it more difficult to getto sleep at night.

• Avoid caffeine – for example in tea,coffee and chocolate – after midday.

•

Eat sensibly to prevent feelinghungry during the night but avoideating and drinking large amounts just before bedtime.

• Avoid drinking alcohol if you experiencesignicant sleep disturbance as it mayaffect 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 forwhat may be stimulating activities,for example watching television,working or eating. It’s best to makethe bedroom a peaceful and pleasantenvironment, dark and quiet and ata comfortable temperature.

• Try to establish a relaxing routine and

go to bed at the same time every day,ideally when you’re sleepy. If you’reunable to sleep after about 20 minutes,get up and do something that’s notoverstimulating (e.g. listen to somesoothing music). Only return to bedwhen sleepy. Try also to get up at aboutthe same time every day.

• Take a warm bath before goingto bed as this may help ease stiffor painful joints.

If your mattress is old or uncomfortable,you should probably consider replacingit. Changing the number or positionof pillows or choosing a soft or mouldedpillow may be helpful if you have neckor upper back pain. Some people nd

it helpful to sleep in a narrow softfoam collar.

See Arthritis Research UK bookletEveryday living and arthritis.

Drug treatmentsIf sleep problems persist, you shouldspeak to your doctor, specialist nurseor therapist, who will be able to offermore advice and prescribe suitable

medications if they’re needed. There are four main groups of drugs thatcan be helpful (see Figure 2). They’re mostlikely to help when there’s a single causeof sleep disturbance, such as arthritispain. Many patients will benet froma combination of drugs from more thanone of these groups. Your GP or hospital

specialist will be able to advise on whichdrugs are most likely to help you.

Painkillers (analgesics) – Takingparacetamol (with or without codeine) just before going to sleep can relievepain symptoms for a time to allow youto get to sleep, but it’s unlikely to last allnight. Non-drowsy formulation painkillersthat include caffeine are unlikely to helpyou sleep.

Anti-inammatory drugs – Slow-releaseformulations of anti-inammatory drugssuch as ibuprofen or naproxen reducepain and stiffness throughout the night.Although these drugs have potentialside-effects, they can be very usefulif prescribed appropriately.

A warm bathbefore bed canrelax you and helpease stiffness.

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Sedating antidepressant drugs –

Some antidepressant drugs such asamitriptyline, dosulepin and trazodonehave sedative effects, which means theymake people feel sleepy, and may alsoreduce chronic pain. These drugs aren’tgiven as sleeping tablets but may improvesleep as an added benet. It’s oftenadvisable to take them a few hours beforegoing to bed so that the effect has worn

off by the morning.

Sedatives (hypnotics) – Temazepam,

zolpidem and zopiclone are examplesof drugs that are given specicallyto help people sleep. They’re sometimescalled hypnotics. They help people to goto sleep but may not maintain sleepthroughout the night. Doctors are oftenvery reluctant to prescribe these drugsbecause of the risk of dependence,but they can be very helpful for short-

term use. In some cases long-term useof these drugs may be preferable to long-term sleep deprivation.

Help people go to sleepbut may not maintain

sleep through the night

Sedativese.g. temazepam,

zolpidem, zopiclone

May reduce chronic painand the sedative effectsmay make you feel sleepy

Sedatingantidepressant drug se.g. amitriptyline,trazodone,dosulepin

Reduce pain andstiffness throughoutthe nightAnti-inammatorydrugs

e.g. ibuprofen, naproxen,diclofenac

Relieve painsymptoms for a short

time before yougo to sleep

Painkillers

(analgesics)e.g. paracetamol

Figure 2 The fourmain groups ofdrugs prescribed forsleep problems

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Many people experience painful musclecramps during the night. Quininesulphate can be a useful drug to reducethese pains, though it doesn’t workon other types of pain.

Research and newdevelopmentsA number of studies have investigatedcognitive behavioural therapy (CBT) asa treatment for sleep problems in peoplewith chronic pain. CBT can be given eitherin group sessions or to individuals andaims to help people change any thoughts,feelings or behaviour that may be havinga negative impact on sleep.

CBT uses a number of different techniques:• Education teaches about sleep and

the factors which help or hinder it(including sleep hygiene).

• Sleep restriction aims to improve sleepefficiency (the proportion of time inbed that is spent sleeping). This is basedon the principle that lying in bed awakefor long periods makes sleep problemsworse in the long term. Bed times andgetting up times are adjusted to betterreect how much sleep you get.

• Stimulus control aims to help people

associate the bed only with sleep.Common strategies include removingthe TV from your bedroom and notworking or reading in bed.

• Cognitive therapy helps people toidentify and re-evaluate any negativethoughts and beliefs about their abilityto sleep.

• Relaxation and imagery training canbe helpful for people who nd it difficultto shut off their mind from the eventsof the day. Relaxation and imagerytechniques can help people to distractthemselves from stimulating thoughts.

Research now aims to establishwhether CBT is an effective treatment

for sleep problems associated withrheumatoid arthritis.

Removing stimulussuch as a TV from

your bedroom mayhelp you sleep.

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GlossaryAnalgesics – painkillers. As well as dullingpain they lower raised body temperature,and most of them reduce inammation.

Biorhythms – physiological functionsthat are regulated by hormones andrepeated in a rhythmic way. Many, such assleep, are based on a 24-hour cycle.

Cognitive behavioural therapy – apsychological treatment based on theassumption that most of a person’sthought patterns and emotional orbehavioural reactions are learned andcan therefore be changed. The therapyaims to help people resolve difficultiesby learning more positive thoughtprocesses and reactions.

Fibromyalgia – a long-term (chronic)form of widespread pain in the musclesand soft tissues surrounding the jointsthroughout the body.

Osteoarthritis – the most commonform of arthritis (mainly affectingthe joints in the ngers, knees, hips),causing cartilage thinning and bonyovergrowths (osteophytes) and resultingin pain, swelling and stiffness.

Rheumatoid arthritis – a commoninammatory disease affecting the joints, particularly the lining of the joint.It most commonly starts in the smaller joints in a symmetrical pattern – that is,for example, in both hands or both wrists

at once.

Where can I nd out more?If you’ve found this information usefulyou might be interested in these othertitles from our range:

Conditions• Back pain• Fibromyalgia• Neck pain• Osteoarthritis• Rheumatoid arthritis

Therapies• Complementary and alternative medicine

for arthritis• Complementary and alternative

medicines for the treatment ofrheumatoid arthritis, osteoarthritis andbromyalgia (80-page special report)

Self-help and daily living• Diet and arthritis• Everyday living and arthritis• Fatigue and arthritis• Keep moving• Pain and arthritis

Drug leaets• Drugs and arthritis• Non-steroidal anti-inammatory drugs

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You can download all of our bookletsand leaets from our website or orderthem by contacting:

Arthritis Research UKPO Box 177ChestereldDerbyshire S41 7TQPhone: 0300 790 0400www.arthritisresearchuk.org

Related organisations The following organisations maybe able to provide additional adviceand information:

Arthritis Care18 Stephenson WayLondon NW1 2HDPhone: 020 7380 6500Helpline: 0808 800 4050www.arthritiscare.org.uk

British Snoring & Sleep ApnoeaAssociationCastle Court41 London RoadReigate

RH2 9RJ Tel: 01737 245 638www.britishsnoring.co.uk

Edinburgh Sleep Centre13 Heroit RowEdinburgh EH3 6HP Tel: 0131 524 9730www.edinburghsleepcentre.com

London Sleep Centre137 Harley StreetLondon W1G 6BF Tel: 020 7725 0523

www.londonsleepcentre.comSleepnetwww.sleepnet.com

Further reading• Desperately Seeking Snoozin’:

The Insomnia Cure from Awaketo Zzz by John Wiedman. Universityof Wisconsin Press 1998. ISBN9780966418958.

• Overcoming Insomnia and SleepProblems: A Self-Help Guide UsingCognitive Behavioural Techniques by Colin A Espie. Robinson Publishing2006. ISBN 9781845290702.

• Say Goodnight to Insomnia: A Drug-Free Program Developed at HarvardMedical School by Gregg D Jacobs.Rodale 2009. ISBN 9781905744381.

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Notes

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We’re here to helpArthritis Research UK is the charityleading the ght against arthritis.

We’re the UK’s fourth largest medicalresearch charity and fund scientic andmedical research into all types of arthritisand musculoskeletal conditions.

We’re working to take the pain awayfor sufferers with all forms of arthritisand helping people to remain active.We’ll do this by funding high-quality

research, providing informationand campaigning.

Everything we do is underpinnedby research.

We publish over 60 information bookletswhich help people affected by arthritisto understand more about the condition,its treatment, therapies and how

to help themselves.We also produce a range of separateleaets on many of the drugs usedfor arthritis and related conditions.We recommend that you read therelevant leaet for more detailedinformation about your medication.

Please also let us know if you’d like

to receive our quarterly magazine,Arthritis Today, which keeps you upto date with current research and

education news, highlighting keyprojects that we’re funding and giving

insight into the latest treatment andself-help available.

We often feature case studies andhave regular columns for questionsand answers, as well as readers’ hintsand tips for managing arthritis.

Tell us what you thinkof our bookletPlease send your views to:[email protected] or write to us at:Arthritis Research UK, PO Box 177,Chestereld, Derbyshire S41 7TQ.

A team of people contributed to this booklet. The original text was written by consultantphysician and rheumatologist Dr FrankMcKenna who has expertise in the subject.It was assessed at draft stage by psychiatristDr Claire Goodchild. An Arthritis Research UK editor revised the text to make it easy to read,and a non-medical panel, including interestedsocieties, checked it for understanding.

An Arthritis Research UK medical advisor,Dr Ben Thompson, is responsible for thecontent overall.

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Get involvedYou can help to take the pain awayfrom millions of people in the UK by:

• Volunteering• Supporting our campaigns• Taking part in a fundraising event• Making a donation•

Asking your company to support us• Buying gifts from our catalogue

To get more actively involved, pleasecall us 0300 790 0400 or e-mail us [email protected]

Or go to:




Arthritis Research UKCopeman House,St Mary’s Court,St Mary’s Gate, Chestereld,Derbyshire S41 7TD

Tel 0300 790 0400 calls charged at standard rate


Registered Charity No 207711© Arthritis Research UK 2011

2062 sleep and arthritis

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