Sleep

Getting the right amount of good quality sleep has many benefits for our physical and mental health. Evidence suggests it’s just as important as having a healthy diet and doing regular exercise.

Good sleep can:

• help your concentration levels
• help you manage pain better
• allow your body to repair damaged tissue
• improve your immune system – the body’s natural defence against illness and injury
• help your mental well-being – not getting enough sleep can make you feel irritable or moody and increase feelings of anxiety and depression
• help you stay at a healthy weight – if you don’t get enough sleep you’re likely to have more chemicals in the body that make you want to eat more, and less of the chemicals that make you feel full.

Getting enough good quality sleep can play a big role in helping you manage a long-term health condition like arthritis. But, the pain from arthritis can make getting good quality sleep difficult.

If you’re having problems sleeping, there are positive steps you can take.

Sleep problems can take several forms:

• Some people have trouble getting to sleep but then sleep through the night.
• Others wake often during the night or wake too early in the morning.
• Some people don’t remember having disturbed sleep but don’t feel refreshed when they wake.

It’s normal to wake up once or twice each night. This only becomes a problem if you can’t get back to sleep again or if you’re not happy with the quality of sleep you’re getting.

Not getting enough sleep can add to any feelings of worry, anxiety and depression. It’s important to address any thoughts or feelings like this, by talking to people, such as family, friends or your doctor if you’re feeling low or worried.

Everyone needs different amounts of sleep. Most adults need somewhere between six and nine hours sleep a night. As we get older, we need less sleep.

You should ask yourself if you’re getting enough good sleep, by thinking about the following.

• Do you feel sleepy during the day?
• Do you struggle with energy levels?
• Do you feel refreshed when you wake up and during the day?

It normally takes people less than half an hour to get to sleep.

Not getting enough good sleep can lower the point at which you feel pain, this is known as your pain threshold. This could lead to:

• increased pain from an already painful condition
• pain from a condition that hadn’t been painful before
• pain that was felt only in a particular part of the body becoming more widespread.

An example of a link between poor sleep and pain is the condition fibromyalgia. This can cause pain and tenderness in many areas of the body. The pain is not directly caused by an injury or damage to a part of the body. It is thought to be caused by a problem with the central nervous system (CNS), which is responsible for processing pain messaging. The CNS misreads messages from other parts of the body and registers only slight touches as pain stimuli. This makes people feel pain when there’s no reason to.

People with fibromyalgia very often have poor sleep patterns. They often say they had disturbed sleep before the pain and stiffness began.

Restless legs syndrome gives people unusual and sometimes unpleasant sensations in their legs that can disrupt sleep. It can make you feel like you want to move your legs. It can occur at any time but is often worse at night.

A related condition called periodic limb movement disorder only occurs at night and causes the arms or legs to jerk or twitch.

These conditions can affect anyone but are quite often linked with long-term conditions. They can also be a side effect of some medications or be caused by not having enough iron or vitamins in your body.

You should see your doctor if either of these conditions are affecting your sleep.

The following can help:

• talking to your doctor about medications that might be causing this, and looking at what changes you might be able to make
• taking iron or vitamin supplements
• avoiding caffeine and alcohol
• stopping smoking
• losing weight if you are overweight
• identifying any stress in your life and taking steps to deal with it
• stretching and massaging your leg muscles.

If your symptoms are severe, your doctor may suggest treatment with a group of drugs called dopamine agonists. Examples of these drugs are ropinirole and pramipexole.

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

Severe snoring may be a sign of obstructive sleep apnoea syndrome, a condition caused by brief blockages of the upper airway during sleep.

You may be more likely to get this if you:

• are overweight
• have a large neck circumference
• smoke
• have diabetes
• have a long-term blocked nose.

It can cause fatigue and can be diagnosed by measuring the level of oxygen in the blood during sleep.

Treatment for obstructive sleep apnoea syndrome includes:

• staying at a healthy weight
• avoiding alcohol
• positive airway pressure, which involves wearing a mask during the night
• drug therapy
• surgery to clear a blockage in the upper airway.

For more information visit the British Snoring and Sleep Apnoea Association website.

Keeping a diary of how well you’re sleeping and nights when you don’t sleep so well, might allow you to spot helpful patterns.

The diary can include:

• the time you went to bed and when you woke up
• whether you got to sleep easily or not
• any causes of disturbance, such as your mood, pain or fatigue
• what you ate and drink in the late afternoon and evening
• your daytime activities.

If your sleep is disturbed by pain, then physiotherapy, exercise and possibly drug treatments could help. However, sleep disturbance is often caused by a number of issues, which may include pain but also fatigue, stress or depression. 

These issues can sometimes be difficult to deal with and might require long-term treatments or solutions.

There are also things you can do in the short term. Healthcare professionals might talk about sleep hygiene, which are ways to give you the best chance of getting a good night’s sleep. Have a read through the sections below, and see if you can try some or all of these tips.

In the bedroom

• Try not to use your bedroom for 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.
• Put the screen down. Phones, tablets, laptops and other electrical devices can make getting to sleep harder. They give off light that can stimulate the brain and make it think it’s daytime and therefore not time to be sleeping.
• A tidy, clean and uncluttered bedroom with clean linen can help you feel relaxed. Fresh potpourri in the room can also make it feel relaxing.
• Thick curtains can help keep out the light and can have big impact on your quality of sleep.
• If your mattress is old or uncomfortable, you should probably consider replacing it. 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. While others like to rest a pillow between their knees, while lying on their side.

Getting into a good routine

• Try getting up and going to bed at the same time, even if you had an unsettled night. This will help to train your brain that you’re tired.
• When you wake up in the morning, get out into the natural light as soon as is practical – it’s good to do this at the same time each day if you can. This will help you reset your body clock and make you feel alert. This will still work if it’s a grey or cloudy day.
• Avoid sleeping during the day because this can make it more difficult to get to sleep at night.
• Take a warm bath before going to bed as this may help ease stiff or painful joints.

Healthy habits

• Avoid caffeine – for example in tea, coffee, chocolate, cola and energy drinks – after midday. This is a stimulant that can cause poor sleep.
• Eat sensibly so you don’t feel hungry during the night but avoid eating and drinking large amounts just before bedtime.
• Avoid drinking alcohol if you’re having difficulty sleeping. While at times it can make you feel sleepy, alcohol can make sleep quality worse and cause you to wake too early feeling unrefreshed.
• There is evidence that smokers are more likely to have sleeping difficulties compared to non-smokers. This is because of nicotine, which is in cigarettes and can cause insomnia and withdrawal symptoms. If you smoke, quitting could really help improve your sleep as well as your overall health. It’s particularly important to avoid smoking during the evening and at night-time.
• Doing regular aerobic exercise can really improve your sleep. This is anything that gets you at least a bit out of breath. For example, it could be brisk walking or swimming. This can help you unwind and will tire you out and lead to deep and refreshing sleep. It’s best to avoid doing any exercise close to bedtime, so that your muscles and joints don’t feel stiff.
• You could try relaxation techniques to help you sleep. Some people find that yogic breathing helps them relax. It involves breathing in slowly and deeply, holding your breath for a few seconds, before breathing out fully and slowly. For more information about how yoga might help you, you could find yoga instructors near you on the British Wheel of Yoga website.

If you do struggle to sleep

• Don’t look at a clock during the night, as this can make you anxious.
• If you’re really struggling to sleep, it might be better to get up and do something that’s not stimulating, such as listening to soothing music or having a milky drink. Only go back to bed when you’re sleepy.
• If there’s anything on your mind, write it down on a pad next to your bed and then try to forget about it. Do this with a pen or pencil and paper, and not a phone or electronic device.
• Try not to worry. Many people do suffer with sleepless nights from time to time and it’s often only temporary.
• If you are regularly waking up in pain, see a relevant healthcare professional, such as your GP, rheumatology consultant, rheumatology nurse or a physiotherapist. There will be things you can do to improve your symptoms, such as changes to your medication, or lifestyle changes, including exercise.
• Talk to your doctor about what time you should take your medication, in case it affects your sleep. For example, taking steroid tablets later in the day can affect the body clock and may disrupt sleep.

For more information and advice about getting a good night’s sleep, visit The Sleep Council’s website.

Research has shown that people who have trouble sleeping may benefit from cognitive behavioural therapy (CBT). This is a talking therapy that can help you manage your problems by changing the way you think and behave. It helps you break down what feels like an overwhelming problem into smaller more manageable parts.

Cognitive behavioural therapy for insomnia (CBT-I) is for people who have trouble sleeping. It uses methods such as:

• sleep restriction – reducing the time in bed so that you’re only in bed when you are tired
• managing worries about sleep
• relaxation training.

Your doctor could give you more information and help you find a service.

If you’re still struggling to sleep, see a doctor. There are drugs that may be helpful if sleep hygiene methods aren’t working. You’ll need to discuss with your doctor or pharmacist the advantages and disadvantages of medication.

Painkillers

Taking paracetamol, with or without codeine, just before going to sleep can ease pain symptoms for a time to allow you to get to sleep, but it’s unlikely to last all night. Non-drowsy painkillers that include caffeine could disrupt your sleep.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs such as ibuprofen or naproxen reduce pain and stiffness. Although these drugs have potential side effects, they can be very useful, particularly in the short term. Taking your last dose of the day before bedtime, with or after food, can reduce pain and stiffness throughout the night.

Sedating antidepressant drugs

Some antidepressant drugs, such as amitriptyline, dosulepin and trazodone, have sedative effects, which means they make you feel sleepy, and may also reduce pain. These drugs aren’t given as sleeping tablets but may improve sleep as an added benefit. It’s often best to take them a few hours before going to bed so that the effect has worn off by the morning.

Sedatives, also known as hypnotics

Temazepam, zolpidem and zopiclone are examples of drugs that are sometimes given to help people sleep. They’re sometimes called hypnotics. They help you go to sleep but may not stop you waking up throughout the night.

Doctors often advise against using sedatives in the long term because of the risk of dependence, which means you can become addicted to them. The effect often wears off after a few days of taking them. There’s also a risk of side effects, but they can be helpful for short-term use. In some rare cases, long-term use of these drugs may be better than long-term sleep loss.

Many people experience painful muscle cramps during the night. Your doctor will review if any medication you’re taking could be causing the cramps, for example diuretics or statins. Doing stretching exercises before you go to bed can help. If the problem continues, you may be prescribed a short course of a drug called quinine sulphate, which can be useful for reducing these pains, though it doesn’t work on other types of pain. Tonic water may also work as it contains a small amount of quinine.

In addition, there are other drugs that are usually prescribed in people who have long-term pain and these drugs may sometimes have useful effects on sleep, for example pregabalin and gabapentin.

We are currently funding research at the University of Aberdeen, to help us understand how pain, sleep, and exercise are interconnected for people with chronic pain. The researchers plan to use the information gathered to design a new combined exercise and sleep programme to trial with patients. If successful, this could reduce pain and disability in patients by improving sleep and exercise habits.