One of the most common topics we get asked about at the clinic is whether sleep problems are symptomatic of fibromyalgia and although problems with sleep are very common, it’s not quite so simple to answer. This is because it may well be a direct symptom for some people, whilst for others it may be caused as a direct consequence of lifestyle choices, or it might even be a bit of both, either way it’s a problem that affects so many of us.
We all know we feel so much better after good night’s sleep, we wake up feeling refreshed and the benefits continue onto optimizing the way we function for the rest of the day.
Quality sleep is vital for maintaining a good state of health and in many ways sleep is a recovery process for the mind and body to recoup and repair. However, when you don’t get enough restorative sleep, the body doesn’t get enough time to complete this essential recovery process and we soon know what we’re missing out on!
Everyone is different when it comes to the number of hours we need for a good night’s sleep, but unrefreshing or poor-quality sleep, the inability to fall asleep and stay asleep, are all defined as insomnia, classified as:
Sleep Onset Insomnia: Difficulties falling asleep
Sleep Maintenance Insomnia: Difficulties staying asleep
Short-term or transient insomnia: Disruption of sleep that lasts from one single night to several weeks
Intermittent or on / off: Occasional episodes of transient insomnia
Constant or chronic: Poor quality sleep that occurs most nights over a month or longer, is referred to as chronic insomnia
It’s estimated that 14,000 people are diagnosed with fibromyalgia every year and seven times more women than men, statistics show that over 50% of people diagnosed have suffered with sleep problems. The most common sleep disorders are difficulty getting off to sleep, frequent interrupted sleep cycles or waking in the early hours. There are several factors that impact on sleep, including:
The Effects of Sleep Deprivation
Overtime, an accumulation of sleep loss results in a “sleep-debt” that must be repaid, otherwise the body pays the consequences, including disruptions of the body’s circadian rhythms and homeostasis, also problems with the body’s metabolic processes and mental health problems.
The lack of restorative sleep, or sleep deprivation, is the cause of many health conditions that affect people with fibromyalgia in several ways:
Increased Pain: Sleep studies on patients with fibromyalgia have shown that the frequency of alpha-wave intrusions during delta-wave sleep have been associated to low level production of Growth Hormone which is necessary for muscle repair.
Interruptions to the sleep cycle can impair the healing of muscle tissue damage, prolonging the transmission of sensory information from the damaged muscle tissue to the central nervous system. This enhances the perception of muscle pain and the discomfort contributes to a bad night’s sleep, in turn, an increased level of pain during a bad night’s sleep generally results in fatigue.
Cognitive Impairment: Sleep deprivation causes drowsiness during the day and in turn can affect mood, cause irritability, lead to relationship problems and productivity. Lack of refreshing sleep makes our decision making and problem solving difficult, as well as reducing the ability to form memories and learn new things.
When you don’t get the sleep that you need you are more likely to feel more fragile and on edge, causing an increase in sensitivity to life’s stressors. When you start to feel easily stressed, it follows that your anxiety levels increase with a ripple effect resulting in a loop of insomnia, heightened anxiety and chronic stress takes hold. Ultimately this can lead to various health problems, such as high blood pressure, heart disease, hormone imbalance and weight gain, type two diabetes, inflammatory illnesses and increased levels of pain are just a few.
At worst, sleep deprivation can cause accidents, some fatal, and according to the National Department of Transportation, nodding off at the wheel causes 1,500 deaths and 40,000 non-fatal injuries every year. You can begin to see why getting the right amount of quality sleep is essential for not only a well-rested mind where you can make better lifestyle choices, but also manage pain and take better care of your health.
Muscle Tissue Repair / Pain Relief: Regeneration and muscle growth rely on the growth hormone produced during the sleep cycle and this function relies on a specific recovery time to be effective. Muscle mass increases the body’s metabolic rate and the number of calories you burn, but lack of sleep interrupts this process and slows the development of muscle mass, despite all attempts at exercise to build muscle. Quality sleep, exercise and a healthy diet are all fundamental to the effectiveness of managing fibromyalgia pain.
Neuro-chemical and Hormone Imbalance: A good night’s sleep is essential for a healthy endocrine system and keeping your hormones in check. Getting a minimum of seven to eight hours sleep each night is needed to support the body’s hormone production.
Studies have shown that less than six hours sleep interrupts the balance of appetite control hormones, ghrelin which stimulates hunger and leptin which signals appetite satisfaction. Lack of sleep influences how your body produces increased levels of ghrelin and decreases the levels of leptin.
When this imbalance occurs it causes food cravings and an unsatiable appetite where no amount of determination works to control hunger, resulting in weight gain or obesity if not managed effectively.
Cytokines are powerful chemicals that help to induce sleep and are involved in the immune system where they regulate various inflammatory responses, studies have shown low level of cytokines in fibromyalgia sufferers.
Frequent sleep disturbance triggers the production of cortisol, a stress hormone involved in several bodily functions. Cortisol activates stress-related fat gain and cravings for salty or sweet foods which are known to increase inflammation. Sugary foods cause a spike in blood sugar (glucose) during sleep which can wake you up from your slumber. Sugary foods increase the body’s need for insulin which allows the body’s cells to use glucose for energy and a long-term imbalance of these hormones may lead to type two diabetes, obesity as well as many other health complications.
Tryptophan is an amino acid (5HTP) and a pre-curser to serotonin, the happy hormone. Tryptophan is available to us in many foods such as turkey, chicken, eggs etc., but only becomes available to the brain when eaten with carbohydrate. Serotonin is involved with the production of melatonin, a hormone secreted by the pineal gland which is essentially needed for the transition of going from being awake to drifting off to sleep.
Melatonin helps to regulate the body’s circadian rhythms, the body’s internal clock which produces melatonin when it gets dark until it dissipates when it becomes day light and serotonin is stimulated under normal circumstances. However, there are many studies where testing on patients with fibromyalgia have shown to have low levels of serotonin and this may also contribute to problems with the sleep-wake cycle.
Quality sleep is also important for the health of female monthly cycles and fertility, where follicle-stimulating and luteinizing reproduction hormones are released during sleep.
How the Body Prepares for Sleep
We might believe that sleep is the time for our body to shut down, when in fact, sleep is an active physiological process vital to our health.
The body’s ability to become drowsy relies on adenosine, which are powerful molecules involved in the digestion process and production of energy. Glucose, (blood sugar) gets broken down into a metabolic cellular pathway where adenosine triphosphate is responsible for the body’s production of energy transportation between cells. This decomposes into adenosine that builds up in the blood stream and inhibits the activity of the central nervous system which causes drowsiness. In simple terms, this is part of the natural sleep-wake cycle, when the body runs out of fuel from the food we eat, adenosine signals the body to become drowsy, essentially telling us to sleep and restore our energy reserves.
Disruption of Sleep and the Effects of Caffeine
Adenosine plays an important role as a neural inhibitor that causes the feeling of drowsiness, signalling the urge to sleep, restore energy levels and initiate a chain reaction of early stages of non-REM sleep which is the essential first stage of sleep. One of the major disruptions to this process is caffeine, which is considered an adenosine blocker and a disrupter of the sleep cycle.
Caffeine, a favourite pick-you-up for many, is abundant in coffee, types of tea and cacao plants. It works by stimulating the nervous system and arousal part of the brain, helping you to stay awake or increase concentration. The downside is that the chemicals in caffeine attach to the same receptors in the brain that adenosine would normally attach to. The result is that adenosine is blocked and prevents the onset of drowsiness that would otherwise occur. However, once the caffeine wears off, the adenosine kicks back in and reboots the process of causing drowsiness but not necessarily at the best time and increases the urge for more caffeine.
This is not good news for your sleep-cycle and causes a peak of alertness that dips back into grogginess, leaving an excessive build-up of adenosine that remains in the body during the day but does not fully dissipate during the normal sleep cycle. When this is the case, it is likely to make you wake up feeling unrefreshed from sleep and tired throughout the rest of day, at least until you re-load your system with more caffeine.
Although small amounts of caffeine have shown to improve mood, increase dopamine and adrenalin, as well as stimulate brain function, too much can lead to addiction, restlessness, palpitations, anxiety and most definitely disrupt a good night’s sleep.
Your Biological Clock
Sleep deprivation can wreck your life so it’s worth having basic understanding of the sleep-wake cycle.
The sleep-wake cycle consists of approximately 8 hours of nocturnal sleep and 16 hours of daytime wakefulness, controlled by two internal biological mechanisms that regulate a 24-hour internal circadian rhythms and homeostasis
Sleep is synchronised to both an external physical environment and behaviour schedules. Light has the strongest influence on humans, but we rely on both light and dark as external signals to set our biological clock which regulates both sleep and time to wake up.
Homeostasis is the mechanism by which the body maintains a stable internal state, including metabolism, heartbeat, respiratory and digestive system, acid-alkaline balance, stress response and keeps track of your need for sleep. The homeostasis sleep drive gets stronger every hour you are awake and like a blueprint, reminds the body to sleep after a certain time, regulating and intensifying the need for sleep following a period of sleep deprivation to recoup the sleep debt.
From the moment we wake, the homeostatic drive for sleep slowly accumulates levels of adenosine throughout the day, promoting arousal particularly in the reticular activating system, (RAS), then finally reaches its peak in the evening which causes the body’s urge to sleep. During the night, various hormones are produced and the levels of adenosine start to decrease, gradually reducing the need for sleep and in combination with the circadian rhythm, urges you to wake up.
A note on the reticular activating system, known as RAS, are a bundle of nerves in the unconscious part of the brain that act as a filter mechanism for information, (stimuli), which is then sent to the conscious part of the brain. Whilst levels of adenosine drop during sleep, this reduces the activity of RAS and filters out unnecessary stimuli information, such as noise, smell and touch, being transmitted to the conscious brain allowing for a peaceful sleep.
A malfunction in this process might account for many fibromyalgia sufferers who complain of repetitive interruptions during their sleep cycle and possibly due to heightened sensitivity to numerous stimuli. Also, it is worth noting that certain medications and drugs such as caffeine, actually block the adenosine receptor, potentially creating havoc with the sleep cycle and the reticular activating system, creating an increase in sensitivities.
The circadian rhythm, your biological clock, consists of a group of nerve cells in the hypothalamus part of the brain called the suprachiasmatic nucleus. Their function is a fine balance of biological cycles, including fluctuations of body temperature, hormone levels and sleep cycle, over a 24-hour period, which is particularly sensitive to major changes in the natural sleep-wake cycle, such as night shift working or time zones.
There is a great deal of evidence that supports the theory that the best quality sleep is attained by adhering to the synchronization of the body’s biological clock, the internal circadian rhythms and the external light-dark cycle. The advice suggests that following a routine of getting to bed and waking up at more or less at the same time on a daily basis, including weekends or holidays.
The Stages of Sleep
Your body has a natural clock called the circadian clock that helps to regulate sleep which is strongly influenced by light and contributes to getting the right mix of sleep. A normal sleep cycle consists of four stages which alternate non-REM and REM (rapid eye movement) every 90 to 110 minutes which is repeated four to six times through the night and is known as “sleep architecture”.
Non-REM (NREM) type of sleep has four stages and involves lower amount of physical activity, breathing and heart rate slows down, body temperature decreases, eye movement stops and brainwaves slow down as the sleep becomes deeper.
REM type of sleep is an active period of sleep with fast, desynchronized brainwaves and when most dreams occur. Heartbeat and breathing increases, muscles become temporarily paralyzed and eyes move rapidly in all directions.
Stage 1: Non-Rem sleep is the dozing off stage when the changeover from wakefulness to sleep occurs. Muscles begin to relax, often causes a twitch or jerk sensation and lasting up to 5 minutes.
Stage 2: Non-REM sleep the body enters a more subdued state, heartbeat and breathing slows down, body temperature drops and eye movement cease. Brain activity slows down with intermittent short bursts of activity which lasts for about 10 – 25 minutes during this first sleep cycle.
Stage 3: Non-REM is part of the sleep cycle that is needed for you to feel refreshed in the morning and is critical for the body to repair and recuperate. Brainwaves and brain activity slow down, but it is thought that this stage of deep sleep is important in contributing to being insightful, your creative thinking and memory. Your muscles continue to relax, heartbeat and breathing are at their lowest as you continue this deep sleep which lasts around 20 – 40 minutes.
Stage 4: Rem sleep is the final stage of the sleep cycle and occurs usually about 90 minutes after first falling asleep. Eyes move rapidly behind closed eyelids, there is mixed frequency brain wave activity, heartbeat and breathing is irregular and speeds up. The muscles in your body become temporarily paralyzed to stop you acting out your dreams and blood pressure rises on the final stage of the cycle which lasts for about 20 – 40 minutes.
The four stages of sleep are repeated 4 – 6 times during the night where you enter REM sleep stage after 90 minutes which may only last minutes during the first cycle and becomes longer during the second half of the night, lasting up to about an hour. REM stage of sleep is believed to be essential to our cognitive functions, such as memory, concentration, learning and creativity.
Although dreams can occur in any sleep stage they are more vivid during REM sleep stage whilst there is an increase in brain activity. The four stages are important and both deep sleep and REM sleep are predominant factors in the body’s ability to recuperate, repair and develop.
For people with fibromyalgia who are frequently awoken during the earlier stages of sleep, may then struggle to enter the cycle of deeper sleep stages where the repair and recuperation takes place. Insomnia may cause a person to not get enough time asleep in order to accumulate the time needed to complete each sleep stage.
Overcoming Sleep Problems
There are many prescriptive medications that help with insomnia which you can get advice from your doctor. There are also many ways you can try to help manage a better night’s sleep, such as:
- Avoid caffeine in the afternoon and evening.
- Cut down on sugar, alcohol and heavy meals before bedtime.
- Regulate the bedroom temperature to no more than 19°C
- Make the room dark.
- Try to keep regular hours, make a habit to go to bed and rise at the same time
- Turn off all social media and TV.
- Give yourself a set time to unwind, either read a book or write a journal to offload any worries.
- Practice a breathing exercise or a body-scan to relax the mind and body.
- Listen to calming music or a yoga nidra session.
- Practice meditation or guided imagery technique.
- Diffuse relaxing aromatherapy oils such as lavender.
- Make your bedroom into a space of relaxation, remove all clutter and work-related items.
- Manage and reduce the stress in your life by building a habit of practising something like mediation, yoga, qigong, singing, dancing, crafting, etc.
- Share your worries and talk to others about your concerns, try not to let things build up.
- Eat a healthy diet of whole foods and naturally rich in tryptophan to increase serotonin, vitamin B complex and magnesium to calm the nerves.
- Try to include daily exercise and get out in the fresh air.
- Try natural remedies such as CBD oil, or herbal teas like chamomile, hops, valerian and lemon balm, which are natural nerve relaxants.
- Embrace the quiet.
There is good evidence researched from sleep studies to show that various foods give promising results as natural remedies to promote a good night’s sleep, here’s just a few:
Tart Cherry Juice, (not to be mistaken for the sweeter cherry), is packed full of antioxidants, anti-inflammatory properties, tryptophan (serotonin pre-curser) and melatonin which acts on the receptors in your body that encourage sleep. This bright red juice is naturally high in potassium which is needed to conduct electrical impulses throughout the body and aids muscle and nerve recovery, which makes it a beneficial tonic for fibromyalgia patients. It has shown to have similar effects as some sleep medications as well as having numerous health benefits and is best when using the natural unsweetened variety.
Almonds are a good source of magnesium, a mineral that is responsible for over 300 functions in the body, including promoting relaxation of the muscles and nerves.
Walnuts are a good source of melatonin and magnesium, as well as many other beneficial nutrients. Eating a handful of walnuts in the evening raises the melatonin levels in the blood and helps to regulate the sleep cycle.
Chamomile tea contains apigenin, one of the bioflavonoids that is known for its sedating properties, helping to reduce the physical symptoms of anxiety. Chamomile is full of nutrients and antioxidants that bind to certain receptors in the brain that help to encourage sleep.
Passionflower tea has been used traditionally for many years to treat a number of ailments, including insomnia. Similar to chamomile, it contains apigenin but also compounds that help to increase the production of GABA, a brain chemical that works to inhibit the activity of glutamate, an abundant excitatory neurotransmitter. Taken as a tea before bed, passionflower is a good alternative to counting sheep.
You might want to consider taking a supplement, such as 5-HTP, a pre-curser to serotonin which converts to melatonin, it is advised that you talk about this with your doctor to check for any contra-indications.
Author Jok Saunders, founder of the Fibro Clinic South West