Increase the Quality of Your Sleep : Painful Sleep: More Than a Nuisance

Almost all patients with pain suffer from sleep problems and the resulting daytime sleepiness and fatigue. Ron, a forty-one-year-old former professional soccer player, said he had not slept more than 2 or 3 hours a night for weeks. While that sounds exaggerated, I’m sure he was basing that on the way he felt each day: fatigued, weary, and irritable with an inability to concentrate or be productive at work. Ron wanted relief—now. But before he could begin to sleep well, I explained that he had to deal with his pain problem. As you probably know, if you are in pain at night, it is virtually impossible to relax and sleep well.

In this last step in your Pain-Free program, I want to help you solve the problem of pain interfering with your sleep. I’ll explain how inflammation and obesity are both linked to quite serious sleep disorders such as obstructive sleep apnea (OSA), a problem in which the person literally stops breathing many times throughout the night. OSA is increasingly common among many overweight patients who also suffer with pain.

Because lack of sleep is now thought to decrease the level of serotonin in the body (a brain neurotransmitter that contributes to a relaxed mental state and also plays a role in the pain that you feel), I will unravel these findings so you can see how the sleep-pain-inflammation puzzle fits together—especially in your situation. Finally, I want you to sleep—tonight! So I’ll suggest some helpful, practical sleep strategies that have worked for my patients and will help you relax your mind and body, ease your pain, and finally get healing sleep.

A century ago, Americans used to sleep an average of 10 hours each night. But that was before Thomas Edison perfected the incandescent lightbulb in 1880. Since then, the number of hours Americans sleep has greatly declined. When you add the addictive power of television, home video, and high-speed Internet, is it any wonder that the average American today only sleeps 6½ hours? According to the National Sleep Foundation, the proportion of adults in the United States sleeping less than seven hours per night has increased from 16 to 37 percent over the past forty years. Not only can lack of sleep put undue stress on the body, it can result in physiological changes that increase your pain, affect your cognitive skills and job performance, increase inflammation in the body, and even seriously disrupt your breathing at night.

Increases in Pain and Moodiness

Many different pain ailments are associated with sleep disturbances. But researchers are not certain if the sleep problem causes the increase in pain or if the pain itself causes the sleep disorder.

There are five stages of sleep (see sidebar, above). REM (rapid eye movement) sleep, during which we dream, is associated with psychological well-being and feeling refreshed upon awakening. People who are deprived of REM sleep complain of irritability and moodiness. Stages 3 and 4 appear to be the most important for physical recovery. If sleep disturbances occur during these stages, you will wake up feeling tired and may complain of muscular aches and pains.

About twenty years ago, scientists in Toronto, Canada, discovered that patients with fibromyalgia syndrome had stages of sleep that were contaminated by an “alpha rhythm,” the normal brainwave of a person who is awake—not asleep. In the study, researchers showed that healthy volunteers deprived of delta sleep (the deepest stage of sleep) by being exposed to noise, also developed periods of deep sleep mixed with alpha waves, again like those brainwaves seen in wakeful states. Interestingly, when deprived of delta sleep, these people experienced musculoskeletal discomfort and mood symptoms similar to those of the patients with fibromyalgia. These findings suggest that this sleep interruption itself may have contributed to the achiness or pain and mood symptoms. Your body needs deep sleep to repair itself.

Poor-quality sleep also leads to lower levels of serotonin in the body. Serotonin is a naturally occurring neurotransmitter (brain chemical) that is associated with a calming, anxiety-reducing feeling in the body. When serotonin is depleted from lack of sleep, the result is an increase in sensitivity to pain, as well as increased feelings of anxiety, malaise, and even depression. There are also studies showing that a decrease in serotonin triggers an increase in appetite, particularly for carbohydrates such as candy, pastries, and other baked goods.

Decreases in Alertness and Performance

Not only is sleep deprivation associated with increased pain or decreased pain tolerance, it causes changes in other mental functioning. If you are sleepy during the day, this can lower your concentration and lessen your short-term memory. Your energy, productivity, and attention to detail are all compromised. Some patients who suffer with night after night of sleep loss because of pain often ask if they have attention deficit disorder (ADD), a problem that is associated with an inability to focus or pay attention, and sometimes with impulsive behaviors.

For instance, perhaps this is coincidence, but I find it unsurprising that both the Chernobyl and Three Mile Island nuclear disasters occurred in the early morning hours, when the body wants and needs sleep. And while most people think that a captain’s drunkenness caused the Exxon Valdez oil spill, the National Commission on Sleep Disorders says otherwise. The real problem may have been the severe fatigue of the ship’s third mate, who was in charge at the time of the accident.

Activities that involve total concentration, such as driving a car, are much riskier because of the tendency for a sleep-deprived person’s attention to wander without diversion or constant stimulation. I find it interesting that the National Commission on Sleep Disorders concluded that drunk driving causes fewer fatalities than does sleepiness. In fact, the National Sleep Foundation estimates that 100,000 traffic accidents and 1,500 fatalities occur each year due to driver fatigue. Studies reveal that the day following the switch to daylight savings time, when an hour of sleep is lost, traffic accidents increase by 7 percent. When we later gain the hour back going off daylight savings, we see the opposite—a 7 percent decrease in traffic accidents.

Increases in Appetite and Weight

A recent study of healthy volunteers in the medical journal Sleep found that those who slept 2 to 4 hours a night were over 200 percent more likely to be obese than those volunteers who got 7 hours of sleep. In fact, one study found, just a 16-minute loss of sleep per night also increased the risk of obesity.

These studies indicate that sleep loss lowers the level of leptin, a hormone that stimulates metabolism and decreases hunger. Sleep loss or shorter hours of sleep appear to boost the concentration of the hormone ghrelin, which increases hunger.

In a study of middle-aged women, researchers concluded that weight gain was related to the amount of sleep each night. This study started about twenty years ago when more than 68,000 women were asked every two years about their sleep patterns as well as their weight. After sixteen years, the findings revealed that those women who slept 5 hours or less each night weighed 5.4 pounds more than the women who slept 7 hours. The researchers thought that the women who slept less were not only threatened by weight gain but by obesity, as well. For instance, women who slept 5 or less hours per night were 15 percent more likely to become obese than were women who slept 7 hours each night.

In line with these studies, there is increasing evidence that people who sleep less than 6 or 7 hours a night have a higher risk for diabetes. Researchers at the University of Chicago found that losing just 3 to 4 hours of sleep over a period of several days is enough to trigger metabolic changes that are consistent with a prediabetic state. The body’s ability to keep blood glucose at an even level declines significantly. This may be because sleep deficit affects the immune function of the body. In one study, scientists found that a 45 percent reduction in total sleep time resulted in a nearly 30 percent reduction in cellular immunity. Getting quality sleep is now considered a basic defense mechanism to staying healthy and preventing disease.

Reductions in Levels of Human Growth Hormone

We now know that as deep sleep decreases, so does the secretion of human growth hormone. By the time a person is thirty-five, this can decrease by as much as 75 percent. Studies have shown that this hormone deficiency can lead to obesity, loss of muscle mass, and a reduced capacity to exercise.

We want to do everything in our power to promote deep sleep and the production of growth hormone, so overweight baby boomers with chronic pain can lose weight, reduce inflammation and pain, and be active again.

Inflammation and Obstructive Sleep Apnea (OSA)

When you lose sleep (even just an hour a night), pro-inflammatory chemicals are markedly increased in the body, resulting in pain. Now some experts believe that there is a possible link between OSA and inflammation.

Snoring is caused by the vibration of the soft parts of the throat while breathing in and out during sleep. OSA involves periods of breath-holding while snoring. The periods of stopped breathing are called apneas, which are caused by obstruction of the upper airway. Apneas may be interrupted by a brief arousal that does not awaken you completely—you often do not even realize that your sleep was disturbed. Yet if your sleep was measured in a sleep disorders laboratory, technicians would record changes in the brain waves that are characteristic of the arousals.

Obstructive sleep apnea results in low oxygen levels in the blood, because the blockages prevent air from getting to the lungs. The low oxygen levels also affect brain and heart function. OSA is more common than asthma in adults, and up to two-thirds of the people who have obstructive sleep apnea are overweight.

For those who have OSA, elevated levels of pro-inflammatory markers in the body can directly worsen of the problem. Those with more than twenty apneas (complete obstructions) per hour of sleep may have a greater risk of dying from cardiac rhythm and rate disturbances, and complications of high blood pressure such as stroke and heart attacks, than do people with fewer apneas.