Abstract
Studies indicate that pain interferes with sleep and, in turn, sleep disturbances increase pain. Statistics show that up to 60% of those with arthritis experience pain during the night. But despite these findings, sleep is not generally addressed as a major treatment concern among this population. This article reviews the relationship between pain and sleep; sleep issues as they relate to 3 common types of arthritis-osteoarthritis, rheumatoid arthritis, and fibromyalgia; and holistic approaches that may be used by the patient in the self-management of pain and sleep.
Arthritis, or rheumatic disease, affects more than 37 million Americans. 1 Some 100 different types of arthritis exist, with the 3 most common forms identified as osteoarthritis (OA), rheumatoid arthritis (RA), and fibromyalgia syndrome (FMS). This article will focus on these conditions for the discussion of pain and sleep.
OA, the most common condition, usually affects the hands and the lower weight-bearing joints, such as the knees and hips. Clinical criteria often used to define OA include joint pain, aching, stiffness, and limitation of motion. 1 Inflammation is also a symptom in some cases. RA is an inflammatory disease that involves soft tissue swelling, typically of the hands and wrists. Associated clinical criteria include morning stiffness of at least 1 hour and soft-tissue swelling of joints. FMS is not as easily defined. Thus, it is described as widespread chronic musculoskeletal pain of unknown cause, involving at least 11 of 18 specified tender points. 2 Fibrous tissue such as muscles, tendons, and ligaments in all 4 body quadrants is affected.
About 70% of persons suffering from chronic pain report poor sleep patterns. 3 Even though this problem is so frequently associated with chronic pain, sleep disturbance has not been addressed as a major treatment concern among those with arthritis. This is interesting in light of a 1996 National Sleep Foundation Gallup Poll finding that 30% of those persons who experienced pain during the night had arthritis. For persons older than 50, the percentage increased to 60%. Among this group, sleeping difficulties occurred on an average of 10.7 nights per month. 4 A similar finding was described by a sample of 242 RA patients, with 57% reporting that their sleep was restless most of the time and 14% indicating that the sleep interference was severe or very severe. 5 This high incidence of sleep disturbance in the arthritis population has been verified by other studies. 6,7
Insomnia, daytime difficulties, and psychological distress are among the sleep-related problems reported by those with chronic pain. This discussion will focus on insomnia, a symptom that may be characterized by delayed sleep onset, awakening from sleep frequently, waking too early in the morning, or feeling sluggish upon awakening. Daytime difficulties that may be worsened by insomnia include pain, fatigue, alertness, and levels of physical and mental function. Psychological distress, including increased depression or anxiety, is another important factor to consider. Whether sleep disturbance precipitates or follows the physiological and psychological issues is debatable. Most likely, they are cyclical in nature. The interrelationships among these sleep-related variables call for a holistic approach to management, involving the patient in self-management.