The American College of Rheumatology (ACR) defines fibromyalgia as, “a common health problem that causes widespread pain and tenderness (sensitivity to touch). The pain and tenderness tend to come and go, and move about the body. Most often, people with this chronic (long-term) illness are fatigued (very tired) and have sleep problems.”
Fibromyalgia is a condition that can complicate sleep. More so, the relationship between fibromyalgia and sleep disturbance is often described as a vicious cycle. The persistent pain prevents sleep continuity and the non-restorative sleep increases the sensitivity to pain.
Why is sleep so important for fibromyalgia?
For starters, sleep is more than just a time to rest the brain. It is an active process that supports the hormonal balance necessary for immune defenses and the anti-inflammatory response to stressors that occur during the wakeful state.
Fibromyalgia patients frequently complain of non-restorative sleep. This complaint is quite different than when a person complains of insomnia. Patients with fibromyalgia awaken frequently during sleep, and often (but not always) have a memory of these waking states or not. The interrupted sleep results in fatigue and lack of energy the next day. Even more disturbing is that the** sensitivity to pain is more pronounced**.
Why are fibromyalgia 'awakenings' different from other forms of insomnia?Insomnia is defined as difficulty initiating or maintaining sleep with resulting daytime consequences. The most pervasive consequence of insomnia is daytime sleepiness, which interferes with the ability to function during the day. However, there are some differences in the disrupted sleep in fibromyalgia. In order to understand the disturbance, here’s a quick primer on the different stages of sleep.
_Sleep stages _
During the waking state, the brain operates at a frequency of over 20 cycles per second. This phenomenon is described as beta waves. During sleep, the brain slows down to fewer than seven cycles per second. During slow wave sleep (delta sleep), the frequency is reduced even more to less than four cycles per second. This very slow frequency is necessary to assimilate external clues from the environment and imprint what we learned during the day.In between wake and sleep there is another zone called alpha. The brain operates at a frequency between seven and 14 cycles per second during alpha. People often enter the alpha phase for relaxation, but also for other purposes such as meditation. Although alpha is a relaxation state, it is not supposed to occur during sleep.
Sleep anomalies during sleep in patients with fibromyalgiaPatients with fibromyalgia may experience a phenomenon called** alpha intrusion into delta**; slow delta waves mix with alpha waves. Some experts have postulated that this is the way pain sensations are processed by the brain of patients with fibromyalgia during sleep - hence the heightened pain effect. This phenomenon has some serious repercussions such as the delta phase not offering the desired restful effect it normally provides.
Calling to mind that delta hases occur more frequently in the first portion of the night’s sleep, it's easier to see why fibromyalgia patients frequently say that their best sleep occurs at the end of the night. Since fibromyalgia patients have less slow wave sleep, they are typically not prescribed Ambien or benzodiazepines, very common medications, for sleep since these drugs further reduce slow wave sleep.
The consequences of lack of deep sleepDuring delta sleep there is a** peak in growth hormone secretion.** This is the hormone that supports repair and building of immune defenses. Deficiency in growth hormone resulting from disturbed sleep will cause impaired resistance to disease and infections. An additional consequence is elevated cortisol during the daytime. High levels of cortisol should only occur during periods of acute stress. This state of chronically elevated cortisol contributes to the feelings of fatigue and restlessness someone with fibromyalgia can experience during the daytime.
The role of 'substance P'
Substance P is a protein that acts as an excitatory neurotransmitter, meaning it works to eventually stimulate the brain as a response to a trigger within the body. Substance P has been shown to mediate nerves that respond to painful stimulation, communicating signals received from nerve sensors to the central nervous system and the brain. Elevated levels of substance P in the cerebrospinal fluid have been demonstrated in patients with conditions including depression, arthritis and fibromyalgia. The theory is that substance P is released during neurogenic inflammation, in response to infection or inflammation.
Sleep deficit, particularly deficit of slow wave sleep, has been shown to decrease the rate of inactivation of substance P, allowing levels to linger longer and thus prolonging the sensation of pain and other unpleasant feelings.** Treating sleep disorders in fibromyalgia**
Very select medications are typically used to help patients with fibromyalgia. Duloxetine (Cymbalta), Pregabalin (Lyrica) and Milnacipram (Savella) all have a unique effect by increasing delta sleep. Muscle relaxants and other non-narcotic pain medications are used for pain relief. These medications should be prescribed by physicians, as they may have unintended side effects or interact with other drugs or medications you are taking.
Managing the disturbed sleep pattern in fibromyalgia may be the key to achieving relief of the daytime fatigue and pain symptoms of this disease. Relaxation measures may play an important role in therapy, and Cognitive behavior therapy (CBT) and cognitive restructuring can also help. Progressive tension of muscles followed by relaxation typically used as one mode of therapy in treating insomnia might not be appropriate for patients with fibromyalgia.
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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, Qualified Medical Examiner for the State of California Department of Industrial Relations, and Director of Intensive Care Services at Glendale Memorial Hospital.His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.