Pain and Sleep: What is Fibromyalgia?
Fibromyalgia is a medical syndrome that causes widespread pain and stiffness in the muscles and joints as well as sleep problems and chronic daytime fatigue. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases at the National Institutes of Health, between 80 and 90% of people diagnosed with fibromyalgia are middle-aged women, although it can affect both sexes and people of all ages. Fibromyalgia is a confusing and often misunderstood condition. In the past, people who sought treatment for fibromyalgia symptoms were frequently told that their symptoms were "all in the head" and that they did not represent any known disease. However, in recent decades medical studies have proven that fibromyalgia does indeed exist, and that it is estimated to affect between 2% and 6% of people worldwide.
For people with fibromyalgia, the combination of pain and sleep disturbance is a double-edged sword: the pain makes sleep more difficult and sleep deprivation exacerbates pain. The good news is that reduction in sleep disturbance is usually followed by improvement in pain symptoms. This also highlights the importance of healthy sleep and access to sleep specialists in treating this disease.
Medical researchers have long sought to clarify the association between sleep disturbance and pain. Very little is known but a few key findings indicate that sleep and pain are intricately linked. For example, studies of patients experiencing pain after surgery show disturbed sleep, reduced rapid eye movement (REM) sleep, and a normalization of sleep as recovery proceeds. People with fibromyalgia may also experience an alteration in their patterns of slow wave sleep, which is the deepest stage of sleep. In one study, researchers selectively deprived a group of healthy middle-aged women of slow wave sleep for a period of three days. In response, the women showed a decreased tolerance for pain and increased levels of discomfort and fatigue, suggesting that such sleep disruption may play an important role in the development of fibromyalgia symptoms.
In addition, sleep aides are widely and increasingly used by people with fibromyalgia, although their long-term effectiveness for alleviation of pain is doubtful. Further research is needed to understand the nature of the relationship between pain and sleep and to develop treatments that can help to improve both pain symptoms and sleep disturbance.
The cause of fibromyalgia is not known but there may be several factors involved. Clinicians who care for patients with fibromyalgia report a range of possible causes such as repetitive stress injuries, automobile accidents or other traumatic events. In some cases, fibromyalgia seems to run in families, although researchers are not sure if this is due to genetic or environmental factors. Fibromyalgia is considered a rheumatoid condition, but it is not truly a form of arthritis. However, people with arthritis are more likely to have fibromyalgia.
A variety of studies have been conducted to find connections between fibromyalgia and other medical conditions such as irritable bowel syndrome, chronic fatigue syndrome, migraines, arthritis, lupus, and major depressive disorder. The results of these studies have been largely inconclusive with respect to specific relationships, but many have established a link between fibromyalgia and heavy use of physician services. In other words, people with fibromyalgia tend to seek medical treatment significantly more often than people without it.
About 20% of fibromyalgia patients also have depression or anxiety disorder. Scientists have recently looked at whether chronic pain may cause depression or whether depression may play a role in people's perception of pain. For example, researchers at the University of Michigan and the University of Cologne in Germany conducted a study of people with fibromyalgia which sought to reveal why symptoms of depression are sometimes associated with increased sensitivity to pain. The researchers were aware that fibromyalgia patients typically show a higher than normal sensitivity to pain regardless of whether they had been diagnosed with major depressive disorder or reported any depressive symptoms. What they were trying to determine was whether antidepressant medication might alleviate this heightened sensitivity. Based on the results of this study, the researchers concluded that treating depression in people with fibromyalgia will not necessarily have an impact on the patients' complaints of pain. Instead, they recommend treating pain and fatigue symptoms separately from depressive symptoms, should they exist at all.
There may also be an association between fibromyalgia and restless legs syndrome (RLS), a neurologic sensorimotor disorder characterized by an overwhelming urge to move the legs when they are at rest. RLS is more common among patients with fibromyalgia and those with rheumatoid arthritis than among people who don't have these conditions. An awareness of this association will help doctors look for and manage RLS symptoms among patients with fibromyalgia.
There are a variety of conditions that could lead to widespread pain and chronic fatigue. However, fibromyalgia typically also includes cognitive difficulties and psychological distress and a complaint of fatigue that is debilitating, unexplained, and unrelieved by rest. It is possible to experience symptoms similar to fibromyalgia if a person is suffering from sleep apnea. In addition, people with fibromyalgia may also suffer from sleep disorders such as sleep disordered breathing. Before seeking medical intervention for fibromyalgia, keeping a sleep diary as well as a sleepiness diary is recommended.
Fibromyalgia usually includes a broad range of symptoms including some combination of the following:
- widespread pain
- sleep disturbances
- chronic daytime fatigue
- morning stiffness in the joints and muscles
- migraine headaches
- irritable bowel syndrome
- painful menstrual periods
- numbness or tingling of the extremities
- restless legs syndrome
- temperature sensitivity
- dizziness and balance problems
- cognitive and memory problems
- mood disturbance such as depression and anxiety
There are no FDA-approved drugs specifically developed for fibromyalgia but there are medications commonly used for other conditions that are effective treatments for fibromyalgia symptoms. In treating fibromyalgia, many physicians focus primarily on pharmacologic treatment, but self-directed and behavioral methods such as exercise and massage therapies have been shown to benefit patients as well. Also, improving sleep usually reduces pain and fatigue and improves daytime functioning.
No one treatment plan is uniformly effective for every fibromyalgia patient; those consisting of a combination of pharmacologic and nonpharmacologic therapies should be designed for each patient, and the clinician may have to try several different combinations before reaching improvement in the patient's symptoms. The important thing to keep in mind is that any treatment plan must address both alleviation of pain and minimization of sleep disturbance.
Fibromyalgia is a persistent condition for which there is no cure. It is common for symptoms of fibromyalgia to wax and wane; they may be more severe at certain times of the day, month, or year and they may remit for an extended period of time only to reappear later either for no apparent reason or following a traumatic event such as an automobile accident. But there are ways of coping with fibromyalgia symptoms and preventing exacerbation of pain. Here are some tips:
- Prioritize sleep – it is important for people with fibromyalgia to maintain a regular sleep schedule and to get treatment for sleep disorders if necessary.
- Create a quiet environment –chronic pain has been known to intensify in the presence of sound stress.
- Exercise – regular exercise is known to improve symptoms in some patients. For people with fibromyalgia, low-impact activities such as walking, yoga or swimming are the best choice.
- Medication – work with a physician to develop an effective medication regime.
- Massage – gentle massage, deep breathing, and relaxation techniques are all generally considered beneficial with respect to chronic pain management.
According to the 1996 NSF Gallup poll, more women (58%) suffer from nighttime pain than men (48%). In the 2000 NSF Sleep in America poll, one in four women reported that pain or physical discomfort interrupted their sleep three nights a week or more.
Reviewed by Sherwood M. Chetlin, MD and Carol Landis, DNSc, RN, FAAN.
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