Harris McIlwain, M.D., C.M.D. is a board-certified rheumatologist, geriatric medical specialist, and founder of the Tampa Medical Group in Florida, and has been in medical practice for twenty-five years. The Tampa Medical Group has four physicians who specialize in rheumatology and internal medicine. With three large pain clinics in the Tampa area, the Group also operates a large osteoporosis clinic and a medical research clinic on Florida's Gulf Coast. Dr. McIlwain and his colleagues see hundreds of patients each week, many suffering with fibromyalgia syndrome. Dr. McIlwain is also an author, and the revised third edition of his popular book, “The Fibromyalgia Handbook, 3rd Edition: A 7-Step Program to Halt and Even Reverse Fibromyalgia” is now available.
According to rheumatologist Harris McIlwain, M.D., C.M.D., “Since there is no cure (yet), physicians have tried a number of different treatments to try to control the pain, fatigue and other problems caused by fibromyalgia. The program we describe in The Fibromyalgia Handbook is one that we've developed over years. This 7-step program offers a majority of patients improvement, helping to make their symptoms manageable and giving them more control in their daily activities.
Because I diagnose and treat fibromyalgia syndrome daily, I am passionate about finding ways to help my patients ease their symptoms and regain their active lives. While most patients rely on medications to ease pain, through years of journal research and professional experience, I have discovered that there is much more to resolving fibromyalgia syndrome than simply taking a drug.
In The Fibromyalgia Handbook, I give a host of safe lifestyle substitutions, winning exercise and nutritional strategies, natural supplements and herbal therapies, mind/body and hands-on therapy tips, as well as the latest medications, that have helped my patients resolve pain – without putting their active lives on hold. For books that tout a miracle cure or breakthrough for FMS, we now know that to be untrue. Yes, some medications, such as the so-called Super Aspirins, can give relief for many FMS patients and can ‘cure’ symptoms, but they cannot cure the disease.”
Following is an excerpt from The Fibromyalgia Handbook, addressing the challenge (and vital importance) of refreshing sleep for FM patients.
End Sleepless Nights
FM patients complain that no matter how long they sleep, it is never restful. Their sleep may be interrupted by frequent awakening, that is, becoming awake enough that they remember these times the next day. Even more common are awakenings that are not enough to remember but that definitely break up their deep sleep. Most patients tell of waking up day after day feeling exhausted. They feel more tired in the morning, and many have great difficulty in concentrating during the day, just as in other situations where sleep is disrupted.
Because obtaining restful sleep is a crucial problem with this disease, it is helpful to understand the characteristics of normal sleep and how this differs from the sleep experienced by FM patients.
Understanding the Stages of Sleep
Studies have demonstrated that we have a built-in cycle of sleep-wake times along with many other cyclic variations in bodily functions, such as glandular secretions, body temperature, heart rate, blood pressure, and bronchial function. These intrinsic cycles are controlled by a group of nerve cells called a circadian pacemaker.
This pacemaker is closely related to parts of the retina (in the back of the eye) and the hypothalamus in the brain. The circadian cycle is actually 25 hours long. Since the cycle is longer than the 24-hour day, some factor must serve to synchronize the body’s pacemaker with the external clock time. These are cues from the environment called zeitgebers (from German, meaning “time givers”). The most important and powerful one is light. The hormone most closely linked to the circadian system is melatonin, which is made by the pineal gland in another part of the brain. Melatonin has been shown to synchronize the sleep-wake cycle to 24 hours in some blind subjects who were otherwise unable to live on a 24-hour day.
In adults, sleep is made up of distinct types or stages with specific characteristics defined by brain waves, eye movements, and muscle tension. The two broad categories of sleep include rapid eye movement (REM) and non-rapid eye movement sleep (NREM). It is during REM sleep that that we have almost all our dreams. (Arousals from this stage of sleep are usually associated with recall of vivid imagery.) In NREM sleep, there are four different stages – 1, 2, 3, and 4 – characterized by different combinations of brain waves, eye movements, and reduced but not absent muscle tension.
In FM, stages 3 and 4 NREM sleep are of the most importance. These stages are defined by relatively large, slow brain waves (delta waves), absent eye movements, and reduced muscle tension. Other names for these stages are “slow-wave sleep” or “delta sleep.”
Fibromyalgia and Sleep
About 20 years ago, researchers in Toronto discovered that patients with FM had NREM (non-rapid eye movement) stages of sleep “contaminated” by an intercurrent alpha rhythm (like that of wakefulness). But whether the sleep disturbance caused the FM symptoms or was secondary to the disease itself could not be determined.
This group of investigators went on to show that healthy subjects selectively deprived of delta sleep (deep sleep) by being exposed to noise developed periods of delta sleep mixed with alpha waves. Interestingly, when deprived of delta sleep these people experienced some musculoskeletal discomfort and mood symptoms similar to those of the patients with FM. These data suggested that the stage 4 sleep disturbance caused the appearance of the achiness or pain and mood symptoms.
However, it was felt that the effect of delta sleep disturbance on symptoms might be determined by examining the physical and psychological characteristics of the healthy subjects. Their subjects were younger than the patient population with FM and free from illnesses and psychological problems, but they were not particularly physically fit. Yet they had the symptoms of FM when put through the sleep-deprivation process. Their relatively sedentary lifestyle may have been significant, because most reports have pointed to the positive influence of exercise on delta sleep.
Sleep disturbances can be triggered in patients by physical or emotional trauma or by a metabolic or other medical problem. Poor sleep can lead to fatigue with resultant diminished exercise causing worsened physical fitness and the establishment of a vicious cycle of inactivity and sleep disturbance with physical and mood-related symptoms. These problems could help lead to the development of FM.
Hormones and Sleep
An interesting study published in the Journal of Clinical Endocrinology and Metabolism (April 2001) revealed that men seem to become more sensitive to the stimulating effects of corticotropin-releasing hormone (CRH) as they get older. This hormone plays a key role in how your body responds to stress. If you are aroused, you will have higher levels of CRH.
In the study, researchers evaluated the sleep habits of twelve middle-aged men and twelve young men over four nights. On one night, the men all received CRH ten minutes after they were asleep. Both groups of men produced higher levels of stress hormones in response to the CRH. While younger men produced higher levels of cortisol (the main stress hormone involved in the “fight or flight” response), middle-aged men stayed awake longer. They also had less slow-wave or deep sleep than did the younger men, showing that middle-aged men may have an increased vulnerability to stress hormones.
This, in part, may explain why insomnia increases in middle age as a result of these dysfunctional sleep mechanisms caused by arousal-producing stress hormones. There are also studies showing that people who spend less time in slow-wave sleep are more prone to depression.
Because of the effects of estrogen on a woman’s sleep pattern, it’s more difficult to study women and sleep. For women in perimenopause or just prior to menopause, the declining levels of the hormone estradiol may increase your chance of poor sleep. In an intriguing study at the University of Pennsylvania Medical Center in Philadelphia published in Obstetrics and Gynecology (September 2001), researchers followed 436 women age 35 to 49 over a two-year period.
About 17 percent of the women reported suffering from poor sleep throughout the entire study period. While researchers blamed anxiety, depression, and caffeine consumption as factors that disturbed the women’s sleep, they also identified low estradiol levels and hot flashes in older women aged 45 to 49 as responsible for the sleepless nights, even though all women were experiencing regular menstrual cycles and had not yet entered menopause.
The study concluded that the decline in estradiol that occurs with ovarian aging might be associated with poor sleep in women. This sleep deprivation results in daytime fatigue and irritability and can even lead to feelings of depression – all symptoms of fibromyalgia syndrome, too.
Accurate Diagnosis is Essential for Proper Therapy
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Many of the symptoms that FM patients experience are shared by those with other sleep disorders. For example, some patients with obstructive sleep apnea, intermittent blockages of the upper airway at the back of the tongue, which occurs in 2 percent of women and 4 percent of men who are 30 to 60 years old, also complain of unrefreshing sleep and “hurting all over” upon arising in the morning. They also have a history of snoring and other symptoms, including morning headaches, dry mouth, and an increased tendency to doze off during the day. Some patients with sleep apnea have high blood pressure.
If your doctor suspects that your sleep disorder may have a different cause, he or she may recommend that you have a sleep study. Sleep studies, called polysomnography, include an electroencephalogram (EEG), which measures the electrical activity of the brain, as well as the monitoring of oxygen levels, movements of the chest wall and abdomen, and nasal and oral airflow.
A sleep study may show apnea (periods without breathing), manifested by absent airflow at nose and mouth in conjunction with ongoing respiratory muscle efforts shown by movement of chest wall and abdomen. An apnea may cause decreases in blood oxygen levels. Sleep is often interrupted at the end of the apnea by awakening. This breaking up of continuous sleep is a major cause of daytime fatigue and sleepiness. Periodic leg movements during sleep, also known as nocturnal myoclonus, may also be associated with alpha intrusions and are a common cause of sleep interruptions. These sleep disorders require specific therapy.
The Problem of Insomnia
Because patients with FM have a specific type of insomnia, a disorder of initiating and/or maintaining sleep, it is important to apply certain treatment measures. Not only is attention to sleep hygiene important, but such stimulants as caffeine and nicotine must be avoided near bedtime. Regular daily exercise including stretching and aerobic activity, is a form of treatment that can help to consolidate sleep and to alleviate other symptoms.
Biofeedback and relaxation techniques, as discussed in chapter 7 of this book, are useful in overcoming problems of initiating sleep. High levels of arousal associated with racing thoughts, worrying, or rumination may also delay sleep onset. Meditation or guided imagery (see chapter 7) can be used to help the patient relax while focusing on a neutral or enjoyable target.
Tips to Encourage Sleep
Establishing better sleep hygiene is vital in managing the symptoms of FM. In our clinic, patients have experienced great success with the following suggestions:
• Sleep only as much as needed to feel refreshed and healthy the following day, not more. Curtailing the time in bed seems to solidify sleep; excessively long times in bed seem related to fragmented and shallow sleep.
• A regular arousal time in the morning strengthens circadian cycling and leads to regular times of sleep onset.
• A steady daily amount of exercise probably deepens sleep; occasional exercise, however, does not necessarily improve sleep the following night.
• Occasional loud noises (e.g., aircraft flyovers) disturb sleep even in people who are not awakened and cannot remember them in the morning. Sound-attenuated bedrooms may help those who must sleep close to noise.
• Although excessively warm rooms disturb sleep, there is no evidence that an excessively cold room solidifies sleep.
• Hunger may disturb sleep; a light carbohydrate snack before bedtime may help you avoid sleep disturbances.
• Caffeine in the evening disturbs sleep, even in those who feel it does not.
• Alcohol may help tense people fall asleep more easily, but ensuing sleep is then fragmented.
• People who awake feeling angry and frustrated because they cannot sleep should not keep trying, but should turn on the light and do something different. You might have a light snack high in carbohydrates, read a book or watch a television show in another room.
• The chronic use of tobacco disturbs sleep.
Another procedure we use to help patients overcome conditioned insomnia is stimulus-control behavior therapy. The goal is to reassociate the bedroom with sleep rather than with frustration and arousal. To achieve this, patients are told that they are “misusing” their bed if they lie awake and frustrated. Richard Bootzin, the behavior therapist who initiated this approach, recommends the following rules:
-Go to bed only when sleepy.
-Use the bed only for sleeping; do not read, watch television, or eat in bed.
-If unable to stay asleep, get up and move to another room. Stay up until you are really sleepy, then return to bed.
-If sleep does not come easily, get out of bed again. The goal is to associate bed with falling asleep quickly.
-Set the alarm and get up at the same time each morning, regardless of how much you slept during the night. This helps the body acquire a constant sleep-wake rhythm.
-Do not nap during the day.
If the above rules are followed, patients will usually sleep little during the first night. By the second or third night, patients are so tired that they fall asleep on the first or second attempt. Sleep patterns then fluctuate for a few weeks, but gradually the bedroom surroundings again become associated with sleep. However, most patients need a lot of encouragement during this difficult reconditioning period.
Precise diagnosis is essential to establish the existence of fibromyalgia and to distinguish this disease from other sleep disorders. Once the diagnosis is made, a multifaceted approach is then required to ensure restful and healing sleep, and may require some combination of supportive psychotherapy, biofeedback-relaxation techniques, physical fitness training, antidepressants, or some other medicine as discussed in chapter 4 of this book, along with careful medical supervision by a physician.HW
Editor’s Note: The preceding excerpt is from Chapter 8 – Step 5, “End Sleepless Nights” of The Fibromyalgia Handbook, 3rd Edition: A 7-Step Program to Halt and Even Reverse Fibromyalgia, and has been reprinted with permission of the author. To purchase a copy of The Fibromyalgia Handbook, 3rd Edition: A 7-Step Program to Halt and Even Reverse Fibromyalgia, go to https://www.immunesupport.com/shop/books.cfm.