Sleepless in Pain

"Sleep, perchance to dream," pleads Shakespeare's Hamlet, anguished over his very, very dysfunctional family. Affairs of the heart and the mind populate the literature as the predominant cause of insomnia, but physical pain certainly ranks a close second. Aeschylus, a couple of millennia ago, wrote about it, juxtaposing the suffering and the hope: "And even in our sleep, pain that cannot forget falls drop by drop upon the heart, and in our own despair, against our will, comes wisdom to us by the awful grace of God".

As a physician who specializes in pain management I am confronted daily with cases considered intractable or at least very difficult to treat, these poor souls often having failed several attempts by other doctors. One of the first items I ask them during the initial consultation is sleep; I often joke that if my patients knew how important a good night sleep is, I'd possibly be out of a job.

We know that sleep is good for us, but we don't know exactly why. Scientists have postulated some sort of evolutionary benefit from sleep, protecting the cavemen, keeping them quiet and still while predators roamed in the dark (so how come people snore?). Anyway, with very rare exceptions, everybody must sleep. Lack of it can lead to problems ranging from fatigue and irritability, to mental impairment, and even death.

Contrary to what people may believe, sleeping is an active process. Let me clarify that: nerve cells in a particular area of the brain accumulate specific chemicals during periods of wakefulness, which eventually causes them to inhibit, or block, nerve cells responsible for alertness in another part of the brain, therefore shutting down the system that keeps us awake. Paradoxically, despite the enormous importance of sleep, even small, mundane things like noise and temperature can easily disrupt it.

Everyone knows that pain can keep us from sleeping but most of us don't realize that lack of sleep may cause, or at least contribute, to some forms of pain, including fibromyalgia (FMS) and headaches. FMS affects mostly women and many of its symptoms are similar to what one would see in cases of sleep deprivation: fatigue, lack of concentration, generalized muscle pain, and depression, just to mention a few. Drugs that normalize sleep and mood are often effective in the treatment of this condition.

Cause and effect between sleep and pain can be blurred in certain medical conditions, such as restless leg syndrome (RLS), a neurological ailment that may be present at one time or another in up to ten percent of people. This curiously distressing condition appears only at rest and mostly at night, and it causes an irresistible urge to move one's limbs in order to alleviate what is best described as a painful numbness in the legs or arms. Severely affected people may not be able to sleep at all, and may spend their nights pacing the floor till exhaustion stops them. To make matters worse, people with RLS often don't get any rest even when they are asleep since they frequently display a twitching and jumping of the legs and the body (the medical term is myoclonus), which may prevent them from obtaining true restorative sleep.

The most common cause of nighttime pain is plain, garden-variety osteoarthritis (OA), the wear and tear of the joints that eventually occurs to all of us as we age. The joints become sensitive, so it is difficult to fall asleep, and something as simple as turning in bed may be problematic. A person afflicted with OA who's lucky enough to occasionally enjoy an uninterrupted sleep is likely to wake up with pain and stiffness, due to the length of time the joints remain immobile.

The pharmacological treatment of pain-induced sleeplessness depends, of course, on the cause of the problem. Neurological conditions like RLS respond quite well to drugs commonly used to treat either Parkinson's disease or seizures, while the pain of OA and other skeletal conditions usually benefits from mild to moderate doses of opiate analgesics. Sleep-inducing drugs may be added to the above regimen only after the original problem has been addressed. The new generation hypnotics, those that are less likely to cause dependency and addiction, should be considered first.

An exercise program, either at the gym or supervised in physical therapy, is an excellent therapeutic modality for many acute and chronic painful conditions and it often improves the quality of sleep as well. The inclusion of stretching exercises and relaxation therapy enhance the chances that the above regimen will provide maximum benefit.


© Dr. Moacir Schnapp and Dr. Kit Mays


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