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Introduction

• Sleep is an important part of all our lives. Waking up in the morning feeling refreshed and ready to start the day is taken for granted by most of us.
• A wide range of acute and chronic painful conditions can interrupt our normal sleep pattern. Chronic pain conditions are more likely to lead to persistent sleep loss.
• Chronic sleep deprivation increases the chances of developing anxiety with depression, chronic muscle pain (myofascial pain syndromes), Fibromyalgia, poor concentration, and irritability .
• Fibromyalgia (Chronic Fatigue Syndrome) is a recognised chronic pain disorder associated with:-
  • Widespread symmetrical muscle pain and tenderness associated with progressive disability and fatigue.
  • Chronic sleep deprivation.
  • Anxiety with depression, and other emotional disturbances.
• Many muscle (myofascial) pain syndromes have similar features as Fibromyalgia, but the muscle pain and tenderness may not be exactly symmetrical, and may be confined to one area of the body. However, sleep disturbance with anxiety with depression are still very common features if the pain has become chronic over several months or years. See Fibromyalgia for more information.
• To find out how to use over the counter pain relieving medicines more effectively, please look at Analgesic Flow Chart.

• Sleep is divided into 2 different phases - Rapid Eye Movement Sleep (REM) and Non Rapid Eye Movement Sleep (NREM).
• We spend about 70% of our time in NREM sleep and 30% in REM sleep. The proportion of each changes through our lives from infancy to senility.

Stage of Sleep			EEG Appearance
Awake
Drowsy
REM
NREM	Trans-itional	Stage 1
		Stage 2
	Deep	Stage 3
		Stage 4

• REM sleep has the following features:-
  • Rapid eye movements associated with typical saw tooth brain wave patterns on EEG (Electro-encephalogram)
  • A rise in heart rate, blood pressure, associated with an irregular breathing pattern
  • Susceptibility to being woken by sensory stimuli - light, noise, touch, pain
  • Paralysis of all muscles except the diaphragm
• NREM sleep can be divided into 2 phases - transitional and deep:-
  • Transitional sleep is divided into stages 1 and 2
    • Stage 1 - The transition from wake to sleep occurs within minutes of the onset of slow rolling eye movements. The subject is less aware of their surroundings then just a few minutes ago. They may waken by a whisper, or noise. They are relaxed, their breathing is more regular and there is more slow, rolling eye movement noticed. There may also be  "hypnogogic experiences" - dream-like sensations of falling, hearing voices, or seeing flashes of pictures. It takes 5 – 10 minutes to progress to Stage 2. Stage 1 accounts for only about 5% of the total sleep time.
    • Stage 2 - Stage two is the first stage of true sleep and accounts for about 50% of total sleep. The subject is even less aware of their surroundings and is characterized by as light sleep since individuals are easily aroused from this sleep state. Stage 1 & 2 are “transitional” stages of sleep. It takes approximately 30 minutes to complete these stages and enter Stage 3.
  • Deep sleep is divided into stages 3 and 4
    • Stages 3 and 4 are also referred as Slow Wave Sleep (Delta Waves). As the subject is in a very relaxed state, they have a slow, regular heartbeat and respiratory rate. Their muscles are very relaxed. It is very difficult to arouse a patient in “Slow Wave Sleep”. If they are awakened, they are confused and slow to react. It is normally easy for them to go back to sleep.
• Normal Sleep Cycles
  • Cycling from deep sleep to REM sleep and back again occurs several times during a normal nights sleep. There is tendency to have more deep sleep at the beginning of the sleep period and increasing amounts of REM later in the period.

• Effects of Sleep Deprivation - The consequences of sleep deprivation include physical effects, mental impairment, and mental health complications. Inadequate rest impairs our ability to think, to handle stress, to cope with pain, to maintain a healthy immune system, and to moderate our emotions. Total sleep deprivation is fatal: lab rats denied the chance to rest die within two to three weeks.
  • Mental Functioning - Without adequate rest, the brain's ability to function quickly deteriorates. Concentration levels drop, and memory becomes impaired. Speech becomes slurred and fragmented, and mental reaction time slows. The brain's ability to problem solve is greatly impaired: decision-making abilities are compromised, and the brain falls into rigid thought patterns that make it difficult to generate new problem-solving ideas. Insufficient rest can also cause people to have hallucinations.
  • Mental Health: Stress, Anxiety, and Mood - Without sufficient rest, emotional mood deteriorates. People become irritable and short-tempered, both with themselves and others. Loss of emotional control is possible, leading to emotional outbursts and even violence. Stress and anxiety levels both rise as a result of sleepiness, which often begins a vicious circle. Insomnia and fatigue leads to stress and anxiety. Stress and anxiety are leading causes of insomnia. Left unchecked, this cycle can result in full-blown anxiety disorders and depression. Stress and anxiety also lead to a general increase in muscle tone, particularly in the neck and shoulder regions.
  • Physical Responses - Insomnia makes it difficult to focus the eyes properly, or to perform fine motor functions as effectively as when well rested. Muscle strength and endurance drops, in part due to lowered glucose metabolism. Appetite tends to increase with insufficient rest, leading to weight gain for some people.
  • The Immune System - Adequate rest and a properly functioning immune system are closely related. Sleep deprivation appears to compromise the immune system by altering the blood levels of specialized immune cells and important proteins called cytokines, resulting in a greater than normal chance of infections.
• Causes of Sleep Deprivation
  • Lifestyle - Fatigue and sleeplessness are often a direct result of lifestyle choices. Drinking caffeine or alcohol before bedtime is among the most common causes of sleep deprivation. Shift work is unavoidable in many professions, and can drastically alter normal circadian patterns.
  • Medication - the most common culprits are:-
    • Antidepressants - particularly MAOI's, SSRI's and Lithium. Tricyclic anti-depressants like amitriptyline are used to treat sleep disorders especially those associated with Fibromyalgia
    • Bronchodilators containing theophyllin used for treating asthma
    • Decongestants containing pseudoephedrine and phenylpropanolamine
    • Sleeping Pills from the benzodiazepine family are often used to treat insomnia, but long-term use is not recommended. They have been shown to disturb the normal NREM : REM sleep ratios during the night, causing the sufferer to awaken unrefreshed even though they've had a reasonable number of hours sleep. They also cause rebound sleeplessness on withdrawal, making them highly addictive. Sleeping pills also worsen obstructive sleep apnoea (see below) especially when mixed with other over the counter sedatives (anti-histamines) and / or alcohol.
  • Medical Conditions - Underlying health problems can cause fatigue by interfering with sleep patterns, particularly painful conditions. Physical health problems such as asthma may make sleeping difficult, while mental health problems, including depression and post-traumatic stress disorder, can lead to insomnia.
    • Fibromyalgia causes chronic pain throughout the body, which often makes sleeping difficult. Sleep disorders and chronic fatigue are common side effects of fibromyalgia. People with the condition can experience sudden brain activity during the night that resembles waking brain patterns: these increases in brain activity hinder the ability to enter deep, restful sleep.
    • Post-Traumatic Stress Disorder - Flashbacks and nightmares characterize post-traumatic stress disorder (PTSD), a severe anxiety disorder that results from living through devastating events. Post-traumatic stress disorder results from events such as military combat, rape, assault, terrorism, natural disasters and other events where serious bodily harm has occurred (or been threatened). Nightmares, anxiety and depression may all occur as a result of PTSD, making it difficult to maintain healthy rest habits.
  • Sleeping Disorders - Narcolepsy, parasomnia, and apnoea are three common sleeping disorders. Over seventy different types exist and can pose serious health risks that require medical treatment.
    • Obstructive sleep apnoea (severe snoring associated with temporary airway obstruction with breathing pauses) may lead to more than 100 brief awakenings per night. Severe drops in oxygen levels lead to heart, lung and brain disorders, whilst chronic sleep deprivation causes extreme sleepiness during the day.
• Reducing Sleep Deprivation
  • Optimise your pain relief - see Analgesic Flow Chart and Tips For Relief for further advice. Seek the advice of your doctor if simple analgesics don't help, or if the symptoms persist or worsen with time. A Pain Clinic Referral can be useful when medications don't help, and when all serious causes of the pain have been eliminated.
  • Rest according to a Schedule - Go to bed and get up at the same time every day, including weekends and vacations. By doing so, your circadian rhythm will not be disturbed.
  • Regular exercise improves sleeping habits. Exercise between twenty to thirty minutes a day for the best results, but take care not to exercise within five hours of bedtime as this may cause difficulty dropping off to sleep.
  • Don't Lie Awake - If you cannot fall asleep, don't lie in bed awake. Worrying about falling asleep actually keeps many people awake. Get up and do something else until you feel sleepy.
  • Limit Alcohol, Nicotine and Caffeine - Nicotine and caffeine are both stimulants, and should be avoided up to 12 hours before bedtime. Alcohol is a sedative, and may appear to promote sleep in the early part of the night, but may then cause a very disturbed sleep pattern for the rest of the night.
  • Eat and Drink Long Before Bedtime - A heavy meal before bed can cause indigestion, which can keep you up. Drinking fluids before bed can interrupt your rest by causing you to get up to urinate. Try to avoid both food and fluids for at least two hours before bedtime.
  • Relax - Spending some down time before bed can relax you enough that falling asleep comes easier. Meditation, relaxation techniques and breathing techniques may all work. Relaxation could be as simple as a warm bath, or quiet reading (not in the bedroom, though).
  • Consider Melatonin supplements - Melatonin is a natural substance that builds up in the body as daylight fades, making people drowsy. While melatonin supplements do seem to help some people, the supplements also build up in the body, and could cause as-yet undiscovered complications.
  • Keep the Bedroom for Two Things - Watching television, paying the bills, reading a book, and listening to music in the bedroom are not recommended. By doing so, you create the expectation in your mind that the bedroom is for activities other than resting. Your bedroom should only be used for sleeping and sex.

Adapted from www.sleep-deprivation.com