Strategies For When You’re Tired of Waking Up Tired
Our previous blog discussed some of the root causes of sleep disturbances among people with FM. We also discovered that if you have FM it’s almost a certainty that your sleep is being affected by one or more of the pathways that FM uses to sabotage quality sleep.
Knowing the many ways that FM can undermine sleep is certainly helpful; in this blog, we’ll look at some concrete actions you may want to explore when you’re working on your personal sleep improvement project.
As always, you are encouraged to partner with your healthcare professional(s) to precisely identify the causes of your sleep disturbances and any potential remedies. Your progress may unfold gradually and could involve some trial and error along the way.
Start By Tracking Your Sleep
There’s a mantra in quality control circles that says, “If you can’t measure it, you can’t improve it.”
Keeping track of your sleep habits and the factors that impact sleep establishes a baseline and allows you to see if the changes you’re making are working. It is also useful data to share with a sleep specialist should you go that route.
There are dozens of options available, some of which are free. The important thing is to keep an accurate record of your sleep, your daily/pre-sleep habits, and your sleep outcomes for an extended period to see what patterns and possible sleep disruptors emerge over time.
High-tech “wearables” such as rings, wristbands, or smartwatches use sensors to measure things like nocturnal movement, oxygen saturation, heart rate variability and respiration, body temperature, noises, etc. to give you feedback on your previous night’s sleep. There are also bedside smartphone apps (called “nearables”) that are available.
Before investing in any expensive technology, it’s worth doing some research. The ease of use and the quality of data they collect can differ quite a bit. While these tools are impressive, keep in mind they may not be as accurate or detailed as measurements from a sleep clinic.
If a wearable or paid app doesn’t currently fit your budget, you can find dozens of free or almost free sleep tracker apps and/or paper-and-pen journals/diaries online.
Find a system (or systems) that works well for you to keep track of the daily/evening habits that may be affecting your sleep as well as your bedtime, sleep duration, and your self-assessment of how refreshed you feel upon waking. Introduce changes slowly and in a controlled manner to allow you to assess if the strategy works for you.
Sleep Hygiene – The Essentials
While these sleep tips are not specific to people with FM, they have a considerable amount of research behind them and therefore are certainly worth trying as you work to optimize your sleep quality.
Circadian Rhythms
The circadian rhythm (CR) is a 24-hour internal clock that responds to changes in light and regulates our sleep-wake cycle, metabolism, and production of hormones. It is controlled in an area of our brain called the suprachiasmatic nucleus (SCN). The SCN is directly affected by light exposure and produces melatonin or cortisol to regulate the sleep-wake cycle.
When the circadian rhythm is working properly, cortisol is released in the morning to jump-start awakening, and then tails off during the day. When darkness takes over melatonin production rises to help induce sleep. Disruptions in the CR can lead to reversals of the cortisol-melatonin rhythm, causing daytime fatigue and drowsiness as well as difficulties in falling and staying asleep. As previously noted, the sleep-wake cycle also influences many other bodily systems, making it a cornerstone of overall wellness.
Seeing the Light, Embracing the Night
Humans evolved to follow the natural cycle of light and darkness. Our ancestors slept when it was dark and were primarily active during daylight. The invention of artificial light changed all that. In the modern world darkness is now optional, and light-emitting devices, such as the one on which you’re reading this blog, are omnipresent. There is little wonder sleep quality has deteriorated among all citizens of the modern world, not just those living with FM.
Modifying your sleep environment and timing to mirror the natural world’s cycle of light and darkness is paramount. FM has lots of ways to undermine your sleep, introducing light when the SCN needs dark to do its job, is making it a harder lift.
Action Items:
Sleep Consistency – 24/7. Researchers have found that consistency in your sleep pattern (especially the time you habitually awaken) is more important than even the duration of sleep. Establish your wake-up time first and then work backward to allow for adequate sleep. On average adults need 7 to 8 hours daily to feel completely rested (but you may need more). Trying to “catch up” on sleep during the weekend (and staying up late because you can) undermines the consistency your sleep cycle needs.
Get At Least 30 Minutes (More is Better) of Sunlight First Thing in the Morning. Exposure to sunlight is essential to resetting your internal clock. In the winter, or when it is overcast you can also try a natural spectrum light source such as a Seasonal Affective Disorder (SAD) lamp. Aim to get light exposure within two hours of waking—the sooner the better!
Eliminate Sources of Light At Least Two Hours Before Bedtime and Throughout the Night.
Keep all light, and especially TV and other electronics, to a minimum as the evening winds down. Blue light, which is emitted by screens, is believed to have the greatest impact, but any intense lighting will short-circuit the signal to start producing melatonin. I use f.lux on my laptop, a free app that adjusts the colour temperature on your screen based on your location and time of day.
Use a low-intensity light (such as a small lamp or night light) to prepare for bed. If you should awaken during the night resist the temptation to check your phone, or better still, leave it in another room. If you have to get up to use the bathroom don’t turn on the lights – a few strategically placed night lights are better and won’t kick your awake cycle into gear.
Use a blackout curtain or other light-blocking blinds to eliminate outside light sources. Ideally, when you’re ready to sleep you shouldn’t be able to see your hand when it’s held out in front of you.
Cover the LED’s on the air conditioner, alarm clock, air purifier, TV etc. They also emit light. Turn them off or cover them to achieve total darkness.
Use a comfortable eye mask when achieving total darkness is not possible.
Other Sleep-Inducing Strategies
There are many other environmental factors and habits which can significantly affect sleep. The following tips are based on widely accepted and well-supported sleep strategies. Use this checklist to help build your personal sleep protocols.
Action Items:
Eliminate noises that do not induce a state of relaxation. The neighbour’s dog barking or traffic noises can keep your brain in a state of alertness. Sound-insulating curtains can help - if ambient noise persists try a white noise machine or good-quality earplugs.
On the other hand, there is evidence that binaural beats in the delta frequency (1-4 Hz) can help those experiencing insomnia fall asleep quicker and obtain more restful sleep. While the research has been limited, playing delta-frequency binaural background music/sound at night would be a zero cost/low risk experiment.
Avoid being very hungry, or very full, before turning in. Late meals (especially those high in carbs) and night-time snacking can disrupt sleep by converting it into sugar (energy) while you’re asleep.
Avoid alcohol, caffeine, nicotine and other stimulants close to bedtime.
Caffeine: Everyone knows that coffee before bed is a bad idea. However, not many people realize the half-life of caffeine is on average 5 hours (the time it takes to clear half of the caffeine dose from your system) and can even be as high as 12 hours. Make a hard rule that you don’t consume coffee, or any other sources of caffeine for at least 8 hours before bed, preferably longer.
Alcohol: affects circadian rhythms, suppresses the production of melatonin, and affects REM sleep. For these reasons and many others unrelated to sleep, if you have FM consume alcohol infrequently and in very small quantities, or not at all.
Nicotine: is a stimulant and is known to disrupt neurotransmitters that are involved in the sleep process. It can also affect circadian rhythms and raise your heart rate, blood pressure, and glucose levels, none of which are conducive to good sleep. In addition, it appears people who smoke are more likely to exhibit symptoms of Obstructive Sleep Apnea, although additional research is needed.
Supplements: certain vitamins such as DHEA, chromium and high doses of vitamin D, Vitamin B-6 and B-12, potassium and coenzyme Q10 can interfere with sleep. If you take these supplements, it is better to take them in the morning and follow your healthcare provider’s recommendation for the dose.
Curtail water consumption in the evening: An unfortunate side effect for some people with FM (and in aging) is difficulties with bladder control. If this describes you, practice staying well hydrated during the day, and then cutting off water or fluid intake before bedtime wind down. Upon awaking drink several glasses of water to rehydrate and boost energy.
Lower the Bedroom Temperature (but not too much): Sleep researchers believe that temperatures above 70F (21 C) or below 60F (15.5 C) are likely to undermine quality sleep. Since our body temperature naturally falls in the evening lowering the bedroom thermostat a few degrees can signal readiness for sleep. The ideal temperature depends on a number of factors including age and the individual’s metabolism. You’ll want to experiment with this, the experts think somewhere around 65 F to 68 F (18.3 to 20 degrees C) is ideal for most people, so start there.
Develop a relaxation regime before sleep: Low stress, low arousal activities such as a warm bath (which actually reduces core body temperature), meditation and reading instead of screen time can prepare your mind for sleep and ease sleep anxieties.
Try a few drops of quality lavender oil in your bath or on your pillow provided you are not allergic or bothered by the scent. Research into lavender suggests that it can aid in relaxation and sleep.
Fibromyalgia Specific Sleep Strategies
Action Items:
Determine If Restless Leg Syndrome (RLS) and Obstructive Sleep Apnea Syndrome (OSAS) Affect You: As we saw in the previous post on FM and sleep, there is a much higher probability that if you have fibromyalgia, you will also suffer from RLS and/or OSAS.
If you have been diagnosed with FM you should insist that you also be assessed for both of these conditions, especially if you have felt symptoms or have been told by someone else (such as a partner) that you have “crazy legs” or breathing stoppages while you’re sleeping.
Restless Leg Syndrome: there are a number of potential treatments or lifestyle modifications available for RLS including heat and cold packs, warm baths, massage, compression or vibration wraps, taking a walk, and supplementing with magnesium, iron and Vitamins C and E. Ideally, you’ll want to have some bloodwork to check your levels.
Obstructive Sleep Apnea Syndrome: this condition can be serious and debilitating because you stop breathing for short and frequent intervals, rousing your brain from sleep. If the test methodology used to assess OSAS (called polysomnography) is positive there are a range of options that your medical provider may suggest. Some are lifestyle changes such as quitting smoking, reducing the use of caffeine, or losing weight.
If the condition is serious a Continuous Positive Airway Pressure device (CPAP), or a similar medical device may be prescribed. For mild to moderate OSAS an oral device that keeps the airway open and unobstructed may work.
There are also new devices on the market that use electrical stimulation of the tongue or airway. In some cases, removing soft tissue surgically or surgery on the jaw may be recommended.
Magnesium: is a well-researched mineral that is vital for many biological functions. Magnesium plays a role in muscle relaxation and neurotransmitter function, both of which are important for sleep. A study by Sendur et al. (2008) found that magnesium supplementation improved sleep quality and reduced pain in fibromyalgia patients.(1) Keep in mind that some forms of magnesium are not well absorbed (in particular magnesium oxide) and can have a laxative effect. Working with your doctor or a naturopath to find the right dose and form for you may be helpful.
Studies suggest that magnesium is also readily absorbed through the skin – using Epsom salts (magnesium sulfate) in an evening bath or magnesium lotion/spray may help promote muscle relaxation and boost the function of sleep neurotransmitters.
5-HTP (5-Hydroxytryptophan): is a precursor to serotonin and has been shown to improve sleep quality in fibromyalgia patients. A study by Caruso et al. (1990) found that 5-HTP supplementation improved sleep and reduced pain in fibromyalgia patients. (2)
Melatonin: as we learned melatonin is the hormone that regulates the sleep part of the circadian cycle. People with fibromyalgia often do not naturally produce melatonin to the same degree as the general population. A study by Citera et al. (2000) found that melatonin supplementation improved sleep quality and reduced pain in fibromyalgia patients. (3)
Melatonin is available over the counter and is generally considered safe for short-term use. If you prefer to go the natural route, tart cherries, goji berries, eggs, fish and nuts are all high in melatonin.
Guard Your Energy: Pace your daytime activities to conserve your energy throughout the day and prevent “crashes.” Do not wait until you are exhausted before going to bed.
Beds, Bedding, and Other Sleeping Comforts: We spend about a third of our life sleeping. A comfortable mattress and pillows are a worthwhile investment. Of course, the term “comfortable” varies from person to person. In general, a medium to medium-firm mattress seems to be the sweet spot for people with FM but you’ll want to experiment. Some mattress companies may allow a trial period and free returns.
Look for a mattress that has good air circulation, minimizes pressure points, and suits your weight and sleeping position (back sleeper, side sleeper, stomach sleeper etc.). If you can’t upgrade your mattress at this time, you could consider investing in memory foam. Just be sure to let it off-gas outside for a bit before you put it on your bed.
Protect your neck while you’re sleeping by using a cervical pillow or by repositioning a
regular pillow to maintain a space between your shoulder and neck.
Finally, natural fibre bedding such as cotton and bamboo are better at breathing and regulating sleep temperatures. For many people who are sensitive to the feel of scratchy or rough materials against their skin, naturally derived bedding will feel much more comfortable.
Mindfulness and Relaxation Techniques
Mindfulness and relaxation techniques, such as deep breathing, and meditation (there are plenty of great YouTube videos if you’re looking for guided support), can help reduce stress and promote relaxation before bed.
Progressive muscle relaxation activates the body’s parasympathetic response and encourages a deep state of physical relaxation. The exercise involves tensing or tightening and then releasing one muscle group at a time. Focusing on the contrast between tension and relaxation is key.
You might find it helpful to use an audio guide that instructs you, allowing you to fully focus on the technique. Such as this free one from McMaster University.
A study by Lauche et al. (2013) found that mindfulness-based stress reduction (MBSR) improved sleep quality and reduced pain in fibromyalgia patients.(4) MBSR is intended to be done in a group setting, so if you’re interested in trying it, check for online or in-person groups. Practices within MBSR sessions can include breathing techniques, gratitude journalling, body scans, loving kindness meditations and yoga. You can practice any of the exercises/techniques that resonate with you on your own.
While exercise consistent with your limitations is highly desirable, it’s best to avoid challenging exercise within 2 hours before bedtime. A relaxed stroll around the block, however, can help lessen pain or the symptoms of RLS, and help reduce stress.
Medications
On a personal level, I first seek non-pharmaceutical solutions for my FM symptoms. Having said that, some individuals report improvements in their condition as a result of using prescription medications. It’s your health and your decision, the important thing is that you understand both the benefits and side effects of any drugs you are prescribed.
Medications and supplements to improve sleep are generally organized into three categories- deep sleep promoters (e.g. pregabalin), sedatives (e.g. melatonin) and stress response blockers (e.g. muscle relaxants).
I recommend The FibroManual: A Complete Fibromyalgia Treatment Guide for You and Your Doctor by Dr. Ginerva Lipton. It includes a helpful section on common sleep medications, along with other research-backed insights that might support your journey.
Conclusion
Sleep disturbances are a common and challenging aspect of fibromyalgia, but with the right strategies, it is possible to improve sleep quality and reduce the impact of this condition on daily life. Whether through medications, supplements, sleep habit modifications, or cognitive-behavioural therapy, there are a variety of options available to help manage sleep issues associated with fibromyalgia.
What strategies or routines have you found helpful for improving your sleep with fibromyalgia?
Citations:
Sendur, O. F., Tastaban, E., Turan, Y., & Yenisey, C. (2008). "The relationship between serum trace element levels and clinical parameters in patients with fibromyalgia." Rheumatology International, 28(11), 1117-1121.
Caruso, I., Sarzi Puttini, P., & Cazzola, M. (1990). "A comparison of 5-hydroxytryptophan and amitriptyline in the treatment of primary fibromyalgia syndrome: a randomized, double-blind, clinical study." Journal of International Medical Research, 18(2), 112-119.
Citera, G., Arias, M. A., Maldonado-Cocco, J. A., Lazaro, M. A., Rosemffet, M. G., Brusco, L. I., & Scheines, E. J. (2000). "The effect of melatonin in patients with fibromyalgia: a pilot study." Clinical Rheumatology, 19(1), 9-13.
Lauche, R., Cramer, H., Dobos, G., Langhorst, J., & Schmidt, S. (2013). "A systematic review and meta-analysis of mindfulness-based stress reduction for fibromyalgia syndrome." Journal of Psychosomatic Research, 75(6), 500-510.
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