Treating Sleep Disorders
Sleep disorders are a defining symptom of Fibromyalgia and contribute to not only excessive daytime sleepiness and fatigue, but also to depression, anxiety, and increased pain and tenderness. Although scientists do not fully understand the relationship between sleep disturbance and pain, it is known that for Fibromyalgia sufferers, improvements in sleep can result in improvements in pain symptoms. In fact, in 2008, the European League Against Rheumatism (EULAR) produced nine key recommendations for the management of Fibromyalgia following a detailed and systematic review of published studies and an expert consensus. The second recommendation calls for the effective pharmacological (i.e., drug) and non-pharmacological treatment of not only pain, but function, depression, fatigue and sleep disturbances (Carville et al., 2008).
Sleep Hygiene Practices
Sleep hygiene practices are important for every patient with Fibromyalgia (Culpepper, 2010). Good sleep hygiene practices include: sleeping only as much as needed in order to feel refreshed; maintaining a sleep diary to gain insight into sleep problems; maintaining regular arousal times in the morning (which promote normal sleep-wake patterns); utilizing relaxation therapies; performing regular exercise during the daytime; avoiding excessive napping; sleeping in a dark, quiet, and cool room; avoiding caffeine and alcohol; and eating a light snack before bed.
Cognitive Behavioral Therapy
Cognitive behavioral therapy is a type of psychotherapy that helps individuals by allowing them to better understand how their thoughts and feelings influence their behaviors. Recent research has demonstrated significant effectiveness for cognitive behavioral therapy for the treatment of insomnia in general (Siebern & Manber, 2011). A 2005 study by Edinger et al. found cognitive behavioral therapy to be extremely effective at improving sleep disturbances in Fibromyalgia patients. In this randomized controlled trial (the “gold standard” design for research studies), the researchers randomly assigned 47 Fibromyalgia patients with documented insomnia (difficulty falling asleep or remaining asleep through the night) to one of three interventions: cognitive-behavioral therapy; sleep hygiene therapy; or usual care for Fibromyalgia with no intervention for sleep disturbances. All subjects, regardless of intervention group, completed daily sleep logs and wore an actigraph (a small sensor that measures rest and activity cycles). The scientists found that those who received the cognitive behavioral therapy experienced the greatest improvements in nighttime wake times (approximately a 50% reduction), versus 20% and 3.5% reductions for the sleep hygiene and usual care groups, respectively. Furthermore, those in the cognitive behavioral therapy group also showed significant improvements in self-rated sleep improvement (57%), versus only 17% for the sleep hygiene group and 0% for the usual care group. Based on their findings, the researchers concluded that cognitive behavioral therapy is a useful intervention for treating sleep disturbances in Fibromyalgia patients.
A 2011 study by Miro et al. also evaluated the use of cognitive behavioral therapy versus sleep hygiene to treat insomnia in Fibromyalgia patients. Much like the findings of Edinger et al. (2005), Miro and colleagues found that those who received six 90-minute sessions of cognitive behavioral therapy had significantly improved alertness, executive functioning, and sleep quality when compared to those who received only usual care and instructions related to sleep hygiene.
A randomized controlled trial conducted in 2008 found that Fibromyalgia patients who were randomized to three hours of warm water exercise weekly for 12 weeks showed significant improvements in sleep quality (Munguia-Izquierdo & Legaz-Arrese, 2008). However, a recent review article evaluated the effects of various forms of aerobic exercise on Fibromyalgia and was not able to detect any significant effects of aerobic exercise on sleep among the studies evaluated (Hauser et al., 2010). The lack of available research and conflicting nature of existing findings points to the need for additional studies to investigate the relationship between exercise and sleep disturbances in Fibromyalgia.
It is important to note that while some medications can be useful to treat sleep disturbances in Fibromyalgia patients, many drugs used to treat other disorders may actually cause sleep disturbances. Examples of these include certain anticonvulsants, beta blockers, antipsychotics, and non-steroidal anti-inflammatory medications (NSAIDS). However, certain medications have shown effectiveness at treating sleep disorders associated with Fibromyalgia. Amitriptyline is an antidepressant commonly used and effective as a means to treat many symptoms associated with Fibromyalgia, including sleep disturbances (Hauser et al., 2011). A 1991 study by Drewes et al. found that the drug zopiclone, a mild sedative, was effective in treating the sleep complaints of 41 Fibromyalgia patients. In particular, significant improvements were seen in daytime tiredness and subjective sleep complaints (Drewes et al., 1991). The drug pregabalin has also been shown in two randomized, double-blind, placebo-controlled trials to improve sleep quality in patients with Fibromyalgia (Arnold et al., 2008; Crofford et al., 2005).
In addition, the drug sodium oxybate has been demonstrated to be effective in reducing sleep disturbances – namely waking periods following the onset of sleep – as well as at increasing the amount of non-REM sleep among Fibromyalgia sufferers. In a randomized, double-blind, placebo-controlled trial of 548 Fibromyalgia patients, Russell et al. found significant improvements in fatigue and sleep disturbance among those treated with sodium oxybate when compared to those who received a placebo. Specifically, the researchers found that patients who took sodium oxybate had fewer periods of nocturnal awakenings (Russell et al., 2011). Another double-blind, randomized, placebo-controlled trial also evaluated sodium oxybate in 304 Fibromyalgia patients and found the drug helpful in improving a variety of sleep-related complaints, including excessive daytime sleepiness, fatigue, and improved the duration of deep sleep cycles (Moldofsky et al., 2010).
Melatonin is a hormone that helps to regulate sleep and wake cycles. A small study has suggested that Fibromyalgia patients may have lower levels of naturally-occurring melatonin during hours of darkness and has offered the theory that perhaps lower levels of melatonin contribute to the increased rate of sleep disturbances experienced by a vast majority of Fibromyalgia sufferers (Wikner et al., 1998). Supplemental melatonin has shown effectiveness in treating sleep-wake cycle disturbances in individuals with depression and other conditions, such as schizophrenia, chronic obstructive pulmonary disease, and dementia. A 2000 study evaluated the use of melatonin at bedtime among 21 Fibromyalgia patients. The investigators studied the effects of melatonin on pain, sleep disturbances, fatigue, depression, anxiety, and overall functioning. At the end of the four week study, the researchers found improved tender point counts as well as sleep quality. However, the authors cited the limitations of their study design and indicated the need for double-blind, placebo-controlled studies to further examine any potential associations (Citera et al. 2000).