Better Nights for Better Days

Overcoming sleep problems

That we are not much sicker and much madder than we are is due exclusively to that most blessed and blessing of all natural graces, sleep. — Aldous Huxley, "Variations on a Philosopher," Themes and Variations, 1950.
by Margaret Wahl on October 1, 2000 - 3:07pm

Scott Porterfield of Hilliard, Ohio, says he's occasionally had to spend the night in his wheelchair because he's found it impossible to get comfortable in bed.

Porterfield, who's 6 feet 3 inches tall and weighs 200 pounds, has Becker muscular dystrophy and enough muscle weakness to keep him nearly immobilized without mechanical aids. His shoulders are uneven, making the left one higher than the right when he tries to lie flat in bed. It's the left shoulder that gives him the most trouble.

"The numbness starts in the shoulder and eventually the whole arm will go numb. It becomes very uncomfortable and at times extremely painful," says the 30-year-old Porterfield.

Unfortunately, such problems aren't uncommon in neuromuscular disease, says neurologist John Kissel, who co-directs the MDA clinic at Ohio State University Medical Center in Columbus. Kissel says a certain amount of musculoskeletal aching and general discomfort goes along with weakness and immobilized joints. Then there's simply the inability to spontaneously move to change position.

Normally, Kissel says, people change position often when they're in bed or give a good stretch to their muscles. If you can't do that, discomfort or even pain can result. "You can start off in a position that's relatively comfortable, but then after a while it's not, and you can't change it."

Kissel has recommended various kinds of pain relief for his patients, including anti-inflammatory medications; TENS (transcutaneous electrical nerve stimulation) units; stretching exercises before bed (these can be done passively, with someone else moving the limbs), preferably after instruction by a physical therapist; and changes of mattresses, pillows and other bed items.

All can be effective to an extent, and sometimes patience and experimentation are needed. "Probably the most common misconception is assuming that changing a mattress will work," Kissel says. "Some people will say, 'I've heard waterbeds can work,' and then they go buy a waterbed and find that it doesn't work for them. Some waterbeds are hard, and some are real soft. Try the bed first."

Kissel adds, "In patients where the problem hangs on, you have to be sure it isn't a psychiatric problem or sleep apnea [cessation of breathing during sleep] or something else." He remembers with regret a young man who continued to complain of insomnia and back pain and was eventually found to have a fractured vertebra.

What is sleep?

At a sleep disorder clinic, technicians can monitor a person’s sleep patterns, breathing changes and muscle movements during sleep. These measures can help identify problems preventing a night’s rest.

After thousands of years of philosophical observations and decades of scientific studies, we still know relatively little about what sleep really is — except that it happens in the brain and that it's absolutely necessary for physical and mental well-being.

The onset of sleep may have something to do with a brain chemical known as GABA (gamma-aminobutyric acid), which quiets the activity of the nerve cells it reaches. Most sleep medications are thought to act by enhancing or imitating GABA's actions. Still, there are so many brain phenomena associated with sleep that it's hard for experts to say which ones actually cause sleep and which ones are just along for the ride.

We know that sleep seems to exist in at least two forms: slow-wave sleep and REM, or rapid eye movement, sleep. During slow-wave sleep, which ranges from light to deep, brain waves are generally slower (farther apart) than they are during wakefulness. During REM sleep, when dreams occur, brain waves more closely resemble wakefulness, and the eyes dart back and forth as if watching a movie, all while the sleeper appears in other ways to be in a deep sleep.

The average person cycles through slow-wave sleep and REM sleep four or five times a night, with slow-wave sleep making up about 75 percent and REM sleep about 25 percent of the night, at least in young adults. The overall pattern of sleep is known as sleep architecture, and it can be altered by pain, stress, disease, medications, alcohol, caffeine, aging and other factors. Some sleep remedies change sleep architecture, resulting in a sleep that's not as refreshing as natural sleep.

During sleep, respiratory movements are less effective, and the upper airway can collapse as certain muscles in the throat area relax.

The breathing connection

Of all the problems that interfere with sleep in someone with a neuromuscular disease, breathing abnormalities are among the most serious. Unfortunately, they're often overlooked unless careful testing, such as a sleep study, is done. (See Quest's two-part series on respiratory care.)

In most neuromuscular disorders, particularly the muscular dystrophies, myasthenias, motor neuron disorders and metabolic muscle diseases, the muscles that control respiration (mostly the diaphragm and those between the ribs) can gradually weaken, interfering with ventilation, the act of taking in air and letting it out.

A noninvasive ventilator used at night can help a person with a neuromuscular disease get better sleep. Photo courtesy of Respironics Inc.

During the night, it's normal to have changes in ventilation. Complex neurologic factors, as well as position and gravity, change nighttime breathing, especially during deep sleep. In the average person, even though breathing efforts are less effective during sleep, they're still good enough. But if respiratory muscles are weak, as they often are in neuromuscular disease, these efforts can easily fall below a safe threshold, leading to low oxygen and high carbon dioxide levels during the night.

It takes quite a bit of respiratory interference to cause shortness of breath. Instead, you're likely to feel groggy during the day, or to doze frequently; appear dull, apathetic or depressed; or often wake with a headache in the morning. You may even be unaware that you're not sleeping well during the night and that your nighttime oxygen and carbon dioxide levels are off.

Some people with neuromuscular disorders also have weakness of the upper airway muscles, so that the upper airway can periodically collapse and block air flow during sleep. A bed partner or caregiver may notice snoring if the airway is partially blocked. Periodic cessations of breathing lasting several seconds, sometimes as many as 20 to 60 times an hour, can occur if it's completely blocked. This latter condition is known as obstructive sleep apnea and can be very serious if left untreated.

Myotonic muscular dystrophy (MMD) seems to be a special case, affecting not only the muscles involved in breathing, but also cells in the brain that control how we breathe. During sleep, many people with this disorder can fail to breathe normally because of this brain factor — a condition known as central sleep apnea (because of the involvement of the central nervous system).

The usual treatment for sleep apnea, whether it's obstructive or central, and for ineffective nighttime ventilation (sleep-related hypoventilation, or hypopnea), is noninvasive positive pressure ventilation. This means using a small ventilator that pumps air into the lungs via a mask that fits over the nose or nose and mouth to assist your breathing.

The type of NIPPV usually used in neuromuscular disease is bilevel positive airway pressure, or BiPAP. (Although often used generically, BiPAP is actually a brand name belonging to Respironics Inc.)

Bilevel pressure, as contrasted with continuous pressure (CPAP), allows a lower pressure to exhale against and delivers a higher pressure on inhalation. CPAP, often used for sleep apnea in people without neuromuscular disease, delivers one level of pressure continuously, making it hard for the person with weak respiratory muscles to exhale.

For some patients, a set volume, rather than a set pressure, of air works better. This requires a different type of device.

Often, the use of nighttime NIPPV markedly improves daytime functioning as well as the quality of sleep.

A screening test for sleep apnea or hypoventilation that affects oxygen levels can be performed using an oxygen sensor (oximeter), a small, surface electrode attached to a finger or earlobe during the night to measure oxygen levels in the blood. A more comprehensive look at sleep-related breathing patterns is achieved with a full sleep study, in which the patient is monitored overnight with electrodes measuring respiratory efforts, oxygen levels and stages of sleep, among other functions. Sometimes, sleep apnea or hypoventilation interfere so much with sleep that the person never reaches deep sleep at all, something only a sleep study can detect.

Taming stress

Leaving your problems at the bedroom door is a good idea for anyone, although it's easier said than done, especially for those with serious illnesses. But, as much as possible, it's important to recognize and deal with stress to get a good night's sleep.

Tom Roth, 43, of Gibsonia, Pa., recently learned he has amyotrophic lateral sclerosis, a disorder that usually leads to complete paralysis and death within a few years. With four young children to support, Roth has plenty to worry about.

Muscle twitches, a common feature of ALS, would be hard enough to take during the night, says Roth, but the psychological component of these twitches makes them much harder to bear.

"The twitching is just a constant reminder of the disease," he says. "It's as if someone's poking me in the back and saying, 'Remember now, you've got ALS.'" Once he does drop off to sleep, twitches and all, he says, "That's when the cramps kick in. They wake me up throughout the night."

Stretching exercises before bed, a heating pad, massages by his wife and, especially, the drug tizanidine (Zanaflex) have helped reduce the twitching and cramping, Roth says. He's had to work harder to tame his worries.

He says he's gotten a surprising amount of help from reading Who Moved My Cheese? by Spencer Johnson (Putnam Publishing Group, 1998), about coping with change and revising goals. The short book chronicles the adventures of four characters (two mice and two humanoids) whose cheese supply has disappeared.

"Basically, all it says is that change is inevitable, so you might as well plan and adapt your situation, be ready for when it does happen. Don't be oblivious to it so that when it happens you don't know what to do," Roth says.

For Roth, adapting to his situation has meant adjusting his work schedule and duties, spending more time on the computer and less in his manufacturing company's warehouse, and shortening his hours. He recently moved his office to a more accessible location in the building.

"The simple thing is that my legs are going to give out sooner or later, so why not move the office now so I don't have to go up and down steps?" he says. "When we put the desk down there, we made it wide enough so that a wheelchair will be able to get in there eventually."

Recently, Roth has put his will and estate papers in order. "You don't want to have to do that kind of stuff, but you gotta," he says.

Roth still attends his 10-year-old son's soccer games. But in anticipation of the day when that won't be possible, he's purchased a video camera, so he can see the game with his family when they return.

"The fortunate thing with this disease is you've got somewhat of a time frame," Roth says. "You've got the opportunity to plan these things out if you use your time right. If you do the planning, you've got that 'I've got that base covered' feeling. You've accomplished something, and you can go on to the next step." And, he hopes, to a better night's sleep.

Dealing with depression

Psychiatrist and sleep specialist Karl Doghramji

Depression is a close cousin of insomnia. Almost everyone with depression has some sleep abnormalities, but the reverse isn't always true: Not everyone with sleep abnormalities is depressed.

It's become commonplace for physicians to assume the person with insomnia is depressed and to prescribe a low dose of an antidepressant without further evaluation, says Merrill Mitler, a neuropharmacologist at the Scripps Research Institute in La Jolla, Calif. Mitler doesn't think that's a good idea, since antidepressants can have undesirable effects and aren't as good as some other drugs at treating insomnia.

Karl Doghramji, a psychiatrist and sleep specialist who directs the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia, says that when he feels a sleep problem is related to a depression he takes care to prescribe antidepressants that are "sleep-friendly," which not all of them are. "It's a bit of an art" to determine whether depression is the underlying cause of insomnia, he says, one he practices on a daily basis.

Sleep hygiene tips

Sometimes, a sleep problem can be caused by bad sleep-related habits. A field known as sleep hygiene has developed to study these patterns, and experts advise the following routines:

  • Avoid caffeine within four to six hours of bedtime.
  • Avoid the use of nicotine close to bedtime or during the night.
  • Don't drink alcoholic beverages within four to six hours of bedtime.
  • While a light snack before bedtime can help promote sound sleep, avoid large meals.
  • Avoid strenuous exercise within six hours of bedtime.
  • Minimize light, noise and extremes of temperature in the bedroom.
  • Try to sleep when you're drowsy.
  • If you're unable to fall asleep or stay asleep, leave your bedroom and engage in a quiet activity elsewhere. Don't permit yourself to fall asleep outside the bedroom. Return to bed when - and only when - you're sleepy. Repeat this process as often as necessary throughout the night.
  • Maintain a regular time to arise, even on days off from work and on weekends.
  • Avoid napping during the day. If daytime sleepiness becomes overwhelming, limit naptime to a single nap of less than no hour, no later than 3 p.m.

Used with permission from the American Academy of Sleep Medicine.

The other side of midnight — daytime sleepiness

Knee wedges and body pillows are among the items that may help someone find a comfortable sleeping position. Photos courtesy of InteliHealth. Others find relief in an adjustable bed such as this Völker bed from Hertz Supply.

The most common cause of excessive daytime sleepiness is insomnia: If you don't sleep well at night you'll be sleepy the next day. Once the nighttime insomnia is treated, drowsiness in the daytime usually decreases. However, there are other causes for daytime sleepiness.

Here again, myotonic dystrophy is a special case. In this disorder, the part of the brain that controls the level of arousal and alertness is often involved. People with myotonic dystrophy, even after their respiratory problems have been brought under control with assisted ventilation, may need additional help in the form of a stimulant medication.

David Rye, a neurologist and sleep specialist at Emory University in Atlanta, has used pemoline (Cylert), methylphenidate (Ritalin) and modafinil (Provigil) for this purpose when patients with myotonic dystrophy and daytime sleepiness come to him from the MDA clinic. He says recent breakthroughs concerning proteins involved in narcolepsy (a brain disorder that causes people to fall asleep frequently during the day) may have application to the daytime sleepiness of myotonic dystrophy.

Rye uses a multiple sleep latency test, in which the subject is asked to take four or five naps at two-hour intervals, as "a way of putting a number" on daytime somnolence. The test measures the kind of daytime sleep experienced (REM sleep is unusual in the normal napper) and the time it takes to fall asleep during the day.

Another evaluation sometimes used is the Epworth Sleepiness Scale (see "How sleepy are you?,"). You can take this test yourself as a way of assessing how sleepy you are during the day.

In addition to the underarousal of myotonic dystrophy, depression and severe cardiac or respiratory impairment can also lead to excessive sleeping during the day. If nighttime insomnia has been adequately treated, these are factors to examine.

Getting help

"Going to the prescription pad" may be the first impulse of the average overworked doctor whose patient complains of insomnia, says Doghramji, but it may not be the best route, especially for people with neuromuscular disorders.

In neuromuscular disorders, the causes of a sleep problem can sometimes be clearly related to the underlying disease: a problem with positioning, muscle pain or obvious respiratory impairment, for example. But they can be more subtle. That's where certified sleep specialists and overnight sleep studies can be useful. To find a sleep disorders center or a sleep specialist in your area, you can contact the American Academy of Sleep Medicine or its associated Board of Sleep Medicine (see "Resources"). Chances are, you'll soon be on your way to better nighttime sleep and better daytime functioning.

Additional consultants for this story were Norma Cooke, neuropsychologist at Baylor College of Medicine and consultant to Baylor's MDA/ALS Center; Adrienne Schwarte, publications assistant at the American Academy of Sleep Medicine; Jeremy Shefner, neurologist and neurophysiologist, director of the MDA/ALS Center at SUNY Upstate Medical University, Syracuse, N.Y.; and Edward Sivak, pulmonologist, consultant to the MDA/ALS Center at SUNY Upstate Medical University.

If you're very sleepy in the daytime, you may not be getting enough sleep at night. Or, as in the case of myotonic dystrophy, brain centers controlling sleepiness may not be functioning properly. This scale can help you determine whether your daytime sleepiness warrants a change in habits or medical attention.

The Epworth Sleepiness Scale
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation Chance of Dozing
Sitting and reading _____
Watching television _____
Sitting inactive in a public place
(such as a theater)
_____
As a car passenger for an hour without a break _____
Lying down to rest in the afternoon _____
Sitting and talking to someone _____
Sitting quietly after lunch without alcohol _____
In a car, while stopping for a few minutes in traffic _____
Total Score _____

A score of 9 or more means you're very sleepy and should consider seeking advice from a professional.

The Epworth Sleepiness Scale was developed by Murray Johns at the Sleep Disorders Unit, Epworth Hospital, Melbourne, Victoria, Australia, and was first published in the December 1991 issue of the journal Sleep.

 

American Academy of Sleep Medicine
6301 Bandel Road NW, Suite 101, Rochester, MN 55901
(507) 287-6006
info@aasmnet.org
www.asda.org
Academic association for sleep medicine that accredits sleep disorders centers; Web site has a state-by-state list of centers.

American Board of Sleep Medicine
6301 Bandel Road NW, Suite 101, Rochester, MN 55901
(507) 287-9819
absm@absm.org
www.absm.org
Affiliated with American Academy of Sleep Medicine. Web site lists sleep specialists by state and by name.

National Sleep Foundation
1522 K Street, NW, Suite 500, Washington, DC 20005
(202) 347-3471
nsf@sleepfoundation.org
www.sleepfoundation.org
An independent, nonprofit organization supporting research and education on sleep and sleep disorders. It has lots of helpful information on Web site and in print.

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