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COVID-somnia and Painsomnia

Sleep neurologists call it “COVID-somnia” — higher levels of sleep disturbances due to the COVID-19 pandemic.

If this sounds familiar, you’re far from alone. Sleep neurologists have been reporting more sleep disturbances and even the misuse of sleep medications not only in people recovering from COVID-19, but also in those affected by fear and social isolation due to the pandemic, according to a recent article in Neurology Today, the official publication of the American Academy of Neurology.

“All our patients are suffering from shifts in their sleep patterns due to their fears about getting the virus, concerns about loved ones, not being able to go to work, not having social contact with others,” Rachel Marie E. Salas, MD, FAAN, associate professor of neurology at the Johns Hopkins Center for Sleep, told Neurology Today.

 Some of these patients now even meet the diagnostic criteria for chronic insomnia, which is not being able to fall asleep within 30 minutes more than three times per week for more than three months.

From February 16 to March 15 of this year (the week COVID-19 was declared a pandemic) the number of prescriptions filled for sleep disorders had already jumped by 14.8 percent, per a report from Express Scripts.

And in a study of 1,138 Hong Kong adults published online in Sleep Medicine in July, a high proportion of participants said their sleep had worsened since the COVID-19 outbreak. In fact, 38 percent reported worsened sleep quality, 30 percent reported greater difficulty in falling asleep, and 29 percent reported shortened sleep duration.

How Sleep Issues Affect People with Chronic Pain and Arthritis

If you live with arthritis or related musculoskeletal pain, sleep is already likely a concern for you. Many patients call this “painsomnia,” which refers to sleep issues that occur because of chronic pain. Poor sleep, in turn, can make pain worse.

For example, 57 percent of patients with rheumatoid arthritis reported non-optimal sleep, which was linked to pain levels, in a 2018 study published in the Journal of Clinical Medicine.

Other research has shown that patients with rheumatoid arthritis have lower overall sleep efficiency and wake up more often.

“In persons with active rheumatoid arthritis [or other kinds of inflammatory arthritis]

, the constant presence of inflammatory mediators at high levels impacts pain pathways,” says Vivek Nagaraja, MD, a clinical rheumatologist and researcher at Michigan Medicine. “Pain processing areas and pathways are closely linked to sleep pathways.”

In other words, the constant presence of joint inflammation could make you more sensitive to pain over time, which in turn could keep you from getting enough good-quality sleep.

The Role that Pain Plays in Sleep

Painsomnia can turn into a vicious cycle of pain, too little sleep, and worsening symptoms.

In a small study of 25 healthy young adults published in The Journal of Neuroscience, participants had a lower threshold for pain (tested by applying heat to their skin) when they were sleep-deprived compared to when they were well-rested.

Researchers found that sleep deprivation increased reactivity in the brain’s somatosensory cortex, which amplified pain signals. It also decreased reactivity in the striatum and insula, areas of the brain responsible for modulating pain.

“One thing we know for sure is that lack of sleep really affects your immune system, and if you’re not sleeping as well as you should, that can aggravate an immune system condition like rheumatoid arthritis,” says Frank Coletta, MD, sleep medicine specialist and director of pulmonary medicine and critical care at Mount Sinai South Nassau in Oceanside, New York.

It’s also important to get enough sleep during the COVID-19 pandemic because too little weakens the body’s defense system, and may make you more vulnerable to contracting germs, per The University of Chicago Medicine.

The Intersection of Painsomnia and COVID-somnia

If you’re already prone to poor sleep due to pain and other arthritis symptoms, the added stress of the COVID-19 pandemic is likely making matters worse.

In a recent poll of Global Healthy Living Foundation (GHLF) and CreakyJoints members, 71 percent reported that they think their sleep quality has gotten somewhat worse or a lot worse since the start of the COVID-19 pandemic. Factors that contributed to this poor sleep quality included the following (respondents could select all that applied):

  • 54% said pain due to their health conditions
  • 25% said other symptoms due to their health conditions
  • 72% said stress due to the uncertain state of things nationally and around the world
  • 59% said stress due to the threat of coronavirus
  • 51% said lack of socializing due to coronavirus restrictions
  • 44% said lack of exercise and/or mobility due to coronavirus restrictions
  • 22% said worsened sleep hygiene due to coronavirus restrictions, such as working in the bedroom or spending more time than you used to in your bedroom

The pandemic is also affecting pain levels, other research shows. People who have bone, joint, and muscle pain experienced worsening symptoms during COVID-19 lockdowns, reported a September study in Rheumatology Advances in Practice. In a survey conducted in late April of more than 600 people with a range of musculoskeletal diseases in the United Kingdom, researchers found that 52 percent percent of participants reported worsening musculoskeletal symptoms such as pain and stiffness since the start of lockdown.

“This survey, conducted in the early stages of the UK ‘lockdown’, suggests that there have been immediate negative consequences for people with musculoskeletal disease,” note the researchers.

Complicated Sleep Struggles: The Patient Perspective

In a free response section of our GHLF survey, more than 200 participants shared more details about their struggles with COVID-somnia and painsomnia. These personal anecdotes shed light on the complicated situations our community is facing. Here are some examples.

Wake up worrying about COVID: “I can’t fall asleep, even though I am tired. Then when I do finally fall asleep, I wake up through the night still worrying about how many more people have COVID since the day before.”

Lack of exercise: “The lack of exercise and mobility has been like a death sentence [for] my pain. Combined with the lack of routine and schedules, I’m an exhausted mess.”

Natural disasters: “Since my sleep has really been impacted, my health has felt much worse, more inflammation, swollen joints, pain in joints, and more overall fatigue has made it even harder to get through all of this. I feel that my regular sleep schedule has really been disrupted since the beginning of the lockdown in California. During the recent wildfires, I was sometimes looking at the news in the middle of the night, and getting emergency alerts, texts from friends. One notification that came at two in the morning said to ‘stay alert.’ Stress from the pandemic, fires, political strife, and increased joint pain makes for really poor sleep. Even when using CPAP for sleep apnea, I wake up worn out from so much going on right now.”

Juggling it all: “I feel in a constant state of stress. I am a mother of two girls. I feel like every choice I make is wrong regarding my kids, school, friends, etc. Being so sick myself, I am such high-risk. It feels like my family resents me for the additional precautions they have to take. I can’t rest or relax. I feel more overworked now than ever in my life. I am homeschooling my kids and my husband is a first responder so I am on my own a lot. I am stressed all the time and cannot sleep from it.”

Lack of energy: “My energy is not what it used to be throughout the day. Can’t fall asleep till later and later at night. Shorter time sleeping. Can take naps which cut into nighttime hours. Complete mess!”

How to Get Better Sleep During the COVID-19 Pandemic

There may not be a magic fix for your COVID-somnia and painsomnia, but the first step is to recognize that you’re not getting the sleep you need to be healthy. Then, consider these trusted sleep hygiene tips and think about how to apply them to your pandemic lifestyle.

1. Get enough exercise

It’s best to try to fit in at least 30 minutes of aerobic exercise four to five days per week for sound sleep. In a 2019 systematic review of 14 studies published in the European Journal of Physiotherapy, researchers found that moderate exercise like walking or doing Pilates was beneficial to sleep quality in both younger and older adults. In fact, moderate physical activity was even more beneficial for sleep quality than vigorous exercise — meaning you don’t have to do sprints to reap the benefits.

Of course, you may be getting less exercise during COVID-19 because you’re self-isolating or feel as though it’s unsafe to go the gym. However, no matter how you manage to squeeze in more physical activity, it can benefit your sleep. Consider:

  • Pace your home while on phone calls to add in steps (this is great if you’re working from home)
  • Do free online exercise videos (look for ones that are gentle, low-impact, or good for people with arthritis)
  • Wear a mask and go up and down the halls or stairways in your apartment building
  • Walk outside (if you can maintain social distance) in short bursts throughout the day

2. Practice mindfulness

Many participants in our poll noted that their minds raced before bed or they had trouble “powering down” their thoughts as they tried to go to sleep. Try to find a “mind-quieting” activity that helps you separate the day from bedtime before you get into bed.

Anything that helps you relax before bed can benefit your sleep, even if it’s just a warm shower. That said, activities that incorporate mindfulness may be particularly effective. “Mindfulness practices go a long way in lowering stress and altering our stress responses,” says Dr. Nagaraja. “These include meditation, breathing exercises, gentle yoga, and tai chi.”

3. Limit screen time

Try not to stay glued to your phone, tablet, or computer until the moment you go to sleep. This is a tough one during the pandemic, when it feels like news is always changing and our phones are always pining with new alerts and bad news. But giving yourself a set time to separate from your device — such as an hour before you want to fall asleep — may help a lot, especially right now.

“The light emitted from a computer screen, especially at night, can activate certain areas of the brain to think that it’s daytime,” says Dr. Coletta. “Limit screen time for the last one or two hours before going to sleep.” 

4. Cut down on the news

With today’s constant news cycle, it can be easy to get swept up in breaking news throughout the day. However, taking breaks from upsetting news can help you better cope with stress, which helps you sleep better.

“Limit the amount of time that you hear, read, or watch news media,” says Dr. Nagaraja.

This is important to do not just right before bed — look at your entire daily news diet. Consider giving yourself a set window to engage with news so you’re not constantly getting sucked in and adding to a mountain of anxiety.

 5. Maintain a bedtime schedule

Even if you’re working from home right now and can stay up — and sleep in — later, stick to a routine schedule as much as possible.

“Make sure you maintain your sleep schedule, going to bed at the same time and waking up at the same time,” says Dr. Coletta. “Sleeping later in the morning can result in a circadian rhythm disorder called delayed sleep phase syndrome.”

Delayed sleep phase syndrome (DSPS) is when your sleep is delayed by two hours or more beyond what is typically considered a conventional bedtime, per Stanford Health Care. That may mean falling asleep after midnight instead of 10 PM, and having trouble getting up for work in the morning.

6. Stick to a daytime schedule

When you’re working from home or simply spending more time inside, you might switch up your schedule more regularly because you have the flexibility to. However, having a routine in your daily life helps you sleep better. It can be helpful to shower, exercise, and eat meals at the same time every day (and avoid eating late at night) for sound sleep. It’s also a good idea to skip naps when you can.

“If you need it and it’s unavoidable, then you should limit your nap to one REM cycle, which is usually 30 to 60 minutes,” says Dr. Coletta. “Anything else may be non-productive and impact your ability to fall asleep at night.”  

7. Avoid working in bed

Skip reading, working, or watching TV in bed — and anything else that might stimulate your mind and prevent you from associating your bed with sleep.

“We often say the bedroom and the bed should only be for two things: sleep and sex,” says Dr. Coletta.

 8. See a doctor if necessary

You should see your doctor if insomnia makes it difficult for you to function during the day.

Red flags that you’re experiencing insomnia can go beyond difficulty falling asleep at night, according to the Mayo Clinic. They may also include:

  • Waking up during the night
  • Waking up too early
  • Not feeling well-rested after a night’s sleep
  • Daytime tiredness or sleepiness
  • Irritability, depression, or anxiety
  • Difficulty paying attention, focusing on tasks, or remembering things
  • Making more errors or accidents
  • Having persistent worries about sleep

“The doctor would take your history of prior sleep disturbances and any mental health issues that might be impacting your sleep to come up with a potential diagnosis,” says Dr. Coletta. “Then they can walk through various interventions, from cognitive behavioral therapy to prescription medicine.”

For more on sleeping soundly tonight, check out 18 more tips that arthritis patients swear by.

Get Free Coronavirus Support for Chronic Illness Patients

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America’s State of Mind Report. Express Scripts. April 16, 2020. https://www.express-scripts.com/corporate/americas-state-of-mind-report.

Delayed Sleep Phase Syndrome. Stanford Health Care. September 24, 2020. https://stanfordhealthcare.org/medical-conditions/sleep/delayed-sleep-phase-syndrome.html.

Grabovac I, et al. Sleep Quality in Patients with Rheumatoid Arthritis and Associations with Pain, Disability, Disease Duration, and Activity. Journal of Clinical Medicine. October 9, 2018.  doi: http://doi.org/10.3390/jcm7100336.

Hurley D. Sleep Neurologists Call It ‘COVID-Somnia’—Increased Sleep Disturbances Linked to the Pandemic. Neurology Today. July 9, 2020. https://journals.lww.com/neurotodayonline/fulltext/2020/07090/sleep_neurologists_call_it.1.aspx.

Insomnia. Mayo Clinic. October 15, 2016. https://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167.

Interview with Frank Coletta, MD, sleep medicine specialist and director of pulmonary medicine and critical care at Mount Sinai South Nassau in Oceanside, New York

Interview with Vivek Nagaraja, MD, a clinical rheumatologist and researcher at Michigan Medicine

Krause AJ, et al. The Pain of Sleep Loss: A Brain Characterization in Humans. The Journal of Neuroscience. March 20, 2019. doi: https://doi.org/10.1523/JNEUROSCI.2408-18.2018.

Smith TO, et al. Accessing health services for musculoskeletal diseases during early COVID-19 lockdown: results from a UK population survey. Rheumatology Advances in Practice. September 22, 2020. doi: https://doi.org/10.1093/rap/rkaa047.

Wang F, et al. The effect of physical activity on sleep quality: a systematic review. European Journal of Physiotherapy. June 24, 2019. doi: https://doi.org/10.1080/21679169.2019.1623314.

Why it’s important to get a good night’s sleep during the coronavirus outbreak. The University of Chicago Medicine. April 16, 2020. https://www.uchicagomedicine.org/forefront/coronavirus-disease-covid-19/advice-for-sleeping-well-during-the-covid-19-outbreak.

Yu BY, et al. Prevalence of sleep disturbances during COVID-19 outbreak in an urban Chinese population: a cross-sectional study. Sleep Medicine. October 2020. doi: https://doi.org/10.1016/j.sleep.2020.07.009.

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