50% MS patients has sleep problems

SLEEP AND M.S.

Insomnia

Nocturnal legs spasm

Narcolepsy

Restless leg syndrome (RLS)

REM sleep behaviour disorder

Sleep disordered breathing

MOST COMMON SYMPTOMS

24 hrs rhythm

Day=awake, night=sleep

Melatonin hormone release helps sleeping

90 min sleep circle

REM (rapid eye movement) circle

NON-REM circle

1, 2, 3, 4 stages – slow waves (NON-REM @beginner of the night and REM at the end of the night)

CIRCADIAN RHYTHM

Good sleep habits: relax before bed,

organise a sleep ritual,

hot bath 1-2 hrs before bed time,

reconsider the duvet cover and bed linen etc, wear comfortable pyjamas,

lights out, quiet, go to bed when tired,

consistent time when go to bed,

do not sleep during day,

do not use caffeine 6hrs before bed time, do not use nicotine close to bed time, do not drink alcohol 4-6 hrs before bed time,

if you do not fall asleep within 10-15 minutes, get up and find something to do to relax you.

SLEEP HYGIENE

Maintain daily activity (exercise regularly)

No sleep over the day

No clock watching whilst in bed

Remember, bed is for sleeping only, no activities

Sleep when you feel sleepy

Non stimulant activities after 4 pm

Reduce fluid intake after 6pm

Use the toilet before going to bed

Do not go to bed hungry or after heavy meal

Avoid vigorous exercises 3 hrs before bed time

Set up alarm to wake you up at the same time every day

INSOMNIA

Treat symptoms first:

MS symptoms such as spasticity, frequent trips to the bathroom (nocturia), or periodic limb movements in sleep

(PLMS) can disturb sleep.

MS symptoms and sleep problems can feel difficult to untangle. For example, MS fatigue can be confused with

lack of sleep.

Speak to your physician about treatments to manage these sleep-disturbing symptoms. Then review bedtime habits

TREATMENT

If MS symptoms are under control and self-help isn't working, consider asking for a referral to a sleep specialist.

Sleep is vital to well being for everyone. Research reports that most adults need eight hours of sleep for learning,

memory and problem solving. Sleep is also important for the heart and vascular system and it helps regulate

hormones that effect immune function, blood sugar, and weight. A chronic lack of sleep also increases the risk for

diabetes, obesity, cardiovascular disease, and mood disorders.

SLEEP SPECIALIST

CLEVELAND, Ohio-- Sleep may play a key role in the production and repair of myelin, the protective covering of nerve cells that is attacked and damaged in people with multiple sclerosis, according to early research in mice

carried out at the University of Wisconsin.

The research found that the rate of production of a type of brain cell called oligodendrocyte precursor cells (OPCs) doubled in sleep relative to waking. OPCs are a type of cell that give rise to myelin in both healthy and injured

adult brains.

“OPCs are among the few brain cells that in an adult brain keep proliferating and dividing and producing more cells,” said Dr. Chiara Cirelli, a professor in the department of psychiatry at the University of Wisconsin and senior author on the paper, which was published online Sept. 4 in The Journal of Neuroscience. “Most all neurons in the

adult brain don’t do that—that’s why people are studying them now quite extensively.”

Cirelli began studying the functions of sleep about 15 years ago, by looking at all the genes that change in an animal’s brain during sleep versus waking. In a 2004 study in the journal Neuron, her research group found that up to five percent of genes expressed in the cortex or "gray matter" of the brain change solely due to whether an

animal is asleep or awake.

In the current study, they looked specifically at OPCs, a type of glial cell. Glial cells are all the brain cells that are not neurons, and used to be thought of as simply the "glue" of the brain, whose only function was to support the

neurons. Now, the glia, which have been discovered to help maintain the brain’s internal equilibrium and produce myelin (among other functions), are the subject of intense scientific focus.

In Cirelli’s current research, sleep-triggered genes produced OPCs, while sleep deprivation led to a suppression of these genes and more activity in genes that have been implicated in cell death and stress responses.

The findings suggest that chronic sleep loss could aggravate symptoms of diseases like MS which involve damage to myelin, Cirelli said, but there is a lot more work to be done before any firm conclusions can be drawn in people.

“Disturbed sleep may aggravate perhaps the symptoms of the disease, in a vicious cycle,” she said. “It would be nice to try to block the vicious cycle and improve the quality of sleep in these patients.”

RESEARCH

Multiple sclerosis , which affects 400,000 people in the United States and has no cure, is a disease in which the body’s own immune system attacks the myelin surrounding nerves and can cause numbness, paralysis

and loss of vision.

In Cirelli’s study, the rate of OPC production was particularly high during rapid eye movement (REM) sleep, which the researchers determined using brain wave measurements in sleeping mice. REM sleep, which is

when people typically dream, occurs at the tail end of a regular sleep cycle.

“What this means, we don’t know,” Cirelli said, “but there might be hormonal changes in non-REM versus REM sleep.”

For example, in older adults prolactin (a hormone which regulates the immune system and is involved in nursing) is released during REM sleep, and studies in pregnant women have shown that as prolactin

increases, symptoms of MS decrease.

“This is just speculation, though,” Cirelli points out. She hopes that other researchers will take up the study of sleep and OPCs in MS.

“It would be nice if someone could follow up and just look to see if there is any indication if the symptoms of the disease are aggravated during periods of especially severe sleep deprivation,” she said.

Her research group plans to study the effect of sleep on gene activation in other glial cells, called astrocytes

RESEARCH CONT.

Tachibana N, et al. Sleep problems in multiple sclerosis.European Neurology 1994;34(6):320-323.

Fleming WE, Pollak CP. Sleep disorders in multiple sclerosis. Seminars Neurology 2005;25(1):64-68.

Tanton BR, et al. Sleep and fatigue in multiple sclerosis.Multiple Sclerosis 2006;12(4):481-486.

REFERENCES

Sleep disturbance in multiple sclerosis:

Paula Cowan, MSc, MS Specialist Physiotherapist Kenilworth Medical Centre, Cumbernauld Way Ahead 2011;15(4):6-7

Clinical messages:

Health professionals need to increase awareness and develop a better understanding of sleep disturbance in the MS population

Investigation of sleep disturbance should be an integral part of the routine neurological assessment

Care pathways need to be identified for the treatment of sleep disturbance

Future direction for effective and efficient intervention for sleep disturbance should come from such directives as SIGN or NICE

guidelines

RECOMMENDATIONS

• Sleep medications are not approved for use by the FDA for long-term management of sleep because they can actually worsen

sleep problems over time.

• Many sleep medications are addictive and so the body builds a tolerance to them. This is especially true of the benzodiazepines,

such as Xanax©, Librium©, Valium© and Ativan©.

• Tapering your use of strong prescribed sleep medications must be done gradually and with medical supervision. Abruptly stopping

your sleep medications can be very dangerous. 

• If you have concerns about how your medication is affecting your sleep, consult your health care provider to discuss alternatives.

MEDICATION AWARENESS

If mood issues such as anxiety or depression are causing sleep difficulties, counselling (psychotherapy) may be an appropriate treatment.

For those with anxiety, relaxation therapy and meditation exercises can help create a restful environment both in your bedroom and in your body and mind. 

Research has shown that the use of special bright lights (phototherapy) can promote sleep. Exposure to these lights at specific times in the day, may help you sleep more at night.

Consult with your health care provider first, as these lights can cause eyestrain and headaches. 

Some people with MS have found over-the-counter natural remedies are effective. Herbal teas such as chamomile, melatonin and valerian may be useful in improving sleep, and these

are sold in health food and drug stores. However, these remedies have multiple drug interactions, and you should consult your doctor or naturopath before using them.

Reference:

Bamer, AM., Johnson, KL., Amtmann, D., Kraft, GH. (2008). Prevalence of sleep problems in individuals with multiple sclerosis. Multiple Sclerosis, 14: 1127-30.

NON-PHARMACOLOGICAL THERAPIES