Sleep is crucial to our health, but is often a challenge for people with spinal cord injuries
In the previous edition of Rolling Inspiration, Diving Deep explored the hidden demons of spinal cord injuries (SCIs); those complications that no one sees but that probably trouble us more than our paralysis. But I left out sleep – a serious omission.
Poor and interrupted sleep has a number of consequences; physical as well as mental and psychological. In this article, I will explore the various causes of disturbed sleeping patterns in persons with SCI, and what can be done about it.
Sleep disorders are common in persons with SCI. Notable lesion-related causes include breathing disorders, abnormal body movements and spasms, a disturbed natural rhythm of sleep and simply being awakened periodically to be repositioned for the prevention of pressure sores.
This compromises daytime functionality, including general alertness, concentration, and physical energy. In many instances, it can also lead to anxiety and depression.
So, let’s examine a few of the more common causes of sleep disorders in persons with SCI.
Sleep disordered breathing
Sleep apnoea is very common in persons with SCI. Causes include a disturbance in the breathing regulatory system, a reduced awareness of having stopped breathing and an increased collapsibility of the upper airways.
Obesity plays a significant role in sleep apnoea in that it compresses the upper airways, and it reduces lung volume. Muscle relaxants such as Baclofen as well as sedatives and narcotic analgesics also impact on breathing.
Sleep apnoea is managed by continuous positive airway pressure (CPAP) – a machine that uses mild air pressure during inspiratory (breathing) to keep breathing airways open while you sleep.
In severe cases, bilevel positive airway pressure (BiPAP) may be used. This is a machine that pushes air into your lungs maintaining a positive pressure while you breathe in and out. In so doing it keeps the lungs inflated.
A perspective on obesity
We need to understand that a major reason for eating is to replenish used up energy. Persons with SCI are paralysed and as such have non-functional, therefore non-energy- using limbs.
Sticking to your pre-SCI eating habits could therefore lead to obesity because we eat more than we need. Visits to a dietician to assist with reorganising your intake of food is therefore a good idea.
Periodic leg movements
This entails repeated flection of the hip and knee joints as well as an upward pulling of the ankle and big toe. This is very sleep- disturbing and often associated with painful muscle spasms.
Periodic leg movements are also often associated with Restless-Leg-Syndrome (uncomfortable leg sensations). While both conditions also affect able-bodied persons, the prevalence is much higher in persons with SCI, particularly in lesions above T10.
Once again, the result is daytime sleepiness and all the other consequences described above.
Treatment with medication appears to be somewhat haphazard. What works for one may not work for another. Trial-and-error seems to be the way to go if the movements and sensations severely impact on sleep.
The Circadian Rhythm is a highly complex neurological process that is disrupted in cervical spine lesions. The outcome is a significant delay in the onset of rapid eye movement (REM) sleep, particularly so in complete lesions.
REM sleep is a very necessary part of a four-stage sleep cycle during which our emotions are processed restoring balance. New learnings and newly acquired skills are processed and committed to memory.
Finally, REM sleep takes the body out of deep sleep and prepares us for wakefulness, making waking up easier.
It is also thought that brain development occurs during REM sleep. It is postulated that this is why new-borns spend most of their sleep time in REM sleep.
The Circadian Rhythm also influences various bodily functions including eating habits, metabolism, hormone release, and body temperature.
Poor sleep quality may interfere with the alignment of your circadian rhythm and cause you to feel more extreme spikes of tiredness throughout the day.
Melatonin supplementation may assist in regulating the Circadian Rhythm, but this must be managed under medical supervision.
SCI and Insomnia
Insomnia is not lesion related but appears to occur more frequently in persons with SCI than in the general population.
Insomnia is defined as difficulty falling or staying asleep that persists for at least three months, occurs at least three nights per week and is accompanied by daytime consequences.
The go-to remedy for persons with insomnia is sedative hypnotics (sleeping tablets), but most prescription sleeping tablets are highly addictive and not recommended for long-term use. (A recommendation that is generally ignored.)
Alternative options include warm milk at bedtime, breathing routines and soft soothing background music. (I find listening to a news channel takes my mind off my own thoughts and puts me to sleep in no time.)
Pressure sore and bladder care
So, just when you have overcome your insomnia and having fallen into a comfortable, gentle slumber, the bedroom light goes on and a voice tells you that it is time to turn … I could use worse words but let’s stick with “Bummer!”
Not only are you wide awake but your mind goes berserk, nuts, bananas; making nocturnal mountains out of daytime molehills and keeps you awake until just before having to catheterise…
There are no treatments or solutions for what is needed. We must just take it in our stride and find ways around it that work for us.
I know the words of about six or seven songs off by heart and sing myself to sleep in my mind. Out loud is scary. But if in your approaching sleepiness you forget the words, just hum the tune. Trying to remember words wakes you up again.
There are several other causes of sleep disturbance in persons with SCI, including:
- Body temperature dysregulation: Following an SCI, the body may struggle to regulate its body temperature. As a result, individuals may become too hot or cold during sleep and wake up.
- Impaired motor control: Inability to or difficulty shifting positions during sleep can cause discomfort.
- Chronic illness: Individuals with chronic illnesses such as hypertension, diabetes, and obstructive pulmonary disease are more likely to experience sleep problems.
- Pain due to secondary complications like spasticity and pressure sores can disrupt sleep.
There are many factors to consider in the management of sleep disorders in persons with SCI, including lesion related, obesity, environment, and care routines, to name a few. Mostly a combination of factors is at work to disrupt sleep in affected individuals.
This makes management highly personalised and includes caregiver understanding, medical intervention and psychological support. Trial-and-error is the name of the game and hopefully this article provides some insight and will help to focus management on an acceptable sleep routine.