Originally published in Massage Bodywork magazine, August/September 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.
In 1960, according to a survey of several thousand participants, most Americans got an average of 8-8.9 hours of sleep each night. In 2002, a comparison survey found we now get an average of 6.9-7 hours of sleep each night, and a significant proportion of us get even less on a regular basis.1
Meanwhile, as our sleep time decreases, many health problems are on the rise: obesity, type 2 diabetes, high blood pressure, heart disease, and chronic pain syndromes like fibromyalgia and chronic fatigue, to name a few. Is it possible that poor or insufficient sleep is linked to these common and often life-threatening problems?What is Healthy Sleep?
While once regarded as simply an empty block of time, we now know that sleep is vital to mental, emotional, and physical well-being. Throughout the day, we accumulate adenosine, a metabolic waste product in the blood. When adenosine levels are high, and when light-sensitive cells in the pineal gland release the hormone melatonin, we interpret this as feeling sleepy. We may be able to temporarily suppress our sleepy sensation with activity or drugs, but adenosine is only broken down and removed while we sleep: we simply cannot adjust to having less sleep than we need. This is why after several days without enough sleep we tend to make up for it with extra long sleep sessions--we are essentially paying our sleep debt.
Sleep scientists have identified two main forms of sleep: REM (rapid eye movement) sleep and non-REM sleep, which is further divided into four stages. Different processes occur in each stage of sleep, and each is important for good health. When humans or other animals are consistently deprived of any stage of sleep, disease is quick to follow.
Most adults spend a little less than half their sleep time in REM sleep, and roughly one-fifth of their time in each of the other stages. This distribution varies during different stages of life, however. Tiny babies and teenagers, for instance, spend significantly more time in Stage 4 sleep, which is when the secretion of growth hormone stimulates the production of new cells. (The upshot of this is that your sixteen-year-old wants to spend the whole weekend in bed only partly because she's lazy--she's also getting strong hormonal signals that she needs this extra time to sleep. I finally bought my teenager a T-shirt showing a splitting cell, with the logo: "On a cellular level, I'm really quite busy.")
Sleep usually starts at Stage 1 of non-REM and goes through to Stage 4, followed by our first REM stage about ninety minutes after we drop off. We get most of our deep sleep (Stages 3 and 4) early in our sleep session. As the night progresses, we spend more time in REM and Stages 1 and 2. In a healthy person, the shifting from one stage to another is smooth and predictable. When sleep becomes disordered and skips between stages, or skips some stages altogether, problems develop rapidly. For these people, the time they spend asleep is less pertinent than how well they sleep. It is perfectly feasible to wake up from nine hours of sleep and not feel rested: this is a reflection of how well a person's sleep is organized.Types of Sleep Disorders
About eighty-five different sleep disorders have been recognized, and some estimates suggest that nearly seventy million Americans experience combinations of these problems. Some of the most common include:
This is the inability to fall asleep or to stay asleep through the night.
This is a "sleep seizure": it involves a sudden onset of REM sleep that may interrupt normal activities.
- Restless leg syndrome/periodic leg movement syndrome.
These two conditions are similar but not synonymous. They both have to do with an irresistible urge to move legs that may be itchy, hot, or uncomfortable while trying to get to sleep.
- Parasomnias (abnormal arousals).
These conditions involve very intense dreaming, talking or walking during sleep, night terrors, or sleep paralysis.
- Obstructive sleep apnea.
This is a condition where structures in the throat or soft palate collapse to temporarily block the air passageway. The leading sign of obstructive sleep apnea is a cessation in breathing that may last several seconds, followed by a loud snoring gasp. Cumulative oxygen deprivation through the night may contribute to morning headaches.
- Central sleep apnea.
This is a central nervous system problem involving a faulty signal to motor neurons that supply breathing muscles.How Does Poor Sleep Interfere with Health?
Poor quality or insufficient sleep impairs optimal function in a variety of ways. Following is a short list of health mechanisms that are negatively affected when good quality sleep is in short supply:
- HPA axis.
Attentive readers may recognize one of my favorite themes here. This topic was addressed in detail in the February/March 2006 issue of Massage Bodywork
, "'Jangled' Adults: Touch and the stress response system,
" pages 122-126. To review briefly, the HPA axis is the link between the hypothalamus, pituitary gland, and adrenal glands. When this connection is strong and healthy, stress responses are appropriate to the perceived threat, and equilibrium is quickly restored when a threat is removed. When the HPA axis is inefficient and sluggish, stress responses tend to be more extreme and longer
lasting. Poor-quality sleep evidently has an impact on the efficiency of the stress-response system: the adrenal secretion cortisol (the hormone associated with long-term, low-grade stress and connective tissue weakening) is released in increased amounts when people are sleep deprived, even during times of day when levels would otherwise drop off.
- Autonomic function.
Sleeplessness or poor quality sleep also affects autonomic function. Sympathetic responses are reinforced, while parasympathetic mechanisms tend to be suppressed. Among the consequences of being stuck in a sympathetic chemical state is the prolonged release of blood glucose from the liver, which may not be accommodated by insulin secretion. Poor quality sleep is being investigated as a contributing factor to insulin resistance and an increased risk of type 2 diabetes, heart disease, and stroke.
- Appetite control.
This is another chemical anomaly resulting from sleeplessness. A peptide from the stomach called ghrelin signals hunger. This chemical is released in abnormally high levels with sleep deprivation. At the same time, leptin secretion is suppressed. Leptin is a hormone from fat cells that signals satiety: it is our indication we have had enough to eat and can stop. Between increased signals to eat, and suppressed signals to stop eating, people who are sleep deprived tend to ingest far more calories than they need, even to make up for the fatigue they feel. These findings have led weight-loss specialists to emphasize to people working to lose weight how important it is to get good quality sleep.Consequences of Inadequate Sleep
All this information leads us to the not-very-surprising conclusion that depriving ourselves of sleep has some serious consequences. In the immediate sense, sleep loss can cause short-term memory loss, a decrease in job performance, reduced alertness, and short-term memory loss.2
It puts stress on personal and professional relationships and interferes with our ability to do complex mental tasks.
More importantly, even short-term sleep deprivation drastically increases the risk of motor vehicle accidents. It is estimated that more than one hundred thousand motor vehicle accidents per year are related to excessive sleepiness. These accidents accompany seventy-one thousand injuries and fifteen hundred deaths each year.3
The risk of industrial and medical accidents is estimated to double when workers are sleep deprived. The Exxon Valdez oil spill and the accidents at the Chernobyl and Three Mile Island nuclear power plants have been attributed to sleepiness.4
The performance of sleep-deprived doctors is commensurate with significant alcohol consumption.5
Long-term consequences of sleep loss have been associated with a plethora of common chronic and sometimes life-threatening problems. These problems are experienced in particularly high numbers among people who are chronically jet-lagged, who frequently change job shifts, or who work late into the night on swing or graveyard shifts. Some of these conditions are associated with being "stuck" in a sympathetic state for a prolonged time, including an increased risk of heart attack and stroke. We have already discussed how poor sleep influences type 2 diabetes and obesity through changes in cortisol secretion and appetite control. An increased risk of depression may be a reflection of poor HPA axis function. The relationship between poor quality sleep and chronic musculoskeletal pain (specifically with osteoarthritis, fibromyalgia, morning headache, and low-back pain) has been clearly demonstrated.6
People who regularly go without enough sleep are also at increased risk for gastrointestinal pain, reduced immunity, and infertility.7Sleeping Aids
One of the frustrating things to watch as we become more aware of the need for good quality sleep is the escalating use of pharmacologic sleep aids. Until recently, the only medications used to induce sleep were highly addictive sedatives, and they were avoided whenever possible. With the development of slightly less habit-forming drugs called nonbenzodiazepine hypnotics (these include Ambien and Lunesta), the stigma on "sleeping pills" has been lifted, and millions of Americans, including children, now use them daily.8
These drugs do not necessarily impose a healthy, organized sleep cycle, however, and they all carry risks. Some drugs may initiate sleep, but they can make it harder to fall asleep the next night, which contributes to dependence and increasing tolerance. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended for pain control but they have been seen to interfere with restorative sleep. Opioids like Oxycontin or Percoset can interfere with central sleep drive and pose a significant risk of addiction. Some drugs that have been developed for parkinsonism have found success in treating restless leg syndrome, a phenomenon that reveals some interesting causative factors for that disorder. Antiseizure drugs may be prescribed to help with sleep, but they tend to linger in the body, creating a hangover effect the next day. Likewise, the antidepressant amitriptyline can be used successfully for pain control in some circumstances, but it too has a reputation for causing daytime drowsiness--the opposite of the desired result!Where Does Massage Fit In?
It won't come as a surprise to learn that massage, in many forms, supports good quality sleep. The mechanism by which massage helps to establish a more organized sleep pattern isn't fully understood, but studies consistently report that subjects who are massaged (with a variety of modalities) experience deeper, more restorative, less disturbed sleep 9
and a reduction in pain-sensitizing neurotransmitters.12
The bodywork doesn't have to take place directly before sleep either; clients report better sleep even several hours after receiving massage.
Finally, as healthcare providers, massage therapists are also healthcare role models. Perhaps the most positive effect we can have on our clients is to walk the talk. It takes a certain discipline to organize one's day to include at least eight hours of time to sleep--it is so tempting to stay up an extra hour for a little time alone (or with the TV or computer). And yet, I encourage us all to practice good sleep hygiene: be consistent about reserving enough time for adequate sleep; keep a sleeping room that is quiet and not too hot, too cold, or too bright; remove irritating stimuli from that environment (that might include the decades-old feather pillow that probably has more dust mites than feathers in it); exercise, but not too close to bedtime; and avoid both stimulants and depressants close to bedtime.
On a personal note, the more I learn about health, the more committed I am to sleep as a central organizing principle on which to build a healthy lifestyle. There is no shortcut to good quality sleep. In our fast-paced, instant-gratification, isn't-there-a-pill-for-that world, we must buck the trend to support ourselves with good food, consistent exercise, and--maybe most importantly--good sleep. Yet, this can be done, and if anyone should be doing it, shouldn't it be massage therapists? Ruth Werner is a writer and educator for massage therapists. She teaches several courses at the Myotherapy College of Utah and is approved by the NCTMB as a provider of continuing education. She wrote
A Massage Therapist's Guide to Pathology Lippincott, Williams Wilkins, 2005), now in its third edition, which is used in massage schools all over the world. Werner is available at www.ruthwerner.com
or firstname.lastname@example.org. Notes
1. Eve Van Cauter et al., "The Impact of Sleep Deprivation on Hormones and Metabolism," Medscape Neurology Neurosurgery 7, no. 1 (2005).
2. Yes, that repeat was on purpose.
3. Eve Van Cauter et al., "The Impact of Sleep Deprivation on Hormones and Metabolism," Medscape Neurology Neurosurgery 7, no. 1 (2005).
4. Margie Patlak, Your Guide to Healthy Sleep, National Institutes of Health Publication Number 06-5271, U.S. Department of Health and Human Services, November 2005. www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf (accessed spring 2006).
5. "Residents' Sleep Deprivation Compares to Alcohol Intoxication," Modern Physician (September 7, 2005), www.americansmadandangry.org/documents/Residents.pdf (accessed spring 2006).
6. Harvey Moldofsky, "Pain and Insomnia: What Every Clinician Should Know," Medscape Neurology Neurosurgery 6, no. 2 (2004).
7. Margie Patlak, "Your Guide to Healthy Sleep."
8. Mayo Foundation for Medical Education and Research, "Sleeping Pills: A prescription for better sleep?" Dec. 9, 2005. www.mayoclinic.com/health/sleeping-pills/SL00010 (accessed spring 2006).
9. K. Culpepper-Richards, "Massage and Sleep Patterns in Critically Ill Patients," American Journal of Critical Care 7, no. 4 (July 1998): 288-99.
11. T. Field et al., "Preschool Children's Sleep and Wake Behavior: Effects of massage therapy," Early Child Development and Care 120 (1996): 39-44; T. Field and M. Hernandez-Reif, "Sleep Problems in Infants Decrease Following Massage Therapy," Early Child Development and Care 168 (2001): 95-104.
12. Ibid. Resources
Breus, Michael. Sleep: More Important Than You Think. Originally published May 2003. Updated March 15, 2006. WebMD. www.webmd.com/content/article/64/72426.htm (accessed spring 2006).
Yunus, Muhammad and Jean Aldag. 2005. Restless Legs Syndrome and Leg Cramps in Fibromyalgia. ImmuneSupport.com.
www.immunesupport.com/library/showarticle.cfm/ID/4268/e/1/T/CFIDS_FM/ (accessed spring 2006).
Touch Research Institute. Massage Therapy Studies. University of Miami School of Medicine. www.miami.edu/touch-research/research.htm#MTS (accessed spring 2006).
Van Cauter, Eve et al. 2005. The Impact of Sleep Deprivation on Hormones and Metabolism. Medscape Neurology Neurosurgery 7, no. 1. Medscape. www.medscape.com/viewarticle/502825 (accessed spring 2006).