Sleep problems are common in 50% of multiple sclerosis (MS) patients, with the most common being insomnia, nocturnal leg spasms, narcolepsy, and restless leg syndrome. Research in mice found sleep plays a key role in producing myelin-forming cells, and sleep deprivation can suppress their production and increase stress genes. Non-pharmacological therapies like relaxation, light therapy, and herbal teas may help improve sleep for some MS patients, though medications should be tapered gradually with medical supervision due to risks of addiction and tolerance.

1. SLEEP AND M.S.
50% MS patients has sleep problems

2. MOST COMMON SYMPTOMS
Insomnia
Nocturnal legs spasm
Narcolepsy
Restless leg syndrome (RLS)
REM sleep behaviour disorder
Sleep disordered breathing

3. CIRCADIAN RHYTHM
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)

4. SLEEP HYGIENE
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.

5. INSOMNIA
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

6. TREATMENT
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

7. SLEEP SPECIALIST
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.

8. RESEARCH
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 publis hed
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 brai n 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 be en
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, Cir elli 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 t o block the
vicious cycle and improve the quality of sleep in these patients.‖

9. RESEARCH CONT.
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 researc hers
determined using brain wave measurements in sleeping mice. REM sleep, which is when people typically dream, occurs at the tai l 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 d uring 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 a re 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

10. REFERENCES
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.

11. RECOMMENDATIONS
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

12. MEDICATION AWARENESS
•
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.

13. NON-PHARMACOLOGICAL
THERAPIES
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.