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The Vicious Cycle of Pain, Sleep Disturbance, and Depression

Discussions within the rheumatoid arthritis community have a recurring theme that RA is not just “a little arthritis.” Sometimes we get offended by others who seemingly disregard the seriousness of this disease or flippantly toss it aside as something which only causes minor aches and pains. However, osteoarthritis (OA) can be no walk in the park either.

Osteoarthritis affects nearly 30 million Americans, and I am one of those. At one time, I thought that perhaps RA was affecting my knees, but my rheumatologist said that she couldn’t detect any swelling in them. A few years ago, however, I was experiencing pain in my right knee such that I sought out an orthopedic doctor who could give me a steroid injection. It worked great and relieved the pain to a point where I could then feel how bad my left knee felt. But I didn’t seek treatment for that knee until last fall when x-rays confirmed osteoarthritis. A steroid injection relieved most of the pain for almost a year.

Near the end of this summer, the pain in my left knee escalated to the point where I sought treatment again. I wasn’t able to sleep through the night because of the pain, nor could I comfortably sit in much of our furniture. This time, however, the orthopedic surgeon suspected a torn meniscus (knee cartilage). MRI scans revealed fraying of the cartilage (no tears) with grade 2-3 cartilage loss (rated on a scale of 0, no loss, to 4, complete loss).

When the doctor called to give me the results, he stated that using an exercise bike on a regular basis would be the best thing I could do for my knees. I asked what else we could do because I still couldn’t sleep through the night, even after the steroid injection! He prescribed a series of injections of a substance called Orthovisc (which I still haven’t been able to try because of a hangup with insurance and the pharmacy).

Why am I sharing this on an RA website? I wanted to bring up the fact that OA can be excruciatingly painful! It can rob you of sleep, wear you down, lead to depression and disability. It may be minor aches and pains for some folks, but for others it can suck you into a vicious cycle of sleep disturbance-pain-depression-disability.

Studies have shown that those with knee OA report issues with initiating sleep (31%), difficulty maintaining sleep at night (81%), and general sleep problems (77%). Sounds like me lately. The only nights I’ve been able to sleep through since August are ones where I go to sleep in a recliner with pillows propping my knees up. Sleeping pills and pain pills can’t even get me through the night in bed if I roll around and put pressure on my knees in a particular way.

A new study published in Arthritis Care & Research, a journal of the American College of Rheumatology (ACR), confirms that sleep disturbances are linked to pain and depression, but not disability, among patients with OA (n=288) at baseline. In individuals with low pain levels, sleep disturbance is unrelated to mood; but where pain is more severe, sleep problems exacerbate depression. Researchers found that sleep problems predicted increases in depression and disability, but not pain, at one-year follow-up 1.

“Sleep disturbance is a common complaint among those with pain, particularly among those with OA,” explains Dr. Patricia Parmelee from the Center for Mental Health & Aging at The University of Alabama in Tuscaloosa. “[Our] study shows that depression plays a strong role in the sleep-pain connection, particularly with severe pain. Further investigation of sleep in disability progression may lead to new interventions that disrupt the cycle of OA distress.”

While I never want to discount the pain and disability associated with RA, I also don’t want to disregard the potentially enormous impact of OA on a person’s life. This experience has led me to wonder just how much pain some of my relatives were in before they decided to undergo knee replacement surgery. I’m not there yet, but now think that it will be part of my future, someday.

An unintended consequence, however, of sleeping in the recliner that has helped to counter reduced mood has been the birth of a lap kitty. Each morning, I wake up with our gray cat, Oscar, happily curled up on my lap. He is literally a warm fuzzy that makes me smile throughout the day.


This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

"Sleep Disturbance in Osteoarthritis: Linkages with Pain, Disability and Depressive Symptoms.” Patricia A. Parmelee, Caitlan A. Tighe and Natalie D. Dautovich. Arthritis Care and Research; Published Online: October 6, 2014 (DOI: 10.1002/acr.22459)


  • Wren moderator
    5 years ago

    Hi, Lisa!
    I’m so glad you wrote about this. Osteoarthritis can be just as painful and disabling as RA, and we do tend to brush it off because those we talk to seem to think that RA is the same as OA–and they mistakenly think of OA as something that causes merely mild, easily treatable pain.

    I have RA that has been slowly getting worse and worse, pain-wise. But I also have OA in my fingertips, which fortunately does tend to be mild, and in my hips, which is much more painful when it acts up. The fact is, any type of arthritis can be excruciating, and those of us who’ve experienced or heard of only the minor end of the pain scale forget how much worse it can actually be.

    I’m glad you’ve discovered a way you can get some sleep at night–and that your buddy Oscar is giving you such joy because of it. I think that animal companions are a “must-have” for anyone who has to cope with chronic pain, illness, and disability. There’s just nothing quite like a soft, furry, warm, friendly beastie to cuddle up with.

  • Connie Rifenburg
    5 years ago

    I am also one of the RA patients who experience Osteo in my hands and knees. I remember when I first brought up my finger joint pain to my RA dr. she poo-poo’d it away by saying “oh that’s not RA, that’s osteoarthritis” and showed me the joints that were RA and those that were Osteo. That was maybe 7+ yrs ago, as I watched my fingers begin to turn at the first joint and show red swollen bumps on each finger, some worse than others, I kept reminding myself this was “only” Osteoarthritis. 🙂

    At the time of the dr.’s comment, it’s true, my RA was in what ended up being a 2-yr flare, and it was the most important thing to stop since it was affecting my lungs and heart too. We had almost run out of drugs to try that I wasn’t showing an allergic reaction to within days. So she was concentrating on the most important things first I’m sure.

    Now, I have been pretty steady on Orenscia, 5 mg of prednisone, and stomach, BP, and RLS meds + 2 doses of oxycodone per day. The problem now is that the Osteo has surpassed the RA in painful daily activities. My hands and legs have swollen with fluid due to a new med for osteoporosis which, altho I only take the med once a week, has a good deal of sodium in it.

    We found on my last bone scan that Osteoporosis has quietly invaded my spine (not hips tho) and I have lost 2 inches in height. So, the next step was adding Lasix and potassium to reduce the swelling, so I could take the needed bone meds.

    There were days that I could barely use my hands to do the simplest tasks, and walking became stiff legged rocking to get from one place to another. Luckily, the Lasix drained the fluid in 3 days with a loss of 10 lbs. But I couldn’t leave the house because I was living in the bathroom. That’s no way to live your life! Supposedly, I should only have to take the Lasix once a week from now on. But I can see already, that the fluid is building up just in 3 days again.

    I guess, my point is, RA in its extreme times, can be incredibly painful and debilitating. Osteoarthritis can ALSO do the same to our bodies, and then we may have to add Osteoporosis to the gang of 3. Large amounts of steroids over an extended period of year are bound to break down the bones. Tendons have spontaneously torn in my shoulders, knees, and muscle tears in my thighs and biceps. These are not so much related to the disease as being a side effect of the medicines that we must take to control the “arthritis” (plural).

    So – among those of us who deal with RA, OA, Osteoporosis, and other forms of side effects of the treatment of these diseases, I think it best not to compare which is worse, but rather how do we cope with each in the best way, to continue to live lives of meaning. Does anyone else feel the same?

    Depression IS a side effect of what we must deal with and I agree that sleeplessness adds to all the other issues too. Some days it feels like climbing a ladder just to get to the top of the diseases and side effects so that we can enjoy a few hours of pain free movement and take care of those everyday things like eating, cleaning, laundry, shopping. May I ask if most people here have a significant other or outside help to assist with these regular daily tasks?

    Thanks for letting me add my opinion to yours Lisa. I agree so much with your comments and know there must be others of us dealing with both diseases.


  • Kellie
    5 years ago

    Replied to wrong spot! Sorry!

  • Kellie
    5 years ago

    You are right. The pain scale is arbitrary. What used to be a 10 for me years ago is now around a 5. I walked around for a month with a torn muscle in my hip. I only went for treatment when my leg would give out at work. RA changes everything.

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