Exploring the role of sleep and coping in quality of life in fibromyalgia

Aquatic therapy improves self-reported sleep quality in fibromyalgia patients: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the effectiveness of aquatic therapy on pain, sleep quality, psychological symptoms, quality of life, and health status in people diagnosed with fibromyalgia.

METHODS

We searched PubMed, CINAHL, The Cochrane Library, PEDro and Scopus databases. Articles were eligible if they were randomised controlled trials (RCTs) analysing the effects of aquatic therapy in adult people diagnosed with fibromyalgia, and published by October of 2022 in English or Spanish. The Cochrane Risk of Bias tool was employed to conduct the methodological quality assessment of the encompassed studies, and the overall quality of evidence for each comparison was determined using the GRADE approach.

RESULTS

Of 375 articles found, 22 met the inclusion criteria. Forest plot analysis of Pittsburgh sleep quality index at short- and mid-term follow-up showed a trend in favour of aquatic therapy, although not statistically significant, with weighted mean difference (WMD) = -1.71 (95% CI: -4.17 to -0.75, p = 0.17). Heterogeneity was substantial (χ2 = 8.74, df = 5 (p < 0.000001; I2 = 95%). Relating the pain outcome by fibromyalgia impact questionnaire (FIQ) short term showed a trend in favour of the aquatic therapy group with WMD = -5.04 (95% CI: - 9.26 to - 0.82, p =  = 0.02) with heterogeneity χ2 = 11.07, df = 4 (p = 0.03; I2 = 64%). Great heterogeneity was found between trials in medium term.

CONCLUSION

This systematic review and meta-analysis demonstrated the effectiveness of aquatic therapy as an adjunct treatment to usual care in people suffering from fibromyalgia. Aquatic therapeutic exercise improves the symptomats of sleep quality, pain, and quality of life of adults with fibromyalgia. Further research on long-term outcomes may contribute to the currently available evidence.

Sleep-EEG in comorbid pain and insomnia: implications for the treatment of pain disorders

Introduction

Patients with chronic pain experience a high prevalence of comorbid insomnia, which is associated with functional impairment. Recent advances in sleep electroencephalography (sleep-EEG) may clarify the mechanisms that link sleep and chronic pain. In this clinical update, we outline current advancements in sleep-EEG assessments for pain and provide research recommendations.

Results

Promising preliminary work suggests that sleep-EEG spectral bands, particularly beta, gamma, alpha, and delta power, may create candidate neurophysiological signatures of pain, and macro-architectural parameters (e.g., total sleep time, arousals, and sleep continuity) may facilitate EEG-derived sleep phenotyping and may enable future stratification in the treatment of pain.

Conclusion

Integration of measures obtained through sleep-EEG represent feasible and scalable approaches that could be adopted in the future. We provide research recommendations to progress the field towards a deeper understanding of their utility and potential future applications in clinical practice.

A web-based educational therapy intervention associated with physical exercise to promote health in fibromyalgia in Brazil: the Amigos De Fibro (Fibro Friends) study protocol

BACKGROUND

Health education is one of the main items to enable health promotion to patients with fibromyalgia. The objective of the study "Amigos de Fibro (Fibro Friends)" is to evaluate the impact of an educational intervention associated with physical exercise based on the web in promoting health and quality of life of patients with fibromyalgia in Brazil.

METHODS

A study with a randomized controlled trial approach will be carried out. The sample will consist of 24 participants, divided into two groups, with 12 individuals each. The experimental group will participate in meetings with lectures, debates, conversation rounds and exercises by a multidisciplinary team. Physical exercises will also be performed in an online environment. On the other hand, the control group will receive an e-book of education and self-care. Primary outcomes will be quality of life. The secondary outcomes will be sociodemographic and health profile, pain intensity, sleep quality, self-care agency, usage and costs of health and social care services, viability of the program and program participation. In addition, a qualitative evaluation process will be carried out with the participants. After the intervention, the data of both groups will be collected again, as well as after 3, 6, and 12 months to verify the effect and the maintenance of the intervention.

DISCUSSION

The results will provide data for studies to consider the use of this tool in the future by professionals working in the field of rheumatology.

TRIAL REGISTRATION

The protocol was registered in the Brazilian Registry of Clinical Trials RBR-3rh759 ( https://trialsearch.who.int/Trial2.aspx?TrialID=RBR-3rh759 ). Date of registration: 07/02/2020].

Prevalence and Characterization of Psychological Trauma in Patients with Fibromyalgia: A Cross-Sectional Study

Background

Preliminary evidence suggests that psychological trauma, especially childhood trauma, is a risk factor for the onset of fibromyalgia (FM).

Objective

The main objective of this study consisted of evaluating the prevalence and detailed characteristics of psychological trauma in a sample of patients with FM, the chronology of trauma across the lifespan, and its clinical symptoms. We also calculated whether childhood trauma could predict the relationship with different clinical variables.

Method

Eighty-eight females underwent an interview to assess sociodemographic data, psychiatric comorbidities, level of pain, FM impact, clinical symptoms of anxiety, depression, insomnia, quality of life, and psychological trauma.

Results

The majority of participants (71.5%) met the diagnostic criteria for current post-traumatic stress disorder (PTSD). Participants reported having suffered traumatic events throughout their lifespan, especially in childhood and early adolescence, in the form of emotional abuse, emotional neglect, sexual abuse, and physical abuse. Traumatic events predict both poor quality of life and a level of pain in adulthood. All patients showed clinically relevant levels of anxiety, depression, insomnia, suicidal thoughts, and pain, as well as somatic comorbidities and poor quality of life. Pain levels predicted anxiety, depression, dissociation, and insomnia symptoms. 84% of the sample suffered one or more traumatic events prior to the onset of pain.

Conclusions

Our data highlight the clinical complexity of patients with FM and the role of childhood trauma in the onset and maintenance of FM, as well as the high comorbidity between anxiety, depression, somatic symptoms, and FM. Our data also supports FM patients experiencing further retraumatization as they age, with an extremely high prevalence of current PTSD in our sample. These findings underscore the need for multidisciplinary programs for FM patients to address their physical pain and their psychiatric and somatic conditions, pay special attention to the assessment of psychological trauma, and provide trauma-focused interventions. Trial registration: ClinicalTrials.gov NCT04476316. Registered on July 20th, 2020.

The Effects of Mindfulness Interventions on Fibromyalgia in Adults aged 65 and Older: A Window to Effective Therapy

Pain usually receives insufficient attention by individuals due to the misconception that pain is a natural consequence of aging. For persons aged 65 and older, a disease requiring further research is fibromyalgia, characterized by chronic pain without clear pathology. Mind-body therapies like mindfulness are beneficial for this population as they affect psychological and biological aspects of pain. These therapies emphasize a nonjudgmental acceptance of thoughts and attention to the experience without attempting to resist or change them. Despite the potential benefits of mindfulness interventions for persons with fibromyalgia aged 65 and older, only few studies have examined the effects of these therapies, yielding conflicting findings. Importantly, no study has yet to be conducted exclusively on this population. This comprehensive review examined existing literature focusing on the effects of mindfulness-based interventions on the physical and mental well-being of persons with fibromyalgia aged 65 and older. It highlights the need for further research on the relationship between mindfulness, fibromyalgia, and gerontology, calling for a standard protocol of intervention.

Introversion, Extraversion, and Worsening of Chronic Pain Impact during Social Isolation: A Mediation Analysis

COVID-19 social distancing mandates increased social isolation, resulting in changes in pain severity and interference among individuals with chronic pain. Differences in personality (e.g., introversion/extraversion) may modulate responses to social isolation. We examined the influence of introversion on reported social distancing-related increases in pain interference and assessed for mediators of this relationship. Individuals with chronic pain (n = 150) completed validated questionnaires 4–8 weeks after implementation of social distancing mandates. Introversion/extraversion was measured using a subscale of the Myers-Briggs Type Indicator and changes in pain and psychosocial variables were calculated by comparing participants’ recalled and current scores. Association between introversion/extraversion and other variables were assessed using linear regression. A parallel mediation was used to examine mediators of the association between introversion and change in pain interference. Higher introversion was associated with a decrease in pain interference after social distancing (Rho = − .194, p = .017). Parallel mediation analysis revealed that the relationship between introversion/extraversion and change in pain interference was mediated by changes in sleep disturbance and depression, such that higher introversion was associated with less isolation-induced sleep disruption and depression, and thereby less worsening of pain interference. These findings suggest that personality factors such as introversion/extraversion should be considered when personalizing treatment of chronic pain.

Development of a novel intervention to improve sleep and pain in patients undergoing total knee replacement

Background

Up to 20% of patients experience long-term pain and dissatisfaction after total knee replacement, with a negative impact on their quality of life. New approaches are needed to reduce the proportion of people to go on to experience chronic post-surgical pain. Sleep and pain are bidirectionally linked with poor sleep linked to greater pain. Interventions to improve sleep among people undergoing knee replacement offer a promising avenue. Health beliefs and barriers to engagement were explored using behaviour change theory. This study followed stages 1–4 of the Medical Research Council’s guidance for complex intervention development to develop a novel intervention aimed at improving sleep in pre-operative knee replacement patients.

Methods

Pre-operative focus groups and post-operative telephone interviews were conducted with knee replacement patients. Before surgery, focus groups explored sleep experiences and views about existing sleep interventions (cognitive behavioural therapy for insomnia, exercise, relaxation, mindfulness, sleep hygiene) and barriers to engagement. After surgery, telephone interviews explored any changes in sleep and views about intervention appropriateness. Data were audio-recorded, transcribed, anonymised, and analysed using framework analysis.

Results

Overall, 23 patients took part, 17 patients attended pre-operative focus groups, seven took part in a post-operative telephone interview, and one took part in a focus group and interview. Key sleep issues identified were problems getting to sleep, frequent waking during the night, and problems getting back to sleep after night waking. The main reason for these issues was knee pain and discomfort and a busy mind. Participants felt that the sleep interventions were generally acceptable with no general preference for one intervention over the others. Views of delivery mode varied in relation to digital move and group or one-to-one approaches.

Conclusion

Existing sleep interventions were found to be acceptable to knee replacement patients. Key barriers to engagement related to participants’ health beliefs. Addressing beliefs about the relationship between sleep and pain and enhancing understanding of the bidirectional/cyclical relationship could benefit engagement and motivation. Individuals may also require support to break the fear and avoidance cycle of pain and coping. A future intervention should ensure that patients’ preferences for sleep interventions and delivery mode can be accommodated in a real-world context.

Actigraphic Physical Activity, Pain Intensity, and Polysomnographic Sleep in Fibromyalgia

INTRODUCTION

Fibromyalgia involves chronic pain and disrupted physical activity and sleep. Research examining the relationship between pre-bedtime physical activity, pain, and objective sleep is limited. This study examined whether objectively measured physical activity levels (via actigraphy), pain intensity, or their interaction are associated with polysomnographic sleep outcomes.

METHODS

Adults with fibromyalgia and insomnia complaints (n = 134, mean age = 52 yrs, SD = 12 yrs, 94% female) completed 14 days of biaxial, wrist worn actigraphy, pain ratings, and a single night of polysomnography (PSG). Average activity for intervals 9:00-12:00, 12:00-15:00, 15:00-18:00, 18:00-21:00 was computed. Multiple regressions examined whether average activity, average evening pain, or their interaction were associated with PSG outcomes: sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency, %stage1, %stage2, %stage3, and %rapid eye movement. Analyses controlled for age, body mass index, average bedtime, time in bed, and sleep/pain medication use.

RESULTS

Greater morning actigraphic physical activity from 9:00 to 12:00 was independently associated with greater %stage 1 sleep (B = 0.01, SE = 0.00, p < .01). Greater afternoon activity from 12:00 to 15:00 independently predicted a higher WASO (p < .001). Associations between afternoon physical activity from 12:00 to 15:00 and greater %stage 1 (p < .001) were significant for at higher (~71/100), average (~52/100), but not lowest (~32/100) pain.

CONCLUSION

Greater morning and afternoon activity is associated with greater PSG sleep fragmentation and greater %stage 1 sleep in individuals with fibromyalgia and insomnia complaints, and the relationship between higher physical activity and greater %stage 1 is stronger for individuals with higher pain. Further studies examining causal pathways between physical activity, activity pacing, and sleep are warranted in fibromyalgia.

Coping Using Sex, Health-Related Behaviors, and Mental Health During COVID-19 Lockdown in the UK

BACKGROUND

Peoples' sexual behaviors have changed during the period of enforced COVID-19 social distancing, in some cases, to cope with negative feelings during lockdown. Research on coping using sex is relatively restricted to samples of men with a history of sexual offending, and it is unknown whether coping using sex is associated with health-related behaviors and mental health in the general population.

AIM

We examined if coping using sex before and during lockdown was associated with adverse outcomes (i.e., self-perceived reduction in health-related behaviors and mental health) in a community sample.

HYPOTHESES

We hypothesized that participants who reported greater use of sex to cope in the weeks preceding lockdown would show a greater decline in health-related behaviors and mental health during lockdown. Furthermore, that changes in coping using sex resulting from lockdown would account for further variance in the worsening of health-related behaviors and mental health.

METHODS

Participants were UK residents, aged 18-60 years, and fluent in English. 789 participants completed an online survey, providing demographic information, self-reported social distancing, loneliness, and coping using sex over a 14-day period during lockdown, and retrospectively preceding lockdown.

OUTCOMES

Participants reported perceived changes in health-related behaviors and mental health symptomatology during lockdown compared to before the pandemic. They also self-reported levels of stress, anxiety and depression during lockdown.

RESULTS

Greater coping using sex prior to lockdown predicted positive change in health-related behaviors, for example, higher scores were associated with participants reporting having exercised and slept more. It was also associated with higher trait levels of anxiety, stress and depression during lockdown. Changes in coping using sex from before to during lockdown did not predict perceived changes in health related behaviors or mental health symptomatology.

CONCLUSIONS

Overall, greater coping using sex prior to lockdown was associated with worse mental health symptomatology during lockdown (anxiety, depression and stress), however, it was also associated with perceived positive change in health-related behaviors compared with before lockdown. This suggests that coping using sex may be associated with negative emotional reactions during lockdown, but may also be linked with positive change in health-promoting behaviors.

Neural activation changes in response to pain following cognitive behavioral therapy for patients with comorbid fibromyalgia and insomnia: a pilot study

STUDY OBJECTIVES

To examine whether cognitive behavioral treatments for insomnia (CBT-I) and pain (CBT-P) lead to neural activation changes in response to pain in fibromyalgia.

METHODS

Thirty-two patients with fibromyalgia (mean age = 55.9, standard deviation = 12.2) underwent an experimental pain protocol during functional magnetic resonance imaging and completed 14-day diaries assessing total wake time, total sleep time, and pain intensity before and after CBT-I, CBT-P, or waitlist control. Random effects analysis of covariance identified regions with significant group (CBT-I, CBT-P, waitlist control) by time (baseline, post-treatment) interactions in blood oxygen level-dependent response to pain. Linear regressions using residualized change scores examined how changes in total wake time, total sleep time, and pain intensity were related to activation (blood oxygen level-dependent) changes.

RESULTS

Twelve regions exhibited small to moderate effects with significant interactions Ps < .00; right hemisphere: inferior frontal, middle occipital, and superior temporal gyri, insula, lentiform nucleus; left hemisphere: angular, superior temporal, midfrontal, inferior occipital, midtemporal, and inferior frontal gyri. Blood oxygen level-dependent response to pain decreased in 8 regions following CBT-I, and in 3 regions following CBT-P (CBT-I effects > CBT-P). Blood oxygen level-dependent response also increased in 3 regions following CBT-P and in 6 regions following waitlist control. Improved total wake time and/or total sleep time, not pain intensity, predicted decreased blood oxygen level-dependence in 7 regions (Ps < .05), accounting for 18%-47% of the variance.

CONCLUSIONS

CBT-I prompted greater decreases in neural activation in response to pain across more regions associated with pain and sleep processing than CBT-P. Reported sleep improvements may underlie those decreases. Future research examining the longer-term impact of CBT-I and improved sleep on central pain and sleep mechanisms is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Sleep and Pain Interventions in Fibromyalgia (SPIN); Identifier: NCT02001077; URL: https://clinicaltrials.gov/ct2/show/NCT02001077.

CITATION

McCrae CS, Craggs JG, Curtis AF, et al. Neural activation changes in response to pain following cognitive behavioral therapy for patients with comorbid fibromyalgia and insomnia: a pilot study. J Clin Sleep Med. 2022;18(1):203-215.

Biopsychosocial Predictors of Quality of Life in Paediatric Patients With Sickle Cell Disease

Sickle cell disease (SCD) refers to a group of inherited blood disorders with considerable morbidity that causes severe pain, reduces life expectancy, and requires significant self-management. Acute painful episodes are the hallmark of SCD, but persistent daily pain is also highly prevalent in this population. Characterising the impact and experience of SCD-related morbidity (i.e., sleep disruption, frequent emergency department visits, cognitive dysfunction) on health-related quality of life (HRQOL) requires multiple assessment methods to best capture the underlying mechanisms. To gain a greater understanding of the effect of common symptom categories on HRQOL and to determine potential pain coping targets, the present study investigated whether demographic, socioeconomic, sleepiness, pain burden, frequency of emergency department (ED) visits, and cognition predicted HRQOL in a paediatric sample of patients with SCD. Our study was a secondary analysis of baseline assessment data of children with SCD aged 8-15 years (n = 30) in the Prevention of Morbidity in Sickle Cell Anaemia Phase 2b (POMSb2) randomised controlled clinical trial of auto-adjusting continuous positive airways pressure. Patients completed cognitive testing (IQ, Processing Speed Index, Delis-Kaplan Executive Function Scale (DKEFS) Tower, Conner's Continuous Performance Test), sleepiness (Epworth Sleepiness Scale), and HRQOL (PedsQL Sickle Cell Module) at baseline. Patients reported pain burden (Sickle Cell Pain Burden Inventory-Youth) each month over 8 visits. Caregivers provided demographic information and reported their child's executive function (Behavioural Rating Inventory of Executive Function) at baseline. Data from our analysis demonstrated that demographic factors (i.e., age, gender, level of neighbourhood deprivation) and treatment variables (i.e., hydroxyurea use) did not independently predict HRQOL, and laboratory values (i.e., haemoglobin, haematocrit, mean oxygen saturation) were not significantly correlated with HRQOL (ps > 0.05). However, sleepiness, pain burden, ED visits, and executive dysfunction independently predicted HRQOL (R ² = 0.66) with large effects (η² = 0.16 to 0.32). These findings identify specific, measurable symptom categories that may serve as targets to improve HRQOL that are responsive to change. This knowledge will be useful for multimodal interventions for paediatric patients with SCD that include sleep management, pain coping strategies, and executive function training.

Cognitive behavioral therapy for insomnia (CBT-i) in patients with fibromyalgia: a systematic review and meta-analysis

PURPOSE

We aimed to evaluate the effectiveness of CBT-i in patients with fibromyalgia in comparison with other non-pharmacological treatments.

METHODS

Randomized controlled trials assessing the effects of CBT-i in adults with fibromyalgia, published in English or Spanish, were eligible. Electronic searches were performed using PubMed, Scopus, The Cochrane Library, WebOfKnowledge and Psicodoc databases in March 2021. The main outcome measures were sleep efficiency and sleep quality. Secondary outcomes included pain, depression, and anxiety.

RESULTS

Of 226 studies reviewed, five were included in the meta-analysis. CBT-i compared with non-pharmacological treatments showed no significant improvements in sleep efficiency (p = 0.05; standardized mean difference (SMD) [95% CI] 0.31 [-0.00 to 0.61]). CBT-i showed significant improvements in sleep quality (p = 0.009; SMD [95% CI] - 0.53 [-0.93 to -0.13]), pain (p = 0.002; SMD [95% CI] - 0.41 [-0.67 to -0.16]), anxiety (p = 0.001; SMD [95% CI] - 0.46 [-0.74 to 0.18]) and depression (p = 0.02; SMD [95% CI] - 0.33 [-0.61 to -0.05]), compared to non-pharmacological treatments. Effect sizes ranged from small to moderate.

CONCLUSIONS

CBT-i was associated with a significant improvement in sleep quality, pain, anxiety, and depression, although these results are retrieved from very few studies with only very low to low quality evidence. Trial registration: The review protocol was registered with PROSPERO (Record ID = CRD42016030161).IMPLICATIONS FOR REHABILITATIONCBT-i has been proven to improve sleep quality, pain, anxiety and depression, although with small effect sizes.Implementing hybrid CBT for pain and sleep or combining CBT and mindfulness may improve symptoms in people diagnosed with FM.This meta-analysis results highlight the need to enhance sleep management skills among people suffering from this health condition.

Multicenter survey of symptoms, work life, economic status, and quality of life of complex regional pain syndrome patients

Background

Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients.

Methods

CRPS patients from 37 university hospitals in South Korea were surveyed. The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL.

Results

A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains.

Conclusions

Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Reduction in movement-evoked pain and fatigue during initial 30-minute transcutaneous electrical nerve stimulation treatment predicts transcutaneous electrical nerve stimulation responders in women with fibromyalgia

ABSTRACT

We previously showed that 1 month of transcutaneous electrical nerve stimulation (TENS) reduces movement-evoked pain and fatigue in women with fibromyalgia (FM). Using data from this study (Fibromyalgia Activity Study with TENS [FAST]), we performed a responder analysis to identify predictors of clinical improvement in pain and fatigue with TENS, validated these models using receiver operator characteristic, and determined number needed to treat and number needed to harm. Participants were randomly assigned to active-TENS (2-125 Hz; highest-tolerable intensity), placebo-TENS, or no-TENS for 1 month. At the end of the randomized phase, placebo-TENS and no-TENS groups received active-TENS for 1 month. The predictor model was developed using data from the randomized phase for the active-TENS group (n = 103) and validated using data from placebo-TENS and no-TENS groups after active-TENS for 1 month (n = 155). Participant characteristics, initial response to TENS for pain and fatigue, sleep, psychological factors, and function were screened for association with changes in pain or fatigue using a logistic regression model. Predictors of clinical improvement in pain were initial response to pain and widespread pain index (area under the curve was 0.80; 95% confidence interval: 0.73-0.87). Predictors of clinical improvement in fatigue were marital status, sleep impairment, and initial response to TENS (area under the curve was 0.67; 95% confidence interval: 0.58-0.75). Number needed to treat for pain and fatigue ranged between 3.3 and 5.3. Number needed to harm ranged from 20 to 100 for minor TENS-related adverse events. The response to an initial 30-minute TENS treatment predicts who responds to longer-term TENS use in women with FM, making this a clinically useful procedure. Number needed to treat and number needed to harm suggest that TENS is effective and safe for managing pain and fatigue in FM.

Cognitive behavioral therapy for insomnia in veterans with gulf war illness: Results from a randomized controlled trial

Aims:

To examine whether cognitive behavioral therapy for insomnia (CBT-I), delivered by telephone, improves sleep and non-sleep symptoms of Gulf War Illness (GWI).

Main methods:

Eighty-five Gulf War veterans (21 women, mean age: 54 years, range 46–72 years) who met the Kansas GWI case definition, the Centers for Disease Control and Prevention (CDC) case definition for Chronic Multisymptom Illness (CMI), and research diagnostic criteria for insomnia disorder were randomly assigned to CBT-I or monitor-only wait list control. Eight weekly sessions of individual CBT-I were administered via telephone by Ph.D. level psychologists to study participants. Outcome measures included pre-, mid-, and post-treatment assessments of GWI and insomnia symptoms, subjective sleep quality, and continuous sleep monitoring with diary. Outcomes were re-assessed 6-months post-treatment in participants randomized to CBT-I.

Key findings:

Compared to wait list, CBT-I produced significant improvements in overall GWI symptom severity, individual measures of fatigue, cognitive dysfunction, depression and anxiety, insomnia severity, subjective sleep quality, and sleep diary outcome measures. The beneficial effects of CBT-I on overall GWI symptom severity and most individual GWI symptom measures were maintained 6-months after treatment.

Significance:

GWI symptoms have historically been difficult to treat. Because CBT-I, which is associated with low stigma and is increasingly readily available to veterans, improved both sleep and non-sleep symptoms of GWI, these results suggest that a comprehensive approach to the treatment of GWI should include behavioral sleep interventions.

Poor Sleep Quality Experience and Self-Management Strategies in Fibromyalgia: A Qualitative Metasynthesis

Poor sleep quality is a major concern and a highly prevalent symptom in fibromyalgia. We aimed to develop a metasynthesis of qualitative studies to assess how people diagnosed with fibromyalgia experience and manage poor sleep quality following the concepts of the Symptom Management Theory. The principles of metasynthesis established by Sandelowski and Barroso were utilized. A pre-planned comprehensive search was implemented in PubMed, Scopus, ISI WebofScience, and Cinahl Plus databases. The methodological quality was assessed following the CASP Qualitative Checklist. The findings of the studies were subjected to a metasummary and a metasynthesis. Seventeen studies were included in the metasynthesis. Two overarching themes were pre-established: (1) experience of poor sleep quality in Fibromyalgia and (2) poor sleep quality management strategies in Fibromyalgia. Four sub-themes emerged from the results: (1) evaluation of poor sleep quality, (2) response to poor sleep quality, (3) management strategies to favor sleep, and (4) managing the consequences of a sleepless night. Poor sleep quality is a severe and disabling symptom that negatively impacts the general health status of people diagnosed with FM. Prescribed treatments are commonly seen as ineffective and self-management strategies are a last resort and do not show beneficial effects.

Efficacy and Safety of ASP0819 in Patients with Fibromyalgia: Results of a Proof-of-Concept, Randomized, Double-Blind, Placebo-Controlled Trial

PURPOSE

ASP0819 is a novel, non-opioid KCa3.1 channel opener that reverses abnormal nerve firing of primary sensory afferent nerves. Currently available treatments for fibromyalgia provide only modest relief and are accompanied by a host of adverse side effects.

PATIENTS AND METHODS

In this phase 2a, double-blind trial (NCT03056690), adults meeting fibromyalgia diagnostic criteria were randomized 1:1 to receive either 15 mg/day of oral ASP0819 (n=91) or placebo (n=95). The primary endpoint was the change from baseline to Week 8 in the mean daily average pain score. Changes in the Fibromyalgia Impact Questionnaire Revised (FIQR) symptoms, function, and overall impact subscales, as well as changes in the patients' global impression of change, were secondary endpoints; treatment effects on FIQR total score and impact on sleep were exploratory analyses.

RESULTS

There was no statistically significant difference between ASP0819 and placebo for the primary endpoint (P=0.086); however, ASP0819 versus placebo significantly improved daily average pain at Weeks 2, 6, and 7 (all P<0.05). Numerical improvements were observed on the FIQR total score and several sleep items showed statistically significant improvements with ASP0819 versus placebo. There were no major safety concerns with ASP0819. Headache was the most common treatment-emergent adverse event (TEAE) occurring in both study arms; most TEAEs were mild or moderate in severity and no TEAEs suggestive of potential drug abuse were observed, as assessed by TEAE reporting and/or safety evaluations. Withdrawal effects also were not observed.

CONCLUSION

ASP0819 demonstrated some signals suggestive of efficacy and had a good tolerability profile in patients with fibromyalgia. Further studies are required to determine if ASP0819 can be a novel non-opioid treatment option in this patient group.

CLINICALTRIALSGOV REGISTRATION

NCT03056690.

Coping Using Sex During the Coronavirus Disease 2019 (COVID-19) Outbreak in the United Kingdom

BACKGROUND

The use of sex to cope with negative affective states during the coronavirus disease 2019 (COVID-19) pandemic may be influenced by various sociodemographic and psychological characteristics.

AIM

We aimed to examine the effects of social distancing, loneliness, difficulties in emotion regulation, and self-regulation on participants self-reported coping using sex during lockdown in the United Kingdom.

METHODS

Participants had to be residents of the United Kingdom, aged between 18-60 years, fluent in English, and had to have an Internet connection. They were instructed not to participate if they had consumed alcohol in the previous 24 hours. A total of 789 participants aged 18-59 years completed an online survey. Participants provided self-report measures of social distancing, loneliness, and difficulties in emotion regulation. A Go/No-Go task was used to assess self-regulation.

OUTCOMES

Participants self-reported their use of sex to cope over a 14-day period during lockdown, as well as retrospectively for a 14-day period immediately preceding lockdown. Coping using sex items included consensual and non-consensual themes.

RESULTS

Overall, there was no increase in coping using sex during lockdown compared with before lockdown. Findings showed that 30% of participants reported increased coping using sex during lockdown compared with before, 29% reported decreased coping using sex, and 41% reported no change. All regression models included age, gender, ethnicity, diagnosis of psychiatric condition, level of education, being at high-risk for difficulties relating to COVID-19, living alone, and diagnosed or suspected COVID-19 as covariates. Being younger, being male, and greater emotion dysregulation were associated with higher coping using sex total and consent subscale scores during lockdown. Being younger, being male, not living alone, and less adherence to social distancing advice were associated with coping using sex with a theme of rape/violence during lockdown.

CLINICAL TRANSLATION

A proportion of participants used sex to cope more often during lockdown compared with before. Less adherence to social distancing advice and emotion dysregulation were associated with using sex to cope during lockdown.

STRENGTHS & LIMITATIONS

Strengths of this study were the large sample size and inclusion of key sociodemographic characteristics as covariates. The main limitations were the cross-sectional design and a sample that was mostly white, educated, and female.

CONCLUSION

Participants who had difficulty regulating emotions were more likely to use sex to cope. It is important that support is available for people who have problems regulating their emotions during the pandemic and that they have access to appropriate help and advice. Gillespie SM, Jones A, Uzieblo K, et al. Coping Using Sex During the Coronavirus Disease 2019 (COVID-19) Outbreak in the United Kingdom. J Sex Med 2021;18:50-62.

Clinical, psychological and quality of life differences in fibromyalgia patients from secondary and tertiary healthcare

BACKGROUND

The 'funnel effect' of Fibromyalgia (FM) assumes that as patients access healthcare services, they present greater severity and a more complex clinical situation than individuals with FM from the general population, but the studies comparing patients treated in different levels of healthcare are scarce. The aim of this study was to analyse the 'funnel effect' hypothesis by comparing patients from secondary and tertiary healthcare services.

METHODS

A cross-sectional sample of female patients was selected in secondary (rheumatology practices - RP) and in tertiary healthcare (chronic pain clinics - CPC). Information about sociodemographic, clinical and psychological characteristics was collected and health related quality of life (HRQL) was assessed.

RESULTS

In total, 55 patients from RP and 60 patients from CPC were included in the comparison. Patients from CPC revealed a worst clinical status (higher number of tender points, medical visits and comorbidity), more somatic symptoms (pain and daytime dysfunction levels) and worst emotional status (more anxiety) than patients from RP. Patients attending CPC also revealed a worst HRQL than RP patients although this difference was mediated by the differences in clinical and psychological variables.

CONCLUSIONS

Our study supports the 'funnel effect' hypothesis among patients of different healthcare levels, with patients from tertiary healthcare services revealing worst clinical status, more somatic and psychological symptoms, and worst HRQL than patients from secondary healthcare services.

SIGNIFICANCE

The worst clinical and psychological status and poorer quality of life in the patients from tertiary healthcare (chronic pain clinics) in relation to the patients from secondary healthcare (rheumatology practices) must be taken into account to design studies that assess any of these aspects, to a proper analysis and interpretation of the data, and to define the scope of its generalization, as data from different clinical settings are not directly comparable.

Associations between objective afternoon and evening physical activity and objective sleep in patients with fibromyalgia and insomnia

Patients with fibromyalgia (FM) suffer from chronic pain, which limits physical activity and is associated with disturbed sleep. However, the relationship between physical activity, pain and sleep is unclear in these patients. This study examined whether actigraphic (Actiwatch-2, Philips Respironics) afternoon and evening activity and pain are associated with actigraphic sleep. Adults with FM and insomnia complaints (n = 160, mean age [M_age ] = 52, SD = 12, 94% female) completed 14 days of actigraphy. Activity levels (i.e., activity counts per minute) were recorded, and average afternoon/evening activity for intervals 12:00-3:00 PM, 3:00-6:00 PM and 6:00-9:00 PM was computed. Multiple linear regressions examined whether afternoon/evening activity, pain (daily evening diaries from 0 [no pain sensation] to 100 [most intense pain imaginable]), or their interaction, predicted sleep onset latency (SOL), wake time after sleep onset (WASO), total sleep time (TST) and sleep efficiency (SE). Greater afternoon activity was independently associated with lower SE (B = -0.08, p < .001), lower TST (β = -0.36, standard error [SE] = 0.06, p < .001) and longer WASO (B = 0.34, p < .001). Greater early evening activity was independently associated with lower SE (B = -0.06, p < .001), lower TST (β = -0.26, SE = 0.06, p < .001) and longer WASO (B = 0.23, p < .001). Self-reported pain intensity interacted with afternoon and early evening physical activity, such that associations between higher activity and lower SE were stronger for individuals reporting higher pain. Late evening activity was not associated with sleep outcomes. Results suggest that in FM, increased afternoon and early evening physical activity is associated with sleep disturbance, and this relationship is stronger in individuals with higher pain.

Predicting Poor Sleep Quality in Fibromyalgia with Wrist Sensors

Fibromyalgia is a musculoskeletal disorder characterized by chronic, widespread muscle pain. This condition is associated with disturbed sleep, which has a direct impact on patient quality of life. Patient-reported outcomes are frequently used to assess sleep quality, but show modest correlations with objective measures of sleep, such as polysomnography. Working towards our goal of an automated ambulatory system of assessing sleep quality, we use features from blood volume pulse (BVP) and electrodermal activity (EDA) collected with a wearable device during sleep. We compare these measurements between individuals with fibromyalgia who experienced poor sleep and individuals in a control group who experienced refreshing sleep. By applying Learning Using Concave and Convex Kernels (LUCCK) and Support Vector Machines (SVM), we achieve mean Area Under the Receiver Operating Characteristic Curve (AUC) of 0.6573 and 0.6526, respectively, by using BVP data for classifying individuals to the two groups.

Protocol for the impact of CBT for insomnia on pain symptoms and central sensitisation in fibromyalgia: a randomised controlled trial

INTRODUCTION

Approximately 50% of individuals with fibromyalgia (a chronic widespread pain condition) have comorbid insomnia. Treatment for these comorbid cases typically target pain, but growing research supports direct interventions for insomnia (eg, cognitive behavioural treatment for insomnia (CBT-I)) in these patients. Previous research suggests sustained hyperarousal mediated by a neural central sensitisation mechanism may underlie insomnia and chronic pain symptoms in fibromyalgia. We hypothesise CBT-I will improve insomnia symptoms, improve clinical pain and reduce central sensitisation. The trial will be the first to evaluate the short-term and long-term neural mechanisms underlying insomnia and pain improvements in fibromyalgia. Knowledge obtained from this trial might allow us to develop new or modify current treatments to better target pain mechanisms, perhaps reversing chronic pain or preventing it.

METHODS AND ANALYSIS

Female participants (n=130) 18 years of age and older with comorbid fibromyalgia (with pain severity of at least 50/100) and insomnia will be recruited from the University of Missouri in Columbia, Missouri, and surrounding areas. Participants will be randomised to 8 weeks (plus 4 bimonthly booster sessions) of CBT-I or a sleep hygiene control group (SH). Participants will be assessed at baseline, post-treatment, 6 and 12 months follow-ups. The following assessments will be completed: 2 weeks of daily diaries measuring sleep and pain, daily actigraphy, insomnia severity index, pain-related disability, single night of polysomnography recording, arousal (heart rate variability, cognitive affective arousal), structural and functional MRI to examine pain-related neural activity and plasticity and mood (depression, anxiety).

ETHICS AND DISSEMINATION

Ethics approval was obtained in July 2018 from the University of Missouri. All data are expected to be collected by 2022. Full trial results are planned to be published by 2024. Secondary analyses of baseline data will be subsequently published.

TRIAL REGISTRATION NUMBER

NCT03744156.

(Neuro)Inflammatory Component May Be a Common Factor in Chronic Widespread Pain and Restless Legs Syndrome

Purpose of Review

Recent studies have linked fibromyalgia (nociplastic pain) and depression to neuroinflammation. Restless legs syndrome (RLS) is highly prevalent in CWP (chronic widespread pain) and FMS (fibromyalgia syndrome) as well as in depression. This review focuses on evidence in the relationship between CWP and RLS and possible common pathophysiological mechanisms.

Recent Findings

CWP is chronic pain spread over various locations of the body and is a cardinal sign of fibromyalgia. Poor sleep quality is a common symptom in fibromyalgia as well as high levels of fatigue, poor cognition, and other associated features which include depression, headache, and abdominal pain. Evidence for a bilateral relationship between pain and sleep deficit is robust. The latest research focus is not only on insomnia symptoms in chronic pain but also on other types of sleep disorders such as RLS which is characterized by complaints of an “urge to move” frequently associated with dysesthesias. These sensations can also have painful characteristics. Thus, there is a possible overlap between these two entities. The high prevalence of RLS (33–54%) in CWP has been shown in several studies. The pathophysiological mechanisms behind CWP and RLS are still not completely known, but there is a rising amount of evidence on proinflammatory and neuroinflammatory processes in CWP. In RLS, there are links to dopaminergic dysfunction and more generally to monoaminergic dysfunctional circuits, BID (brain iron deficiency), altered glutamatergic neurotransmission, and genetic traits. Depression is a common comorbidity as well in CWP as RLS, and proinflammatory mechanisms have also been demonstrated in this condition.

Summary

The association between CWP and RLS is shown to be high and the pathogenesis of both conditions is still not completely understood. Recent research is focusing on proinflammatory and neuroinflammatory processes, not uniquely emerging in fibromyalgia/CWP, but inflammatory features have been found in depression as well as in sleep deficit. Proinflammatory/neuroinflammatory processes may be an underlying, common factor in both CWP and RLS that future research should investigate further.

Linking Nonrestorative Sleep and Activity Interference Through Pain Catastrophizing and Pain Severity: An Intraday Process Model Among Individuals With Fibromyalgia

Nonrestorative sleep is a key diagnostic feature of the musculoskeletal pain disorder fibromyalgia and is robustly associated with poor physical functioning, including activity interference. However, the mechanisms through which nonrestorative sleep elicits activity interference among individuals with fibromyalgia at the within-person level remain unclear. The present study tested the following 3-path mediation model, using data gathered from a 21-day electronic daily diary in 220 individuals with fibromyalgia: previous night nonrestorative sleep → morning pain catastrophizing → afternoon pain severity → end-of-day activity interference. Results of multilevel structural equation modeling supported the 3-path mediation model. Previous night's nonrestorative sleep and morning pain catastrophizing were also directly related to end-of-day activity interference. Previous night nonrestorative sleep did not significantly predict afternoon pain severity while controlling for the effect of morning pain catastrophizing. Greater nonrestorative sleep during the previous night and a higher level of morning pain catastrophizing appear to serve as risk factors for experiencing greater daily pain and activity interference later in the day. These findings point to the potential utility of targeted interventions that improve both sleep quality and pain catastrophizing to help individuals with chronic pain engage in important daily activities despite experiencing pain. PERSPECTIVE: This study provides a better understanding of how nonrestorative sleep is associated with daily activity interference among individuals with fibromyalgia. An intervention that targets attenuating nonrestorative sleep and pain catastrophizing may help improve daily physical functioning of this population.

Patient Reported Outcome Measures of Sleep Quality in Fibromyalgia: A COSMIN Systematic Review

Poor sleep quality is a common concern and a troublesome symptom among patients suffering from fibromyalgia. The purpose of this review was to identify and describe the available patient reported outcome measures (PROMs) of sleep quality validated in adult people diagnosed with fibromyalgia. The COSMIN and PRISMA recommendations were followed. An electronic systematized search in the electronic databases PubMed, Scopus, CINAHL Plus, PsycINFO, and ISI Web of Science was carried out. Validation studies of PROMs of sleep quality in fibromyalgia published in English or Spanish were included. The selection of the studies was developed through a peer review process through the online software "COVIDENCE". The quality of the studies was assessed using the COSMIN Risk of Bias checklist. A total of 5 PROMs were found validated in patients with fibromyalgia: (1) Pittsburgh Sleep Quality Index (PSQI), (2) Jenkins Sleep Scale (JSS), (3) Sleep Quality Numeric Rating Scale (SQ-NRS), (4) Medical Outcomes Study-Sleep Scale (MOS-SS), and (5) Fibromyalgia Sleep Diary (FSD). The quality of the evidence was very good and the quality of the results ranged from moderate to high. All the included PROMs, except for the FSD, showed adequate psychometric properties and, therefore, are valid and reliable tools for assessing sleep quality in the context of FM. However, none of the studies analyzed all the psychometric properties of the included PROMs as established in the COSMIN guidelines, highlighting that this is a potential field of research for future investigations.

Association of ferritin levels with depression, anxiety, sleep quality, and physical functioning in patients with fibromyalgia syndrome: a cross-sectional study

Aim

To determine the frequency of ferritin deficiency in individuals with fibromyalgia syndrome (FMS) and to evaluate the association of ferritin level with depression, anxiety, sleep quality, and physical functioning.

Methods

This cross-sectional study, conducted from 2016 to 2017, compared the frequency of ferritin deficiency between 100 non-anemic fibromyalgia patients and 100 non-anemic individuals without FMS. Serum ferritin level of <30 ng/mL indicated iron deficiency. FMS patients filled out demographic questionnaire, Fibromyalgia Impact Questionnaire, Beck Anxiety Inventory, Beck Depression Inventory, and Pittsburg Sleep Quality Index.

Results

Median serum ferritin level was 20.95 ng/mL. A total of 64% of patients and 42% of controls had iron deficiency. Beck Anxiety Inventory, Beck Depression Inventory, and Pittsburgh Sleep Quality Index scores were not associated with ferritin levels. FMS patients with poor sleep quality had significantly higher Beck Depression Inventory, Beck Anxiety Inventory, and Fibromyalgia Impact Questionnaire scores (P < 0.05). In individuals with poor sleep quality, lower ferritin levels also correlated with higher Beck Depression Inventory scores (r = -0.277, P < 0.05). Sleep quality was not significantly associated with age, body mass index, duration of diagnosis, and serum ferritin levels.

Conclusions

Patients with fibromyalgia syndrome have a rather high prevalence of non-anemic iron deficiency. No associations were found between serum ferritin level and anxiety, depression, sleep quality, and physical functioning.

ClinicalTrials.gov identifier: NCT03825393.

Mindfulness is associated with sleep quality among patients with fibromyalgia

AIM

Previous studies suggest higher mindfulness may be associated with better sleep quality in people with chronic pain conditions. However, the relationship between mindfulness and sleep in fibromyalgia patients, who commonly suffer from sleep problems, remains unstudied. We examined the relationship between mindfulness and sleep, and how this relationship may be mediated by depression, anxiety, and pain interference in fibromyalgia patients.

METHOD

We performed a cross-sectional analysis of baseline data from a randomized trial in fibromyalgia patients. We measured mindfulness (Five Facet Mindfulness Questionnaire), sleep quality and disturbance (Pittsburgh Sleep Quality Index [PSQI], PROMIS Sleep Disturbance [PROMIS-SD]), pain interference (PROMIS Pain Interference), and anxiety and depression (Hospital Anxiety and Depression Scale). Pearson correlations were used to examine associations among mindfulness and sleep quality and disturbance. Mediation analysis was conducted to assess whether pain interference, depression, and anxiety mediated the relationship between mindfulness and sleep.

RESULTS

A total of 177 patents with fibromyalgia were included (93% female; mean age 52 ± 12 years; body mass index 30 ± 7 kg/m² ; 59% White). Higher mindfulness was associated with better sleep quality and less sleep disturbance (PSQI r = -0.23, P = .002; PROMIS-SD r = -.24, P = .002) as well as less pain interference (r = -.31, P < .0001), anxiety (r = -.58, P < .001), and depression (r = -0.54, P < .0001). Pain interference, depression, and anxiety mediated the association between mindfulness and sleep quality and disturbance.

CONCLUSION

Higher mindfulness is associated with better sleep in patients with fibromyalgia, with pain interference, depression, and anxiety mediating this relationship. Longitudinal studies are warranted to examine the potential effect of cultivating mindfulness on sleep in fibromyalgia.

A Comparative Study of Fibromyalgia, Rheumatoid Arthritis, Spondyloarthritis, and Sjögren’s Syndrome; Impact of the Disease on Quality of Life, Psychological Adjustment, and Use of Coping Strategies

Background

Fibromyalgia, rheumatoid arthritis, spondyloarthritis, and Sjögren’s syndrome are chronic rheumatic diseases with very different clinical characteristics, but which share symptoms such as pain and fatigue. The aim of the study was to examine the impact of the disease on psychological adaptation in fibromyalgia compared with other rheumatic diseases (rheumatoid arthritis, spondyloarthritis, and Sjögren’s syndrome).

Methods

In a multicenter study, 165 women with rheumatic diseases (48 with fibromyalgia, 47 with rheumatoid arthritis, 47 with spondyloarthritis, 23 with Sjögren’s syndrome) completed the General Health Questionnaire–28 (emotional distress), Fatigue Severity Scale (fatigue), Fibromyalgia Impact Questionnaire (impact of the disease), Coping Strategies Questionnaire (coping), and Mini International Neuropsychiatric Interview (comorbidity with DSM IV axis-I disorders). We used the Kruskal-Wallis test, Mann-Whitney U test, and chi2 test to compare comorbid anxiety and depressive disorders and to compare the impact of the disease on patients’ mental well-being and daily life and adjustment (coping strategies).

Results

Anxiety and depressive disorders were more common in fibromyalgia patients; they had higher scores on impact of the disease, physical symptoms, pain, and fatigue than rheumatoid arthritis patients and reported more fatigue than patients with spondyloarthritis. Overall, they used more maladaptive coping strategies (less use of distancing from pain than patients with rheumatoid arthritis and spondyloarthritis, less use of ignoring pain sensations, and more use of catastrophizing than those with rheumatoid arthritis). No differences were found between fibromyalgia and Sjögren’s syndrome on impact and adjustment.

Conclusions

Compared with other rheumatic diseases, fibromyalgia has a greater impact on daily life; patients have more difficulty adjusting to the disease and generally use poorer strategies to cope with pain.

Learning Using Concave and Convex Kernels: Applications in Predicting Quality of Sleep and Level of Fatigue in Fibromyalgia

Fibromyalgia is a medical condition characterized by widespread muscle pain and tenderness and is often accompanied by fatigue and alteration in sleep, mood, and memory. Poor sleep quality and fatigue, as prominent characteristics of fibromyalgia, have a direct impact on patient behavior and quality of life. As such, the detection of extreme cases of sleep quality and fatigue level is a prerequisite for any intervention that can improve sleep quality and reduce fatigue level for people with fibromyalgia and enhance their daytime functionality. In this study, we propose a new supervised machine learning method called Learning Using Concave and Convex Kernels (LUCCK). This method employs similarity functions whose convexity or concavity can be configured so as to determine a model for each feature separately, and then uses this information to reweight the importance of each feature proportionally during classification. The data used for this study was collected from patients with fibromyalgia and consisted of blood volume pulse (BVP), 3-axis accelerometer, temperature, and electrodermal activity (EDA), recorded by an Empatica E4 wristband over the courses of several days, as well as a self-reported survey. Experiments on this dataset demonstrate that the proposed machine learning method outperforms conventional machine learning approaches in detecting extreme cases of poor sleep and fatigue in people with fibromyalgia.

Cognitive behavioral treatments for insomnia and pain in adults with comorbid chronic insomnia and fibromyalgia: clinical outcomes from the SPIN randomized controlled trial

STUDY OBJECTIVES

To examine the effects of cognitive behavioral treatments for insomnia (CBT-I) and pain (CBT-P) in patients with comorbid fibromyalgia and insomnia.

METHODS

One hundred thirteen patients (Mage = 53, SD = 10.9) were randomized to eight sessions of CBT-I (n = 39), CBT-P (n = 37), or a waitlist control (WLC, n = 37). Primary (self-reported sleep onset latency [SOL], wake after sleep onset [WASO], sleep efficiency [SE], sleep quality [SQ], and pain ratings) and secondary outcomes (dysfunctional beliefs and attitudes about sleep [DBAS]; actigraphy and polysomnography SOL, WASO, and SE; McGill Pain Questionnaire; Pain Disability Index; depression; and anxiety) were examined at posttreatment and 6 months.

RESULTS

Mixed effects analyses revealed that both treatments improved self-reported WASO, SE, and SQ relative to control at posttreatment and follow-up, with generally larger effect sizes for CBT-I. DBAS improved in CBT-I only. Pain and mood improvements did not differ by group. Clinical significance analyses revealed the proportion of participants no longer reporting difficulties initiating and maintaining sleep was higher for CBT-I posttreatment and for both treatments at 6 months relative to control. Few participants achieved >50% pain reductions. Proportion achieving pain reductions of >30% (~1/3) was higher for both treatments posttreatment and for CBT-I at 6 months relative to control.

CONCLUSIONS

CBT-I and CBT-P improved self-reported insomnia symptoms. CBT-I prompted improvements of larger magnitude that were maintained. Neither treatment improved pain or mood. However, both prompted clinically meaningful, immediate pain reductions in one third of patients. Improvements persisted for CBT-I, suggesting that CBT-I may provide better long-term pain reduction than CBT-P. Research identifying which patients benefit and mechanisms driving intervention effects is needed.

CLINICAL TRIAL

Sleep and Pain Interventions in Fibromyalgia (SPIN), clinicaltrials.gov, NCT02001077.

Gray Matter Changes Following Cognitive Behavioral Therapy for Patients With Comorbid Fibromyalgia and Insomnia: A Pilot Study

STUDY OBJECTIVES

Insomnia frequently co-occurs with fibromyalgia, which is associated with gray matter atrophy. We examined the effect of cognitive behavioral therapy for insomnia (CBT-I) and pain (CBT-P) on cortical thickness.

METHODS

Patients with fibromyalgia and insomnia underwent MRI before and after random assignment to CBT-I (n = 14), CBT-P (n = 16), or waitlist control (WLC; n = 7).

RESULTS

Repeated-measures analyses of variance revealed significant interactions for two regions (left lateral orbitofrontal cortex, left rostral middle frontal, Ps < .05) and trends for four regions (right medial orbitofrontal cortex, right posterior cingulate, left caudal middle frontal, left transverse temporal; Ps < .10). Cortical thickness increased in all regions for CBT-I and decreased in five regions for CBT-P and WLC. Hierarchical regressions revealed that for the CBT-I group, reductions in wake after sleep onset were associated with an increase in cortical thickness.

CONCLUSIONS

Our pilot study presents novel evidence suggesting that CBT-I may slow or reverse cortical gray matter atrophy in patients with fibromyalgia and insomnia.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Identifier: NCT02001077, Title: Sleep and Pain Interventions in Fibromyalgia (SPIN), URL: https://clinicaltrials.gov/ct2/show/NCT02001077.

Effects of Mindfulness Training on Sleep Problems in Patients With Fibromyalgia

Fibromyalgia syndrome (FMS) is a complex psychosomatic pain condition. In addition to generalized pain and various cognitive difficulties, new FMS diagnostic criteria acknowledge fatigue and sleep problems as core aspects of this condition. Indeed, poor sleep quality has been found to be a significant predictor of pain, fatigue, and maladaptive social functioning in this patient group. While there is promising evidence supporting the role of mindfulness as a treatment for FMS, to date, mindfulness intervention studies have principally focused on dimensions of pain as the primary outcome with sleep problems either not being assessed or included as a secondary consideration. Given the role of sleep problems in the pathogenesis of FMS, and given that mindfulness has been shown to improve sleep problems in other clinical conditions, the present study explored the effects of a mindfulness-based intervention known as Flow Meditation (Meditación-Fluir) on a range of sleep-related outcomes (subjective insomnia, sleep quality, sleepiness, and sleep impairment) in individuals with FMS. Adult women with FMS (n = 39) were randomly assigned to the 7 weeks mindfulness treatment or a waiting list control group. Results showed that compared to the control group, individuals in the mindfulness group demonstrated significant improvements across all outcome measures and that the intervention effects were maintained at a 3 month follow-up assessment. The Meditación-Fluir program shows promise for alleviating sleep problems relating to FMS and may thus have a role in the treatment of FMS as well as other pain disorders in which sleep impairment is a central feature of the condition.

The role of mirtazapine in patients with fibromyalgia: a systematic review

Mirtazapine is commonly used to treat major depressive disorder. Due to its effects on multiple neurotransmitters, it has been investigated for possible benefits in patients with fibromyalgia. The objective of this systematic review is to assess the efficacy and safety of mirtazapine in the treatment of patients with fibromyalgia. Pubmed (1946-May 2018), Embase (1947-May 2018), CENTRAL, and ClinicalTrials.gov were queried using the search term combination: fibromyalgia, pain, chronic pain, neuralgia, neuropathic pain, chronic widespread pain, or chronic pain syndrome and mirtazapine. Studies appropriate to the objective were evaluated, including three randomized, placebo-controlled trials and one open-label trial, investigating the effect of mirtazapine in patients with fibromyalgia. In patients with fibromyalgia, treatment with mirtazapine resulted in improvements in pain, sleep, and quality of life. Study durations ranged from 6 to 13 weeks and studies used varying dosing strategies for mirtazapine. Minor occurrences of somnolence, weight gain, nasopharyngitis, dry mouth, and increased appetite were reported with mirtazapine use. Based on the reviewed literature, mirtazapine appears to be a promising therapy to improve pain, sleep, and quality of life in patients with fibromyalgia. These benefits were demonstrated in patients that were treatment naïve and those that had failed previous therapies. Additional clinical evidence through larger and longer length trials would be of benefit to further define the role of mirtazapine for patients with fibromyalgia.

Do People With Chronic Pain Judge Their Sleep Differently? A Qualitative Study

People with chronic pain often report sleep of "poor quality." However, it is unclear what defines sleep quality and whether their sleep quality judgment is influenced by factors other than sleep. We purposively interviewed 17 participants with and without chronic pain and thematically analyzed their interview transcripts. Four salient criteria for judging sleep quality were (a) memories of night-time sleep disruptions, (b) feelings on waking and cognitive functioning during the day, (c) ability to engage in daytime physical and social activity, and (d) changes in physical symptoms (and pain intensity among participants with chronic pain). Sleep quality judgment is complex and involves retrospective decision making influenced by not only memories of the night but also how we feel and what we do during the day.

Objective measures of sleep in fibromyalgia syndrome: Relationship to clinical, psychiatric, and immunological variables

We aimed to investigate the changes in the objective and subjective sleep variables during painful episodes of fibromyalgia and post-episode period, and to evaluate the impact of the sleep variables on the current clinical, psychological, and immunologic parameters. Thirty-one consecutive patients who were referred to the Erenköy Physical Therapy and Rehabilitation Polyclinic with a diagnosis of fibromyalgia were evaluated before and in the sixth week of the acute pain treatment. The sleep variables were measured by polysomnography, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. The clinical and psychiatric assessment of patients was performed by using Fibromyalgia Impact Questionnaire; Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms; and Visual Analog Scale. Serum pro-inflammatory molecules were measured to evaluate the immunological status. The pain treatment significantly affected subjective sleep variables, psychiatric variables, clinical variables, and IL-6 levels. The subjective sleep parameters, clinical and psychiatric variables, and IL-6 levels were improved with pain treatment in fibromyalgia. The objective sleep variables, IL-1 and TNF-alpha levels were not significantly improved with the pain treatment, and they were not related to clinical presentation of patients with fibromyalgia. Subjective variability of sleep contributes to the clinical presentation, suggesting that the objective structure is trait-specific with IL-1 and TNF-alpha.

The association between pain and sleep in fibromyalgia

OBJECTIVE

To clarify the association between pain and sleep in fibromyalgia.  Methods: Electronic databases, including PsycINFO, the Cochrane database for systematic reviews, PubMed, EMBASE, and Ovid were searched to identify eligible articles. Databases independently screened and  the quality of evidence using a reliable and valid quality assessment tool was assessed.  Results: In total, 16 quantitative studies fulfilled the inclusion criteria. According to the results, increased pain in fibromyalgia was associated with reduced sleep quality, efficiency, and duration and increased sleep disturbance and onset latency and total wake time. Remarkably, depressive symptoms were also related to both pain and sleep in patients with fibromyalgia.   Conclusion: Management strategies should be  developed to decrease pain while increasing sleep quality in patients with fibromyalgia. Future studies should also consider mood disorders and emotional dysfunction, as comorbid conditions could occur with both pain and sleep disorder in fibromyalgia.

The relationship between sleep quality and fibromyalgia symptoms

This study investigated the relationship between sleep quality and fibromyalgia symptoms in 326 patients. The Pittsburgh Sleep Quality Index was used to assess the presence of sleep disorders. Multivariate analysis of variance was performed to determine the influence of fibromyalgia symptoms on sleep quality. The prevalence of sleep disorders was 92.9 percent. Patients reported generalized pain (88.3%), memory failure (78.5%), moodiness (59%), excessive anxiety (77.5%), and concentration difficulties (69.1%). Patients with more symptoms reported poor sleep quality ( p < .05; d = .74), and the total Pittsburgh Sleep Quality Index score correlated with the number of symptoms ( p < .01). Sleep quality has an important association with fibromyalgia symptoms.

Emotion, emotion regulation and sleep: An intimate relationship

In recent years, research has witnessed an increasing interest in the bidirectional relationship between emotion and sleep. Sleep seems important for restoring daily functioning, whereas deprivation of sleep makes us more emotionally aroused and sensitive to stressful stimuli and events. Sleep appears to be essential to our ability to cope with emotional stress in everyday life. However, when daily stress is insufficiently regulated, it may result in mental health problems and sleep disturbances too. Not only does emotion impact sleep, but there is also evidence that sleep plays a key role in regulating emotion. Emotional events during waking hours affect sleep, and the quality and amount of sleep influences the way we react to these events impacting our general well-being. Although we know that daytime emotional stress affects sleep by influencing sleep physiology, dream patterns, dream content and the emotion within a dream, its exact role is still unclear. Other effects that have been found are the exaggeration of the startle response, decrease in dream recall and elevation of awakening thresholds from rapid eye movement (REM), REM-sleep, increased or decreased latency to REM-sleep, increase in percentage of REM-density, REM-sleep duration, as well as the occurrence of arousals in sleep as a marker of sleep disruption. Equally, the way an individual copes with emotional stress, or the way in which an individual regulates emotion may modulate the effects of emotional stress on sleep. The research presented here supports the idea that adaptive emotion regulation benefits our follow-up sleep. We thus conclude the current review with a call for future research in order to clarify further the precise relationship between sleep, emotion and emotion regulation, as well as to explain further how sleep dissolves our emotional stress.

Somatic symptom presentations in women with fibromyalgia are differentially associated with elevated depression and anxiety

This study examined whether depression and anxiety differentially relate to fatigue, sleep disturbance, pain catastrophizing, fear of movement, and pain severity in women with fibromyalgia. Baseline data from the Fibromyalgia Activity Study with Transcutaneous Electrical Nerve Stimulation were analyzed. Of 191 participants, 50 percent reported high anxiety and/or depression (17% high anxiety, 9% high depression, and 24% both). Fatigue and sleep impairment were associated with high depression (p < 0.05). Pain severity, pain catastrophizing, and fear of movement were associated with high anxiety and high depression (p < 0.05). Possible implications for underlying mechanisms and the need for targeted treatments are discussed.

Measuring Treatment Outcomes in Comorbid Insomnia and Fibromyalgia: Concordance of Subjective and Objective Assessments

STUDY OBJECTIVES

In insomnia, actigraphy tends to underestimate wake time compared to diaries and PSG. When chronic pain co-occurs with insomnia, sleep may be more fragmented, including more movement and arousals. However, individuals may not be consciously aware of these arousals. We examined the baseline concordance of diaries, actigraphy, and PSG as well as the ability of each assessment method to detect changes in sleep following cognitive behavioral therapy for insomnia (CBT-I).

METHODS

Adults with insomnia and fibromyalgia (n = 113) were randomized to CBT-I, CBT for pain, or waitlist control. At baseline and posttreatment, participants completed one night of PSG and two weeks of diaries/actigraphy.

RESULTS

At baseline, objective measures estimated lower SOL, higher TST, and higher SE than diaries (ps < 0.05). Compared to PSG, actigraphic estimates were higher for SOL and lower for WASO (ps < 0.05). Repeated measures ANOVAs were conducted for the CBT-I group (n = 15), and significant method by time interactions indicated that the assessment methods differed in their sensitivity to detect treatment-related changes. PSG values did not change significantly for any sleep parameters. However, diaries showed improvements in SOL, WASO, and SE, and actigraphy also detected the WASO and SE improvements (ps < 0.05).

CONCLUSIONS

Actigraphy was generally more concordant with PSG than with diaries, which are the recommended assessment for diagnosing insomnia. However, actigraphy showed greater sensitivity to treatment-related changes than PSG; PSG failed to detect any improvements, but actigraphy demonstrated changes in WASO and SE, which were also found with diaries. In comorbid insomnia/fibromyalgia, actigraphy may therefore have utility in measuring treatment outcomes.

Resistance exercise improves physical fatigue in women with fibromyalgia: a randomized controlled trial

Background

Fibromyalgia (FM) affects approximately 1–3 % of the general population. Fatigue limits the work ability and social life of patients with FM. A few studies of physical exercise have included measures of fatigue in FM, indicating that exercise can decrease fatigue levels. There is limited knowledge about the effects of resistance exercise on multiple dimensions of fatigue in FM. The present study is a sub-study of a multicenter randomized controlled trial in women with FM. The purpose of the present sub-study was to examine the effects of a person-centered progressive resistance exercise program on multiple dimensions of fatigue in women with FM, and to investigate predictors of the potential change in fatigue.

Methods

A total of 130 women with FM (age 22–64 years) were included in this assessor-blinded randomized controlled multicenter trial examining the effects of person-centered progressive resistance exercise compared with an active control group. The intervention was performed twice a week for 15 weeks. Outcomes were five dimensions of fatigue measured with the Multidimensional Fatigue Inventory (MFI-20). Information about background was collected and the women also completed several health-related questionnaires. Multiple linear stepwise regression was used to analyze predictors of change in fatigue in the total population.

Results

A higher improvement was found at the post-treatment examination for change in the resistance exercise group, as compared to change in the active control group in the MFI-20 subscale of physical fatigue (resistance group Δ –1.7, SD 4.3, controls Δ 0.0, SD 2.7, p = 0.013), with an effect size of 0.33. Sleep efficiency was the strongest predictor of change in the MFI-20 subscale general fatigue (beta = −0.54, p = 0.031, R² = 0.05). Participating in resistance exercise (beta = 1.90, p = 0.010) and working fewer hours per week (beta = 0.84, p = 0.005) were independent significant predictors of change in physical fatigue (R² = 0.14).

Conclusions

Person-centered progressive resistance exercise improved physical fatigue in women with FM when compared to an active control group.

Trial registration

ClinicalTrials.gov NCT01226784. Registered 21 October 2010.

Sleep and sleepiness in environmental intolerances: a population-based study

BACKGROUND

About one fourth of the general population report environmental intolerance (EI) to odorous/pungent chemicals, certain buildings, electromagnetic fields (EMFs), and/or sounds. EI sufferers show various clinical features, of which sleep disturbance is one. Sleep disturbance is common also in the general population, but it is not known whether the disturbance is more prominent in EI sufferers than in individuals who do not experience EI. Therefore, EI was compared on various sleep aspects with referents without EI.

METHODS

A population-based sample of 3406 individuals, aged 18-79 years, was recruited from Northern Sweden. Sleep quality, non-restorative sleep, daytime sleepiness, obstructive breathing, and nocturnal insomnia were assessed with the Karolinska Sleep Questionnaire. Single questions assessed time slept, amount of hours of needed sleep, and extent of enough time slept.

RESULTS

All four EI groups, compared to the referents, reported significantly poorer sleep quality, more non-restorative sleep, more daytime sleepiness, more obstructive breathing and higher prevalence of nocturnal insomnia than the referents. Nocturnal insomnia was an important factor for EI groups attributing their most prevalent symptoms to chemicals and sounds, irrespective of distress and certain syndromes. None of the EI groups differed significantly from the referents on time slept, but reported needing more sleep time (the EMF-intolerance group showing only a tendency), and all four groups reported to perceive enough sleep to a significantly lesser extent.

CONCLUSION

Sleep disturbance and daytime sleepiness are more common in individuals reporting EI compared to normal referents. Moreover, nocturnal insomnia is an important symptom in its own right in various types of EI. This evokes the question of whether or not sleep therapy may attenuate the severity of the EI.