Nighttime sleep and daytime functioning (sleepiness and fatigue) in less well-defined chronic rheumatic diseases with particular reference to the 'alpha-delta NREM sleep anomaly'

Comparing patients treated with CBT for insomnia with healthy sleepers and sleepers with past insomnia on dimensions of sleep health

OBJECTIVES

To compare patients treated with cognitive behavioral therapy for insomnia (CBT-I) with healthy sleepers and individuals with past but not current insomnia on multidimensional sleep health.

METHODS

The study evaluates CBT-I on six dimensions of sleep health (regularity, satisfaction, alertness, timing, efficiency, duration) in a sample of individuals with insomnia compared to two other unique sleep samples. Participants were in one of three groups: insomnia (CUR, n = 299), healthy sleeper (HS, n = 122), or past insomnia (PAST, n = 35). Daily diaries and validated measures were employed to capture six dimensions of sleep health. The CUR group received four 60-minute sessions of CBT-I every 2weeks, and sleep health indices were measured at baseline and post-treatment. The HS and PAST groups were measured only at baseline.

RESULTS

Results of the pairwise t tests indicated improvements in sleep satisfaction, alertness (fatigue but not sleepiness), timing, efficiency, and duration (Cohen's d=0.22 to 1.55). ANCOVA models revealed significant differences in sleep health scores between treated insomnia patients and the other two sleep groups. Treated patients demonstrated less bedtime and risetime variability, in addition to lower napping duration. Overall, the study observed significant changes in various domains of sleep health after four sessions of cognitive behavioral therapy for insomnia; however, differences remain when compared to the other groups in the study.

CONCLUSION

There may be ongoing sleep vulnerability in patients treated with cognitive behavioral therapy for insomnia though future inclusion of a control group would increase internal validity. Borrowing from transdiagnostic sleep modules may be helpful to support remaining deficits after cognitive behavioral therapy for insomnia.

Daytime Central Thalamic Deep Brain Stimulation Modulates Sleep Dynamics in the Severely Injured Brain: Mechanistic Insights and a Novel Framework for Alpha-Delta Sleep Generation

Loss of organized sleep electrophysiology is a characteristic finding following severe brain injury. The return of structured elements of sleep architecture has been associated with positive prognosis across injury etiologies, suggesting a role for sleep dynamics as biomarkers of wakeful neuronal circuit function. In a continuing study of one minimally conscious state patient studied over the course of ~8½ years, we sought to investigate whether changes in daytime brain activation induced by central thalamic deep brain stimulation (CT-DBS) influenced sleep electrophysiology. In this patient subject, we previously reported significant improvements in sleep electrophysiology during 5½ years of CT-DBS treatment, including increased sleep spindle frequency and SWS delta power. We now present novel findings that many of these improvements in sleep electrophysiology regress following CT-DBS discontinuation; these regressions in sleep features correlate with a significant decrease in behavioral responsiveness. We also observe the re-emergence of alpha-delta sleep, which had been previously suppressed by daytime CT-DBS in this patient subject. Importantly, CT-DBS was only active during the daytime and has been proposed to mediate recovery of consciousness by driving synaptic activity across frontostriatal systems through the enhancement of thalamocortical output. Accordingly, the improvement of sleep dynamics during daytime CT-DBS and their subsequent regression following CT-DBS discontinuation implicates wakeful synaptic activity as a robust modulator of sleep electrophysiology. We interpret these findings in the context of the “synaptic homeostasis hypothesis,” whereby we propose that daytime upregulation of thalamocortical output in the severely injured brain may facilitate organized frontocortical circuit activation and yield net synaptic potentiation during wakefulness, providing a homeostatic drive that reconstitutes sleep dynamics over time. Furthermore, we consider common large-scale network dynamics across several neuropsychiatric disorders in which alpha-delta sleep has been documented, allowing us to formulate a novel mechanistic framework for alpha-delta sleep generation. We conclude that the bi-directional modulation of sleep electrophysiology by daytime thalamocortical activity in the severely injured brain: (1) emphasizes the cyclical carry-over effects of state-dependent circuit activation on large-scale brain dynamics, and (2) further implicates sleep electrophysiology as a sensitive indicator of wakeful brain activation and covert functional recovery in the severely injured brain.

Acute effects of radiofrequency electromagnetic field emitted by mobile phone on brain function

Due to its attributes, characteristics, and technological resources, the mobile phone (MP) has become one of the most commonly used communication devices. Historically, ample evidence has ruled out the substantial short-term impact of radiofrequency electromagnetic field (RF-EMF) emitted by MP on human cognitive performance. However, more recent evidence suggests potential harmful effects associated with MP EMF exposure. The aim of this review is to readdress the question of whether the effect of MP EMF exposure on brain function should be reopened. We strengthen our argument focusing on recent neuroimaging and electroencephalography studies, in order to present a more specific analysis of effects of MP EMF exposure on neurocognitive function. Several studies indicate an increase in cortical excitability and/or efficiency with EMF exposure, which appears to be more prominent in fronto-temporal regions and has been associated with faster reaction time. Cortical excitability might also underpin disruption to sleep. However, several inconsistent findings exist, and conclusions regarding adverse effects of EMF exposure are currently limited. It also should be noted that the crucial scientific question of the effect of longer-term MP EMF exposure on brain function remains unanswered and essentially unaddressed. Bioelectromagnetics. 38:329-338, 2017. © 2017 Wiley Periodicals, Inc.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

The acute effects of alcohol on sleep electroencephalogram power spectra in late adolescence

BACKGROUND

Alcohol's effect on sleep electroencephalogram (EEG) power spectra during late adolescence is of interest given that this age group shows both dramatic increases in alcohol consumption and major sleep-related developmental changes in quantitative EEG measures. This study examined the effect of alcohol on sleep EEG power spectra in 18- to 21-year-old college students.

METHODS

Participants were 24 (12 female) healthy 18- to 21-year-old social drinkers. Participants underwent 2 conditions: presleep alcohol and placebo, followed by standard polysomnography with comprehensive EEG recordings.

RESULTS

After alcohol, mean breath alcohol concentration at lights-out was 0.084%. Interaction effects indicated simultaneous increases in frontal non-rapid eye movement sleep (NREM) delta (p = 0.031) and alpha (p = 0.005) power in the first sleep cycles following alcohol consumption which was most prominent at frontal scalp sites (p < 0.001). A decrease in sigma power (p = 0.001) was also observed after alcohol.

CONCLUSIONS

As hypothesized, alcohol increased slow wave sleep-related NREM delta power. However, there was a simultaneous increase in frontal alpha power. Results suggest that alcohol may exert an arousal influence which may compete with the sleep maintenance influence of increased delta activity. The phenomenon is similar to, or the same as, alpha-delta sleep which has been associated with the presence of disruptive stimuli during sleep. This may have negative implications for the impact of presleep alcohol consumption on sleep and consequent daytime functioning.

Sleep Disturbances and Osteoarthritis

Sleep disturbances are particularly troublesome in patients with painful rheumatic disease. This article reviews the literature specifically published on sleep disturbances in osteoarthritis, a prevalent pathology and leading cause of disability. Several aspects of the relationship between sleep and osteoarthritis are discussed, including epidemiology, pathophysiological hypotheses, and treatment outcomes. Sleep is of central importance in the well-being of patients and should systematically be assessed in patients with osteoarthritis. When needed, a specific treatment of sleep disorders should be associated with an optimal management of pain to achieve synergistic improvements in quality of life. More large-scale studies are needed to identify predictive factors of sleep impairment in osteoarthritis.

Sleep disturbances of adult women suffering from fibromyalgia: a systematic review of observational studies

Although sleep complaints are often reported in patients with fibromyalgia syndrome (FMS), there is no conclusive evidence that these complaints represent symptomatic disorders of sleep physiology. Thus, the question of the role of sleep disturbances as an etiological or maintenance factor in FMS remains open. This study identifies the subjective and objective characteristics of sleep disturbances in adult women diagnosed with FMS. We carried out a systematic review of publications since 1990, the publication year of the American College of Rheumatology criteria of FMS. We selected empirical studies comparing sleep characteristics of adult women with FMS and healthy women or women with rheumatic diseases. We identified 42 articles. Patients with FMS were more likely to exhibit sleep complaints and also a less efficient, lighter and fragmented sleep. The evidence of a FMS signature on objective measures of sleep is inconsistent, however, as the majority of studies lacks statistical power. Current evidence cannot confirm the role played by sleep physiology in the pathogenesis or maintenance of FMS symptoms; nonetheless, it is clear that sleep disturbances are present in this syndrome.

Relationship between sleep and pain in adolescents with juvenile primary fibromyalgia syndrome

STUDY OBJECTIVES

To investigate sleep quality in adolescents with juvenile primary fibromyalgia syndrome (JPFS) and determine whether sleep abnormalities, including alpha-delta sleep (ADS), correlate with pain intensity. We hypothesized that successful treatment for pain with exercise therapy would reduce ADS and improve sleep quality.

DESIGN

Single-center preintervention and postintervention (mean = 5.7 ± 1.0 weeks; range = 4.0-7.3 weeks) observational study.

PATIENTS

Ten female adolescents (mean age = 16.2 ± 0.65 SD yr) who met criteria for JPFS and completed treatment.

INTERVENTIONS

Multidisciplinary pain treatment, including intensive exercise therapy.

MEASUREMENTS AND RESULTS

Pain and disability were measured by a pain visual analog scale (VAS) and the functional disability inventory. Subjective sleep measures included a sleep VAS, an energy VAS, and the School Sleep Habits Survey. Objective sleep measures included actigraphy, polysomnography (PSG), and the Multiple Sleep Latency Test. Baseline PSG was compared with that of healthy age- and sex-matched control patients. At baseline, patients had poorer sleep efficiency, more arousals/awakenings, and more ADS (70.3% of total slow wave sleep [SWS] versus 21.9% SWS, P = 0.002) than controls. ADS was unrelated to pain, disability, or subjective sleep difficulty. After treatment, pain decreased (P = 0.000) and subjective sleep quality improved (P = 0.008). Objective sleep quality, including the amount of ADS, did not change.

CONCLUSIONS

Although perceived sleep quality improved in adolescents with JPFS after treatment, objective measures did not. Our findings do not suggest exercise therapy for pain improves sleep by reducing ADS, nor do they support causal relationships between ADS and chronic pain or subjective sleep quality.

Ultra-slow delta power in chronic fatigue syndrome

The role of sleep in patients diagnosed with chronic fatigue syndrome is not fully understood. Studies of polysomnographic and quantitative sleep electroencephalographic (EEG) measures have provided contradictory results, with few consistent findings in patients with Chronic Fatigue Syndrome (CFS). For the most part, it appears that delta EEG activity may provide the best discrimination between patients and healthy controls. A closer examination of delta activity in the very slow end of the frequency band is still to be considered in assessing sleep in CFS. The present preliminary study compared absolute and relative spectral power in conventional EEG bands and ultra-slow delta (0.5-0.8Hz) between 10 young female patients with the CFS and healthy controls without psychopathology. In absolute measures, the ultra-slow delta power was lower in CFS, about one-fifth that of the control group. Other frequency bands did not differ between groups. Relative ultra-slow delta power was lower in patients than in controls. CFS is associated with lower ultra-slow (0.5-0.8Hz) delta power, underscoring the importance of looking beyond conventional EEG frequency bands. From a neurophysiological standpoint, lower ultra-slow wave power may indicate abnormalities in the oscillations in membrane potential or a failure in neural recruitment in those with CFS.

Sleep, stress, neurocognitive profile and health-related quality of life in adolescents with idiopathic musculoskeletal pain

OBJECTIVES

The aims of this study were to measure levels of sleep, stress, and depression, as well as health-related quality of life, and to assess the neurocognitive profiles in a sample of adolescents with idiopathic musculoskeletal pain.

METHODS

Nineteen adolescents with idiopathic musculoskeletal pain and 20 age-matched healthy control subjects were evaluated regarding their levels of sleep and stress, as well as quality of life, and underwent neurocognitive testing.

RESULTS

The sample groups consisted predominantly of females (84%), and the socioeconomic status did not differ between the two groups. In addition, the occurrence of depressive symptoms was similar between the two groups; specifically, 26% of the idiopathic musculoskeletal pain patients and 30% of the control subjects had scores indicative of depression. Teenagers in the group with idiopathic musculoskeletal pain reported poorer quality of life and sleep scores than those in the control group. Regarding stress, patients had worse scores than the control group; whereas 79% of the adolescents with idiopathic musculoskeletal pain met the criteria for a diagnosis of stress, only 35% of the adolescents in the control group met the criteria. In both groups, we observed scores that classified adolescents as being in the resistance phase (intermediate) and exhaustion phase (pathological) of distress. However, the idiopathic musculoskeletal pain group more frequently reported symptomatic complaints of physical and emotional distress. The neurocognitive assessment showed no significant impairments in either group.

CONCLUSION

Adolescents with idiopathic musculoskeletal pain did not exhibit cognitive impairments. However, adolescents with idiopathic musculoskeletal pain did experience intermediate to advanced psychological distress and lower health-related quality of life, which may increase their risk of cognitive dysfunction in the future.

Continuous positive airway pressure in severe obstructive sleep apnea reduces pain sensitivity

STUDY OBJECTIVE

To evaluate effects of CPAP on pain sensitivity in severe OSA patients.

DESIGN

Within-subject treatment study.

SETTING

Hospital-based sleep disorders center.

PATIENTS

Twelve severe OSA patients (7 men, 5 women), 50.2 ± 12.5 years, with no pain.

INTERVENTIONS

The morning after a diagnostic nocturnal polysomnogram (NPSG), patients underwent a training session of finger withdrawal latency (FWL) testing to a radiant heat stimulus, a validated human behavioral model of thermal nociception. Baseline FWL in seconds was obtained after the training session. CPAP pressure was titrated on a second night in the laboratory. Two nights after titration, patients returned to sleep in the laboratory on CPAP. FWL was tested in the morning after awakening, after 6-8 wks of CPAP use, and finally (within 6-8 weeks) after 2 nights of discontinuation of CPAP. Mean FWL in seconds (sec) was compared using MANOVAs with nights as the within subject variable.

RESULTS

Apnea-hypopnea index (AHI) decreased from 50.9 ± 14.5 to 1.4 ± 1.0 with CPAP, and sleep continuity improved. In parallel, FWL increased significantly from a mean baseline of 9.8 ± 1.3 sec to 13.7 ± 5.1 sec (P = 0.01) and with continued CPAP use (5.1 ± 2.3 h nightly) for 6-8 weeks FWL remained elevated (21.1 ± 16.2 sec). After the 2-night CPAP discontinuation, apnea/hypopneas returned and sleep was fragmented (AHI = 32.6 ± 19.8). FWL decreased to 11.6 ± 5.9 sec relative to intermediate-term CPAP use (P = 0.03).

CONCLUSION

CPAP treatment reduces pain sensitivity in OSA patients. Future studies will focus on patients with OSA and chronic pain and identify mediating mechanisms.

Prevalence of insomnia and impact on quality of life among community elderly subjects with tinnitus

OBJECTIVES

We sought to determine the prevalence of insomnia and its impact on the quality of life (QoL) among community elderly subjects (at least 65 years of age) with subjective tinnitus.

METHODS

After household selection with multistage stratified area probability sampling, face-to-face interviews were used to obtain self-reports of subjective tinnitus and insomnia, and QoL was assessed with the WHOQoL-Bref instrument.

RESULTS

Among 1302 elderly subjects, there were 183 subjects (109 female and 74 male) with tinnitus. Among those with tinnitus, insomnia was encountered in 95 (51.9%) and was found to be significantly more common among those with tinnitus than among those without (378 of 1119, or 33.8%; p = 0.002). The insomnia symptoms included difficulty in maintaining sleep in 73.4% of subjects, difficulty in falling asleep in 70.0%, early morning wakefulness in 64.3%, nonrestorative sleep in 35.1%, and daytime sleepiness in 34.7%. Univariate analysis revealed difficulty with falling asleep (p = 0.01) and early morning wakefulness (p = 0.05) to be significantly associated with tinnitus among the symptoms. Student's t-test and logistic regression analysis revealed significant deterioration in the total QoL and in the physical, psychological, social, and environmental QoL domains among elderly subjects who had tinnitus with insomnia as compared with those without insomnia.

CONCLUSIONS

We believe that insomnia is significantly more common among elderly subjects with tinnitus than among those without, and that its presence further depreciates the QoL in these elderly individuals.

Fibromyalgia and fatigue: central processing, widespread dysfunction

Biological and psychological bases for the covariation of pain and fatigue in fibromyalgia (FM) are reviewed. FM is characterized as a disorder of central sensitization, with pain and fatigue as the most prominent symptoms. The roles of sleep disturbance and affective dysregulation as both precipitants and consequences of pain and fatigue in FM are discussed. It is argued that a positive affective disturbance may uniquely characterize pain and fatigue symptoms in FM. Finally, pharmacological and nonpharmacological treatments for FM are highlighted, with an emphasis on the efficacy of these treatments in alleviating pain and fatigue symptoms.

Light sleep and sleep time misperception - relationship to alpha-delta sleep

OBJECTIVE

We investigated the association of alpha-delta sleep (A-DS) with: (1) perception of light sleep and (2) discrepancy between subjective and objective sleep duration.

METHODS

We analyzed data from 5764 individuals who underwent polysomnography (PSG) and replied questions about quantity and quality of sleep, including sleep depth. The difference between objectively recorded sleep time and subjectively estimated sleep time was calculated. Alpha-delta sleep (A-DS) was visually scored in a scale from 1 to 4, based on the density and overnight duration of alpha activity and confirmed using spectral array of the electroencephalographic activity.

RESULTS

A-DS scores 1-4 occurred in, respectively, 37.9%; 31.3%; 20.5%; and 6.2% of the cases. ANOVA showed significant difference of light sleep sensation (p<0.001) and sleep time underestimation (p<0.001) among the four A-DS categories. Regression to explain both light sleep and sleep time underestimation, controlling for confounders, confirmed A-DS as a significant regressor.

CONCLUSIONS

This study of a large prospective sample provides evidence for the association of alpha-delta sleep with subjective sensation of light sleep and with sleep time underestimation.

SIGNIFICANCE

Alpha-delta sleep may be a marker of the physiological disorder underlying light sleep and sleep state misperception.

Electroencephalographic correlates of Chronic Fatigue Syndrome

BACKGROUND

Unremitting fatigue and unrefreshing sleep, hallmark traits of Chronic Fatigue Syndrome (CFS), are also pathognomonic of sleep disorders. Yet, no reproducible perturbations of sleep architecture, multiple sleep latency times or Epworth Sleepiness Scores are found to be associated consistently with CFS. This led us to hypothesize that sleep homeostasis, rather than sleep architecture, may be perturbed in CFS. To probe this hypothesis, we measured and compared EEG frequencies associated with restorative sleep between persons with CFS and matched controls, both derived from a population-based sample.

METHODS

We evaluated overnight polysomnography (PSG) in 35 CFS and 40 control subjects. PSG records were manually scored and epochs containing artifact removed. Fast Fourier Transformation was utilized to deconstruct individual EEG signals into primary frequency bands of alpha, delta, theta, sigma, and beta frequency domains. The spectral power of each frequency domain for each sleep state was compared between persons with CFS and matched controls.

RESULTS

In persons with CFS, delta power was diminished during slow wave sleep, but elevated during both stage 1 and REM. Alpha power was reduced during stage 2, slow wave, and REM sleep. Those with CFS also had significantly lower theta, sigma, and beta spectral power during stage 2, Slow Wave Sleep, and REM.

DISCUSSION

Employing quantitative EEG analysis we demonstrate reduced spectral power of cortical delta activity during SWS. We also establish reduced spectral power of cortical alpha activity, with the greatest reduction occurring during REM sleep. Reductions in theta, beta, and sigma spectral power were also apparent.

CONCLUSION

Unremitting fatigue and unrefreshing sleep, the waking manifestations of CFS, may be the consequence of impaired sleep homeostasis rather than a primary sleep disorder.

Objective measures of disordered sleep in fibromyalgia

OBJECTIVE

Patients with fibromyalgia syndrome (FM) complain of inadequate sleep, which could contribute to common symptoms including sleepiness, fatigue, or pain. However, measures that consistently and objectively distinguish FM patients remain elusive.

METHODS

Fifteen women with FM and 15 age- and gender-matched controls underwent 3 nights of polysomnography; Multiple Sleep Latency Tests to assess sleepiness; testing of auditory arousal thresholds during non-REM stage 2 and stage 4 sleep; overnight assessment of urinary free cortisol; and analysis of 24-hour heart rate variability.

RESULTS

On the second night of polysomnography, women with FM in comparison to controls showed more stage shifts (p = 0.04) but did not differ significantly on any other standard polysomnographic measure or on the Multiple Sleep Latency Tests. Alpha EEG power during deep non-REM sleep, alone or as a proportion of alpha power during remaining sleep stages, also failed to distinguish the groups, as did auditory arousal thresholds. Urinary free cortisol did not differ between FM and control subjects in a consistent manner. However, decreased short-term heart rate variability (HRV) and especially ratio-based HRV among FM subjects suggested diminished parasympathetic and increased sympathetic activity, respectively. Other HRV measures suggested decreased complexity of HRV among the FM subjects.

CONCLUSION

Standard measures of sleep, a gold-standard measure of sleepiness, quantified alpha-delta EEG power, auditory arousal thresholds, and urinary free cortisol largely failed to distinguish FM and control subjects. However, HRV analyses showed more promise, as they suggested both increased sympathetic activity and decreased complexity of autonomic nervous system function in FM.

Delta sleep instability in children with chronic arthritis

The objective of the present study was to evaluate the expression of a cyclic alternating pattern (CAP) in slow wave sleep (SWS) in children with the well-defined chronic syndrome juvenile idiopathic arthritis (JIA). Twelve patients (9-17 years of age), 7 girls, with JIA were compared to matched controls by age, pubertal stage and gender. After one night of habituation in the sleep laboratory, sleep measurements were obtained by standard polysomnography with conventional sleep scoring and additional CAP analyses. The sleep parameters of the JIA and control groups were similar for sleep efficiency (91.1 +/- 6.7 vs 95.8 +/- 4.0), sleep stage in minutes: stage 1 (16.8 +/- 8.5 vs 17.8 +/- 4.0), stage 2 (251.9 +/- 41 vs 262.8 +/- 38.1), stage 3 (17.0 +/- 6.0 vs 15.1 +/- 5.7), stage 4 (61.0 +/- 21.7 vs 77.1 +/- 20.4), and rapid eye movement sleep (82.0 +/- 27.6 vs 99.0 +/- 23.9), respectively. JIA patients presented nocturnal disrupted sleep, with an increase in short awakenings, but CAP analyses showed that sleep disruption was present even during SWS, showing an increase in the overall CAP rate (P < 0.01). Overall CAP rate during non-rapid eye movement sleep was significantly higher in pediatric patients who were in chronic pain. This is the first study of CAP in pediatric patients with chronic arthritis showing that CAP analyses can be a powerful tool for the investigation of disturbance of SWS in children, based on sleep EEG visual analysis.

Sleep-related problems in common medical conditions

Common medical problems are often associated with abnormalities of sleep. Patients with chronic medical disorders often have fewer hours of sleep and less restorative sleep compared to healthy individuals, and this poor sleep may worsen the subjective symptoms of the disorder. Individuals with lung disease often have disturbed sleep related to oxygen desaturations, coughing, or dyspnea. Both obstructive lung disease and restrictive lung diseases are associated with poor quality sleep. Awakenings from sleep are common in untreated or undertreated asthma, and cause sleep disruption. Gastroesophageal reflux is a major cause of disrupted sleep due to awakenings from heartburn, dyspepsia, acid brash, coughing, or choking. Patients with chronic renal disease commonly have sleep complaints often due to insomnia, insufficient sleep, sleep apnea, or restless legs syndrome. Complaints related to sleep are very common in patients with fibromyalgia and other causes of chronic pain. Sleep disruption increases the sensation of pain and decreases quality of life. Patients with infectious diseases, including acute viral illnesses, HIV-related disease, and Lyme disease, may have significant problems with insomnia and hypersomnolence. Women with menopause have from insomnia, sleep-disordered breathing, restless legs syndrome, or fibromyalgia. Patients with cancer or receiving cancer therapy are often bothered by insomnia or other sleep disturbances that affect quality of life and daytime energy. The objective of this article is to review frequently encountered medical conditions and examine their impact on sleep, and to review frequent sleep-related problems associated with these common medical conditions.

Normal cerebrospinal fluid levels of hypocretin-1 (orexin A) in patients with fibromyalgia syndrome

BACKGROUND

The hypothalamic neuropeptide hypocretin (orexin) modulates sleep-wake, feeding and endocrine functions. Cerebrospinal fluid (CSF) hypocretin-1 (Hcrt-1) concentrations are low in patients with narcolepsy-cataplexy, a sleep disorder characterized by hypersomnolence and rapid eye movement (REM) sleep abnormalities.

METHODS

We determined CSF Hcrt-1 concentrations of patients with the fibromyalgia syndrome (FMS), a condition characterized by fatigue, insomnia and in some cases daytime hypersomnolence.

RESULTS

Basal CSF levels of Hcrt-1 in FMS did not differ from those in healthy normal controls.

CONCLUSIONS

These findings suggest that abnormally low Hcrt-1 is not a likely cause of fatigue in FMS.

Chronic fatigue, unrefreshing sleep and nocturnal polysomnography

BACKGROUND AND PURPOSE

To investigate the complaint of unrefreshing sleep with study of sleep electroencephalogram (EEG) in patients with chronic fatigue.

PATIENTS AND METHODS

Fourteen successively seen patients (mean age: 41.1 9.8) who complained of chronic fatigue but denied sleepiness and agreed to participate were compared to 14 controls (33.6+/-10.2 years) who were monitored during sleep recorded in parallel. After performing conventional sleep scoring we applied Fast Fourier Transformation (FFT) for the delta 1, delta 2, theta, alpha, sigma 1, sigma 2, beta EEG frequency bands. The presence of non-rapid eye movement (NREM) sleep instability was studied with calculation of cyclic alternating pattern (CAP) rate. Two-way analysis of variance (ANOVA) was performed to analyze FFT results and Mann-Whitney U-test to compare CAP rate in both groups of subjects.

RESULTS

Slow wave sleep (SWS) percentage and sleep efficiency were lower, but there was a significant increase in delta 1 (slow delta) relative power in the chronic fatigue group when compared to normals (P<0.01). All the other frequency bands were proportionally and significantly decreased compared to controls. CAP rate was also significantly greater in subjects with chronic fatigue than in normals (P=0.04). An increase in respiratory effort and nasal flow limitation were noted with chronic fatigue.

CONCLUSIONS

The complaints of chronic fatigue and unrefreshing sleep were associated with an abnormal CAP rate, with increase in slow delta power spectrum, affirming the presence of an abnormal sleep progression and NREM sleep instability. These specific patterns were related to subtle, undiagnosed sleep-disordered breathing.

Hydrotherapy and conventional physiotherapy improve total sleep time and quality of life of fibromyalgia patients: Randomized clinical trial

OBJECTIVE

To compare hydrotherapy (HT) and conventional physiotherapy (CP) in the treatment of fibromyalgia (FM), regarding quality of life (QOL), total sleep time (TST), and total nap time (TNT).

METHODS

Fifty outpatients, all female, 30-60 years old, diagnosed with FM, were randomly assigned to two groups to carry out 3 weeks of treatment with HT or CP. In the beginning and in the end of treatment, patients were evaluated with the SF-36 questionnaire to measure QOL and the sleep diary for TST and TNT. Data analyses were blind.

RESULTS

All 24 HT patients increased 1h in TST compared to 19 CP patients. TNT decreased in the HT group. QOL improved for the two groups in all domains when pre- and post-intervention were compared, but there was no difference between groups.

CONCLUSION

HT is more effective than CP to improve TST and to decrease TNT in FM patients.

Pain, psychological variables, sleep quality, and natural killer cell activity in midlife women with and without fibromyalgia

In women with fibromyalgia (FM), central nervous system (CNS) dysfunction in pain, mood, and sleep processes could be associated with changes in immune system indicators. The primary purpose of this study was to compare pain, psychological variables, subjective and objective sleep quality, lymphocyte phenotypes and activation markers, and natural killer activity (NKA) in midlife women with and without FM. A secondary purpose was to explore relationships among these variables in a step-wise regression. Subjects had pain pressure tender points assessed, completed a psychiatric interview and questionnaires (Beck Depression Inventory, SCL-90, Profile of Mood States, subjective sleep), and underwent polysomnograhic assessment for two consecutive nights. Lymphocyte phenotypes, activation markers, and NKA were assessed from blood drawn the morning after sleep laboratory night 2. Compared to controls, women with FM had lower pain thresholds, more psychological distress, higher depression scores, and reduced subjective and objective sleep quality. They also had fewer NK cells (p <.009) and more NK cells that expressed the IL-2 receptor (p <.04), but these differences were not statistically significant after correction for multiple comparisons. NKA was not statistically significantly lower in the women with FM compared to controls. In a multiple regression of age, tender point threshold, depression, psychological distress, and sleep efficiency, only the effect of group was significant (F = 5.479, p <.03) on NKA. In conclusion, we found little evidence to support the hypothesis that pain, mood, and sleep symptoms are associated with changes in the enumeration of peripheral lymphocytes or function in FM.

How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature

Sleep disturbance is perhaps one of the most prevalent complaints of patients with chronically painful conditions. Experimental studies of healthy subjects and cross-sectional research in clinical populations suggest the possibility that the relationship between sleep disturbance and pain might be reciprocal, such that pain disturbs sleep continuity/quality and poor sleep further exacerbates pain. This suggests that aggressive management of sleep disturbance may be an important treatment objective with possible benefits beyond the improvement in sleep. Little is known, however, about how to effectively treat sleep disturbance associated with pain or whether such treatment might have beneficial effects on reducing pain. A small, but growing literature has applied cognitive-behavioral therapies (CBT) for either pain management or insomnia to patients with chronic pain. In this article, we review the longitudinal literature on sleep disturbance associated with chronic pain and clinical trial literatures of cognitive-behavior therapy for pain management and insomnia secondary to chronic pain with the aim of evaluating whether the relationship between clinical pain and insomnia is reciprocal. While methodological problems are common, the literature suggests that the relationship is reciprocal and CBT treatments for pain or insomnia hold promise in reducing pain severity and improving sleep quality. Directions for future research include the use of validated measures of sleep, longitudinal studies, and larger randomized clinical trials incorporating appropriate attentional controls and longer periods of follow-up.

Sleep and chronic pain: challenges to the alpha-EEG sleep pattern as a pain specific sleep anomaly

OBJECTIVE

The alpha-EEG sleep anomaly has been associated with chronic benign pain syndromes. Although controversial, the anomaly is believed by some to be an important biologic correlate of certain otherwise poorly explained painful conditions (e.g., fibromyalgia and chronic fatigue syndrome). To shed further light on this phenomenon, this study compared the sleep and psychological characteristics of chronic pain patients who exhibited the alpha-EEG sleep anomaly with pain-free psychiatric and medical patients who also were found to exhibit the alpha-EEG anomaly.

METHODS

The alpha-EEG sleep was identified in the polysomnographic records of 5% of over 1000 consecutive sleep patients. Objective sleep parameters, daytime sleepiness and psychological characteristics (Minnesota Multiphasic Personality Inventory [MMPI] scores) of patients exhibiting this anomaly were examined.

RESULTS

The alpha-EEG anomaly was identified in only 5% of the total patient sample. Patients with the alpha-EEG anomaly could be further classified into three diagnostic subgroups: chronic pain, psychiatric and other medical/sleep disorders, The subgroups were compared on sleep parameters and psychological characteristics. Less than 40% of the patients exhibiting the alpha-EEG anomaly experienced chronic pain. Chronic pain patients evidenced disturbed sleep patterns and psychological characteristics that were for the most part similar to those observed in some pain-free medical and psychiatric patients. Only the medical subgroup exhibited objective daytime sleepiness. The alpha-EEG sleep disturbance was not accounted for by psychological characteristics.

CONCLUSIONS

These findings challenge the notion that alpha-EEG sleep is of direct etiological significance in producing the pain complaint among patients with chronic pain since the alpha-EEG sleep was not a sufficient condition for pain.

Insomnia: Epidemiology, characteristics, and consequences

Insomnia is a symptom of difficulty initiating and maintaining sleep or experiencing nonrefreshing sleep and is associated with daytime consequences. Although insomnia is typically secondary to a medical, psychiatric, circadian, or sleep disorder, it can also be a primary disorder. Primary insomnia is estimated to occur in 25% of all chronic insomnia patients. It is hypothesized to be a disorder of hyperarousal, which has been supported by research on the autonomic nervous system and hypothalamic-pituitary-adrenal axis function. Chronic insomnia is prevalent in 10% of the adult population. Age, sex, medical and psychiatric disease, and shift work all represent an increased risk of chronic insomnia. The morbidity of insomnia varies as a function of etiology. While transient insomnia produces sleepiness and impairment in psychomotor performance, chronic insomnia is associated with absenteeism, frequent accidents, memory impairment, and greater health care utilization. The most consistent impact of insomnia is a high risk of depression.