Sleep Disorders in Multiple Sclerosis

Relationship between sleep disorders and information processing speed in multiple sclerosis

OBJECTIVES

It is estimated that up to 65 % of pwMS (people with multiple sclerosis) experience varying degrees of cognitive impairment, the most commonly affected domain being Information Processing Speed (IPS). As sleep disturbance is a predictor of detriments in IPS, the authors aimed to study the association between the severity of Restless Legs Syndrome (RLS) and Obstructive Sleep Apnea (OSA) symptoms with IPS in pwMS.

METHODS

In a cross-sectional study, the authors enrolled people with relapsing-remitting and secondary progressive MS referred to the comprehensive MS center of Kashani Hospital in Isfahan, Iran. The authors used Berlin and STOP-Bang questionnaires for assessing OSA symptoms, and the International Restless Legs Syndrome Study Group (IRLSSG) scale for the presence and severity of symptoms of RLS. The authors used the Integrated Cognitive Assessment (ICA) test, a language and education-independent tool, to assess visual processing speed.

RESULTS

The authors included 211 pwMS, with a mean age of 36.73 ± 8.9 (81.9 % female). PwMS with higher RLS scores showed lower IPS, with ICA indexes of 0.66 ± 0.09 vs. 0.61 ± 0.12 in low- and high-risk RLS groups, respectively (p < 0.01). There were no significant associations between IPS as measured by the ICA index and OSA symptom severity.

CONCLUSION

The authors found impairments in IPS in pwMS to be linked with the severity of RLS symptoms, but not with OSA. Considering the high prevalence and underdiagnosis of RLS in pwMS, and the profound impact of IPS on quality of life, this association highlights the importance of screening and treating RLS in this population.

Sleep quality in multiple sclerosis: A systematic review and meta-analysis based on Pittsburgh Sleep Quality Index

BACKGROUND

Sleep quality is individual satisfaction with the sleep experience and the Pittsburgh Sleep Quality Index (PSQI), one of the most reliable subjective measurements of sleep quality, assesses the quality of sleep over the previous month. This study aimed to explore the sleep quality in multiple sclerosis (MS) patients in comparison to healthy controls (HCs).

METHODS

Following the Joanna Briggs Institute (JBI) methods and PRISMA statement, a systematic search was conducted through PubMed, Web of Science, Scopus, and Embase online databases and studies that assessed the sleep quality based on the PSQI, in MS patients and HCs were included. The risk of bias in the included studies was assessed using the JBI critical appraisal tools and meta-analysis was conducted by the third version of Comprehensive Meta-Analysis (CMA3) software.

RESULTS

Out of 1574 identified records, 13 studies were included. Regarding the PSQI scores, the difference was statistically significant between patients with MS and HCs (10 studies; I2:94.59%; Standard difference in means: 1.056; 95%CI: 0.758-1.372; p-value < 0.001). MS patients were found to have more prevalence of poor sleep quality (PSQI > 5); however, the difference was not statistically significant (4 studies; I2: 87.08%; odds ratio: 2.31;95% CIs: 0.82-6.35; p-value: 0.113).

CONCLUSIONS

The limited available evidence suggests that subjective sleep quality is affected by MS and it should be considered by the clinicians for prevention of sleep-related symptoms such as depression and anxiety. Future well-designed prospective studies are needed to reach a comprehensive conclusion in this regard.

FUNDING

This study was supported by the Student Research Committee, Tabriz University of Medical Sciences (Registration Code: 70999).

Dysphagia assessment in patients with multiple sclerosis - an additional piece to disability burden

OBJECTIVE

People with multiple sclerosis (MS) might experience symptoms that are usually underestimated. Dysphagia should be evaluated within the Expanded Disability Status Scale (EDSS), but clinicians often do not assess it properly. The objectives of this study are as follows: To assess the prevalence of dysphagia in patients with MS utilizing the Swallowing Disturbance Questionnaire (SDQ); to examine the correlation with the EDSS; to investigate the relationship between dysphagia and clinico-demographic characteristics of MS.

METHODS

In total, 177 MS patients underwent evaluations with EDSS, SDQ, cognitive functions, anxiety, depression, fatigue, and sleep quality tests. We compared clinico-demographic data of patients with and without dysphagia and native-EDSS to SDQ-EDSS.

RESULTS

Out of the 177 MS patients, 56% of individuals were identified having dysphagia according to the SDQ with 41 patients exhibiting mild dysphagia, 31 showing moderate dysphagia and 27 patients having severe dysphagia. Only 6 patients had dysphagia recorded in the EDSS. SDQ-EDSS scores were significantly higher than native scores. Dysphagia was associated with depressive symptoms and sleep quality.

INTERPRETATION

Dysphagia affects up to 56% of MS patients. The SDQ questionnaire is useful for identifying dysphagia, which can help in capturing disease progression and preventing complications like aspiration pneumonia. The SDQ-EDSS was higher than the native-EDSS, reflecting the poor ability of the native-EDSS to evaluate certain symptoms such as dysphagia. The SDQ correlated with depressive symptoms, which are associated with a greater perception of MS symptoms, and poor sleep quality, which could be associated with the triggering of pathogenic mechanisms responsible for disease progression.

Sleep and cognitive outcomes in multiple sclerosis; a systematic review

BACKGROUND

Multiple sclerosis (MS) is a disabling disease of the central nervous system. People living with MS often have co-existing sleep disorders and cognitive dysfunction. The objective of this study was to scrutinize the relationship between cognitive outcomes and sleep conditions in MS.

METHODS

This study followed the Joanna Briggs Institute's (JBI) and PRISMA guidelines. PubMed, Scopus, Embase, and Web of Science databases were searched and original studies delineating the relationship between sleep status and cognitive findings in MS patients‌ were included. The risk of bias was assessed using the JBI critical appraisal tools.

RESULTS

In the final review, out of 1635 screened records, 35 studies with 5321 participants were included. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and polysomnography were the most common assessment tools for evaluation of sleep condition, and cognitive evaluations were conducted using the tests including Paced Auditory Serial Addition Test (PASAT), California Verbal Learning Test (CVLT), Symbol Digit Modalities Test (SDMT) and Brief Visuospatial Memory Test (BVMT). Assessing the quality of studies showed no significant bias in most of the included articles. A link between sleep condition and cognitive abilities was suggested in the literature, especially with objective measurement of sleep condition; however, current evidence did not support a substantial association between self-reported sleep quality and processing speed and working memory in patients with MS.

DISCUSSION

Evidence proposes sleep is an independent factor associated with cognitive outcomes in MS. Given the limitations of the evidence such as the lack of well-designed prospective studies, these findings need to be interpreted with caution.

The relationship between sleep quality and gait in people with multiple sclerosis: A pilot study

Background

Gait deficits are common among people with multiple sclerosis (PwMS). Therefore, investigating factors that may influence walking in PwMS is important. Previous studies in older adults and other neurological populations demonstrated the relationship between sleep quality and gait performance. Despite the fact that the prevalence of poor sleep quality is very high among PwMS, little is known about the effect of sleep quality on gait among PwMS.

Objective

This study aimed to explore the relationship between sleep quality and gait performance in PwMS.

Methods

Forty-one PwMS participated in the study between February 2019 and December 2019. Participants were asked to walk at a self-selected speed over 10 m with an inertial measurement unit (IMU) attached over the back. Walking speed, step length (left and right), and step time were calculated. Sleep was estimated objectively using a wrist-worn triaxle-accelerometer; the derived parameters were sleep efficiency (SE) and the number of awakening after sleep onset (NASO).

Results

SE significantly correlated with step length (p = 0 . 02 ). Furthermore, the NASO significantly correlated with gait speed (p = 0 . 03 ), and step-time (p = 0 . 02 ). These correlations remained significant even after adjusting for age and disease duration.

Conclusion

We observed that when corrected for disease duration and age there were relationships between NASO and SE to gait parameters; these observations warrant further investigations.

Impact of treatment with dimethyl fumarate on sleep quality in patients with relapsing-remitting multiple sclerosis: A multicentre Italian wearable tracker study

Background

Sleep disorders are common in patients with multiple sclerosis and have a bidirectional interplay with fatigue and depression.

Objective

To evaluate the effect of treatment with oral dimethyl fumarate on the quality of sleep in relapsing-remitting multiple sclerosis.

Methods

This was a multicentre observational study with 223 relapsing-remitting multiple sclerosis subjects starting treatment with dimethyl fumarate (n=177) or beta interferon (n=46). All patients underwent subjective (Pittsburgh Sleep Quality Index) and objective (wearable tracker) measurements of quality of sleep. Fatigue, depression, and quality of life were also investigated and physical activity was monitored.

Results

Patients treated with dimethyl fumarate had significant improvement in the quality of sleep as measured with the Pittsburgh Sleep Quality Index (p<0.001). At all-time points, no significant changes in Pittsburgh Sleep Quality Index score were observed in the interferon group. Total and deep sleep measured by wearable tracker decreased at week 12 with both treatments, then remained stable for the total study duration. Depression significantly improved in patients treated with dimethyl fumarate. No significant changes were observed in mobility, fatigue and quality of life.

Conclusion

In patients with relapsing-remitting multiple sclerosis, the treatment with dimethyl fumarate was associated with improvements in patient-reported quality of sleep. Further randomised clinical trials are needed to confirm the benefits of long-term treatment with dimethyl fumarate.

Sleep Disturbances, Degree of Disability and the Quality of Life in Multiple Sclerosis Patients

Sleep disturbances are pervasive in patients with multiple sclerosis (MS), with incidence about four times higher compared to the general population. The most frequent primary sleep problems include insomnia, restless leg syndrome, sleep-related movement disorders, and sleep-disordered breathing. This study aims to assess the relationships between sleeping problems and the quality of life (QoL) in MS patients. This cross-sectional study was conducted among 152 MS patients (mean age: 36.27 ± 9.60) between November 2018 and February 2019 at a neurological health center in Wroclaw, Poland. The study was based on a questionnaire that included questions concerning sociodemographic and clinical data in addition to the following standardized questionnaires: Athens Insomnia Scale (AIS), Epworth Sleepiness Scale (ESS), and Multiple Sclerosis International Quality of Life (MusiQoL). The degree of physical disability was evaluated following the Expanded Disability Status Scale (EDSS). Analysis of the research material showed that 66.45% of MS patients had insomnia, and 41.45% presented with daytime sleepiness. The QoL of respondents was assessed as average (50.73). Univariate linear regression model analysis showed the effects of professional status, daytime sleepiness, insomnia, and degree of disability on the QoL of MS patients. Sleep disturbances are widespread in MS patients. The presence of sleep disturbances (insomnia and daytime sleepiness) significantly affects the QoL of MS patients.

Multiple Sclerosis and related disorders

Multiple Sclerosis (MS) is a common neuroinflammatory disorder which is associated with disabling clinical consequences. The MS disease process may involve neural centers implicated in the control of breathing, leading to ventilatory disturbances during both wakefulness and sleep. In this chapter, a brief overview of MS disease mechanisms and clinical sequelae including sleep disorders is provided. The chapter then focuses on obstructive sleep apnea-hypopnea (OSAH) which is the most prevalent respiratory control abnormality encountered in ambulatory MS patients. The diagnosis, prevalence, and clinical consequences as well as data on effects of OSAH treatment in MS patients are discussed, including the impact on the disabling symptom of fatigue and other clinical sequelae. We also review pathophysiologic mechanisms contributing to OSAH in MS, and in turn mechanisms by which OSAH may impact on the MS disease process, resulting in a bidirectional relationship between these two conditions. We then discuss central sleep apnea, other respiratory control disturbances, and the pathogenesis and management of respiratory muscle weakness and chronic hypoventilation in MS. We also provide a brief overview of Neuromyelitis Optica Spectrum Disorders and review current data on respiratory control disturbances and sleep-disordered breathing in that condition.

The Relationship Between Sleep Quality, Sleep-Related Biomarkers, and Motor Skill Acquisition in People With Multiple Sclerosis: A Pilot Study

OBJECTIVE

Neurorehabilitation that involves learning new motor skills is one of the promising clinical methods for motor recovery in people with multiple sclerosis (PwMS); therefore, factors that influence the acquisition of motor skills in PwMS need to be investigated. Sleep disturbances are common in PwMS; however, no study has investigated the effect of sleep and sleep-related biomarkers on skill acquisition in PwMS. This study aimed to examine the effect of sleep and sleep-related biomarkers on motor acquisition in PwMS.

METHODS

Forty participants with MS and 40 controls were recruited in this study. To assess motor acquisition, each participant was asked to perform a novel game through a virtual reality (VR) system 5 times (blocks). The main outcome measures for each block were the required time to complete the VR game and the recorded errors. The difference in scores between Block 5 and Block 1 for both outcomes were considered to represent motor skill acquisition. Sleep was assessed by self-report using the Pittsburgh Sleep Quality Index (PSQI) and objectively using sleep monitor technology. Serotonin level was assessed using means of enzyme-linked immunosorbent assay using plasma samples.

RESULTS

There were significant positive correlations in both groups between motor skill acquisition and PSQI score. In PwMS, significant negative correlation between motor skill acquisition and sleep efficiency and significant positive correlation between motor skill acquisition and sleep latency were also observed. Interestingly, a significant negative correlation was observed between motor skill acquisition and the plasma serotonin level in both groups. Most of these correlations remained significant after controlling for disease severity, fatigue, baseline performance, and cognitive status.

CONCLUSION

Sleep quality may influence motor skill acquisition in PwMS. Circulatory serotonin level might explain this relationship.

IMPACT

Physical therapists are encouraged to be aware of sleep quality and sleep assessment. Sleep management strategies should be considered when treating PwMS.

Feasibility and treatment effect of cognitive behavioral therapy for insomnia in individuals with multiple sclerosis: A pilot randomized controlled trial

BACKGROUND

At least 40% of individuals with multiple sclerosis (MS) exercise chronic insomnia, and the prevalence is likely higher due to underdiagnosis. Poor sleep quality has been associated with increased fatigue, anxiety, depression, and risk of relapse in individuals with MS. While cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia, the treatment effect of CBT-I in people with MS is unclear.

OBJECTIVE

This pilot randomized control trial (RCT) assessed the feasibility and treatment effect of CBT-I to improve sleep quality and fatigue in individuals with MS with symptoms of insomnia.

METHODS

Thirty-three individuals with MS (30 females, 3 males; 30 relapsing-remitting; 3 secondary-progressive; 53.0 ± 9.4 years old) with symptoms of insomnia were randomized into one of three arms: 1. 6-week CBT-I program, 2. 6-week active control, or 3. Single session of sleep education. Participants completed surveys to assess sleep quality, fatigue, sleep self-efficacy, depression, and anxiety.

RESULTS

CBT-I in individuals with MS is feasible with high retention and adherence rate. All groups experienced a large magnitude of improvement in insomnia symptoms. The CBT-I and brief education groups experienced a large magnitude of improvement in sleep quality and fatigue. Only the CBT-I group demonstrated a large magnitude of improvement in sleep self-efficacy and depression.

CONCLUSION

This is the first study to prospectively demonstrates that CBT-I is feasible in people with MS and produces promising improvements in insomnia severity, sleep quality, sleep self-efficacy and comorbid symptoms of fatigue, depression, and anxiety. Future studies are needed to determine mechanisms for these improvements and expand the scope of individuals with MS who may benefit from CBT-I. Furthermore, considering the moderate to large improvements experienced by the brief education group and the limited number of CBT-I providers, a stepped-care approach warrants consideration.

The effects of aerobic exercise on sleep quality measures and sleep-related biomarkers in individuals with Multiple Sclerosis: A pilot randomised controlled trial

BACKGROUND

Sleep disturbances are highly prevalent in people with multiple sclerosis(MS), and are associated with pain, fatigue, depression, and reduced quality of life (QoL). Importantly, sleep has been considered a critical brain state for motor learning and memory consolidation. Therefore, interventions that target sleep managementin people with MS are needed.

OBJECTIVES

To explore the effects of a six weeks moderate-intensity aerobic exercise intervention on sleep characteristics and sleep-related biomarkers specifically serotonin, melatoninand cortisol in people with MS using a pilot randomized controlled trial.

METHODS

Participants were randomly allocated to either a moderate-intensity aerobic exercise program (MAE, n = 20) or a home exercise program (HEP, n = 20). Participants were assessed at baseline and follow-up. Subjective and objective measures were used to assess sleep quality. The Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were used to subjectively assess sleep. While Actigraphy was used to objectivelyassess sleep. Blood samples were collected for measurement of cortisol, melatonin and serotonin from MS participants in both groups at 8:00 am±1 hour.

RESULTS

Seventeen participants in the MAE and 13 in the HEP group completed the study. Compared to the HEP group, people with MS who participated in a moderate-intensity aerobic exercise experienced significant improvements (P < 0.05) on the PSQI, ISI, and several objective sleep parameters measured using actigraphy. Only the serotonin levels increased significantly over the six-week period in the MAE group compared to the HEP group. The change score in serotonin (from baseline to follow up assessment) was significantly correlatedwith the change score in PSQI (r = -0.97, p < 001) and the change score in ISI (r = -0. 56, p = 0.015) only in the MAE group but not the HEP group.

CONCLUSIONS

Exercise may be a non-pharmacological, inexpensive, safe method to improve sleep quality in people with MS. The improvement in the serotonin level due to aerobic exercisemight explain one of the physiologic mechanisms driving these improvements.

Comparison of prevalence rates of restless legs syndrome, self-assessed risks of obstructive sleep apnea, and daytime sleepiness among patients with multiple sclerosis (MS), clinically isolated syndrome (CIS) and Neuromyelitis Optica Spectrum Disorder (NMOSD)

BACKGROUND

Prevalence rates for restless legs syndrome (RLS) and risk of Obstructive Sleep Apnea (OSA) in individuals with Neuromyelitis Optica Spectrum Disorder (NMOSD) and Clinically Isolated Syndrome (CIS) are unknown. The aims of the present study were to assess symptoms of RLS and self-assessed risks of OSA in individuals with NMOSD and CIS, to compare these prevalence rates with those of persons with multiple sclerosis (MS), and to associate RLS and OSA with expanded disability status scale (EDSS) scores, daytime sleepiness, fatigue, paresthesia, and medication.

METHODS

A total of 495 individuals (mean age = 34.92 years, 84.9% females) were assessed. Of these, 24 had NMOSD, 112 had CIS and 359 had MS. Trained neurologists ascertained individuals' neurological diagnoses, assessed their EDSS scores, and conducted a clinical interview to assess RLS. Additionally, participants completed questionnaires covering sociodemographic information, risks of snoring and OSA, daytime sleepiness, fatigue, paresthesia and medication.

RESULTS

Prevalence rates of RLS were 45.8% in NMOSD, 41.1% in CIS, and 28.7% in MS. Prevalence rates of self-assessed risks of OSA were 8.3% in NMOSD, 7.7% in CIS, and 7.8% in MS; these rates were not significantly different. Across the entire sample and within the diagnostic groups, RLS and OSA scores were unrelated to EDSS, daytime sleepiness, fatigue or medication.

CONCLUSIONS

Individuals with NMOSD, CIS and MS have high prevalence rates for RLS and self-assessed risks of obstructive sleep apnea syndrome (OSAS), which are unrelated to EDSS, daytime sleepiness, fatigue, paresthesia, or medication. Sleep issues should be monitored during routine check-ups for individuals with NMOSD and CIS.

Behavioural phenotypes in the cuprizone model of central nervous system demyelination

The feeding of cuprizone (CPZ) to animals has been extensively used to model the processes of demyelination and remyelination, with many papers adopting a narrative linked to demyelinating conditions like multiple sclerosis (MS), the aetiology of which is unknown. However, no current animal model faithfully replicates the myriad of symptoms seen in the clinical condition of MS. CPZ ingestion causes mitochondrial and endoplasmic reticulum stress and subsequent apoptosis of oligodendrocytes leads to central nervous system demyelination and glial cell activation. Although there are a wide variety of behavioural tests available for characterizing the functional deficits in animal models of disease, including that of CPZ-induced deficits, they have focused on a narrow subset of outcomes such as motor performance, cognition, and anxiety. The literature has not been systematically reviewed in relation to these or other symptoms associated with clinical MS. This paper reviews these tests and makes recommendations as to which are the most important in order to better understand the role of this model in examining aspects of demyelinating diseases like MS.

Compared to an active control condition, in persons with multiple sclerosis two different types of exercise training improved sleep and depression, but not fatigue, paresthesia, and intolerance of uncertainty

BACKGROUND

In persons with multiple sclerosis (MS), physical activity favorably impacts on psychological well-being. The aims of the present study were to investigate the influence of physical activity on depression, fatigue, sleep, paresthesia, and personality traits (intolerance of uncertainty), and to explore, if endurance training or coordinative training are superior to an active control condition.

METHODS

92 female individuals with MS (mean age: 37.36 years; mean EDSS: 2.43) took part in this intervention study. Participants were randomly assigned either to endurance training, coordinative training, or to an active control condition. At baseline, 4 weeks, and 8 weeks later at the end of the study, participants completed questionnaires on sleep, depression, fatigue, paresthesia and intolerance of uncertainty. Exercise training interventions took place three times/week for 45 min/session. Participants in the active control condition also met with the same duration and frequency.

RESULTS

Sleep complaints and symptoms of depression decreased over time, but more so in the exercising groups, compared to the active control group. No changes over time and between groups were observed for fatigue, paresthesia, and intolerance of uncertainty.

CONCLUSIONS

Both endurance and coordinative exercising had the potential to favorably impact on some aspects of cognitive-emotional processing, while also an active control condition appeared to have a positive impact.

In Patients With Multiple Sclerosis, Both Objective and Subjective Sleep, Depression, Fatigue, and Paresthesia Improved After 3 Weeks of Regular Exercise

Background: Multiple sclerosis (MS) patients suffer from various difficulties including sleep complaints, symptoms of depression and fatigue, paresthesia, and cognitive impairments. There is growing evidence that regular physical activity has a positive effect on both sleep and psychological functioning, though there is limited evidence of this kind for MS patients. The aim of the present study was therefore to investigate the impact on this patient group of a regular exercise program with respect to subjective and objective sleep, depression, paresthesia, fatigue, and cognitive performance. Methods: A total of 46 patients [mean age: 50.74 years; Expanded Disability Status Scale (EDSS): mean: 5.3, 78.4% females] completed this 3-week intervention study. At baseline and 3 weeks later, they answered questionnaires covering sociodemographic information, subjective sleep, depression, fatigue, paresthesia, and subjective physical activity. Objective sleep [sleep electroencephalogram (EEG) recordings] and cognitive performance were also assessed at both time points. Patients participated in a regular exercise activity every weekday for about 60 min. Results: Compared to the baseline, by the end of the study, objective sleep had significantly improved (sleep efficiency, sleep onset latency, and wake time after sleep onset), and symptoms of sleep complaints, depression, fatigue, and paresthesia were significantly reduced. Subjective physical activity (moderate and vigorous) and cognitive performance also increased over the course of the intervention. Conclusions: In patients with MS, participation in regular exercise impacted positively on their objective and subjective sleep, depression, paresthesia, fatigue, and cognitive performance.

A Review of Herbal Therapy in Multiple Sclerosis

Multiple sclerosis is a complex autoimmune disorder which characterized by demyelination and axonal loss in the central nervous system (CNS). Several evidences indicate that some new drugs and stem cell therapy have opened a new horizon for multiple sclerosis treatment, but current therapies are partially effective or not safe in the long term. Recently, herbal therapies represent a promising therapeutic approach for multiple sclerosis disease. Here, we consider the potential benefits of some herbal compounds on different aspects of multiple sclerosis disease. The medicinal plants and their derivatives; Ginkgo biloba, Zingiber officinale, Curcuma longa, Hypericum perforatum, Valeriana officinalis, Vaccinium macrocarpon, Nigella sativa,Piper methysticum, Crocus sativus, Panax ginseng, Boswellia papyrifera, Vitis vinifera, Gastrodia elata, Camellia sinensis, Oenothera biennis, MS14 and Cannabis sativa have been informed to have several therapeutic effects in MS patients.

Sleep quality, daytime sleepiness, fatigue, and quality of life in patients with multiple sclerosis treated with interferon beta-1b: results from a prospective observational cohort study

Background

Sleep disorders and fatigue are common in multiple sclerosis (MS). The underlying causes are not fully understood, and prospective studies are lacking. Therefore, we conducted a prospective, observational cohort study investigating sleep quality, fatigue, quality of life, and comorbidities in patients with MS.

Methods

Patients with relapsing-remitting MS or clinically isolated syndrome treated with interferon beta-1b were followed over two years. The primary objective was to investigate correlations between sleep quality (PSQI), fatigue (MFIS), and functional health status (SF-36). Secondary objectives were to investigate correlations of sleep quality and daytime sleepiness (ESS), depression (HADS-D), anxiety (HADS-A), pain (HSAL), and restless legs syndrome (RLS). We applied descriptive statistics, correlation and regression analyses.

Results

139 patients were enrolled, 128 were available for full analysis. The proportion of poor sleepers (PSQI≥5) was 55.47% at the beginning and 37.70% by the end of the study (106 and 41 evaluable questionnaires, respectively). Poor sleepers performed worse in MFIS, SF-36, ESS, HADS-D, and HADS-A scores. The prevalence of patients with RLS was low (4.5%) and all were poor sleepers. Poor sleep quality was positively correlated with fatigue and low functional health status. These relationships were corroborated by multivariable-adjusted regression analyses. ESS values and poor sleep quality at baseline seem to predict sleep quality at the one-year follow-up. No variable predicted sleep quality at the two-year follow-up.

Conclusions

Our results confirm the high prevalence of poor sleep quality among patients with MS and its persistent correlation with fatigue and reduced quality of life over time. They highlight the importance of interventions to improve sleep quality.

Trial registration

The study was registered at clinicaltrials.gov: NCT01766063 (registered December 7, 2012). Registered retrospectively (first patient enrolled December 6, 2012).

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1113-5) contains supplementary material, which is available to authorized users.

Case Report: Rapid Eye Movement Sleep Behavior Disorder as the First Manifestation of Multiple Sclerosis: A Case Report and Literature Review

Rapid eye movement sleep behavior disorder (RBD) is a parasomnia characterized by brief recurrent episodes of loss of muscle atonia during rapid eye movement sleep, with enacted dreams that cause sleep disruption. Patients with multiple sclerosis (MS) have an increased risk compared with the general population to be affected by a sleep disturbance, including RBD. Patients affected, however, uncommonly can present RBD as the first clinical manifestation of MS without other neurologic deficits. These clinical presentations have usually been attributed to inflammatory lesions in the pedunculopontine nuclei, located in the dorsal pons. We present a case of RBD in a 38-year-old woman who was later diagnosed as having MS due to imaging findings and development of focal neurologic deficits. MS should be considered among the differential diagnoses in patients who present with symptoms of RBD, particularly if they are young and female.

PER3 VNTR polymorphism in Multiple Sclerosis: A new insight to impact of sleep disturbances in MS

BACKGROUND

Multiple Sclerosis (MS) is a degenerative disease of central nervous system caused by an immune response against the myelin. About half of MS patients suffers from sleep disturbances. The circadian clock genes such as PER3 controls circadian rhythm and sleep. Due to the role of PER3 in sleep disturbances and regulation of immune response, it is possible that PER3 dysregulation increase risk of MS disease.

METHODS

Study groups included 160 MS patients and 160 healthy volunteers. PER3 VNTR polymorphism was evaluated by PCR method. The genotypic and allelic distribution analyzed by chi square test.

RESULTS

There was a significant association between genotype PER3^4/4, and 4-repeat allele with MS disease (p = 0.014 and p < 0.001 respectively). The association analysis of PER3 VNTR polymorphism with gender status among MS group, and MS onset showed that there was a significant correlation between PER3^4/4 genotype with female gender and early onset of MS disease (p = 0.033 and p = 0.028 respectively).

CONCLUSION

Our data suggest that, PER3^4/4 genotype may accelerate the course of disease in MS susceptible individuals.

Positive correlation between functional disability, excessive daytime sleepiness, and fatigue in relapsing-remitting multiple sclerosis

METHOD

Retrospective review of medical records from patients with multiple sclerosis to collect data on severity of fatigue, disability, daytime sleepiness, and depression. From 912 medical records reviewed, 122 reported daytime sleepiness: 67% had relapsing remitting, 12% had primary progressive, and 21% had secondary progressive.

RESULTS

In 95% of the patients with relapsing remitting who complained of daytime sleepiness and fatigue, association was found between these symptoms and neurological disability. Patients with relapsing remitting who complained of daytime sleepiness and fatigue also experienced depression (p = 0.001). No association between fatigue, excessive daytime sleepiness, depression, and disability was found in patients with progressive disease.

CONCLUSION

In relapsing remitting, there is correlation between functional disability, excessive daytime sleepiness and fatigue, a finding not confirmed in primary progressive and secondary progressive form.

Qualitative Experience of Sleep in Individuals With Spinal Cord Injury

Poor sleep contributes to adverse health outcomes making it important to understand sleep in medically vulnerable populations, including those with spinal cord injury (SCI). However, little attention has been paid to circumstances specific to SCI that may negatively affect sleep, or to consequences of poor sleep in this population. The objective of this study was to examine the experience of sleep among individuals with SCI. Secondary analysis using thematic coding of qualitative data from an ethnographic study of community-dwelling adults with SCI was conducted. Sleep-related data were found in transcripts for 90% of the sample. Participants described diminished sleep duration and irregular sleep patterns. Several factors contributing to poor sleep were identified, including SCI-related circumstances and sleep environment. Participants also discussed how poor sleep affected occupational engagement. This study highlights the extent of sleep disturbance experienced after SCI and the subsequent impact on occupational performance, and provides direction for clinical practice.

Sleep Disorder as a Triggering Factor for Relapse in Multiple Sclerosis

BACKGROUND/AIMS

To determine the effect of sleep disturbances on predisposing multiple sclerosis (MS) patients for acute relapse.

METHODS

This case-control study was conducted on 80 MS patients including 40 patients in the remission phase and 40 in the relapse phase. Patients were asked to fill in the Pittsburgh Sleep Quality Index to determine their sleep quality during the previous month. Individuals with scores of 5 or less were considered having normal sleep quality.

RESULTS

Mean ± SD ages were 32.5 ± 7.7 and 30.2 ± 7.2 years among patients with and without acute relapses, respectively (p > 0.05). The mean disease duration and disease severity (according to Expanded Disability Status Scale [EDSS]) were comparable across the groups (p > 0.05). Among those with and without acute exacerbations, 87.5 and 50% had poor sleep quality, respectively (p = 0.0001), with OR of 1.75 (95% CI 1.25-2.43). The age, gender, EDSS, and disease duration did not associate with sleep quality in either groups (p > 0.05).

CONCLUSIONS

This study showed that sleep disturbance might be a trigger for an acute MS exacerbation. Increasing the awareness of specialists and routine screening of sleep disorders in MS patients are warranted, as treatment of these disorders might decrease the likelihood of acute relapses.

Randomized controlled trial of exercise interventions to improve sleep quality and daytime sleepiness in individuals with multiple sclerosis: A pilot study

BACKGROUND

Nearly 70% of individuals with multiple sclerosis (MS) experience sleep disturbances. Increasing physical activity in people with MS has been shown to produce a moderate improvement in sleep quality, and exercise has been shown to improve sleep quality in non-neurologically impaired adults.

OBJECTIVE

The purpose of this pilot randomized controlled trial study was to examine the effect of two exercise interventions on sleep quality and daytime sleepiness in individuals with MS.

METHODS

Twenty-eight individuals with relapsing-remitting or secondary progressive MS were randomized into one of two 12-week exercise interventions: a supervised, moderate-intensity aerobic exercise (AE) program or an unsupervised, low-intensity walking and stretching (WS) program. Only individuals who were ≥ 70% compliant with the programs were included in analysis (n = 12 AE; n = 10 WS).

RESULTS

Both groups demonstrated a moderate improvement in sleep quality, although only the improvement by the WS group was statistically significant. Only the AE group demonstrated a significant improvement in daytime sleepiness. Change in sleep quality and daytime sleepiness was not correlated with disease severity or with change in cardiovascular fitness, depression, or fatigue.

CONCLUSION

The mechanisms for improvement in sleep quality and daytime sleepiness need further investigation, but may be due to introduction of zeitgebers to improve circadian rhythm.

Low Prevalence of Sleep Disorders in Demyelinating Disease in a Northern Tenerife Population

STUDY OBJECTIVES

Sleep disorders are seen in patients with demyelinating disease (DD) more often than in the general population. Combination of physical and psychological factors such as pain, spasms, nocturia, depression, anxiety, or medication effects could contribute to sleep disruption. Frequently, these disturbances have a major impact on health and quality of life of patients. The aim of this study was to estimate the prevalence of sleep disorders in patients seen in the DD consultation.

METHODS

240 patients; mean age 43 years, 187 women; 163 patients with multiple sclerosis (MS): 144 relapsing-remitting, 19 progressive forms, 36 clinically isolated syndrome, 26 radiological isolated syndrome, and 15 patients with others DD. All participants completed questionnaires: Pittsburgh, Epworth, and Stanford scales, indirect symptoms of RLS and Obstructive Sleep Apnea, Fatigue Severity Scale, and Multiple Sclerosis Quality of Life-54.

RESULTS

Moderate/severe insomnia 12.5%, OSA 5.8%, RLS 9.6% (confirmed 3 cases), narcolepsy 0, fatigue (> 4) 24.6%. Physical QoL 66.6 ± 19.6, Mental QoL 66.1 ± 21.9. Patients with an established diagnosis showed higher scores on insomnia compared to the group of CIS and RIS (F = 3.85; p = 0.023), no differences were in the other parameters. Fatigue showed high correlation with insomnia (r = 0.443; p < 0.001), RLS (r = 0.513; p < 0.001), and sleepiness (r = 0.211; p = 0.001). None of the variables included in the regression model were shown to be predictors of Physical and Mental QoL.

CONCLUSIONS

A high percentage of our sample sleeps well. Emphasize the low prevalence of sleep disorders (insomnia, fatigue, RLS, etc). We detected an overestimation in the RLS questionnaire and the low QoL recorded.

Outcomes of Cognitive-Behavioral Treatment for Insomnia on Insomnia, Depression, and Fatigue for Individuals with Multiple Sclerosis: A Case Series

BACKGROUND

This clinical case series examined outcomes of cognitive-behavioral therapy for insomnia (CBT-I) in individuals with multiple sclerosis (MS). Current literature links insomnia with higher rates of depression and fatigue in individuals with MS. However, no research to date evaluates a targeted psychotherapeutic intervention for insomnia in this population.

PARTICIPANTS AND METHODS

Eleven individuals with a diagnosis of MS and insomnia participated in individual or group-based CBT-I sessions at the Cleveland Clinic Sleep Disorders Center between 2008 and 2013. A medical record review examined these individuals' self-reported experiences of insomnia, depression, and fatigue at the preintervention and postintervention levels using the Insomnia Severity Index, nine-item Patient Health Questionnaire, and Fatigue Severity Scale. Total sleep time was also reported at pretreatment and posttreatment intervals.

RESULTS

Overall, participants reported improvements regarding insomnia, fatigue, and depression after CBT-I. Total sleep time also increased by an average of 1.5 hours. Despite overall improvement, symptoms of fatigue, insomnia, and depression persisted, at varying levels, for most participants.

CONCLUSIONS

These results strongly suggest that CBT-I may serve as an effective clinical intervention for individuals with MS who report symptoms of insomnia. Given the considerable overlap of experiences of insomnia, depression, and fatigue in people with MS, CBT-I may also be helpful in identifying areas that may require additional clinical intervention for persistent symptoms of depression and fatigue. Further research is necessary.

Fatigue, Sleep Quality, and Disability in Relation to Quality of Life in Multiple Sclerosis

BACKGROUND

Quality of life (QOL) is impaired in multiple sclerosis (MS) in part due to physical disability. MS-associated fatigue and poor sleep are common and treatable features of MS that affect QOL. We assessed the association between fatigue, sleep quality, and QOL in people with MS.

METHODS

Cross-sectional data were collected from 217 patients with MS. Health-related QOL (MS Quality of Life-54), fatigue (Fatigue Severity Scale [FSS]), and sleep quality (Pittsburgh Sleep Quality Inventory [PSQI]) were assessed. Expanded Disability Status Scale scores were also provided by a qualified neurologist.

RESULTS

The mean ± SD age of the 217 patients was 32.6 ± 8.6 years, and 79% were female. One hundred fifty-two patients (70.0%) were classified as poor sleepers based on PSQI scores; 122 (56.2%) had significant fatigue based on FSS results. The mean ± SE physical (PCS) and mental (MCS) health composite scores of the MSQOL-54 were 40.12 ± 1.27 and 43.81 ± 1.61, respectively. There was a strong statistically significant positive correlation between PCS scores and MCS (r = 0.58), FSS (r = 0.49), and PSQI (r = 0.52) scores. MCS scores were strongly correlated with FSS (r = 0.53) and PSQI (r = 0.35) scores. Age exhibited statistically significant negative correlations with PCS (r = -0.21) and MCS (r = -0.58) scores, and was statistically significantly correlated with FSS (r = 0.23) and PSQI (r = 0.21) scores. Expanded Disability Status Scale scores were strongly correlated with FSS scores.

CONCLUSIONS

These findings support screening of fatigue severity and sleep quality and their effects on QOL.

Sleep disorders in patients with multiple sclerosis

OBJECTIVE

Poor sleep is a frequent symptom in patients with multiple sclerosis (MS). The objective of the study was to assess the relationship between nocturnal polysomnographic (PSG) findings and quality of sleep, fatigue, and increased daytime sleepiness among patients with MS.

METHODS

Clinical characteristics were collected. Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), and International Restless Legs Syndrome Rating Scale were used to assess quality of sleep, fatigue, excessive daytime sleepiness, and the presence of restless legs syndrome (RLS). All patients underwent nocturnal diagnostic PSG examination.

RESULTS

Fifty patients with MS were enrolled into the study. Age was the only independent variable significantly determining apnea-hypopnea index and desaturation index (DI) (beta = 0.369, p = 0.010, beta 0.301, p = 0.040). PSQI and ESS score were significantly higher in a population with RLS (p = 0.004, p = 0.011). FSS significantly correlated with DI (r = 0.400, p = 0.048). Presence of RLS was the only independent variable significantly determining PSQI and ESS (p = 0.005, p = 0.025). DI and presence of RLS were independent variables determining FSS (p = 0.015, p = 0.024).

CONCLUSION

Presence of RLS seems to be the main factor determining poor sleep, fatigue, and daytime somnolence. Sleep disordered breathing and its severity influences only fatigue in patients with MS.

Fatigue in multiple sclerosis: a look at the role of poor sleep

Fatigue is a frequent and debilitating symptom of multiple sclerosis (MS) with rates ranging anywhere from 53 to 90%. Despite its high prevalence and grave impact on overall functioning and quality of life, the accurate definition, quantification, and etiology of fatigue have plagued the MS literature and clinical care for decades. With regard to its etiology, MS-related fatigue has been construed as being either primary or secondary. Primary fatigue is purported to be related to centrally mediated processes of the disease whereas secondary fatigue is thought to be a result of the host of factors that may accompany MS (e.g., depression, sleep disturbance). The present paper focuses on secondary fatigue and the role of sleep disturbance, in particular. Despite the intuitive assumption that sleep problems could contribute to fatigue, sleep problems in MS have gone fairly unrecognized until recently. The present paper provides a brief review of the literature pertaining to the prevalence and nature of sleep problems in MS as well as their association with fatigue. A replication of this author’s and others work is presented further demonstrating that sleep disturbance is a significant contributor to fatigue in MS when taking into account disease variables, depression, and sleep disturbance.

Autonomic dysfunction in multiple sclerosis

Multiple sclerosis (MS) is the leading cause of neurological disability in young adults. Since the pathophysiology of MS is characterized by dissemination in space, as well as in time, the autonomic nervous system is inevitably damaged in the course of the disease in many patients and the proportion of affected patients increases with disease duration. Autonomic dysfunction (AD) in MS is explained by lesions in regions responsible for autonomic regulation such as nuclei in the periventricular region of fourth ventricle in the brainstem as well as medullar lesions. Reports about frequency of AD in MS patients vary notably between groups. Nevertheless its impact on quality of life is substantial but, unfortunately, often overlooked. The aim of this article is to present a concise review of various symptoms and signs of autonomic system dysfunction in MS.

Yawning, fatigue, and cortisol: expanding the Thompson Cortisol Hypothesis

Yawning and its involvement in neurological disorders has become the new scientific conundrum. Cortisol levels are known to rise during stress and fatigue; yawning may occur when we are under stress or tired. However, the link between yawning, fatigue, and cortisol has not been fully understood. Expansion of the Thompson Cortisol Hypothesis proposes that the stress hormone, cortisol, is responsible for yawning and fatigue especially in people with incomplete innervation such as multiple sclerosis. This informs our understanding of the functional importance of the brain stem region of the brain in regulating stress and fatigue.

Multiple sclerosis symptom management

Multiple sclerosis (MS) is the most common cause of nontraumatic disability in young adults. The increasing emphasis on early treatment with disease-modifying therapies has the goal of preventing long-term disability. However, current disease treatments are only partially effective, and most patients experience a variety of neurologic symptoms at various times during their disease course. Because these symptoms often have a profound impact on social, occupational and physical performance, effective symptom management is an important component of therapy to maintain quality of life. Effective symptom management often requires a multidisciplinary team approach. This review outlines general principles of the management of MS symptoms.

The sleep-immunity relationship

Research models show a strong interrelationship between sleep quality and immune function. The proinflammatory cytokines, interleukin-1, interleukin-6, and tumor necrosis factor α are classified as official sleep-regulatory substances. However, sleep-promoting properties are also possessed by several other immune and proinflammatory cellular classes. This article reviews the current physiologic evidence for the prominent somnogenic and sleep-regulatory properties inherent to these immune substances. Clinical examples of this relationship are discussed from the perspective of infectious and primarily immune-related conditions associated with significant sleep disruption and from the perspective of immune dysregulation associated with several primary sleep disorders.

Psychiatric symptoms in patients with multiple sclerosis

OBJECTIVES

This study was intended to identify general psychiatric symptoms in multiple sclerosis (MS) patients and to determine the distribution of these psychiatric symptoms by type of MS and degree of disability.

METHODS

One hundred fifty-two volunteers, 76 MS patients and 76 healthy controls, matched in terms of age, gender, marital status, years spent in education and income, were included. Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, State-Trait Anxiety Inventory, Pittsburgh Sleep Quality Index, Padua Inventory, Rosenberg Self-Esteem Scale and Eating Attitude Test. Degree of disability was determined using the Expanded Disability Status Scale (EDSS). In addition to being compared between the patient and control groups, scale scores were also compared between groups established on the basis of relapsing-remitting or progressive forms of MS, neurological disability and ambulatory ability. Correlations were determined between EDSS scores and psychiatric scale scores.

RESULTS

In addition to symptoms of depression, anxiety and sleep impairment in MS patients, we also determined that less studied symptoms such as somatization, obsession, compulsion, interpersonal sensitivity, anger-hostility, phobic anxiety, paranoid ideation, psychoticism, low self-esteem and distorted eating attitudes were also more frequent compared to the healthy controls. Some symptoms were also more prevalent in progressive MS patients compared to relapsing-remitting subjects. Symptoms increase as degree of disability rises and ambulatory capacity declines.

CONCLUSION

Depressive, anxious and sleep impairment symptoms are not the only ones seen in MS patients; other psychiatric symptoms are also common. Further studies are needed to investigate the frequency and causes of these little-investigated symptoms. As seen in patients with a progressive course and greater neurological disability, more psychiatric symptoms develop in patients with more severe disease.

Fatigue and its association with sleep disorders, depressive symptoms and anxiety in patients with multiple sclerosis

BACKGROUND AND PURPOSE

The aetiopathogenesis of fatigue in multiple sclerosis (MS) is not clear. It could be associated with structural changes of the central nervous system, but also with mood and sleep disorders. The purpose of the study was to evaluate frequency of fatigue and its association with sleep and mood disorders in MS patients.

MATERIAL AND METHODS

The examined group consisted of 122 MS patients (mean age 37.7 ± 10.8 years). The following questionnaires were used: Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS), Montgomery-Asberg Depression Rating Scale (MADRS), and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Fatigue was present in 75 MS patients (61.5%). Excessive daytime sleepiness was observed in 25 (20.5%), insomnia in 73 patients (59.8%). According to MADRS, depressive symptoms were present in 33 (27%), according to HADS in 15 people (12.3%). Anxiety was present in 32 patients (26.2%). We observed an association between fatigue (FSS) and sleep disorders (ESS, AIS) and also between fatigue and either depression (MADRS, HADS-D) or anxiety (HADS-A). The FSS score was not associated with age, sex, disease course and duration, Expanded Disability Status Stage (EDSS), treatment or level of education in MS patients. In inactive professionally people we noted significantly higher FSS scores (44.8 ± 13.8) in comparison with active individuals (37.2 ± 14.9; p = 0.0053).

CONCLUSIONS

Fatigue is a very common symptom in MS, sometimes associated with sleep disorders, depressive symptoms or anxiety. The treatable causes of fatigue in MS such as sleep and mood disturbances should be identified and treated.