The association between pain and sleep in fibromyalgia

The role of pain intensity and depressive symptoms in the relationship between sleep quality and postural control among middle-aged and older adults with Fibromyalgia

OBJECTIVE

Fibromyalgia (FM) is a chronic pain condition often accompanied by sleep problems and depression that are each associated with reduced physical ability including postural control. Research supports a sequential association between pain intensity and depression in FM, and poor sleep quality may play a key role in this relationship. This study aimed to verify a serial pattern of associations among sleep quality, pain intensity, and depressive symptoms and quantify these effects on objective postural control.

DESIGN

Community-residing adults diagnosed with FM (n = 155; Mage = 61.08, SD = 7.70; 93% female; 79% White) were included in this cross-sectional study.

MAIN OUTCOMES

Participants self-rated sleep quality (restorative sleep, sleep waking, and sleep latency), pain intensity, and depressive symptoms, and the Fullerton Advanced Balance (FAB) scale and 8-Foot Up and Go Test (8FUPGT) measured objective postural control.

RESULTS

Findings indicated that the serial association between pain intensity and depressive symptoms fully mediated the relationship between sleep quality and both FAB (95% CI [-.125, -.013]), and 8FUPGT (95% CI [.002, .033]) performance.

CONCLUSION

Findings highlight the serial association of pain intensity and depressive symptoms with objective postural control performance and the potential for sleep and depression interventions that may maximize functional outcomes in FM.

Gender differences in symptomatology, socio-demographic information and quality of life in Spanish population with long COVID condition: a cross-sectional study

Introduction

Long COVID patients experience a decrease in their quality of life due to the symptomatology produced by the disease. It is also important to understand how long COVID affects both men and women. The objective of this study is to examine the impact of long COVID symptomatology on the quality of life of Spanish adults from a gender perspective.

Methods

An observational and cross-sectional study was carried out. Participants were able to complete an online questionnaire using an online platform. A sample of 206 people participated in the study.

Results

The 80.6% of the sample were women with a mean age of 46.51 (±8.28) and the 19.4% were men with a mean age of 48.03 (±9.50). The medium score in the PAC19-QoL test was 141.47 (±24.96) and segmented by gender, 141.65 (±23.95) for women and 140.82 (±28.66) for men. The most common symptoms in women were muscle and joint pain (94.6%), fatigue (94.0%), discomfort (92.2%), difficulty concentrating (91.0%), and memory loss (88.6%). For men the symptoms included muscle and joint pain (97.5%) and fatigue (97.5%) both occupying first position, discomfort (92.0%), difficulty concentrating (90.0%), mood disturbances (90.0%), and memory loss (87.5%). The chi-square test showed statistical significance (p < 0.005) for socio-demographic information, quality of life scores, and long COVID symptoms by intensities.

Conclusion

This study shows that there are gender differences in the way that long COVID is experienced.

Sleep profile and its correlation with clinical variables in fibromyalgia syndrome: A cross-sectional study

Objective

A scarcity of literature exists on sleep quality in fibromyalgia syndrome (FMS) in Indian patients. The current study described the sleep profile of patients with FMS with poor sleep quality residing in urban Bangalore and determined the relationship between poor sleep and fibromyalgia variables.

Methods

Eighty-six patients with FMS were included in the study. Pittsburgh Sleep Quality Index (PSQI) and Revised Fibromyalgia Impact Questionnaire (FIQR) were used to evaluate the sleep profile and fibromyalgia variables. Spearman's rank correlation, t-test, and one-way analysis of variance were used for the analyses.

Results

Ninety-one percent of patients with FMS were identified as poor sleepers (PSQI >5). The mean PSQI global score of the included patients was 12.04 ± 3.5. The global sleep score varied with sex (p = 0.003) and fibromyalgia severity (p = 0.001). A significant correlation was found between PSQI global score and FIQR total score (r = 0.4, p < 0.001), FIQR subdomains (r = 0.2-0.4, p < 0.05), and FMS duration (r = 0.26, p < 0.05). The PSQI global score was also correlated with pain, depression, memory, anxiety, balance, and sensitivity (r = 0.2-0.3, p < 0.05).

Conclusion

Sleep disturbance is highly prevalent in patients with FMS residing in urban Bangalore. Sleep quality tends to worsen in females with increasing FMS severity and duration but does not differ across other demographic variables. Sleep quality is significantly correlated with somatic as well as psychological variables. Future studies evaluating the predictors of poor sleep are needed to further corroborate these findings.

The efficacy of telephone-delivered cognitive behavioral therapy in people with chronic illnesses and mental diseases: A meta-analysis

COVID-19 pandemic led to an increase of remote treatments, such as telephone-delivery cognitive behavioral therapy (T-CBT). To our knowledge, no meta-analyses studied the effect of T-CBT in chronic and/or mental illnesses on multiple psychological outcomes. Therefore, our study aims to evaluating the efficacy of T-CBT compared to other interventions (treatment as usual, TAU, or face-to-face CBT). Each effect size (ES) was calculated in Hedges' g and pooled together to produce a mean ES for each outcome (depression, anxiety, mental and physical QoL, worry, coping, and sleep disturbances). The meta-analysis included 33 studies with a randomized controlled trial design. A large ES was found when comparing the efficacy of T-CBT against TAU on depression (g = 0.84, p < 0.001), whereas a moderate ES was found on anxiety (g = 0.57; p < 0.001), and a small effect on mental quality of life (g = 0.33, p < 0.001), sleep disturbances (g = 0.37, p = 0.042), coping (g = 0.20, p = 0.016) and worry (g = 0.43, p = 0.001). The meta-analysis comparing the efficacy of T-CBT and CBT on depression revealed a not significant pooled ES (g = 0.06, p = 0.466). The results provided evidence that T-CBT could be to be more effective than TAU conditions in multiple psychological outcomes, and as efficient as face-to-face CBT in treating depression.

Effects of resistance training on sleep of patients with fibromyalgia: A systematic review

This study investigated the effects of resistance training (RT) on the sleep quality of patients with fibromyalgia (FM), through a systematic review. The search was carried out in the PubMed, Embase, Scopus, and Web of Science databases. Initially, 148 studies were found, of which six were included for qualitative analysis. Four studies showed significant improvement in sleep after RT. Compared to other exercise modalities, RT proved to be superior to flexibility training and equivalent to aerobic exercise. Interventions lasted from 4 to 21 weeks, the weekly frequency ranged from two to three times, and the intensity ranged from 40% to 80% 1RM, with exercises for the major muscle groups. RT is an intervention that can be used to treat FM, however, more studies are needed to verify its effectiveness in improving sleep.

Gender, Mental Health and Socioeconomic Differences in Fibromyalgia: A Retrospective Cohort Study Using Real-World Data from Catalonia

The main objective of our study was to assess the associated risk between fibromyalgia (FM) and the incidence of the diagnosis of anxiety and depression in the general population during the years 2010-2017 in Catalonia.

METHOD

A retrospective cohort study was designed using the Information System for Research Development in Primary Care database. All patients with FM were included (n = 56,098) and matched to the control group in a 1:2 pairing ratio (n = 112,196). The demographic variables studied were sex, age and socio-economic status.

RESULTS

Patients with FM have a lower survival rate if they are also diagnosed with anxiety and depression during the entire study period, with the rate being 26.6% lower in FM patients at an 8-year follow-up (0.58, 95%CI: 0.57-0.59 vs. 0.79, 95%CI: 0.78-0.79). There is a 58% reduction in the risk of developing anxiety and/or depression in the control group vs. the FM group (p-value < 0.05), and by 45% in male vs. female sex (p-value < 0.05).

CONCLUSIONS

FM is a disease that is associated with anxiety and depression, and men are at lower risk of anxiety and depression after FM diagnosis.

Effectiveness of aquatic therapy on sleep in persons with fibromyalgia. A meta-analysis

CONTEXT

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal condition characterized by persistent, widespread pain, myofascial tenderness, negative affect, fatigue, memory problems and sleep disturbances.

OBJECTIVE

To summarize the evidence of the effects of aquatic therapy on sleep quality in patients with FMS.

METHODS

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2020 (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO), whit the registration number CRD42021249982. Cochrane library, Medline (PubMed), Science Direct Web of Science (WOS), Scopus, and PEDro were searched from inception until September 2021. The search included only randomized clinical trials.

RESULTS

Of the 7711 studies identified in the initial search, a total of 7 trials (361 participants) satisfied the eligibility criteria. Finally, a meta-analysis was conducted with 6 studies (311 participants). The overall pooled effect favored aquatic therapy interventions in improving sleep quality in patients with FMS (pooled MD, -2.05; 95% CI, -4.35 to 0.25).

CONCLUSIONS

The results of this systematic review and meta-analysis provide evidence that aquatic therapy improved sleep quality in patients with FMS. This study highlights the importance of aquatic therapy for sleep. Nonetheless, although an aquatic therapy intervention may represent a good option to improve sleep, given the low number of studies the evidence should be taken with caution.

Quality of life in patients with fibromyalgia: Contributions of disease symptoms, lifestyle and multi-medication

Fibromyalgia (FM) is a disease characterized by the presence of chronic and widespread musculoskeletal pain, which causes a high negative impact on the quality of life (QoL). Although there are many studies about the QoL of patients with FM, it is unknown which variables have a main influence on it. Therefore, in the present study, we aimed to determine which FM symptoms predict a worse QoL and also to establish whether lifestyle and multi-medication are associated to QoL. We assessed a sample of 134 women with FM using a semi-structured clinical interview to explore lifestyle (diet, exercise, smoking) and medication use, and questionnaires to cover the main symptoms of this disease and QoL (SF-36). We found that the patients with FM had a poor QoL, being “physical pain” and “vitality” the most affected domains. A linear regression analysis showed that depression and anxiety assessed by HADS were the FM symptoms which most significantly predicted QoL, explaining 49% of the variance. Concerning lifestyle/medication influences, we found that multiple drug treatment and smoking also predicted a worse QoL (14%). Moreover, patients who practiced exercise regularly showed better QoL than patients who did not (regardless of the severity of FM). Thus, our results suggest that treatment strategies to improve QoL in FM should be focused on improving psychological distress, promoting regular exercise and reducing smoking and multi-medication. The data highlights the role of positive self-management practices to improve QoL in FM.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Differences and Correlations of Anxiety, Sleep Quality, and Pressure-Pain Threshold between Patients with Chronic Low Back Pain and Asymptomatic People

Background. Chronic low back pain (CLBP) is a clinically common and expensive disease. Patients frequently take sick leaves because of pain and dysfunction, and their unpleasant life and work experiences cause psychological depression and anxiety and affect their quality of life. Sleep disturbance is a common problem among patients with low back pain (LBP) with more than 50% complaining about poor sleep quality. This study aimed to explore the correlations between anxiety, sleep quality, and pressure-pain threshold (PPT) and their differences between patients with CLBP and asymptomatic people. Methods. Forty patients with CLBP and 40 asymptomatic people were recruited. Relevant data, including State-Trait Anxiety Inventory, Pittsburgh Sleep Quality Index, and PPT, were individually and independently collected by blinded physiotherapists with a practicing certificate and then statistically analyzed. An independent sample t-test was used to determine the intergroup differences between patients with CLBP and asymptomatic populations. Pearson correlation coefficient was employed for correlation analysis. Results. The CLBP group had significantly higher anxiety scores (41.64 ± 9.88 vs. 36.69 ± 8.31; t = −2.496, $p=0.015$ ) than the asymptomatic group. A significant difference was found in the total score of the Pittsburgh Sleep Quality Index (6.41 ± 2.43 vs. 5.09 ± 2.18; t = −2.628, $p=0.010$ ) but not in the trait anxiety (44.00 ± 7.83 vs. 42.67 ± 9.51; t = −0.695, $p=0.489$ ) of the two groups. State−Trait Anxiety Inventory showed a low to moderate negative correlation with PPT. No remarkable correlation was observed between Pittsburgh Sleep Quality Index and PPT. Conclusions. Patients with CLBP showed considerably worse state anxiety and sleep quality than asymptomatic people; however, no substantial difference in PPT was found between the two groups. The results suggest that in clinical practice, the focus should include pain and related social and psychological factors. CLBP treatment could be considered from multiple perspectives and disciplines.This trial is registered with Chinese Clinical Trial Registry (Trial registration: ChiCTR-TRC-13003701).

Test-Retest Reliability and Responsiveness of PROMIS Sleep Short Forms Within an RCT in Women With Fibromyalgia

Background: Nonrestorative sleep is commonly reported by individuals with fibromyalgia, but there is limited information on the reliability and responsiveness of self-reported sleep measures in this population.

Objectives: (1) Examine the reliability and validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) sleep measures in women with fibromyalgia, and (2) Determine the responsiveness of the PROMIS sleep measures to a daily transcutaneous electrical nerve stimulation (TENS) intervention in women with fibromyalgia over 4 weeks compared with other measures of restorative sleep.

Methods: In a double-blinded, dual-site clinical trial, 301 women with fibromyalgia were randomly assigned to utilize either Active-TENS, Placebo-TENS, or No-TENS at home. Measures were collected at baseline and after 4 weeks of treatment. To assess self-reported sleep, the participants completed three PROMIS short forms: Sleep Disturbance, Sleep-Related Impairment, Fatigue, and the Pittsburgh Sleep Quality Index (PSQI). To assess device-measured sleep, actigraphy was used to quantify total sleep time, wake after sleep onset, and sleep efficiency. Linear mixed models were used to examine the effects of treatment, time, and treatment*time interactions.

Results: The PROMIS short forms had moderate test–retest reliability (ICC 0.62 to 0.71) and high internal consistency (Cronbach's alpha 0.89 to 0.92). The PROMIS sleep measures [mean change over 4 weeks, 95% confidence interval (CI)], Sleep Disturbance: −1.9 (−3.6 to −0.3), Sleep-Related Impairment: −3 (−4.6 to −1.4), and Fatigue: −2.4 (−3.9 to −0.9) were responsive to improvement in restorative sleep and specific to the Active-TENS group but not in the Placebo-TENS [Sleep Disturbance: −1.3 (−3 to 0.3), Sleep-Related Impairment: −1.2 (−2.8 to 0.4), Fatigue: −1.1 (−2.7 to 0.9)] or No-TENS [Sleep Disturbance: −0.1 (−1.6 to 1.5), Sleep-Related Impairment: −0.2 (−1.7 to 1.4), Fatigue: –.3 (−1.8 to 1.2)] groups. The PSQI was responsive but not specific with improvement detected in both the Active-TENS: −0.9 (−1.7 to −0.1) and Placebo-TENS: −0.9 (−1.7 to 0) groups but not in the No-TENS group: −0.3 (−1.1 to 0.5). Actigraphy was not sensitive to any changes in restorative sleep with Active-TENS [Sleep Efficiency: −1 (−2.8 to 0.9), Total Sleep Time: 3.3 (−19.8 to 26.4)].

Conclusion: The PROMIS sleep measures are reliable, valid, and responsive to improvement in restorative sleep in women with fibromyalgia.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT01888640.

Daily Variation in Sleep Quality is Associated With Health-Related Quality of Life in People With Spinal Cord Injury

OBJECTIVE

Although sleep difficulties are common after spinal cord injury (SCI), little is known about how day-to-day fluctuations in sleep quality affects health-related quality of life (HRQOL) among these individuals. We examined the effect of sleep quality on same-day HRQOL using ecological momentary assessment methods over a 7-day period.

DESIGN

Repeated-measures study involving 7 days of home monitoring; participants completed HRQOL measures each night and ecological momentary assessment ratings 3 times throughout the day; multilevel models were used to analyze data.

SETTING

Two academic medical centers.

PARTICIPANTS

A total of 170 individuals with SCI (N=170).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily sleep quality was rated on a scale of 0 (worst) to 10 (best) each morning. Participants completed end-of-day diaries each night that included several HRQOL measures (Sleep Disturbance, Sleep-related Impairment, Fatigue, Cognitive Abilities, Pain Intensity, Pain Interference, Ability to Participate in Social Roles and Activities, Depression, Anxiety) and ecological momentary assessment ratings of HRQOL (pain, fatigue, subjective thinking) 3 times throughout each day.

RESULTS

Multilevel models indicated that fluctuations in sleep quality (as determined by end-of-day ratings) were significantly related to next-day ratings of HRQOL; sleep quality was related to other reports of sleep (Sleep Disturbance; Sleep-related Impairment; Fatigue) but not to other aspects of HRQOL. For ecological momentary assessment ratings, nights of poor sleep were related to worse pain, fatigue, and thinking. Generally, sleep quality showed consistent associations with fatigue and thinking across the day, but the association between sleep quality and these ecological momentary assessment ratings weakened over the course of the day.

CONCLUSIONS

Findings highlight the important association between sleep and HRQOL for people with SCI. Future work targeting sleep quality improvement may have positive downstream effects for improving HRQOL in people with SCI.

Sleeping is a nightmare: A qualitative study on the experience and management of poor sleep quality in women with fibromyalgia

AIM

This study aimed to explore the experience and management of poor sleep quality in Spanish women with fibromyalgia (FM).

DESIGN

This was a qualitative study based on one-to-one interviews.

METHODS

Twenty-one adult women diagnosed with FM were recruited from the community between January and March 2020. Data were collected through in-depth semistructured one-to-one interviews, using an interview guide of open questions about the experience and management of poor sleep quality, and were analyzed with thematic qualitative analysis. The symptom management theory was used as a biopsychosocial conceptual framework.

RESULTS

The results were organized into two themes: (a) experience of poor sleep quality and (b) management strategies for poor sleep quality. Poor sleep quality was found to be a severe symptom of FM that negatively impacts pain, fatigue, stiffness, mental health, and quality of life. The participants perceived pharmacological treatment to be the main approach of health care professionals for improving sleep, and most did not want this form of treatment. Self-management strategies lack clear beneficial effects on sleep quality.

CONCLUSION

Women with FM recognize that they need to receive more information from nurses and allied professions about sleep in the context of FM and how to effectively manage poor sleep quality.

IMPACT

This study contributes to a better understanding of how women with FM experience and manage poor sleep quality. More information about management strategies for poor sleep quality from nurses and other health care professionals is needed in women with FM. The results of this study can be applied by nurses and health care professionals, including sleep educators, in the treatment of this patient group.

Assessment of sleep quality in fibromyalgia syndrome and its effect on postural balance and functional status

BACKGROUND

Patients with fibromyalgia syndrome (FMS) often have sleep problems and balance disorders.

OBJECTIVE

The aim of the study was to examine sleep quality and balance disorders and the relationship between sleep quality and balance, functional status and the frequency of falls in patients with FMS.

METHODS

Fifty women with FMS and 50 healthy women were included in the study. Sleep quality was assessed with the numeric rating scale (NRS) and the Pittsburgh Sleep Quality Index (PSQI) and balance and balance self-confidence were assessed with the Berg Balance Scale (BBS) and Activities-Specific Balance Confidence (ABC) Scale, respectively. Functional status and symptom severity of patients were assessed with the Fibromyalgia Impact Questionnaire (FIQ) and the Symptom Impact Questionnaire (SIQR). The number of falls in the last six months were recorded.

RESULTS

In the patient group, sleep quality scores were significantly higher, and BBS and ABC scores were significantly lower than the control group. NRS scores were significantly correlated with the BBS, FIQ, and SIQR scores, and the PSQI scores were significantly correlated with the BBS and ABC scores and the number of falls in FMS.

CONCLUSION

This study showed that the prevalence of sleep and balance disorders is higher in FMS patients. A relationship was reported between the sleep quality and balance and functional status and frequency of falls.

Mapping of predictors of the disengagement of the descending inhibitory pain modulation system in fibromyalgia: an exploratory study

BACKGROUND

The main symptoms of fibromyalgia comprise diffuse pain, disability, depressive symptoms, catastrophizing, sleep disruption and fatigue, associated with dysfunction of the descending pain-modulating system (DPMS).

OBJECTIVES

We aimed to identify patterns of main symptoms of fibromyalgia and neuroplasticity biomarkers (i.e. brain-derived neurotrophic factor (BDNF) and S100B protein) in non-responders to the conditioned pain modulation task (CPM-task) induced by immersion of hand in cold water (0-1°C). Furthermore, we evaluated if these patterns predict responsiveness to CPM-task.

METHODS

This cross-sectional study included 117 women with fibromyalgia ((n = 60) non-responders and (n = 57) responders), with age ranging from 30 to 65 years old. We analysed changes in numerical pain scale (NPS-10) during the CPM-task using a standardized protocol.

RESULTS

A hierarchical multivariate logistic regression analysis was used to construct a propensity score-adjusted index to identify non-responders compared to responders to CPM-task. The following variables were retained in the models: analgesic use four or more times per week, heat pain threshold (HPT), poor sleep quality, pain catastrophizing, serum levels of BDNF, number of psychiatric diagnoses and the impact of symptoms of fibromyalgia on quality of life. Receiver operator characteristics (ROC) analysis showed non-responders can be discriminated from responders by a composite index of more frequent symptoms of fibromyalgia and neuroplasticity markers (area under the curve (AUC) = 0.83, sensitivity = 100% and specificity = 98%).

CONCLUSION

Patterns of fibromyalgia symptoms and neuroplasticity markers may be helpful to predict responsiveness to the CPM-task which might help personalize treatment and thereby contribute to the care of patients with fibromyalgia.

Pain in Women: A Perspective Review on a Relevant Clinical Issue that Deserves Prioritization

Introduction

Gender equity and gender medicine are opportunities not to be missed, and this Expert Group Opinion Paper on pain in women aims to review the treatment of pain conditions mainly affecting women, as well as the fundamental aspects of the different clinical response to drug treatment between the genders, and what can be done for gender-specific rehabilitation.

Methods

Perspective review.

Results

Genotypic and phenotypic differences in pain between the sexes are conditioned by anatomical, physiological, neural, hormonal, psychological, social, and cultural factors, such as the response to pharmacological treatment to control pain. The examination of these factors shows that women are affected by pain diseases more frequently and severely than men and that they report pain more frequently and with a lower pain threshold than men. Some forms of pain are inherently related to gender differences, such as pain related to the genitourinary system. However, other forms of chronic pain are seen more frequently in women than men, such as migraine, rheumatological, and musculoskeletal pain, in particular fibromyalgia.

Discussion

Research is needed into the pathophysiological basis for gender differences in the generation of acute pain and maintenance of chronic pain, including the factors that put women at higher risk for developing chronic pain. In addition, different specialties need to collaborate to develop gender-related diagnostic and therapeutic guidelines, and healthcare professionals need to upskill themselves in the appropriate management of pain using existing diagnostic tools and therapeutic options.

Correlating cognition and cortical excitability with pain in fibromyalgia: a case control study

BACKGROUND

Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal symptoms, primarily attributed to sensitization of somatosensory system carrying pain. Few reports have investigated the impact of fibromyalgia symptoms on cognition, corticomotor excitability, sleepiness, and the sleep quality - all of which can deteriorate the quality of life in fibromyalgia. However, the existing reports are underpowered and have conflicting directions of findings, limiting their generalizability. Therefore, the present study was designed to compare measures of cognition, corticomotor excitability, sleepiness, and sleep quality using standardized instruments in the recruited patients of fibromyalgia with pain-free controls.

METHODS

Diagnosed cases of fibromyalgia were recruited from the Rheumatology department for the cross-sectional, case-control study. Cognition (Mini-Mental State Examination, Stroop color-word task), corticomotor excitability (Resting motor threshold, Motor evoked potential amplitude), daytime sleepiness (Epworth sleepiness scale), and sleep quality (Pittsburgh sleep quality index) were studied according to the standard procedure.

RESULTS

Thirty-four patients of fibromyalgia and 30 pain-free controls were recruited for the study. Patients of fibromyalgia showed decreased cognitive scores (p = 0.05), lowered accuracy in Stroop color-word task (for color: 0.02, for word: 0.01), and prolonged reaction time (< 0.01, < 0.01). Excessive daytime sleepiness in patients were found (< 0.01) and worsened sleep quality (< 0.01) were found. Parameters of corticomotor excitability were comparable between patients of fibromyalgia and pain-free controls.

CONCLUSIONS

Patients of fibromyalgia made more errors, had significantly increased reaction time for cognitive tasks, marked daytime sleepiness, and impaired quality of sleep. Future treatment strategies may include cognitive deficits and sleep disturbances as an integral part of fibromyalgia management.

Behavior-analytic intervention for women with fibromyalgia and insomnia: a single subject design

This study evaluated the effects in the pain and sleep, and the clinic significance after an analytic-behavioral intervention to manage the condition of the physical and interpersonal environment related to pain. Four women with fibromyalgia and insomnia participated in a study with intervention withdrawal multiple baseline design and initial, intermediate, final, and follow-up assessments. Self-report instruments were used to assess pain intensity and disability, sleep quality, and insomnia severity, besides the actigraphy. Data showed that the intervention (20 sessions) was effective in reducing the sleep and pain problems in all participants by shifting two participants from clinical to non-clinical status in sleep indicators. The gains were maintained or increased in follow-up measures. However, the results should take into consideration the clinical condition and other variables that may have individually impacted the results.

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

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

The impact of glucocorticoids and statins on sleep quality

Glucocorticoids and statins are the foundation of lifelong therapies and as such, may generate a variety of side effects. Among these, sleep impairments are one of the least explored and, simultaneously, majorly underestimated in clinical practice. Based on the available evidence, we have concluded that glucocorticoid action on the suprachiasmatic nucleus (SCN) that drives sleep disturbances is dual in nature. It involves both serotonin depletion and reduced arginine vasopressin signalling in the SCN. The former seems to involve activation of glucocorticoid receptors in the dorsal raphe, whereas the latter likely results from changes in glucose serum levels affecting the SCN, among other blood-borne factors which are yet to be discovered. Literature remains inconclusive when it comes to statins. Their diverse potential to cross the blood-brain barrier is considered the key factor determining statins' capability to evoke sleep impairments. Concurrently, an effect similar to that produced by steroids occurs - alteration in serum levels of blood-borne factors, such as glucose, which is a likely cause of statin-induced sleep disturbances.

Dietary Interventions in the Management of Fibromyalgia: A Systematic Review and Best-Evidence Synthesis

Fibromyalgia syndrome (FMS) is characterised by chronic widespread pain alongside fatigue, poor sleep quality and numerous comorbidities. It is estimated to have a worldwide prevalence of 1.78%, with a predominance in females. Treatment interventions for fibromyalgia have limited success, leading to many patients seeking alternative forms of treatment, including modifications to their diet and lifestyle. The effectiveness of dietary changes in fibromyalgia has not been widely researched or evaluated. This systematic review identified twenty-two studies, including 18 randomised control trials (RCTs) and four cohort studies which were eligible for inclusion. In total these studies investigated 17 different nutritional interventions. Significant improvements in reported pain were observed for those following a vegan diet, as well as with the low fermentable oligo di-mono-saccharides and polyols (FODMAP) diets. Supplementation with Chlorella green algae, coenzyme Q10, acetyl-l-carnitine or a combination of vitamin C and E significantly improved measures of pain. Interpretation of these studies was limited due to the frequent poor quality of the study design, the wide heterogeneity between studies, the small sample size and a high degree of bias. Therefore, there is insufficient evidence to recommend any one particular nutritional intervention for the management of fibromyalgia and further research is needed.

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

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

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

Aim

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

Methods

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

Results

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

Conclusions

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

ClinicalTrials.gov identifier: NCT03825393.

Prevalence of Poor Sleep Quality in Patients With Hypertension in China: A Meta-analysis of Comparative Studies and Epidemiological Surveys

OBJECTIVE

This meta-analysis examined the prevalence of poor sleep quality and its associated factors in patients with hypertension in China.

METHODS

Both English (PubMed, PsycINFO, EMBASE) and Chinese (Wan Fang Database and Chinese National Knowledge Infrastructure) databases were systematically and independently searched. The random-effects model was used to estimate the prevalence of poor sleep quality in Chinese patients with hypertension. The funnel plot and Egger's tests were used to assess publication bias.

RESULTS

The prevalence of poor sleep quality in 24 studies with 13,920 hypertensive patients was 52.5% (95% confidence interval [CI]: 46.1-58.9%). In contrast, the prevalence of poor sleep quality in six studies with 5,610 healthy control subjects was 32.5% (95% CI: 19.0-49.7%). In these studies, compared to healthy controls, the pooled odds ratio (OR) of poor sleep quality was 2.66 (95% CI: 1.80-3.93) for hypertensive patients. Subgroup and meta-regression analyses revealed that patients in hospitals were more likely to have poor sleep quality than patients in the community. Studies with smaller sample size, studies using convenience or consecutive sampling and those published in Chinese reported higher prevalence of poor sleep quality. Furthermore, poor sleep quality was more common in older and male hypertensive patients, while the proportion of poor sleep quality was negatively associated with survey year.

CONCLUSION

Appropriate strategies for screening, prevention, and treatment of poor sleep quality in this population should be developed.

Utilization of Overnight Pulse Oximetry in Fibromyalgia Patients

To assess whether the Berlin Sleep Questionnaire and the Snoring, Tired, Observed, Pressure, Body mass, Age, Neck, and Gender questionnaire (STOP-BANG) might be suitable replacements for an overnight sleep pulse oximetry as screening tools for sleep disordered breathing in patients with fibromyalgia. Participants: From June 8, 2018 through July 25, 2018, adult patients with a confirmed diagnosis of fibromyalgia (via the 1990 and/or 2010 American College of Rheumatology Fibromyalgia Classification Criteria) who attended Mayo Clinic's Fibromyalgia Treatment Program were invited to participate in the study. Methods: The design was a prospective comparative study with a retrospective chart review component. Participants completed 2 validated surveys: the Berlin Sleep Questionnaire and the STOP-BANG. Medical records were reviewed for demographic information and overnight pulse oximetry test results. Results: Results from both questionnaires indicate that there is an association between sleep apnea risk category (defined by questionnaire) and oximetry results. Fisher's exact test for STOP-BANG and Berlin Sleep Questionnaire are statistically significant (P < .001), indicating that participants at high risk for sleep apnea (based on the questionnaires) had a greater prevalence of abnormal oximetry results than those at low risk for sleep apnea. Participants who were classified as high risk (85.7%) or intermediate risk (61.5%) on the STOP-BANG questionnaire for sleep apnea had abnormal oximetry results. Participants who scored as high risk (85.7%) for sleep apnea on the Berlin Sleep Questionnaire had abnormal oximetry results. Conclusions: In patients with fibromyalgia, the Berlin Sleep Questionnaire and the STOP-BANG questionnaires could be beneficial in determining the probability of obstructive sleep apnea and the subsequent need for pulse oximetry testing, in higher risk patients.

Possible Molecular Mediators Involved and Mechanistic Insight into Fibromyalgia and Associated Co-morbidities

Fibromyalgia is a chronic complex syndrome of non-articulate origin characterized by musculoskeletal pain, painful tender points, sleep problems and co-morbidities including depression, migraine. The etiopathogenesis of fibromyalgia is complex, variable and remains inconclusive. The etiological factors that have been defined include stress, genetic predisposition and environmental components. As per the reports of the American College of Rheumatology (ACR) the prevalence of fibromyalgia varies from 2 to 22% among the general population with poor diagnostic features primarily pain. Fibromyalgia encompasses a spectrum of co-morbid conditions with multifarious pathogenesis. The highly prevalent manifestations of fibromyalgia include heterogeneous pain and aches. Biochemical and neurobiological elements of fibromyalgia include neurotransmitters, hypothalamic pituitary adrenal axis (HPA axis), inflammatory cytokines, monoaminergic pathway, opioid peptides, sex hormones, nerve growth factor (NGF) and local free radical insult. An imbalance in the serotonergic system is the major underlying etiological factor that has been explored most widely. Owing to complex interplay of diverse pathophysiological pathways, overlapping co-morbidities such as depression have been clinically observed. Therapeutic management of fibromyalgia involves both non pharmacological and pharmacological measures. The current review presents various dysregulations and their association with symptoms of fibromyalgia along with their underlying neurobiological aspects.

Subjective sleep quality as a mediator in the relationship between pain severity and sustained attention performance in patients with fibromyalgia

Pain severity and sleep are associated with cognitive performance in patients with fibromyalgia. This study examined whether sleep mediates the relationships of pain severity with psychomotor vigilance and attention in patients with fibromyalgia by analysing 80 patients with fibromyalgia. Cognitive performance, pain severity and sleep parameters were determined using the Psychomotor Vigilance Task, Brief Pain Inventory-Short Form and sleep diaries of seven consecutive nights, respectively. The patients' demographic data were analysed for potential confounding factors. After adjustment for these confounders, a series of regression analyses was performed to examine the mediating role of sleep. The results indicated that higher pain severity was strongly associated with poorer sustained attention and lower sleep quality, the total effects of pain severity on psychomotor vigilance and attention were significant (c path: β = 0.23, p = 0.04), and pain severity was a significant sleep quality predictor (a path: β = -0.33, p < 0.01). When sleep quality was entered into the regression model (a × b path), the effects of pain severity on psychomotor vigilance and attention became non-significant (c' path: β = 0.15, p = 0.20) after adjustment of age, indicating a complete mediating effect of sleep quality in the pain severity-cognitive performance relationship. In conclusion, sleep quality mediates the pain severity-cognitive performance relationship: pain affects sleep quality, which in turn impairs sustained attention. Our findings provide further insight into the processes underlying the relationship between pain and poor cognitive function. Improved sleep quality may offset the detrimental effects of pain on sustained attention.