Alpha sleep and information processing, perception of sleep, pain, and arousability in fibromyalgia

Elevated tau and β-amyloid in the serum of fibromyalgia patients

OBJECTIVE

Fibromyalgia (FM) is a chronic widespread pain syndrome. Although its mechanism remains relatively unknown, accelerated neurodegeneration in the brain has been reported in patients with FM. Sleep disturbance can increase the risk of neurocognitive disorders, which are associated with tau and beta-amyloid (Aβ) protein accumulation. We hypothesize neurodegeneration in patients with FM may be associated with sleep disturbance.

METHODS

In this case-control study, we analyzed serum tau and Aβ levels and their association with symptom profiles for patients with FM, by recruiting 22 patients with FM and 22 age-matched healthy participants. The visual analog scale, Fibromyalgia Impact Questionnaire, pressure pain threshold test, Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory-II, Beck Anxiety Inventory, and serum tau and beta-amyloid-42 (Aβ-42) levels were recorded. The Mann-Whitney test was conducted to compare questionnaire and protein level results between the groups. Pearson correlation test was conducted to investigate the correlation of questionnaire scores with tau and Aβ-42 levels in patients with FM. The significance level was set at P < .05.

RESULTS

Serum tau and Aβ-42 levels were significantly higher in patients with FM than in controls. A positive correlation between serum tau levels and PSQI scores was observed in patients with FM (r = 0.476, P = .025). We found that only sleep disturbance in patients with FM was significantly associated with higher serum tau levels among all symptom scores.

CONCLUSIONS

We suggest sleep disturbance may play a vital role in the pathomechanism of accelerated neurodegeneration in FM.

Experience and sleep-dependent synaptic plasticity: from structure to activity

Synaptic plasticity is important for learning and memory. With increasing evidence linking sleep states to changes in synaptic strength, an emerging view is that sleep promotes learning and memory by facilitating experience-induced synaptic plasticity. In this review, we summarize the recent progress on the function of sleep in regulating cortical synaptic plasticity. Specifically, we outline the electroencephalogram signatures of sleep states (e.g. slow-wave sleep, rapid eye movement sleep, spindles), sleep state-dependent changes in gene and synaptic protein expression, synaptic morphology, and neuronal and network activity. We highlight studies showing that post-experience sleep potentiates experience-induced synaptic changes and discuss the potential mechanisms that may link sleep-related brain activity to synaptic structural remodelling. We conclude that both synapse formation or strengthening and elimination or weakening occur across sleep. This sleep-dependent synaptic plasticity plays an important role in neuronal circuit refinement during development and after learning, while sleep disorders may contribute to or exacerbate the development of common neurological diseases. This article is part of the Theo Murphy meeting issue 'Memory reactivation: replaying events past, present and future'.

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

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

The association between pain and sleep in fibromyalgia

OBJECTIVE

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

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

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

Decrease of Serum IGF-1 Level is Not Associated With Obstructive Sleep Apnea in Fibromyalgia Patients

Objectives

This study aims to investigate the relationship of serum insulin-like growth factor 1 (IGF-1) level with obstructive sleep apnea, the Pittsburgh sleep quality index (PSQI), age, body mass index, and fibromyalgia impact questionnaire (FIQ) in fibromyalgia syndrome (FMS) patients.

Patients and methods

A total of 105 female patients (mean age 41.8±9.0 years; range 26 to 55 years) with fibromyalgia (FMS group) who were diagnosed according to 2010 American College of Rheumatology criteria, and 51 female patients (mean age 39.9±10.8 years; range 24 to 54 years) with mechanical low back pain (MLBP) (control group) were included in the study. Age, smoking, educational status, tender point number, body mass index, duration of disease, FIQ, PSQI, and polysomnographic assessment of both FMS and control groups were recorded.

Results

Sleep disorder was detected in 88 patients in FMS group and 15 patients in control group (p<0.05). The PSQI score was higher in the FMS group compared to the control group (9.9±4.6 vs. 5.7±3.5). The FIQ score was higher in the FMS group compared to the control group (53.4±17.4 vs. 26.4±13.9; p<0.05). The serum IGF-1 level of FMS group was significantly lower than that of the control group (140.6±49.5 ng/mL vs. 177.2±58.5 ng/mL; p<0.05). In the FMS group, an examination of the correlation between serum IGF-1 level with the age, body mass index, obstructive sleep apnea syndrome, FIQ, and PSQI revealed a negative correlation between serum IGF-1 with the age and PSQI. The obstructive sleep apnea syndrome ratios of study groups were comparable with regard to the frequencies of mild, moderate, and severe obstructive sleep apnea syndrome.

Conclusion

In FMS patients, serum IGF-1 levels may decrease due to age and PSQI; however, this may not be related to the severity of obstructive sleep apnea.

Exploring the associations shared by mood, pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample

OBJECTIVE

Sleep disturbance in chronic pain is common, occurring in two-thirds of patients. There is a complex relationship between chronic pain and sleep; pain can disrupt sleep and poor sleep can exaggerate pain intensity. This may have an impact on both depressive symptoms and attention to pain. This study aims to evaluate the relationship between chronic pain and sleep, and the role of mood and attention.

METHODS

Chronic pain patients, recruited from a secondary care outpatient clinic, completed self-report measures of pain, sleep, depressive symptoms and attention to pain. Hierarchical regression and structural equation modelling were used to explore the relationships between these measures. Participants (n = 221) were aged between 20 and 84 (mean = 52) years.

RESULTS

The majority of participants were found to be 'poor sleepers' (86%) with increased pain severity, depressive symptoms and attention to pain. Both analytical approaches indicated that sleep disturbance is indirectly associated with increased pain severity Instead the relationship shared by sleep disturbance and pain severity was further associated with depressive symptoms and attention to pain.

CONCLUSIONS

Our results indicate that sleep disturbance may contribute to clinical pain severity indirectly though changes in mood and attention. Prospective studies exploring lagged associations between these constructs could have critical information relevant to the treatment of chronic pain.

Addressing sleep disturbances: an opportunity to prevent cardiometabolic disease?

There is increasing awareness of the role of sleep disturbance as an important factor in health and disease. Although sub-clinical sleep disturbances (insufficient sleep duration or inadequate sleep quality) may be difficult to assess with conceptual and/or methodological clarity, this review attempts to summarize and synthesize these findings. First, the concept of sleep disturbance in a public health context is introduced, to provide context and rationale. Second, operational definitions of 'cardiometabolic disease' and 'sleep disturbance' are offered, to address many unclear operationalizations. Third, the extant literature is summarized regarding short or long sleep duration and/or insufficient sleep, insomnia and insomnia symptoms, general (non-specific sleep disturbances), circadian rhythm abnormalities that result in sleep disturbances, and, briefly, sleep-disordered breathing. Fourth, the review highlights the social/behavioural context of sleep, including discussions of sleep and race/ethnicity, socio-economic position, and other social/environmental factors, in order to place these findings in a social-environmental context relevant to public health. Fifth, the review highlights the issue of sleep as a domain of health behaviour and addresses issues regarding development of healthy sleep interventions. Finally, a research agenda of future directions is proposed.

Effect of pregabalin on sleep in patients with fibromyalgia and sleep maintenance disturbance: a randomized, placebo-controlled, 2-way crossover polysomnography study

OBJECTIVE

To assess the effect of pregabalin on polysomnographic (PSG) measures of sleep and patient-rated sleep, tiredness, and pain in fibromyalgia patients.

METHODS

We performed a randomized, double-blind, placebo-controlled, 2-period crossover PSG study. Patients ages ≥18 years with fibromyalgia satisfied subjective and objective sleep disturbance criteria prior to randomization. Eligible patients were randomized (1:1) to pregabalin (300-450 mg/day) or placebo for crossover period 1, and vice versa for period 2. Each crossover period comprised a dose-adjustment and dose-maintenance phase, with a 2-week taper/washout between periods. In-laboratory PSGs were recorded during 2 consecutive nights at screening and at the end of each crossover period. The primary end point was the difference in sleep maintenance defined by PSG-recorded wake after sleep onset (WASO; minutes) between 4 weeks of treatment with pregabalin and with placebo. Other PSG measures; patient-rated sleep, tiredness, and pain; and tolerability were assessed.

RESULTS

Of 119 patients randomized (103 women [86.6%], mean age 48.4 years), 102 (85.7%) completed both periods. Patients treated with pregabalin showed a reduction in PSG-determined WASO versus treatment with placebo (week 4 difference: -19.2 minutes [95% confidence interval (95% CI) -26.7, -11.6]; P < 0.0001). Pain score improved (decreased) with pregabalin versus placebo treatment at all 4 weeks (week 4 difference: -0.52 [95% CI -0.90, -0.14]; P = 0.0084). Modest (ρ = <0.3) but significant correlations were found between PSG sleep assessments and ratings of pain and sleep quality. Frequently reported all-causality adverse events (pregabalin versus placebo) were: dizziness (30.4% versus 9.9%), somnolence (20.5% versus 4.5%), and headache (8.9% versus 8.1%).

CONCLUSION

Patients with fibromyalgia treated with pregabalin had statistically significant and meaningful improvements in sleep, as assessed by PSG. Patients with fibromyalgia also reported decreased daily pain. Pregabalin was well tolerated.

Neurobiology underlying fibromyalgia symptoms

Fibromyalgia is characterized by chronic widespread pain, clinical symptoms that include cognitive and sleep disturbances, and other abnormalities such as increased sensitivity to painful stimuli, increased sensitivity to multiple sensory modalities, and altered pain modulatory mechanisms. Here we relate experimental findings of fibromyalgia symptoms to anatomical and functional brain changes. Neuroimaging studies show augmented sensory processing in pain-related areas, which, together with gray matter decreases and neurochemical abnormalities in areas related to pain modulation, supports the psychophysical evidence of altered pain perception and inhibition. Gray matter decreases in areas related to emotional decision making and working memory suggest that cognitive disturbances could be related to brain alterations. Altered levels of neurotransmitters involved in sleep regulation link disordered sleep to neurochemical abnormalities. Thus, current evidence supports the view that at least some fibromyalgia symptoms are associated with brain dysfunctions or alterations, giving the long-held “it is all in your head” view of the disorder a new meaning.

Can neuroimaging help us to understand and classify somatoform disorders? A systematic and critical review

OBJECTIVE

Debate about the nature of somatoform disorders and their current diagnostic classification has been stimulated by the anticipation of new editions of Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases and Related Health Problems diagnostic classifications. In the current paper, we review systematically the literature on the neuroimaging of somatoform disorders and related conditions with the aim of addressing two specific questions: Is there evidence of altered neural function or structure that is specifically associated with somatoform disorders? What conclusions can we draw from these findings about the etiology of somatoform disorders?

METHODS

Studies reporting neuroimaging findings in patients with a somatoform disorder or a functional somatic syndrome (such as fibromyalgia) were found using Pubmed, PsycINFO, and EMBASE database searches. Reported structural and functional neuroimaging findings were then extracted to form a narrative review.

RESULTS

A relatively mature literature on symptoms of pain and less developed literatures on conversion and fatigue symptoms were identified. The available evidence indicates that, when compared with nonclinical groups, somatoform diagnoses are associated with increased activity of limbic regions in response to painful stimuli and a generalized decrease in gray matter density; however, methodological considerations restrict the interpretation of these findings.

CONCLUSIONS

Whereas the neuroimaging literature has provided evidence about the possible mechanisms underlying somatoform disorders, this is not yet sufficient to provide a basis for classification. By adopting a wider variety of experimental designs and a more dynamic approach to diagnosis, there is every reason to be hopeful that neuroimaging data will play a significant role in future taxonomies.

Impaired memory consolidation during sleep in patients with functional memory disorder

Functional memory disorder (FMD) is characterized by mnestic and attentional deficits without symptoms of mild cognitive impairment or dementia. FMD usually develops in subjects with high psychosocial stress level and is classified to the somatoform disorders. We assessed memory performance (procedural mirror tracing task, declarative visual and verbal memory task) and other cognitive functions before and after one night of sleep in 12 FMD patients (mean age: 51.7 yrs, 7 females) and 12 healthy subjects matched for age, gender and IQ. Memory performance and other neurocognitive tasks did not differ between the groups at baseline. After one night of sleep, FMD patients showed an impairment of declarative memory consolidation compared to healthy subjects (visual task: p=0.004; verbal task: p=0.039). Spectral analysis of sleep-EEG indicated an increased cortical excitation in FMD. We hypothesize that a hyperarousal state in FMD might contribute to sleep disturbance implicating negative effects on declarative memory consolidation.

Fibromyalgia and fatigue: central processing, widespread dysfunction

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE

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

Dysfunctional beliefs, stress and sleep disturbance in fibromyalgia

OBJECTIVE

To explore sleep-related dysfunctional beliefs, stress levels and sleep quality in patients with fibromyalgia in comparison to healthy controls.

METHODS

One hundred sixty-six participants (83 patients with fibromyalgia and 83 healthy controls) completed self-report measures exploring beliefs and attitudes about sleep, perceived stress, sleep quality and levels of pain and fatigue.

RESULTS

Relative to healthy controls, patients with fibromyalgia revealed significantly higher levels of dysfunctional beliefs and attitudes about sleep and perceived stress. High dysfunctional beliefs were significantly associated with poorer sleep quality and high perceived stress was significantly related to higher sleep disturbances and daytime dysfunction.

CONCLUSIONS

Beliefs about sleep and perceived stress play a significant role in the sleep quality of patients with fibromyalgia. Interventions to improve sleep quality for people with fibromyalgia need to identify and address dysfunctional beliefs about sleep and incorporate stress management approaches.

Positive sleep state misperception – A new concept of sleep misperception

OBJECTIVES

To better define the concept of sleep misperception and analyse a category of patients who overestimate their sleep. At present, a condition of underestimation of sleep is classified as paradoxical insomnia. Overestimation of sleep has also been reported in the past, with no clear reference to corresponding polysomnographic (PSG) findings or its clinical significance.

PATIENTS AND METHODS

Patients were recruited from the general population undergoing a PSG assessment for a cross-sectional retrospective study in a sleep clinic affiliated with a tertiary health center.

RESULTS

A group of patients who overestimated their sleep had mostly non-discriminating PSG findings when compared to patients who underestimated their sleep, and correct estimators. The only parameters that were significantly different were objective sleep duration and efficiency, and, importantly, respective multiple sleep latency test (MSLT) results. The patients who overestimated their sleep had a mean MSLT result of 7.8 min, which indicates moderate daytime sleepiness. Patients who underestimated their sleep and correct estimators had the respective MSLT results of >10 min, making a statistically significant difference.

CONCLUSION

The authors identified a condition opposite the previously described sleep underestimation, and named it 'positive sleep state misperception' (PSSM). The condition is characterised by a gross overestimation of sleep. Inadequate sleep results in a clinically significant excessive daytime sleepiness, which patients were not able to predict. The authors propose a new model that incorporates both ends of the sleep misperception spectrum.

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

OBJECTIVE

The objective of this study was to explore the effect of sleep and coping on health-related quality of life in fibromyalgia syndrome (FMS).

METHODS

Patients diagnosed with FMS (N=101) completed the Positive and Negative Affect Schedule, the Pittsburgh Sleep Quality Index, the COPE, and the Medical Outcomes Study--Short-Form Health Survey for the previous month.

RESULTS

Poor sleep quality was reported by 99% of participants. Sleep quality was significantly predictive of pain, fatigue, and social functioning in patients with FMS. Active coping, planning, acceptance, and seeking instrumental and emotional social support were not predictive of health outcomes in FMS. However, the use of restraint coping was predictive of poorer physical functioning.

CONCLUSION

Sleep quality has significant implications for health-related quality of life in FMS. The use of coping strategies contributed little to the models' ability to predict health outcomes in FMS. Interventions designed to improve sleep quality may help to improve health-related quality of life for patients with FMS.

Prediction of Pain Outcomes in Korean Older Adults: Use of a Structural Equation Model

OBJECTIVE

To construct a structural equation model of pain adjustment outcomes (e.g., depression and fatigue) in Korean older adults based on the cognitive-behavioral model of chronic pain.

METHODS

Nonexperimental research design. Data were collected by questionnaires from 271 Korean older adults. Data analysis was conducted with SPSS 10.1 for descriptive statistics and a PC-LISREL program for covariance structural analysis.

RESULTS

In this study, based on the modifications, chi-square statistics were changed, the goodness-of-fit index was 0.97, the adjusted goodness-of-fit index was 0.93, the root mean square residual was 0.04, the normal fit index was 0.98, and the non-normed fit index was 0.98. Path coefficients and their statistical significance for the revised model were as follows: pain adjustment and pain beliefs were found to have a significant direct effect on pain coping. The variable directly related to pain beliefs was pain adjustment, and variables directly influencing fatigue were pain coping and pain beliefs. Lastly, pain adjustment, pain coping, and fatigue were found to have a significant direct effect on depression. Also, pain adjustment, pain coping, and pain beliefs were found to have a significant indirect effect on depression. In conclusion, pain adjustment, pain coping, pain beliefs, and fatigue all contributed to depression. Fifty-four percent of depression could be explained by these variables.

CONCLUSIONS

This modified model is considered appropriate for explaining and predicting pain adjustment outcomes in Korean older adults. Also, the findings support the development of an intervention strategy to improve pain coping, negative pain beliefs, fatigue, and depression caused by poor pain adjustment.

Excessive daytime sleepiness: considerations for the psychiatrist

Excessive daytime sleepiness or pathologic sleepiness is a complaint found in patients who experience somnolence at unwanted times and adversely affects their daytime function. Although psychiatric illness, chronic medical illness, or medication side effects may be causes for fatigue, insufficient sleep is the most common cause of excessive daytime sleepiness in the general population. When an individual complains of frank sleepiness, in addition to insufficient sleep, important considerations in these patients are disturbances in the normal homeostatic mechanisms that govern sleep and wakefulness. This article summarizes the clinical presentation, the differential diagnosis, commonly used diagnostic tools, and treatment options for patients complaining of excessive daytime sleepiness.

Time Estimation in Good and Poor Sleepers

Time estimation was examined in 148 older good and poor sleepers in analogue and naturalistic sleep settings. On analogue tasks, both "empty" time and time listening to an audiobook were overestimated by both good and poor sleepers. There were no differences between groups. "Empty" time was experienced as "dragging." In the sleep setting, most poor sleepers underestimated nocturnal sleep and overestimated awake times related to their own sleep problem: sleep onset vs. sleep maintenance insomnia. Good sleepers did the opposite. Severity of sleep problem and size of time estimation errors were unrelated. Greater night-to-night wake time variability was experienced by poor than by good sleepers. Psychological adjustment was unrelated to time estimations and to magnification or minimization of sleep problems. The results suggest that for poor sleepers who magnify their sleep problem, self-monitoring can be of benefit by demonstrating that the sleep problem is not as severe as believed.

Prevalence of sleep disturbance and its relationship to pain in adults with chronic pain

The study examined the prevalence and relationship between sleep disturbance and chronic pain. Research questions were: (1) What is the prevalence of sleep disturbance in adults with chronic pain, and how does this prevalence compare with healthy and insomniac adults? (2) What is the relationship between sleep disturbance and chronic pain? (3) What is the relationship of patient characteristics to sleep? This descriptive, correlational field study was done at an interdisciplinary pain clinic, sampling 99 adults, and using an 11-point pain scale and a visual analog sleep scale. For every disturbance item, more than 47% of subjects reported a score of 50 or higher, twice as high as those for healthy adults, indicating disrupted sleep. For every effectiveness item, more than 54% of subjects reported a score of 50 or less, significantly lower than for healthy adults, indicating poor sleep quality. For every supplementation item, more than 60% reported mean scores of 10 or less, indicating minimal napping, yet scores were higher than for healthy adults. For all three scales, scores were similar to the mean scores for insomniacs. Soundness of sleep showed a small but significant positive (r <.30) correlation with years of pain. Supplementation scale items were not correlated with either years of pain or pain intensity. Fragmentation was significant on the basis of gender, with men having higher scores than women. Age was a negative predictor of sleep latency. Education and age were negative predictors of the quality of sleep.

The effect of combined therapy (ultrasound and interferential current) on pain and sleep in fibromyalgia

Multidisciplinary treatment has proven to be the best therapeutic option to fibromyalgia (FM) and physiotherapy has an important role in this approach. Considering the controversial results of electrotherapy in this condition, the aim of this study was to assess the effects of combined therapy with pulsed ultrasound and interferential current (CTPI) on pain and sleep in FM. Seventeen patients fulfilling FM criteria were divided into two groups, CTPI and SHAM, and submitted to pain and sleep evaluations. Pain was evaluated by body map (BM) of the painful areas; quantification of pain intensity by visual analog scale (VAS); tender point (TP) count and tenderness threshold (TT). Sleep was assessed by inventory and polysomnography (PSG). After 12 sessions of CTPI or SHAM procedure, patients were evaluated by the same initial protocol. After treatment, CTPI group showed, before and after sleep, subjective improvement of pain in terms of number (BM) and intensity (VAS) of painful areas (P<0.001, both); as well as objective improvement, with decrease in TP count and increase in TT (P<0.001, both). Subjective sleep improvements observed after CTPI treatment included decrease in morning fatigue and in non-refreshing sleep complaint (P<0.001, both). Objectively, PSG in this group showed decrease in sleep latency (P<0.001) and in the percentage of stage 1 (P<0.001), increase in the percentage of slow wave sleep (P<0.001) and in sleep cycle count (P<0.001). Decrease in arousal index (P<0.001), number of sleep stage changes (P<0.05) and wake time after sleep onset (P<0.05), were also observed and no difference regarding pain or sleep parameters were verified after SHAM procedure. This study shows that CTPI can be an effective therapeutic approach for pain and sleep manifestations in FM.

Sleep disturbances linked to fibromyalgia

Fibromyalgia (FM) is a chronic muscle disorder characterized by muscle aches and pain of varying intensities. Sleep disturbances have been recognized as one of the probable causes of this disorder. Pharmacological and nonpharmacological approaches are often used to manage the symptoms of sleep disturbances. This article provides a brief background on FM, discusses the physiology of sleep, reviews the current literature on sleep disturbances associated with FM, provides insight to interventions that might be beneficial given the data available, and recommends ongoing research.

Use of actigraphy for monitoring sleep and activity levels in patients with fibromyalgia and depression

OBJECTIVE

The hallmark symptom of fibromyalgia (FM) is widespread chronic pain, but most patients are also impaired due to fatigue and sleep disturbance, and there is a strong association with depression. We compared levels of activity and sleep patterns in FM patients, with and without comorbid depression, to those of normal healthy controls and depressed patients.

METHODS

Actigraphy was carried out on 16 patients with uncomplicated FM, 6 FM patients with comorbid depression, 9 patients with recurrent major depression, and 28 healthy controls over a period of 5-7 days. The means of daytime activity levels, nighttime activity levels, and percentage time spent asleep during the daytime and nighttime were calculated and compared.

RESULTS

Controls showed high levels of activity during the day and uninterrupted periods of sleep at night. Patients with FM alone showed similar levels of daytime activity, but disturbed sleep with significantly increased levels of activity at night compared to normal controls. Patients with depression alone also showed disturbed sleep compared to normal controls. However, patients with FM and comorbid depression showed the most impairment, with significantly reduced daytime activity and significantly increased daytime sleeping compared to controls, as well as more sleep interruption and movement during the night.

CONCLUSION

Actigraphy is a useful means of studying activity levels and sleep patterns and demonstrated significant differences between FM patients with and without comorbid depression.

Can valerian improve the sleep of insomniacs after benzodiazepine withdrawal?

PURPOSE

The authors studied the sleep of patients with insomnia who complained of poor sleep despite chronic use of benzodiazepines (BZDs). The sample consisted of 19 patients (mean age 43.3+/-10.6 years) with primary insomnia (DSM-IV), who had taken BZDs nightly, for 7.1+/-5.4 years. The control group was composed of 18 healthy individuals (mean age 37+/-8 years). Sleep electroencephalogram (EEG) of the patients was analyzed with period amplitude analysis (PAA) and associated algorithms, during chronic BZD use (Night 1), and after 15 days of a valerian placebo trial (initiated after washout of BZD, Night 2). Sleep of control subjects was monitored in parallel.

RESULTS

Valerian subjects reported significantly better subjective sleep quality than placebo ones, after BZD withdrawal, despite the presence of a few side effects. However, some of the differences found in sleep structure between Night 1 and Night 2 in both the valerian and placebo groups may be due to the sleep recovery process after BZD washout. Example of this are: the decrease in Sleep Stage 2 and in sigma count; the increase in slow-wave sleep (SWS), and delta count, which were found to be altered by BZD ingestion. There was a significant decrease in wake time after sleep onset (WASO) in valerian subjects when compared to placebo subjects; results were similar to normal controls. Nonetheless, valerian-treated patients also presented longer sleep latency and increased alpha count in SWS than control subjects.

CONCLUSIONS

The decrease in WASO associated with the mild anxiolytic effect of valerian appeared to be the major contributor to subjective sleep quality improvement found after 2-week of treatment in insomniacs who had withdrawn from BDZs. Despite subjective improvement, sleep data showed that valerian did not produce faster sleep onset; the increase in alpha count compared with normal controls may point to residual hyperarousabilty, which is known to play a role in insomnia. Nonetheless, we lack data on the extent to which a sedative drug can improve alpha sleep EEG. Thus, the authors suggest that valerian had a positive effect on withdrawal from BDZ use.

The mesograde amnesia of sleep may be attenuated in subjects with primary insomnia

In this study, we pilot tested one of the more controversial components of the Neurocognitive Model of Insomnia; the proposition that subjects with chronic primary insomnia are better able to recall and/or recognize information from sleep onset intervals than good sleeper controls. Nine subjects participated in this pilot study, five of whom had a complaint of insomnia. The remaining four subjects were self-reported good sleeper controls. Subjects were matched for age, sex, and body mass. All subjects spent two nights in the sleep laboratory. The first night served as an adaptation night. The second night served as the experimental night during which a forced awakening and memory task was deployed. In this procedure, subjects were played single-word stimuli across four time periods: at natural sleep onset (Trial 1) and at the sleep onset transitions following three forced awakenings (Trials 2-4 from Stage 2 sleep). All subjects were awakened after about 6 h had elapsed from lights out and were tested for free recall and recognition memory for the word stimuli. The insomnia subjects, tended to identify more of the word stimuli on the recognition task (average for the four trials) and recognized significantly more of the words that were presented at sleep onset proper (Trial 1). This finding suggests that the natural mesograde amnesia of sleep may be attenuated in subjects with insomnia.

Presleep cognitions in patients with insomnia secondary to chronic pain

This study had two primary objectives: (1) characterize the content of presleep cognitions of chronic pain patients and (2) evaluate the association between presleep cognitions and sleep disturbance. Thirty-one outpatients with benign chronic pain completed the Beck Depression Inventory, pain and sleep diaries and participated in an in vivo, presleep thought sampling procedure for 1 week in their homes. The three most frequently reported presleep cognitions were general pain-related thoughts (36%), thoughts about the experimental procedure (27%), and negative sleep-related thoughts (26%). Stepwise multiple regression analyses found the presleep thoughts pertaining to pain and environmental stimuli were significantly associated with sleep continuity, independent from the effects of depression and nightly pain severity. Pain severity was found to be positively associated with Wake After Sleep Onset Time. These results are consistent with cognitive-behavioral models of primary insomnia and suggest the content of presleep cognitive arousal may contribute to sleep disturbance secondary to pain.

Alpha sleep characteristics in fibromyalgia

OBJECTIVE

To characterize the patterns of alpha electroencephalographic sleep and their associations with pain and sleep in patients with fibromyalgia.

METHODS

Pain and sleep symptoms of 40 female patients with fibromyalgia and 43 healthy control subjects were studied before and after overnight polysomnography. Blinded analyses of alpha activity in non-rapid eye movement (non-REM) sleep were performed using time domain, frequency domain, and visual analysis techniques.

RESULTS

Three distinct patterns of alpha sleep activity were detected in fibromyalgia: phasic alpha (simultaneous with delta activity) in 50% of patients, tonic alpha (continuous throughout non-REM sleep) in 20% of patients, and low alpha activity in the remaining 30% of patients. Low alpha activity was exhibited by 83.7% of control subjects (P < 0.01). All fibromyalgia patients who displayed phasic alpha sleep, activity reported worsening of pain after sleep, compared with 58.3% of patients with low alpha activity (P < 0.01) and 25.0% of patients with tonic alpha activity (P < 0.01). Postsleep increase in the number of tender points occurred in 90.0% of patients with phasic alpha activity, 41.7% of patients with low alpha activity, and 25.0% of patients with tonic alpha activity (P < 0.01). Self ratings of poor sleep were reported by all patients with phasic alpha activity, 58.3% of patients with low alpha activity (P < 0.01), and 12.5% of patients with tonic alpha activity (P < 0.01). Patients with phasic alpha activity reported longer duration of pain than patients in other subgroups (P < 0.01). Additionally, patients with phasic alpha sleep activity exhibited less total sleep time than patients in other subgroups (P < 0.05), as well as lower sleep efficiency (P < 0.05) and less slow wave sleep (P < 0.05) than patients with a tonic alpha sleep pattern.

CONCLUSION

Alpha intrusion during sleep can be of different patterns. Phasic alpha sleep activity was the pattern that correlated better with clinical manifestations of fibromyalgia.

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

For the past 25 years, the 'alpha-delta NREM sleep abnormality' has been used by some as a defining or legitimizing marker for poorly defined rheumatic diseases such as fibromyalgia and chronic fatigue syndrome. Comprehensive review of the literature reveals no support for such a conclusion. Most studies involve small numbers of patients. The lack of control subjects, non-standardized recording techniques, and confusion between tonic and phasic alpha frequency activity patterns make comparison difficult. There is much evidence that this sleep EEG pattern is not only non-specific, but may actually reflect a sleep maintaining process. The 'sleep fragmentation' theory of the complaint of non-restorative sleep in this patient population is invalidated by the fact that conditions characterized by severe sleep fragmentation, such as obstructive sleep apnea, are not associated with musculoskeletal symtoms. It is difficult to attribute musculoskeletal symptoms to disorders of sleep in view of the fact that the only organ of the body known to benefit from sleep, or to be adversely affected by lack of sleep, is the brain. It is concluded that fibromyalgia and chronic fatigue syndrome are associated with subjective sleep complaints, but do not represent sleep disorders.

Sleep and circadian rhythm disorders in fibromyalgia

Fibromyalgia (FM) is a syndrome of generalized muscle pain that is also associated with equally distressing symptoms of sleep disturbance and fatigue. FM shows clinical overlap with other stress-associated disorders, including chronic fatigue syndrome (CFS) and depression. All of these conditions have the features of disrupted sleep patterns and dysregulated biologic circadian rhythms, such as stress hormone secretion. This review focuses on the role of sleep and circadian rhythm disorders in FM and, in the absence of any specific treatment for FM, presents a pragmatic therapeutic approach aimed at identifying and treating comorbid sleep and depressive disorders, optimizing sleep habits, and judicious use of pharmacologic agents.