Comparison of Sleep Problems in Individuals with Spinal Cord Injury and Multiple Sclerosis

Insomnia severity predicts depression, anxiety, and posttraumatic stress disorder in veterans with spinal cord injury or disease: a cross-sectional observational study

STUDY OBJECTIVES

To assess the association of insomnia symptoms and psychiatric symptoms in patients with spinal cord injury or disease (SCI/D).

METHODS

In this cross-sectional observational study, veterans with SCI/D (n = 72; mean = 59.85 ± 10.4 years; 92% male) completed baseline measures, including the Insomnia Severity Index (ISI) during the baseline phase of a clinical trial on treatment of sleep disorders in veterans with SCI/D. Depression severity was measured by the Patient Health Questionnaire (PHQ-9; sleep items excluded), anxiety severity was measured by the Generalized Anxiety Disorder screener (GAD-7), and probable posttraumatic stress disorder (PTSD) was measured by the Primary Care PTSD screener. Blocked regression was used to evaluate the impact of insomnia symptoms (ISI) on mental health measures after accounting for demographics and level of spinal cord injury/disease.

RESULTS

On average, participants scored in the mild range for depression (PHQ-9 = 7.4 ± 5.9) and anxiety severity (GAD-7 = 6.1 ± 6.1). In total, 36.1% (n = 26) screened positive for probable PTSD. ISI explained 19% of the variance in PHQ-9 and 20% of the variance in GAD-7 (P < .001) over and above demographics and SCI/D level of injury/disease. Odds of probable PTSD were increased 1.22-fold for each 1 unit increase in ISI (P = .001) after accounting for demographics and level of injury/disease.

CONCLUSIONS

In veterans with SCI/D, insomnia severity was linked to depression and anxiety symptom severity and risk of PTSD. Study results warrant further research to evaluate the impact of insomnia treatment on depression, anxiety, and PTSD in patients with SCI/D.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Treatment of Sleep-disordered Breathing in Patients With SCI; URL: https://clinicaltrials.gov/ct2/show/NCT02830074; Identifier: NCT02830074.

CITATION

Kelly MR, Zeineddine S, Mitchell MN, et al. Insomnia severity predicts depression, anxiety, and posttraumatic stress disorder in veterans with spinal cord injury or disease: a cross-sectional observational study. J Clin Sleep Med. 2023;19(4):695-701.

Nocturnal bladder emptying and Quality of Life in patients with spinal cord injury

BACKGROUND

Little is known about the relationship between sleep disruption due to nocturnal bladder emptying and Quality of Life in patients with spinal cord injury.

AIM

The aim of this study was to evaluate the possible influence of number of nocturnal bladder emptying, bladder emptying method and nocturnal incontinence on the Quality of Life of patients with spinal cord injury.

DESIGN

The design of this paper is a cross-sectional descriptive study.

SETTING

The setting is in- and outpatient.

POPULATION

Seventy-nine patients aged between 18 and 77 years with SCI in a first rehabilitation period or follow-up.

METHODS

Patients were asked to complete Short Form-36 and Incontinence Quality of Life questionnaires and a medical information form. Independent samples t-tests and ANOVA were used to compare scores between groups.

RESULTS

The response rate was 71 out of 79 (89%; 51 males and 20 females). 16 paraplegic and 4 tetraplegic patients were chronic, 29 paraplegic and 22 tetraplegic patients were in rehabilitation therapy or had finished this treatment recently. The paraplegic group had a significantly better Short Form-36 total score and emotional function score, while the tetraplegic group had a significantly better Incontinence Quality of Life total score and avoidance and limiting behavior score. The paraplegic patients with 0-1 nocturnal bladder emptying had better Short Form-36-derived Quality of Life than those with ≥2 emptying. Quality of Life score was not associated with gender, leg oedema, incontinence, or acute/chronic group. Incontinence Quality of Life score was significantly better for patients with incomplete spinal cord injury. Fully completed questionnaires were returned by 36 patients; at least 1 item was missing for 35 participants.

CONCLUSIONS

General Short Form-36-derived Quality of Life was better for the paraplegic population. Incontinence-related Quality of Life was better in tetraplegic patients, most of whom used suprapubic catheterization. Paraplegic patients had compromised sleep and Quality of Life when the patient had to wake up two or more times at night to empty the bladder by voiding or intermittent catheterization. The high number of incomplete responders indicates the shortcomings of Quality-of-Life questionnaires for wheelchair-bound patients with spinal cord injury.

CLINICAL REHABILITATION IMPACT

The use of suprapubic catheterization should be considered to improve Quality of Life for tetraplegic patients. For paraplegic patients, we must focus urological policy on aiming to reduce the number of nighttime bladder emptying to one or none.

Perceived sleep problems after spinal cord injury: Results from a community-based survey in Switzerland

Objective: To investigate the burden of sleep problems within the Spinal Cord injured (SCI) community with respect to the general population (GP) in Switzerland. The study further explored potential predictors for receiving treatment for sleep problems after SCI.Design: Cross-sectional study.Setting: SCI community in Switzerland.Participants: Individuals diagnosed with an SCI, aged 16 years or older that permanently reside in Switzerland (N = 1549).Interventions: Not applicable.Outcome measures: Perceived sleep problems within the SCI community and GP. For those with sleep problems and SCI, an indicator for having received treatment was measured.Results: 58.8% of survey participants indicated having a sleep problem; 69.4% of those with a sleep problem did not indicate receiving treatment. Amongst people living with an SCI, individuals between the ages of 46-60 years (adjusted Odds Ratio, OR = 3.07; 95% CI 1.54-6.16), participants reporting severe financial hardship (OR = 2.90; 95% CI) 1.69-4.96, and those that indicated having pain (OR = 5.62; 95% CI 3.52-8.98) were more likely to have a chronic sleep problem. In comparison to the Swiss GP, the prevalence of having a sleep problem was 18% higher among persons with SCI, with the largest discrepancy for males with paraplegia between the ages of 46-60 years (Prevalence ratio, PR = 1.28; 95% CI, 1.21-1.36).Conclusion: Individuals with SCI experience more sleep problems compared to the Swiss GP. Findings from this study suggest that clinical screening for sleep issues targeting high risk groups is needed to reduce the large prevalence of non-treatment in individuals with SCI.

Improvement in sleep outcomes with a 17β-estradiol-progesterone oral capsule (TX-001HR) for postmenopausal women

Objective:

The aim of the study was to evaluate the effects of TX-001HR, a single-capsule 17β-estradiol–progesterone on sleep parameters in postmenopausal women with vasomotor symptoms (VMS) using the Medical Outcomes Study (MOS)-Sleep scale questionnaire in the REPLENISH trial.

Methods:

In the REPLENISH trial (NCT01942668), women were randomized to one of four doses of TX-001HR or placebo, and the 12-item MOS-Sleep questionnaire (secondary endpoint) was self-administered at baseline, week 12, and months 6 and 12. Changes from baseline in the MOS-Sleep total score and 7 subscale scores were analyzed for treatment groups versus placebo at all time points. Somnolence was also collected as an adverse event.

Results:

Women (mean age 55 y) were randomized to TX-001HR (estradiol/ progesterone [E2/P4] [mg/mg]) doses: 1/100 (n = 415), 0.5/100 (n = 424), 0.5/50 (n = 421), 0.25/50 (n = 424), or placebo (n = 151). TX-001HR significantly improved MOS-Sleep total score, Sleep Problems Index II subscale, and sleep disturbance subscale versus placebo at all time points, except with 0.25 mg E2/50 mg P4 at week 12. Differences in LS mean changes between TX-001HR and placebo for MOS-Sleep total scores ranged from −6.5 to −7.6 at 12 months (all; P ≤ 0.001). All doses of TX-001HR significantly improved the Sleep Problems Index I subscale at all time points. The sleep somnolence subscale significantly improved from baseline with 0.5 mg E2/100 mg P4 and 0.5 mg E2/50 mg P4 at month 12. The incidence of somnolence as a treatment-emergent adverse event ranged from 0.2% to 1.2% versus 0% with placebo.

Conclusion:

TX-001HR significantly improved MOS-Sleep parameters from baseline to week 12, which was sustained for up to 12 months, and was associated with a very low incidence of somnolence.

Sleep-Disordered Breathing and Spinal Cord Injury: A State-of-the-Art Review

Individuals living with spinal cord injury or disease (SCI/D) are at increased risk for sleep-disordered breathing (SDB), with a prevalence that is three- to fourfold higher than the general population. The main features of SDB, including intermittent hypoxemia and sleep fragmentation, have been linked to adverse cardiovascular outcomes including nocturnal hypertension in patients with SCI/D. The relationship between SDB and SCI/D may be multifactorial in nature given that level and completeness of injury can affect central control of respiration and upper airway collapsibility differently, promoting central and/or obstructive types of SDB. Despite the strong association between SDB and SCI/D, access to diagnosis and management remains limited. This review explores the role of SCI/D in the pathogenesis of SDB, poor sleep quality, the barriers in diagnosing and managing SDB in SCI/D, and the alternative approaches and future directions in the treatment of SDB, such as novel pharmacologic and nonpharmacologic treatments.

Sleep Disordered Breathing and Spinal Cord Injury: Challenges and Opportunities

Purpose of review

This paper focuses on the sleep disorders in patients with spinal cord injury (SCI/D), particularly mechanism of sleep disordered breathing (SDB) and challenges in diagnosis and management. Based on a review of recent literatures and studies the paper summarizes some main challenges with respect to management of SDB in patients with SCI; and what are the responsible mechanisms of disease? What are the barriers in diagnosing and treating SDB using standard treatment such as positive airway pressure (CPAP)?.

Recent findings

Previous studies have shown that most SCI/D patients have SDB with heterogeneity in prevalence mainly related to using different definition or methods of diagnosing SDB, while recent studies using new definition of SDB based on recommended criteria from the American Academy of Sleep Medicine (AASM) and also include the data on effect of SCI/D level on prevalence and describe different type of SDB. Furthermore, recent data describes simplified method of diagnosing SDB by using a combination of home sleep apnea testing and transcutaneous CO2 monitoring. Finally, emerging data has been pointing at strong relationship between SDB and cardiovascular disease including nocturnal hypertension in patients with SCI/D.

Summary

The findings indicate that early testing for SDB and associated cardiovascular disease in patients with SCI is recommended and could be beneficial in reduced the high morbidity and mortality in this group of patients with disability. In addition, studies on treatment of other sleep disorders in SCI/D are not available to inform clinical decision making. Understanding the pathophysiology of sleep disorders in SCI/D is critical for the development of new effective therapies. This review provides evidence for best practices; highlights new discoveries for the diagnosis and management of sleep disorders in SCI/D, and discuss challenges and future directions.