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Sleep Disturbances in Fibromyalgia Patients Robert Bennett MD, FRCP, MACR.

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Presentation on theme: "Sleep Disturbances in Fibromyalgia Patients Robert Bennett MD, FRCP, MACR."— Presentation transcript:

1 Sleep Disturbances in Fibromyalgia Patients Robert Bennett MD, FRCP, MACR

2 Disclosure Research support : Forest, Jazz, Pfizer Advisory Boards: Lilly, Jazz Speaker Bureaus: None

3 3 Key References 1)Rosenthal MS, Physiology and neurochemistry of sleep. Am. J. Pharm. Educ., 62, 204-208, 1998 2)Passarella S et al. Diagnosis and treatment of insomnia. Am J Health-Syst Pharm. 2008; 65:927-34 3)Moldofsky H. Rheumatic manifestations of sleep disorders. Curr Opin Rheumatol 2010;22(1):59-63

4 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management Objectives

5 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management


7 The Principles and Practice of Medicine William Osler MD, 1892 Neurasthenia: a condition of weakness or exhaustion of the nervous system 1. Sleeplessness is a frequent concomitant 2. The majority are moody or depressed 3. They have weariness on the least exertion 4. The aching pain in the back of the neck is the most constant complaint 5. There are spots of local tenderness in the spine

8 Alpha-delta sleep

9 First Scientific Study in FM Delta (1cps) Alpha + delta Auditory stimulation in a healthy control Moldofsky et al. Psychosomatic Med. 37:341-351, 1975

10 Objectives 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management

11 A.REM sleep B.Non-REM sleep Stage 1 - Transition from wake to sleep Stage 2 – Largest percentage of sleep Stages 3 and 4 – Restorative sleep There are 4 to 5 cycles of REM and non-REM sleep each night Each cycle lasts 1.5 to 2 hours Sleep stages

12 REM Stage 1 Stage 2 Stage 3 Stage 4

13 Polysomnography

14 Polysomnographic data is reviewed in 30 second "epochs" Sleep latency Sleep efficiency Percent time in REM and non-REM sleep Percent time in each of the 4 sleep stages Electro-oculogram (EOG) EMG chin EMG tibialis anterior Nasal air flow Chest and abdominal movements Oxygen saturation ECG The number of minutes of sleep divided by the number of minutes in bed. Normal is approximately 85 to 90% or higher. Iber, C et al. The AASM Manual for the Scoring of Sleep: American Academy of Sleep Medicine, Westchester, IL 2007

15 Sleep architecture Decreasing frequency Increasing amplitude

16 Drowsy EEG During the earliest phases of sleep, when people are drowsy the brain produces beta waves (13–35 Hz). As the brain begins to relax slower alpha waves (8–12 Hz) are produced. During this time when you are not quite asleep, people may experience vivid sensations known as hypnagogic hallucinations. Another very common event is myoclonic jerks. Beta waves (12-30 HZ) Eyes open Eyes closed Alpha waves (8 – 12 HZ) EEG leads Chin EMG EOG

17 Stage 1 sleep Slow rolling eye movements Theta waves (4–7.5 Hz) with some alpha Chin EMG EOG EEG leads Stage 1 is a transition period between wakefulness and sleep. In Stage 1, the brain produces high amplitude theta waves (4–7 Hz), which are very slow brain waves. This period of sleep lasts only 5-10 minutes. If you awaken someone during this stage, they might report that they weren't really asleep.

18 Stage 2 sleep Stage 2 lasts for approximately 20 minutes, mainly theta waves (4–7 Hz). Then the brain begins to produce bursts of rapid, rhythmic brain wave activity known as sleep spindles and K-complexes. Body temperature starts to decrease and heart rate begins to slow. Minimal eye movement Minimal chin EMG Theta waves (4–7 Hz)

19 Stages 3 and 4 of non-REM sleep Predominant delta waves (0.5–3.5 Hz) Stages 3 and 4 are often referred to as delta sleep because slow brain waves known as delta waves (0.1 – 4 Hz) occur during this time. Stages 3/4 are a deep sleep that lasts for approximately 30 minutes. Bed-wetting, night terrors and sleepwalking are most likely to occur at the end of stage 4 sleep. It is followed by REM sleep. Some eye movement

20 REM sleep Starts after loss of chin EMG Rapid eye movements Bursts of alpha activity Rapid eye movement (REM) sleep is characterized by eye movement, increased respiration rate and increased brain activity.. Vivid dreams often occur in this sleep stage. Dreaming occurs is due to increased brain activity, but voluntary muscles become paralyzed.

21 Sleep control mechanisms Encephalitis lethargica

22 1.A somnolent-opthalmoplegic form with profound sleepiness often leading to coma and death, paralysis of cranial nerves and expressionless faces. 2.A hyperkinetic form with restlessness, twitching of muscles, anxiety and severe insomnia. 3.An akinetic form with muscle weakness, rigidity, and severe insomnia (postencephalitic parkinsonism). An epidemic that spread throughout the world from 1977 to 1928. Sleep control mechanisms Encephalitis lethargica Postulated cause is a mutation of the H1N1 influenza virus ? N-methyl-D-aspartate (NMDA) receptor antibody mediated

23 Sleep control mechanisms Constantin von Economo 1876 - 1931 Von Economo, reported that encephalitis lethargica was due to injury to the posterior hypothalamus and rostral midbrain. He recognized that one group of individuals infected during the same epidemic instead had the opposite problem: a prolonged state of insomnia that occurred with lesions of the pre-optic area and basal forebrain. He hypothesized that lesions of the posterior hypothalamus could cause the disease we now call narcolepsy. Based on his observations, von Economo predicted that the region of the hypothalamus near the optic chiasma would contain sleep- promoting neurons, whereas the posterior hypothalamus would contain neurons that promote wakefulness.

24 Sleep control mechanisms Orexin neuronal projectins Orexin neurons originating in the posterior hypothalamus regulate sleep and wakefulness by sending excitatory projections to the entire CNS, with particularly dense projections to monoaminergic and cholinergic nuclei in the brain stem.

25 Sleep Awake Sleep control mechanisms VLPO = ventrolateral pre-optic nucleus (GABA & galanin) ORX = orexin nucleus (orexins) LC = locus ceruleus (nor-adrenaline) Raphe = raphe magnus (serotonin) TMN = tubermammilary nucleus (histamine)

26 Objectives 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management

27 DSM-IV criteria for primary insomnia: 1) A complaint of difficulty falling asleep, staying asleep or non-restorative sleep 2) Duration of 1 month 3) Causes clinically significant distress or impairment 4) Does not occur exclusively during the course of a mental disorder 5) Is not due to another medical or sleep disorder or effects of medications/substance abuse Insomnia – definition

28 Riemann et al. Pharmacopsychiatry. 2011 Jan;44(1):1-14. Insomnia - consequences 1) Fatigue / malaise 2) Impaired attention, concentration, memory 3)Vocational dysfunction 4)Daytime sleepiness 5) Motivation / energy / initiative reduction 6) Proneness for errors / accidents at work or while driving 7) Tension headache 8) Obesity / diabetes 9) Hypertension 10) Depression / anxiety 11) Coronary heart disease 12) Increased mortality Sleep loss may transiently improve depression

29 Hyperarousal Sleep disturbance Neurobiological alterations Dysfunctional behavior Stressors Long-term consequences Insomnia – mechanisms

30 Am J Psychiatry 2004; 161:2126–2129 Insomnia – mechanisms

31 (A)Patients with insomnia: brain areas where metabolism was not decreased in waking and sleep states (B)Healthy subjects: brain areas where metabolism, while awake, was higher than in patients with insomnia Insomnia – mechanisms Interacting neural networks are involved in the neurobiology of insomnia: 1. General arousal system (ascending reticular formation and hypothalamus), 2. Emotion-regulating system (hippocampus, amygdala, and anterior cingulate cortex), 3. Cognitive system (prefrontal cortex)

32 Objectives 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management

33 Sleep disturbances in FM Insomnia α intrusion rhythm cyclic alternating rhythm (CAP) Periodic limb movements (PLM/RLS) Snoring and arousals Apnea and hypopnea Periodic breathing Bruxism

34 First Scientific Study in FM (1975) Delta (1cps) Alpha + delta Moldofsky et al. Psychosomatic Med. 37:341-351, 1975 Auditory stimulation in healthy controls

35 ECG R. leg L. leg Chin EMG EEG leads Normal sleep α-EEG sleep Alpha – delta sleep

36 Cyclic alternating pattern (CAP) in FM J Rheumatol 2004; 31:1193–9 Cyclic Alternating Pattern: A New Marker of Sleep Alteration in Patients with Fibromyalgia? Maurizio Rizzi, Piercarlo Sarzi-puttini, Fabiola Atzeni, Franco Capsoni, Arnaldo Andreoli, Marica Pecis, Stefano Colombo, Mario Carrabba, Margherita Sergi Found CAP pattern in 68% FM patients vs 45% controls. Hypothesized that CAP in FM maybe a result of chronic pain reducing sleep efficiency, causing more CAP and more arousals and increasing the occurrence of periodic breathing.

37 Cyclic alterating pattern in FM Sergi et al. Eur Resp J 1999; 14:203-208 R. EOG L. EOG EEG Air flux Thorax EMG Abdomen %O 2 sat.

38 Upper airway resistance syndrome The upper airway resistance syndrome (UARS) is a form of sleep-disordered breathing in which repetitive increases in resistance to airflow within the upper airway lead to brief arousals and daytime somnolence. Patients do not meet criteria for obstructive sleep apnea. Manometry and pneumotachographic are the "gold standard" for diagnosis. Sleep 2004 May 1;27(3):459-66 Now considered to be same as cyclic alterating rhythm

39 Periodic leg movements (PML) PLM is a repetitive cramping or jerking of the legs during sleep; it can range from a small movements in the ankles and toes, to wild flailing of all 4 limbs PLM is the 4 th leading cause of insomnia PLM affects about 5% of total population More common in women (~20% of females age 50) PLM affects about 60% of all FM patients Natarajan R. Review of periodic limb movement and restless leg syndrome. J Postgrad Med 2010;56:157-6

40 Restless legs syndrome J Clin Sleep Med 2010;6(5):423-427 RLS symptoms FM patients = 33% Healthy controls = 3.1% Conclusions: There is a high prevalence and odds of having RLS in FM patients. Clinicians should routinely query FM patients regarding RLS symptoms because treatment of RLS can potentially improve sleep and quality of life in these patients.

41 RLS associations Hereditary (~50%) Uremia (~50%) Narcolepsy (~50%) Pregnancy (~20%) Diabetes REM sleep behavioral disorder Parkinsons disease Hypothyroidism Iron deficiency (ferritin 50 ng/ml) Some drugs (TCAs, SSRIs, DA, L-thyroxine, tramadol, benadryl) Opioid / benzodiazapine withdrawal

42 Sleep apnea

43 Excessive daytime sleepiness * Epworth score usually 15 Loud snoring - more prominent in obstructive sleep apnea Abrupt awakenings with shortness of breath – more prominent in central sleep apnea Observed episodes of apnea during sleep Awakening with a dry mouth or sore throat Morning headache Difficulty losing weight Hypertension, gastric reflux, arrythmias

44 Obstructive sleep apnea

45 Central sleep apnea Central

46 Objectives 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management

47 SITUATIONScore 1. Sitting and reading 2. Watching TV 3. Sitting inactive in a public place 4. As a passenger in a car for an hour 5. Lying down to rest in the afternoon 6. Sitting and talking to someone 7. Sitting quietly after a lunch without alcohol 8. In a car, while stopped for a few minutes in traffic How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? 0 = no chance, 1= slight chance 2 = moderate chance 3 = high chance Epworth sleepiness scale ( ANALYSIS Score of 1-6 getting enough sleep Score of 4-8 the average score Score of 9-15 very sleepy and need further evaluation Score of 16 dangerously sleepy and urgently need specialist evaluation/polysomnogram

48 (1)Do you have uncomfortable feelings or sensations in the legs (or urge to move the legs) while sitting or lying down? (2) Is the discomfort was worse when resting? (3) Is the discomfort improved or resolved with walking? (4) Is the discomfort worse in the evening or nighttime? Restless legs questionnaire Hening WA et al. The Johns Hopkins diagnostic interview for the restless legs syndrome. Sleep Med 2003;4:137-41 Crawling Tingling Cramping Creeping Pulling Painful Electric Itchy Gnawing Aching Score of 4 provides 90% diagnostic sensitivity

49 * A diagnosis of PLMS requires 3 periods of 30 movements followed by partial arousal or awakening Periodic limb movement disorder (PLMD) (nocturnal myoclonus) 1)Patient has RLS 2)Report from sleep partner 3)Polysomnogram 4)Response to dopamine agonist * Diagnostic considerations: 80% of RLS patients have periodic limb movement disorder (PLMD) Paradoxically only 30% PLMD patients have RLS

50 Polysomnography

51 SLEEP 2003;26(6):754-60 Polysomnography is indicated when a sleep-related breathing disorder or periodic limb movement disorder is suspected, initial diagnosis is uncertain, treatment fails, or precipitous arousals occur with violent or injurious behavior. Polysomnography is not indicated for the routine evaluation of transient insomnia, chronic insomnia, insomnia associated with psychiatric disorders or insomnia associated with fibromyalgia or chronic fatigue syndrome.

52 Objectives 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management

53 Chronic Pain Disturbed sleep Chicken or Egg? Dysfunctional sleep and pain ?

54 Clin J Pain Volume 27, Number 5, June 2011 A night of poor sleep was followed by increased pain ratings the following day and a day of increased pain was followed by a night of poor sleep. Dysfunctional sleep and pain

55 SLEEP 2007;30(4):494-505 Dysfunctional sleep and pain MEASUREMENTS: Nocturnal Polysomnography (PSG) Wrist Actigraphy Sleep and Pain Diaries Diffuse Noxious Inhibitory Controls (DNIC)

56 Dysfunctional sleep and pain FA underwent 8 forced awakenings (one per hour) on nights 3-5.

57 Impaired sleep is associated with reduced activation of the inhibitory pain pathway Bottom line: Frequent sleep disruptions cause a reduction in the descending inhibitory control system for pain

58 Chronic Pain Disturbed sleep Dysfunctional sleep and pain ?

59 Sleep improvement reduces pain Spaeth et al. Annals of the Rheumatic Diseases (in press) FIQ sleep vs pain VAS (r=0.7, p<0001)

60 Objectives 1)Historical aspects of sleep in FM 2)Physiology of sleep 3)Insomnia 4)Disturbed sleep in FM patients 5)Evaluation of disturbed sleep in FM 6)Disturbed sleep and pain 7)Management

61 Management of FM associated sleep disorders 1)Explore sleep hygiene and behavioral issues 2)Look for an associated primary sleep disorder: RLS/PLM, sleep apnea, UARS, bruxism 3)Review current medications for sleep side effects 4)Review all previous treatments 5)Assess for nocturnal pain generators 6)Screen for depression and anxiety Modified from Abad VC et al. Sleep Med ReV 2008;12:211-228 Cramps Carpal tunnel Bursitis Spinal OA Spinal stenosis OA hip or knee

62 Comment: Young and middle-age patients with sleep-onset insomnia can often derive significantly greater benefit from CBT than pharmacotherapy. CBT should be considered a first line intervention for chronic insomnia. JAMA. 2001;285:1856-1864 CBT for insomnia

63 Basic principles of CBT Sleep hygiene Stimulus control Sleep restriction

64 1)Maintain a regular sleep schedule 2)Sleep as long as necessary to feel rested (usually 7 to 8 hours for adults) and then get out of bed 3)Adjust the bedroom environment to decrease stimuli (light, sound, temperature) 4)Try not to force sleep (see sleep restriction) 5)Resolve concerns or worries before bedtime 6)Avoid caffeinated beverages after lunch 7)Avoid alcohol and tobacco in late afternoon and evening 8)Exercise regularly, preferably more than 4 hours prior to bedtime 9)Avoid daytime naps that are longer than 20 to 30 minutes or occur late in the day Sleep hygiene

65 Rationale: Patients with insomnia often associate their bed and bedroom with the fear of not sleeping. The longer they stay in bed the stronger the association becomes. Stimulus control 1)Patients should not go to bed until they are sleepy 2)Set an alarm clock to wake them at the same time every morning, including weekends. 3)They should not engage in activities that reward them for being awake, such as eating or watching TV. 4)They should not spend more than 20 minutes in bed awake. 5)If they are awake after 20 minutes, they should leave the bedroom and engage in a relaxing activity. 6)They should not return to bed until they feel tired. 7)If they return to bed and still cannot sleep within 20 minutes, the process should be repeated.

66 Rationale: Many patients with insomnia stay in bed trying to get to sleep. Sleep restriction therapy increases the drive to sleep by limiting the total time allowed in bed. Sleep restriction therapy 1)Decrease the time spent in bed to equal the time that the patient reports sleeping (but not less than 5 hours per night) 2)The patient reports the amount of sleep obtained the previous night and the amount of time spent in bed. 3)The clinician then computes the sleep efficiency (reported time asleep divided by the reported time in bed). 4)The time in bed is increased by 15 to 30 minutes once the sleep efficiency exceeds 85 percent. 5)This process is repeated until the patient reports improved sleep without residual daytime sleepiness. Spielman et al. Insomnia: Sleep restriction therapy. Insomnia Diagnosis and Treatment, Informa UK Ltd, London 2010. p.277.

67 Drug Action Dose (mg) Half-life (h) Estazolam 1 BzRA 1–2 10–24 Flurazepam 1 BzRA 15–30 48–120 Temazepam 1 BzRA 15–308–20 Triazolam 1 BzRA 0.125–0.25 2.4 Quazepam 1 BzRA 7.5–15 48–120 Zolpidem 2 BzRA 5–10 1.4–3.8 Zolpidem ER 2 BzRA 6.25–12.5 2.8 Zaleplon 2 BzRA 5–20 1.0 Eszopiclone 2 BzRA1–3 6.0 Ramelteon 3 MtRa 8 1–2.6 Type 1 indicates benzodiazepines, type 2 indicates non-benzodiazepines, and type 3 indicates melatonin. FDA approved drugs for the treatment of insomnia Sleep onset insomnia use a short-acting medication: Zolpidem Capelin Triazolam Lorazepam Ramelteon Sleep maintenance insomnia use a longer- acting medication : Low dose doxepin Zolpidem ER Eszoplicone Temazepam Estazolam From: UpToDate 2011

68 Slow wave sleep enhancers GABA reuptake inhibitor: Tiagabine GABA enhancer: Sodium oxybate (not approved for FM) Selective GABA A agonist Gaboxadol (not available in USA) VDCC α2δ calcium channel modulators: Gabapentin/pregabalin 5-HT[2A] receptor antagonist: Ritanserin, ketanserin (not available in USA) GGABA rec. subunits

69 OnsetDurationREMSWS Benzodiazapines Benzo. Receptor Anti-histamines (old) Anti-histamines (newer) Anti-epileptics (old) Anti-epileptics (newer) TCAs and SARIs SSRIs and SNRIs Ramelteon Sodium oxybate Tiagabine Psychostimulants β adrenergic blockers α adrenergic blockers Corticosteroids Drugs and sleep architecture

70 J Rheumatol. Epub Sep 2, 2011 An 8 week study of cyclobenzaprine (1–4 mg hs) in 37 FM subjects and 36 controls. Subjects had to have the α-EEG sleep anomaly in 40% epochs of non-REM sleep Low dose cyclobenzaprine

71 % Change Cyclobenz. % Change Placebo P-value Pain -* Fatigue - 14.0+ 4.300.13 Tenderness - 30.1+ 3.200.03* HAD depression - 22.2+ 10.40.02* Total sleep time + Sleep efficiency + 15.6+ 3.60.09 % Stage 3 sleep + 16.2- 2.800.17 % Stage 4 sleep - 28.6+ 22.90.03* Low dose cyclobenzaprine

72 RLS / PLM management General measures Correct iron deficiency Stop aggravating drugs Dopamine agonists Gabapentin, pregabalin, valproate Clonidine Clonazepam Opioids Relaxing bedtime routine Regular stretching Minimize caffeine, alcohol, tobacco Avoid exercise 2 h before sleep Cold compress application Carbidopa Levodopa Pramipexole Ropinirole Pergolide Cabergoline Anti-nausea drugs OTC antihistamines Antidepressants (TCAs and SSRIs) Antipsychotics Tramadol

73 Sleep apnea management

74 Future Directions 1.Individualized management of insomnia 2.Widespread adoption of CBT as an initial management strategy 3.Improved non-benzodiazepines 4.Development of Orexin modulators 5.Newer 5-HT receptor antagonists


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