Hypersomnolence in Fibromyalgia Syndrome
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Clinical and Experimental Rheumatology 2002; 20: 69-72. BRIEF PAPER Hypersomnolence in ABSTRACT Introduction O b j e c t ive : To eva l u ate hy p e rs o m n o - Fi b ro mya l gia syndrome (FMS) is a fibromyalgia syndrome lence in patients affected by fibromyal - common condition causing generalized gia syndrome. muscle pain (1). This syndrome affects P. Sarzi-Puttini, M. Rizzi1, Methods: Thirty consecutive patients up to 3-4% of the general population A. Andreoli1, B. Panni, a ffected by fi b ro mya l gia syndro m e and is one of the most common diag- M. Pecis1, S. Colombo1, (FMS) (28 F) completed a sleep ques - noses seen in ambu l at o ry office set- tionnaire and underwent the following tings. 80 to 90% of patients are women, 2 M. Turiel , M. Carrabba, evaluations: lung function tests; poly - and the peak age is 30-50 years (2). M. Sergi1 somnography; the Epworth sleepiness The criteria used for its diagnosis were scale (ESS), whi c h measures sleep com - s t ated by the A m e rican College of Unità Operativa di Reumatologia, 1Unità plaints and daytime hypersomnolence; Rheumatology in 1990 (3). The pain is Operativa di Fisiopatologia Respiratoria, and the visual analogical scale (VAS) wi d e s p re a d , lasting for at least thre e 2Cattedra di Medicina Interna, Azienda to detect subjective pain, fatigue, anxi - months, bilateral, above and below the Ospedaliera, Polo Universitario L. Sacco, ety and depression. waist, axial,and involving at least 11 of Milan, Italy. Results: The FMS patients were divid - 18 specified tender points. Other char- Please address correspondence and ed into two groups based on their ESS acteristics of the syndrome - often pre- reprint requests to: P. Sarzi-Puttini, MD, score. Patients complaining of daytime sent, but not essential for the diagnosis Unità Operativa di Reumatologia, hypersomnolence had a higher number - are chronic fatigue, migraine, irritable Azienda Ospedaliera, Polo Universitario of tender points (15 ±2 vs. 12 ±1, p< bowel syndrome, headache, paresthe- L. Sacco, Via G.B. Grassi 74, 20157 Milan, Italy. E-mail: [email protected] 0.01), a higher subjective pain score sias, Raynaud’s like symptoms, depres- (72±15 vs. 52±13, p<0.05),and more sion, anxiety and non-restorative and/ Received on February 16, 2001; accepted in revised form on September 5, 2001. fatigue (p<0.05). The diffusing capaci - or disturbed sleep (4). ty of the lung (Tlco) was more impaired The reported complaint of poor sleep is © Copyright CLINICAL AND and the occurrence of periodic breath - so common in FMS patients that in EXPERIMENTAL RHEUMATOLOGY 2002. ing was higher. FMS patients com - some case series its prevalence is near- plaining of daytime somnolence had ly 100% (5-7). The observation that a Key words: Fibromyalgia, hyper- s i g n i fi c a n t ly less efficient sleep than neurasthenic musculoskeletal pain syn- somnolence, polysomnography, sleep. the FMS patients with no daytime som - drome can be elicited in normal volun- nolence (p <0.05), i.e. a lower propor - teers undergoing selective deep NREM tion of stage 3 sleep (5± 2% vs. 12 ± sleep deprivation (7) seems to suggest 3%; p < 0.001), stage 4 sleep (1± 0.5% that a vicious circle may be in opera- vs . 4±1% ; p<0. 0 0 1 ) , and twice as many tion, with pain impaired sleep leading arousals per hour of sleep (p < 0.01). to a worsening of the disease. Moldof- The re s p i rat o ry pat t e rn of FMS pa - sky et al. proposed an alpha intrusion tients with hypersomnolence showed a on delta sleep in 1975 (8) as a marker higher occurrence of periodic breath - of the sleep impairment typical of FMS ing (p<0.05). The short length of apno - p at i e n t s , but this has not been con- as and hypopnoeas did not affect the firmed by other studies (9, 10), while apnea/hypopnea index (5.1 ± 3 vs. 7 ± an association between alpha intrusion 4; ns), but FMS patients with daytime in NREM sleep and other FMS symp- hypersomnolence had a greater num - toms has been variously confirmed (11) ber of desaturations per hour of sleep and rejected (5) by different trials. (11 ±6 vs. 6± 5; p < 0.05). Pulmonary The hypothesis that other disorde r s cau- volumes did not differ between the two sing sleep fragmentation, such as sleep groups. The EES score was significant - apnea syndrome (12), might be blamed ly correlated in FMS patients, and even for the non-refreshing sleep symptoms m o re marke d ly in the FMS pat i e n t s reported by FMS patients was not con- with hypersomnolence, TLco, A/I, and firmed by a controlled study (13). disease duration. The ESS score was However, increased daytime sleepiness correlated significantly with the num - is one of the most important symptoms ber of tender points only in FMS pa - in fi b ro mya l gia patients. The aim of tients with daytime hypersomnolence. this study was to compare sleep com- C o n cl u s i o n : The occurrence of day - plaints, sleep architecture, number of time hypersomnolence in FMS patients arousals,alpha-delta activity, and respi- is linked to a greater severity of fibro - ratory function in patients with FMS myalgia symptoms and to more severe and hypersomnolence versus fibromy- polysomnographic alterations. algia with no daytime sleepiness. 69 BRIEF PAPER Hypersomnolence in fibromyalgia / P. Sarzi-Puttini et al. Materials and methods mocouples and thoracic and abdominal the lung with the single breath holding Population.Thirty eligible consecutive belts with built-on piezo electro d e s method (TLco), i n cluding membra n e Caucasian patients (28 females) aged recorded airflow and ventilatory efforts (Dm) and capillary (Vc) components 51.2 ± 8.9 years with FMS, diagnosed re s p e c t ive ly. Oxyhaemoglobin sat u ra- (T.T Autolink Mo r gan , An d o ver , MA , according to the 1990 American Col- tion was recorded by finger pulse oxi- USA) and blo o d gas analysis (BG3, l ege of Rheumat o l ogy Classifi c at i o n m e t ry (Pulsox-7 Minolta, O s a k a , I n s t ru m e n t ation Lab o rat o ry, Pa d e rn o Criteria (3), were invited to participate Japan). The transducers and lead wires Dugnano, Italy). in this study. A 2-week wash-out period allowed normal positional changes dur- Statistical analysis. Data were report- for any pharm a c o l ogical tre at m e n t ing sleep. Bedtime and awakening time ed as mean ± standard deviation. Statis- re l ated to FMS was requested of all were at each subject’s discretion; the tical analysis of the anthro p o m e t ri c patients. A sleep questionnaire and the polysomnography was terminated after data, polysomnographic recordings and Epworth Sleepiness Scale (ESS) were final awakening. In order to avoid the lung function tests was perfo rm e d then administered to all subjects and first night effect, each subject spent 2 using the unpaired Student’s t test. the FMS patients were divided in two nights in the sleep laboratory; only data Pearson’s chi square was used for other subsets according to the presence or ab- recorded during the second night were comparisons of means and proportions. sence of hypersomnolence. No differ- evaluated. The Mann-Wh i t n ey U test and the ence was observed in the disease dura- S l e ep and bre athing va ri ables we re Spearman Rank correlation were used tion (7.3±3.1 vs. 5.9±3.8), age (52.2 ± stored on an optical disk and then man- where appropriate.The level of signifi- 8.9 vs. 51.4 ± 2 yrs), sex (15/1 vs. 12/1 ually scored by two physicians, blind- cance was p < 0.05. All statistical ana- F/M) and body mass index (BMI) (25.8 ed, in 30s epochs, according to stan- lyses were performed using the statisti- ± 3.7 vs. 25.5 ± 3.1 Kg/m2) between the dard criteria (15). The correlation be- cal pack age SPSS 9.0 (SPSS Inc. , patients with and without hypersomno- tween sleep, breathing and body posi- Chicago, IL, USA). lence (HS). Informed consent was ob- tion was analysed automatically by the tained in all cases. The Hospital Medi- computer. Results cal Ethics Committee ap p roved the Apneas we re defined as 10-second FMS patients we re divided into two study. pauses in res p i r ation. Hypopnoeas wer e groups according to their ESS score: 16 Clinical evaluation. In all subjects the d e fined as a decrement in airfl ow ³ FMS patients with hy p e rs o m n o l e n c e following clinical variables were evalu- 50%, associated with either an arousal (FMS+HS) and 14 FMS patients with- ated: examination of 18 tender points at the end of the episode or a fall in ar- out hypersomnolence (FMS-HS). using the protocol of Wolfe et al. (3) (a terial oxygen saturation ³ 4%. The res- Patients complaining of daytime hyper- score for number of tender points was piratory disturbance index (RDI) was somnolence had a higher number of obtained and could range from 0 to 18); defined as the average number of epi- tender points (p<0.