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Sleep Apnea in Patients with Fibromyalgia: a Growing Concern

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Sleep Apnea in Patients with Fibromyalgia: a Growing Concern FIBROMYALGIA Illustration by: Anthony Di Lauri Di Anthony by: Illustration Sleep Apnea in Patients With Fibromyalgia: A Growing Concern Patients with fibromyalgia have a tenfold increase in sleep-disordered breathing, including obstructive sleep apnea. Proper diagnosis and treatment will improve health and quality of life for fibromyalgia patients. Victor Rosenfeld, MD Medical Director Neurology and Sleep Services SouthCoast Medical Group Savannah, GA, ibromyalgia (FM) is a widespread pain and fatigue been recognized as more than a pain syndrome. Research- syndrome without a known cause. The prevalence of ers’ understanding that FM involves central nervous system FFM ranges from 2% to 3% of the general population, sensitization and deep sleep dysregulation have changed with women affected six to nine times more frequently the focus of FM diagnosis and treatment. Revised diagnos- than men.1 It is estimated that the prevalence increases in tic criteria are illustrated in Table 1. As such, clinicians have women as they age, from 4% at age 20 to 8% by age 70.1-3 begun to recognize that the treatment of sleep and fatigue Most patients with FM complain of hurting all over— comorbitities should be a major focus in the management from head to toe. The neck, back, hips, and shoulders are of FM patients. The objective of this article is to review typically prominent sites of pain. Patients also will fre- current diagnosis and treatment options for sleep-related quently complain of poor sleep, burning and numb sensa- problems in patients with FM, including a case presenta- tions, dry eyes and mouth, temperature sensitivity (feel- tion representative of a common FM patient. ing cold), headaches, fatigue, dizziness, abdominal and bladder problems, sensitivities to medications, restless leg Sleep Disturbances syndrome, jaw discomfort, and difficulties with mood and According to a recent article, sleep and fatigue symptoms memory. have surpassed pain as the most prominent complaints From its earliest description in the literature, FM has in FM patients (see Table 2).4 It is now known that FM June 2011 | Practical Pain Management 77 Sleep Apnea in Patients With Fibromyalgia: A Growing Concern Table 1. American College of Rheumatology New Diagnostic contributes to sleep complaints Criteria for Fibromyalgia among patients with FM. In the past, the diagnosis of alpha-wave The American College of Rheumatology (ACR) has recommended a revised Fibromyalgia intrusions could be very time con- Diagnostic Criteria (FDC), which does not include the tender point examination and puts more suming, with researchers counting 1 emphasis on the broad spectrum of symptoms commonly seen in fibromyalgia patients. the intrusions by hand over many hours. Today, diagnostic approaches, Widespread Pain Index (WPI) 0-19 including the use of quantitative electroencephalography (qEEG), can Ask about pain in 19 body regions easily demonstrate alpha-wave intru- sions in deep sleep (see Figure 1).5 Symptom Severity Scale (SS) 0-12 Figure 2 shows alpha-wave intru- sion during delta waves on a sleep Symptom domains 3 (0-3 severity): (fatigue, cognition, tired) hypnogram from an overnight sleep study using polysomnography (PSG) 0=None, 1=Slight/mild, 2=Moderate, 3=Severe in a patient with FM. More than 90% of patients with FM will have Somatic symptoms (0-3 scale) based on number of other symptom domains: alpha-wave intrusions during their sleep and it is thought that this phe- 0=None, 1=Few, 2=Moderate, 3=Many nomenon contributes to pathology and complaints in patients with FM. ACR 2010 FDC confirmed diagnosis if: WPI≥ 7 + SS ≥5 OR WPI 3-6 + SS ≥9 Recent therapeutic approaches that Source: Wolfe F, Clauw DJ, Fitzcharles MA et al. The American College of Rheumatology preliminary target this phenomenon, such as the diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. γ-aminobutyric acid (GABA)-type 2010;62(5):600-610. B agonist, sodium oxybate, has been shown to reduce alpha-wave intru- Table 2. Summary of Most Prominent Complaints in sions, as well as improve symptoms of Fibromyalgia Patients pain and fatigue.6,7 In addition to alpha-wave intru- Symptoms Mean Severity (SD) sion that may impair the restorative aspect of sleep, FM patients usually Morning stiffness 7.2 (2.5) have diminishment of the overall amount of deep sleep. In the normal Fatigue 7.1 (2.1) population, slow-wave sleep (SWS) should account for 20% to 25% of Nonrestorative sleep 6.8 (2.0) sleep, but in the FM population it is typically much less. In Figure 3, Pain 6.4 (2.0) a normal sleep hypnogram demon- strates normal deep sleep predomi- Forgetfulness 5.9 (2.7) nantly in the first 5 hours of sleep as compared to a FM patient who does Note that pain is rated below fatigue and sleep. Source: Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with not enter deep sleep for any signifi- fibromyalgia. BMC Musculoskelet Disord. 2007; 8 : 27. cant period of time and has multiple unexplained arousals. patients suffer from a litany of sleep Perhaps the most common sleep Patients with sleep disordered issues including nonrestorative sleep problem seen in patients with FM is breathing (SDB) also can present with alpha-wave intrusions, insom- nonrestorative sleep. The majority of with a number of complaints, includ- nia, restless leg syndrome, hypersom- patients with FM will have alpha- ing drowsiness, inability to sleep, nia such as narcolepsy, and obstruc- wave intrusions during deep sleep. cognitive dysfunction, fatigue, mood tive sleep apnea (OAS). It is thought that this phenomenon complaints, and decreased libido. A 78 Practical Pain Management | June 2011 Sleep Apnea in Patients With Fibromyalgia: A Growing Concern FM. Since we know that patients with FM can have poor quality sleep, the identification of a treatable sleep disorder such as SDB is something that can greatly benefit this patient population. Patients with FM and SDB have added risk factors—prescription of sedative or narcotic agents, which can cause or worsen SDB. With the airway blocked, air cannot reach the lungs and oxygen levels drop. This causes the brain to slightly wake up; this is referred to as a microarousal. These brief repeated arousals cause sleep to be nonrestorative and put stress on the heart and other organs. Figure 1: Alpha wave intrusion (top line) clearly demonstrated by quantitative electroencephalography Sleep Apnea analysis can be seen in parallel with delta waves (second line) in this patient with fibromyalgia. One of the more serious SDBs is OSA. The condition is characterized by loud, frequent snoring and involves the par- tial or complete collapse of the airway during sleep. With OSA, muscles in the throat start to relax during sleep, which makes it more likely for the air- way to collapse. An apnea is described as a cessation of airflow >10 seconds. A hypopnea is typically defined as a decrease in airflow of at least 30% associated with a decrease in oxygen saturation of >4%. Episodes can occur hundreds of times in one night. A large neck (greater than 18 inches in men or 16 inches in women), body mass index (BMI) >35 kg/m2, a retrusive jaw, or large tonsils in children can predispose patients to OSA. Figure 2. Alpha waves superimposed on delta waves during slow-wave sleep in a patient with Obstructive sleep apnea can cause fibromyalgia. excessive daytime drowsiness, which can affect performance at work and small case study demonstrated that volunteers developed pain and cogni- quality of life. When oxygen levels treatment of SDB could improve tive dysfunction similar to that seen drop, numerous physiologic changes symptoms in patients with FM.8 We in the FM population; findings that occur, including elevated cortisol lev- also know that disruption of deep support the association between dys- els, hyperglycemia, insulin resistance, sleep in healthy individuals can pre- functional sleep and FM.9 and increase in sympathetic tone with dispose them to increases in pain per- Given the plethora of complaints increased heart rate and blood pressure. ception and cognitive difficulties. A common in both patients with FM Because of this, OSA has been linked number of smaller trials have shown and SDB, there has been new inter- to a number of medical conditions, that when deprived of SWS, healthy est in ruling out SDB in patients with including high blood pressure, stroke, June 2011 | Practical Pain Management 79 Sleep Apnea in Patients With Fibromyalgia: A Growing Concern REM Sleep Wake or prevents apneas and hypopneas. REM Advancements in CPAP technology Stage 1 (eg, improvements that allow ambient Stage 2 air to be humidified without manual Deep 10pm 11pm 12pm 1am 2am 3am 4am 5am 6am 7am adjustment) can significantly reduce Time the amount of condensation that accu- mulates in the tubing that connects Sleep stage diagram of a normal night’s sleep. the machine to the mask. REM Sleep Today, most CPAP machines are Wake equipped with expiratory pressure REM relief that maintains positive pressure Stage 1 Stage 2 during inspiration, but reduces pres- Deep sure during exhalation. The reduction 10pm 11pm 12pm 1am 2am 3am 4am 5am 6am 7am in pressure during exhalation makes it Time easier for the patient to breathe. The Sleep stage diagram of a person with fibromyalgia. titrated pressure is the pressure of air Figure 3. A normal sleep hypogram showing 25% deep sleep in the first 5 hours of sleep (above) and in at which most (if not all) apneas and in a fibromyalgia patient (below), where there is no deep sleep. hypopneas have been prevented, and REM, rapid eye movement it is usually measured in centimeters of water (cm/H2O). A typical CPAP heart attack, atrial fibrillation, gastro- as low-sleep efficiency and increased machine can deliver pressures between esophageal reflux, diabetes, and glau- period limb movements also can be 4 and 20 cm/H2O.
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