How does Fibromyalgia Affect Sleep?

Fibromyalgia is a generalized chronic pain syndrome characterized by a wide spectrum of symptoms, including fatigue, headaches, muscle stiffness, and emotional distress. Studies shows that it affects up to 5% of the general population with a clear predominance in women.

“Fibromyalgia (FM) is a medically unexplained illness characterized by four quadrant pain lasting at least 3 months and accompanied by multiple areas of tenderness on palpation of the body using 4 kg force. FM occurs more often in women than men but is quite common in both sexes, occurring in approximately 3% of the population. Although sleep difficulties are not part of standard diagnostic criteria, insomnia complaints of poor and nonrestorative sleep are common and have been associated with intense of pain, fatigue, sleepiness, and cognitive difficulties in FM.

FM frequently occurs in conjunction with chronic fatigue syndrome (CFS). CFS is a medically unexplained condition characterized by persistent or relapsing fatigue lasting at least 6 months, which substantially reduces normal activity. In addition to severe fatigue, one of the eight symptoms used for diagnosing CFS is ‘unrefreshing sleep’ and this sleeprelated problem is the most common complaint among CFS patients. Although, FM and CFS often have similar symptoms, including sleep-related complaints, differences between FM and CFS exist. In this chapter, we will review studies on sleep in FM and CFS patients in order to better understand differences between them. Polysomnographic studies have shown sleep problems in FM by using simple descriptive statistics, for instance, increased non-rapid eye movement (non-REM) Stage 1 sleep, reduced slow-wave (Stages 3 and 4) sleep, more arousals, prolonged sleep onset, reduced sleep efficiency, etc. Sleep problems in CFS shown by polysomnographic studies are quite similar to those in FM. However, we have shown that dynamic aspects of sleep, a new way of assessing sleep, are different between patients with CFS alone compared to those with CFS+FM. The probability of transition from rapid eye movement (REM) sleep to waking in CFS is greater than in healthy controls. Probabilities of transitions from waking, Stage 1 sleep, and REM sleep to Stage 2 and those from slow.”¹

Chronic pain and depression that accompany fibromyalgia can have a negative impact on your sleep. For a long time, doctors paid little attention to sleep problems compared to other manifestations of fibromyalgia. However, it is currently one of the symptoms that is most evaluated, especially because of the impact it has on the quality of life. This difficulty to sleep well is very recurrent, although in many cases sleep deprivation is linked to other pathologies. Any chronic type of pain can directly affect the ability to rest, however, scientific studies still need to confirm this relationship.

“Sleep is a regular circadian phase of reduced activity and responsiveness, with characteristic physiologic changes, especially in the brain. The cyclicity of sleep is linked to other biologic circadian rhythms, such as hormone secretion (e.g., growth hormone, prolactin, and melatonin), body temperature and blood pressure. Research about sleep disorders in patients with chronic pain, particularly in FM patients, overlaps the concept of non restorative sleep. The restorative theory considers brain activity during sleep essential to restore body and mind. As non restorative sleep is common in patients with organic sleep disorders, it has been considered a symptom of insomnia. Many studies have investigated the symptoms of insomnia associated with chronic pain syndromes, particularly FM and chronic pain fatigue syndrome, but there are few studies about non restorative sleep: a greater knowledge of non restorative sleep and its mechanisms could provide important insights into the causes of FM and related condition. Poor sleep quality or quantity increases the risk of medical and psychiatric diseases.”²

Fibromyalgia patients present a significant deterioration of their physical and mental health, even more so than those who have other rheumatic or immune diseases. Although it does not have a definite cause, its appearance is related to an erratic nervous system, a sedentary lifestyle, and genetics. Unfortunately, fibromyalgia affects all phases of sleep, which includes falling asleep and staying asleep. Add this to the fact that chronic pain causes heightened alertness, which could explain the inadequate sleeping patterns of these patients.

“Nonrestorative sleep has received increased attention in the literature and has been associated not only with fibromyalgia, but also with chronic fatigue syndrome, insomnia, and obstructive sleep apnea. On the other hand, primary sleep disorders, such as obstructive sleep apnea and restless legs syndrome, have been reported among patients with fibromyalgia, and a genetic study found common genetic characteristics between fibromyalgia and narcolepsy. Female sex remains a predictor of fibromyalgia, and the average age of onset is between 30 and 50 years, dropping off after 80 years. The prevalence in middle-aged and overweight women may contribute to further sleep disorders, such as sleep apnea, and inspiratory airflow limitation with arousals.”³

Pathophysiology

“Although the etiology remains unclear, characteristic alterations in the pattern of sleep and changes in neuroendocrine transmitters such as serotonin, substance P, growth hormone and cortisol suggest that regulation of the autonomic and neuro-endocrine system appears to be the basis of the syndrome. Fibromyalgia is not a life-threatening, deforming, or progressive disease. Anxiety and depression are the most common association. Aberrant pain processing, which can result in chronic pain, may be the result of several interplaying mechanisms. Central sensitization, blunting of inhibitory pain pathways and alterations in neurotransmitters lead to aberrant neuro-chemical processing of sensory signals in the CNS, thus lowering the threshold of pain and amplification of normal sensory signals causing constant pain. The frequent comorbidity of fibromyalgia with mood disorders suggests a major role for the stress response and for neuroendocrine abnormalities. The hypothalamic pituitary axis (HPA) is a critical component of the stress-adaptation response. In FMS, stress adaptation response is disturbed leading to stress induce symptoms. Psychiatric co-morbidity has been associated with FMS and needs to be identified during the consultation process, as this requires special consideration during treatment.”⁴

Fibromyalgia patients also tend to suffer from restless leg syndrome and sleep apnea. As a result, they wake up tired and groggy. Sleep deprivation affects the perception of pain and the capacity of muscle tissues to repair. Therefore, the treatment of fibromyalgia also aims to regulate sleep cycles in order to reduce diurnal effects, such as stiffness, pain, and concentration issues known as ‘fibro-fog’.

“Many cases of fibromyalgia do not precisely align with a standardized set of diagnostic criteria. However, it is not believed to be a diagnosis of exclusion, although some healthcare providers have labeled it as such. Because there is an absence of absolute, definitive diagnostic criteria with universal applicability, providers often settle upon this diagnosis following negative testing for other differentials. Rather than assuming a diagnosis of fibromyalgia, care-fully considering a multitude of potential diagnoses will decrease the likelihood of a misdiagnosis. Five of the common differentials to consider in patients exhibiting symptoms of fibromyalgia are mental health disorders, hypothyroidism, rheumatoid arthritis, adrenal dysfunction, and multiple myeloma. Diagnosis is difficult and frequently missed because symptoms are vague and generalized. Despite this, three main symptoms are referred by almost every patient: pain, fatigue, and sleep disturbance. In particular the physician must investigate the features of the pain: it is typically diffuse, multifocal, deep, gnawing, or burning. It often waxes and wanes and is frequently migratory. If this is the case, fibromyalgia should be suspected since often this kind of pain is not the result of inflammation or damage in the area of the region(s) of interest. It is also important to evaluate additional symptoms, which may seem unrelated to fibromyalgia, such as weight fluctuations, morning stiffness, irritable bowel disease, cognitive disturbance, headaches, heat and cold intolerance, irritable bladder syndrome, rest-less legs, and Raynaud’s

phenomenon. The musculoskeletal and neurological examinations are normal in fibromyalgia patients.”⁵

In general, common treatments are non-benzodiazepine hypnotics. However, benzodiazepines are also used, but in moderate amounts. The use of antidepressants is considered opportune, given the fact that it plays an important role as a serotonin modulator. With the stimulation provided by this neurotransmitter, the patient will not only improve sleep, but also fibromyalgia in general.

Tips to help you sleep

 If you suffer from fibromyalgia, some tips that will help you sleep are:

• Lying on your side
• Shorten the amount of time spent in bed (if it is too long) and try waking up every day at the same time to regulate your circadian rhythm.
• Practice relaxation techniques offered by yoga or massages.
• Stretch your muscles on a daily basis and perform low impact physical activities.
• Avoid sudden changes in temperature.
• Refrain from consuming alcohol, caffeine, or other stimulants.
• Consume a light dinner to avoid any inflammatory process that might add to sleep disturbance.

“In general, exercise and psychoeducational approaches have the greatest evidence of efficacy among non-pharmacological therapies,2 but they need to be tailored to the individual. Pre-exercise biomechanical assessment and subsequent exercise monitoring by a knowledgeable physical therapist are desirable for all but the mildest cases. Promotion of daily physical activity can be assisted by use of an actimeter.34 Referral to a psychologist should be considered in all patients, particularly those who are more psychologically distressed.”⁶

Fibromyalgia produces sleep disorders that cause the patient to fall into a vicious self-sustaining cycle. Painful sensations prevent a proper rest, while insomnia and sleep interruptions aggravate the daytime symptoms. Besides the treatment for pain relief, it is necessary to take measures to improve quantity and quality of sleep.

References:

(1) Togo, F., Kishi, A., & Natelson, B. H. (2012). Sleep and Fibromyalgia. In New Insights into Fibromyalgia. IntechOpen. Available online at https://pdfs.semanticscholar.org/ea02/41b9ef254e3f686674742777ab8d58855af8.pdf

(2) Rizzi, M., Cristiano, A., Frassanito, F., Macaluso, C., & Airoldi, A. (2016). Sleep disorders in fibromyalgia syndrome. J Pain Relief, 5(232), 2167-0846. Available online at https://www.omicsonline.org/open-access/sleep-disorders-in-fibromyalgia-syndrome-2167-0846-1000232.pdf

(3) Roizenblatt, S., Neto, N. S. R., & Tufik, S. (2011). Sleep disorders and fibromyalgia. Current pain and headache reports, 15(5), 347-357. Available online at https://www.researchgate.net/publication/51148719_Sleep_Disorders_and_Fibromyalgia

(4) Jahan, F., Nanji, K., Qidwai, W., & Qasim, R. (2012). Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management. Oman medical journal, 27(3), 192. Available online at http://www.omjournal.org/images/234_M_Deatials_Pdf_.pdf

(5) Bellato, E., Marini, E., Castoldi, F., Barbasetti, N., Mattei, L., Bonasia, D. E., & Blonna, D. (2012). Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain research and treatment, 2012. Available online https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3503476/

(6) Kwiatek, R. (2017). Treatment of fibromyalgia. 40(5), 179. Available online at https://www.nps.org.au/assets/17e8817307b03ee8-bfdbae282af3-treatment-of-fibromyalgia-40-179.pdf