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Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy
EJINME-02953; No of Pages 2 European Journal of Internal Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy Keywords: Fibromyalgia Obstructive sleep apnea CPAP
Dear Editor, Fibromyalgia is a common disorder characterized by widespread musculoskeletal pain, stiffness, paresthesia and proneness to fatigue. The prevalence has been reported to be 3.4 percent in women and 0.5 percent in men, increasing with age to 7.4 percent in women between the ages of 70 and 79 years [1]. Disturbed sleep has been implicated as a key factor for the pathogenesis [2]. Data regarding the prevalence of obstructive sleep apnea (OSA) and the role of continuous positive airway pressure (CPAP) are sparse. The aim of the study is to evaluate the incidence of fibromyalgia in patients with OSA and to determine the role of CPAP in their treatment. We studied 900 consecutive OSA subjects from the outpatient department for sleep-related disorders from January 2009 to February 2013. All patients were subjected to a sleep study with a 25-channel portable polysomnography recording device (Somtè PSG, Compumedics, Australia). Patients also completed Epworth sleepiness questionnaire and underwent a thorough medical history and a full medical examination. The diagnosis of OSA was made according to the recommendations of the American Academy of Sleep Medicine. The diagnosis of fibromyalgia was made following the fibromyalgia diagnostic criteria of the American College of Rheumatology (ARA 2010 version). A total of 135 (15%) patients fulfilled the ARA criteria for fibromyalgia, the mean age was 70 ± 12 years; 100 of the patients were men (74%). In all subjects, we performed a 6-min walking test (6MWT), evaluated symptoms severity scale (SS) and CPAP titration scores. All patients completed the SF-36 (short-form health survey) standard questionnaire. Five patients refused any treatment, whereas 30 patients were excluded because they did not respect the scheduled follow-up. One hundred patients were treated with CPAP therapy (group 1). We scheduled a follow-up at 3 and 6 months. The control group (group 2) was composed of 50 patients with fibromyalgia coming from the outpatient unit of the Department of Internal Medicine and were treated with conventional therapy (tricyclics, serotonin reuptake inhibitors and gabapentanoids.) Continuous variables are expressed as mean ± SD. Qualitative variables are expressed as a percentage. A two-tailed unpaired t test or Mann–Whitney U test for independent samples was used to compare variables between patients with or without OSA. χ2 test was used for qualitative variables. All subgroup analyses were performed using Bonferroni’s correction to adjust for multiple comparisons. Data were analyzed with SPSS, version 17.0 (IBM) and Stata 12.0 statistical software.
The Apnea Hypopnea Index (AHI) decreased significantly in group 1: from 60 ± 20 to 11 ± 6 after 3 months (p b 0.001). The distance walked significantly improved in the CPAP group after 3 months (7.50 ± 4.50 increase in meters walked) versus 3.5 ± 1.5 in group 2 (p b 0.001). The SS was reduced significantly in group 1, from 8.0 ± 4 to 3 ± 2 after 3 months, whereas in group 2, we observed only a non-significant reduction, from 8 ± 3.7 to 6 ± 1. The SF-36 had a similar trend. The physical component summary score (PCS) increased significantly in the CPAP group from a baseline value of 35 ± 15 to 55 ± 10 and to 60 ± 10 (6 months) versus 32 ± 17 to 35 ± 20 and to 40 ± 15 in the control group (Fig. 1). The improvement in the mental component summary score (MCS) was less evident and went from 32 ± 10 to 40 ± 8 in group 1 versus 35 ± 12 to 38 ± 9 in group 2. Available evidence implicates central nervous system and sleep disorders (difficulty falling asleep, difficulty staying asleep and early morning awakening) as keys to maintaining pain and other core symptoms of F. and related conditions [1–3]. Data regarding the role of OSA in this setting are sparse. Smith and coworkers studied the wives of 17 male OSA patients. They speculated that sharing a bed with a man with OSA may contribute to impaired sleep and clinical manifestations of musculoskeletal pain. They demonstrated the lower sleep quality and an increase in pain threshold in this subset of subjects [4]. Gold and colleagues studied 28 consecutive female patients with fibromyalgia and 11 patients with upper airway resistance syndrome (UARS) by using full-night polysomnogram and CPAP with quantitative monitoring of inspiratory airflow. They found that 27 patients had sleep-disordered breathing with an inspiratory airflow limitation. Treatment with nasal CPAP resulted in an improvement in functional symptoms as assessed by a validated questionnaire [5]. Our study demonstrated that fibromyalgia is common in OSA patients (15% in our series of cases) and is far more common in men (74%), while in the general population the female/male ratio is 9:1.
Fig. 1. SF-36, short-form health survey; PCS, physical component.
http://dx.doi.org/10.1016/j.ejim.2015.06.010 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Marvisi M, et al, Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.06.010
2
Letter to the Editor
CPAP therapy seems to be more effective than conventional pharmacologic approaches in our endpoints: 6MWT, SS and SF-36 questionnaire. Our study has some limitations: the control group did not appear adequately matched with the study group for some parameters like BMI and sex, and by design it is an observational longitudinal study. On the other hand, our study has some strengths: the number of patients and the accurate selection of subjects (clinical history and clinical examination). In conclusion, OSA is frequent in patients with fibromyalgia and it would seem important to rule out the presence of this comorbidity, above all, for the apparent effectiveness of CPAP treatment in these patient phenotypes. References [1] Mannarino MR, Di Filippo R, Pirro M. Obstructive sleep apnea. Eur J Intern Med 2012; 23:586–93. [2] Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014;311:1547–55.
[3] Okifuji A, Habe BD. Management of fibromyalgia syndrome: Review of evidence. Pain Ther 2013;2:87–104. [4] Smith AK, Togeiro SM, Tufik S. Disturbed sleep and musculoskeletal pain in the bed partner of patients with obstructive sleep apnea. Sleep Med 2009;10:904–12. [5] Gold AR, Dipalo S, Gold MS. Inspiratory airflow dynamics during sleep in women with fibromyalgia. Sleep 2004;27:459–66.
Maurizio Marvisi⁎ Laura Balzarini Chiara Mancini Sara Ramponi Chiara Marvisi Department of Internal Medicine, Pneumology and Cardiology, Istituto Figlie di S. Camillo, Cremona, Italy ⁎Corresponding author. E-mail address: [email protected]. 10 June 2015 Available online xxxx
Please cite this article as: Marvisi M, et al, Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.06.010
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy Keywords: Fibromyalgia Obstructive sleep apnea CPAP
Dear Editor, Fibromyalgia is a common disorder characterized by widespread musculoskeletal pain, stiffness, paresthesia and proneness to fatigue. The prevalence has been reported to be 3.4 percent in women and 0.5 percent in men, increasing with age to 7.4 percent in women between the ages of 70 and 79 years [1]. Disturbed sleep has been implicated as a key factor for the pathogenesis [2]. Data regarding the prevalence of obstructive sleep apnea (OSA) and the role of continuous positive airway pressure (CPAP) are sparse. The aim of the study is to evaluate the incidence of fibromyalgia in patients with OSA and to determine the role of CPAP in their treatment. We studied 900 consecutive OSA subjects from the outpatient department for sleep-related disorders from January 2009 to February 2013. All patients were subjected to a sleep study with a 25-channel portable polysomnography recording device (Somtè PSG, Compumedics, Australia). Patients also completed Epworth sleepiness questionnaire and underwent a thorough medical history and a full medical examination. The diagnosis of OSA was made according to the recommendations of the American Academy of Sleep Medicine. The diagnosis of fibromyalgia was made following the fibromyalgia diagnostic criteria of the American College of Rheumatology (ARA 2010 version). A total of 135 (15%) patients fulfilled the ARA criteria for fibromyalgia, the mean age was 70 ± 12 years; 100 of the patients were men (74%). In all subjects, we performed a 6-min walking test (6MWT), evaluated symptoms severity scale (SS) and CPAP titration scores. All patients completed the SF-36 (short-form health survey) standard questionnaire. Five patients refused any treatment, whereas 30 patients were excluded because they did not respect the scheduled follow-up. One hundred patients were treated with CPAP therapy (group 1). We scheduled a follow-up at 3 and 6 months. The control group (group 2) was composed of 50 patients with fibromyalgia coming from the outpatient unit of the Department of Internal Medicine and were treated with conventional therapy (tricyclics, serotonin reuptake inhibitors and gabapentanoids.) Continuous variables are expressed as mean ± SD. Qualitative variables are expressed as a percentage. A two-tailed unpaired t test or Mann–Whitney U test for independent samples was used to compare variables between patients with or without OSA. χ2 test was used for qualitative variables. All subgroup analyses were performed using Bonferroni’s correction to adjust for multiple comparisons. Data were analyzed with SPSS, version 17.0 (IBM) and Stata 12.0 statistical software.
The Apnea Hypopnea Index (AHI) decreased significantly in group 1: from 60 ± 20 to 11 ± 6 after 3 months (p b 0.001). The distance walked significantly improved in the CPAP group after 3 months (7.50 ± 4.50 increase in meters walked) versus 3.5 ± 1.5 in group 2 (p b 0.001). The SS was reduced significantly in group 1, from 8.0 ± 4 to 3 ± 2 after 3 months, whereas in group 2, we observed only a non-significant reduction, from 8 ± 3.7 to 6 ± 1. The SF-36 had a similar trend. The physical component summary score (PCS) increased significantly in the CPAP group from a baseline value of 35 ± 15 to 55 ± 10 and to 60 ± 10 (6 months) versus 32 ± 17 to 35 ± 20 and to 40 ± 15 in the control group (Fig. 1). The improvement in the mental component summary score (MCS) was less evident and went from 32 ± 10 to 40 ± 8 in group 1 versus 35 ± 12 to 38 ± 9 in group 2. Available evidence implicates central nervous system and sleep disorders (difficulty falling asleep, difficulty staying asleep and early morning awakening) as keys to maintaining pain and other core symptoms of F. and related conditions [1–3]. Data regarding the role of OSA in this setting are sparse. Smith and coworkers studied the wives of 17 male OSA patients. They speculated that sharing a bed with a man with OSA may contribute to impaired sleep and clinical manifestations of musculoskeletal pain. They demonstrated the lower sleep quality and an increase in pain threshold in this subset of subjects [4]. Gold and colleagues studied 28 consecutive female patients with fibromyalgia and 11 patients with upper airway resistance syndrome (UARS) by using full-night polysomnogram and CPAP with quantitative monitoring of inspiratory airflow. They found that 27 patients had sleep-disordered breathing with an inspiratory airflow limitation. Treatment with nasal CPAP resulted in an improvement in functional symptoms as assessed by a validated questionnaire [5]. Our study demonstrated that fibromyalgia is common in OSA patients (15% in our series of cases) and is far more common in men (74%), while in the general population the female/male ratio is 9:1.
Fig. 1. SF-36, short-form health survey; PCS, physical component.
http://dx.doi.org/10.1016/j.ejim.2015.06.010 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Marvisi M, et al, Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.06.010
2
Letter to the Editor
CPAP therapy seems to be more effective than conventional pharmacologic approaches in our endpoints: 6MWT, SS and SF-36 questionnaire. Our study has some limitations: the control group did not appear adequately matched with the study group for some parameters like BMI and sex, and by design it is an observational longitudinal study. On the other hand, our study has some strengths: the number of patients and the accurate selection of subjects (clinical history and clinical examination). In conclusion, OSA is frequent in patients with fibromyalgia and it would seem important to rule out the presence of this comorbidity, above all, for the apparent effectiveness of CPAP treatment in these patient phenotypes. References [1] Mannarino MR, Di Filippo R, Pirro M. Obstructive sleep apnea. Eur J Intern Med 2012; 23:586–93. [2] Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014;311:1547–55.
[3] Okifuji A, Habe BD. Management of fibromyalgia syndrome: Review of evidence. Pain Ther 2013;2:87–104. [4] Smith AK, Togeiro SM, Tufik S. Disturbed sleep and musculoskeletal pain in the bed partner of patients with obstructive sleep apnea. Sleep Med 2009;10:904–12. [5] Gold AR, Dipalo S, Gold MS. Inspiratory airflow dynamics during sleep in women with fibromyalgia. Sleep 2004;27:459–66.
Maurizio Marvisi⁎ Laura Balzarini Chiara Mancini Sara Ramponi Chiara Marvisi Department of Internal Medicine, Pneumology and Cardiology, Istituto Figlie di S. Camillo, Cremona, Italy ⁎Corresponding author. E-mail address: [email protected]. 10 June 2015 Available online xxxx
Please cite this article as: Marvisi M, et al, Fibromyalgia is frequent in obstructive sleep apnea and responds to CPAP therapy, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.06.010