Elsevier

Sleep Medicine Reviews

Volume 21, June 2015, Pages 86-99
Sleep Medicine Reviews

Clinical review
Sleep disturbances of adult women suffering from fibromyalgia: A systematic review of observational studies

https://doi.org/10.1016/j.smrv.2014.09.001Get rights and content

Summary

Although sleep complaints are often reported in patients with fibromyalgia syndrome (FMS), there is no conclusive evidence that these complaints represent symptomatic disorders of sleep physiology. Thus, the question of the role of sleep disturbances as an etiological or maintenance factor in FMS remains open. This study identifies the subjective and objective characteristics of sleep disturbances in adult women diagnosed with FMS. We carried out a systematic review of publications since 1990, the publication year of the American College of Rheumatology criteria of FMS. We selected empirical studies comparing sleep characteristics of adult women with FMS and healthy women or women with rheumatic diseases. We identified 42 articles. Patients with FMS were more likely to exhibit sleep complaints and also a less efficient, lighter and fragmented sleep. The evidence of a FMS signature on objective measures of sleep is inconsistent, however, as the majority of studies lacks statistical power. Current evidence cannot confirm the role played by sleep physiology in the pathogenesis or maintenance of FMS symptoms; nonetheless, it is clear that sleep disturbances are present in this syndrome.

Introduction

Fibromyalgia syndrome (FMS) is characterized by chronic widespread musculoskeletal pain and multiple tender points [1], [2]. The prevalence rate of FMS in the general population is high, ranging from 1.3% to 4.7%, and is more common among middle-aged and older women [3]. The syndrome has a severe impact on health systems due to the frequent health care utilization and treatment costs [4]. Recent estimates suggest that, only in the United States, the costs for managing care of patients with FMS have a combined value of up to $10,000 per patient per year [5]. FMS also has a great impact on patients' and their relatives' quality of life as it is a significant source of suffering [6].

The new American College of Rheumatology (ACR) criteria for FMS [2] recognize the role of other non-specific pain-related symptoms in the severity of FMS. Thus, beyond pain, the diagnosis for FMS is now based on a large number of symptoms and comorbidities [2], including sleep disturbances, fatigue, headache and migraine syndrome, neuropathic disorders, anxiety and/or depression disorders [4], [7]. Among these, sleep disturbance is one of the most common and relevant symptoms in FMS [8]. Experimental and clinical studies on the complex relationship between sleep and pain have shown that pain can disrupt sleep and, at the same time, sleep deprivation can enhance pain sensitivity [9]. This so-called vicious cycle clearly explains this incapacitating condition: a day with intense pain is followed by a night of poor sleep quality and a poor night's sleep is followed by a reduction of pain perception threshold – i.e., an increase in pain intensity [10]. Moreover, a recent review of longitudinal studies suggests that sleep disturbances portend future pain better than pain portends future sleep disturbances [11]. It is also known that other symptoms of FMS (e.g., psychological distress, fatigue) are intrinsically related to sleep disturbances [12]. Thus, the early recognition and management of sleep disturbances in FMS patients might help to ameliorate morbidity in this syndrome [13], as suggested by several clinical trials using cognitive-behavioral therapy for insomnia [14], [15]. Additionally, the study of sleep physiology and sleep behavior in these specific patients might improve the explanatory power of models that try to relate the etiology of FMS to sleep disturbance [16], ∗[17], [18], ∗[19].

Although subjective poor sleep quality is a consistent and relevant finding among patients with FMS [20], the presence of specific polysomnographic sleep patterns in FMS is not yet clear. In fact, more than two decades of sleep research in FMS have not yielded robust findings about a FMS signature on objective assessments of sleep parameters. Polysomnography (PSG), as the gold standard sleep measure, still has not revealed a unique and consistent FMS pattern in sleep architecture among patients. The conflicting findings across studies make integrative conclusions on the basis of PSG difficult. Several studies have found low sleep efficiency [21], [22], [23], long wake time after sleep onset [21], [24], [25], and high percentage of light sleep [21], [23], [26], [27] to be common in FMS sleep patterns. Furthermore, some studies have suggested microstructure abnormalities in FMS patients, mainly an electroencephalography (EEG) non-REM sleep anomaly [19] characterized by high alpha frequency band power (7.5–11 Hz) (α-EEG sleep) [28]. Contrarily, several studies have reported minimal differences [25], [29], [30] or no abnormalities at all between FMS patients and controls [31], suggesting that sleep complaints in FMS only reflect sleep misperception (e.g., [32]). These discrepancies in results might be due to the heterogeneity that characterizes the clinical profiles of FMS patients [33] and to inconsistencies in the studies' methods and recording tools [9]. Thus, a systematic review of the methodology and overall quality of sleep studies in FMS, which has not been performed as of yet, could reconcile the contradictory results of these studies. Here, we reviewed observational studies that assessed objective and/or subjective sleep parameters in FMS patients compared with healthy controls and/or rheumatologic patients (sleep disturbances might be associated to various rheumatologic disorders, and not only to FMS [34]).

Section snippets

Study eligibility criteria

We followed specific inclusion criteria to select the articles analyzed in this review following the “PICOS” approach [35] (see Table 1): 1) participants: adult women diagnosed with FMS according the ACR 1990 classification criteria [1]; 2) study design: observational designs (ex post facto studies); 3) comparisons: healthy women or women patients with other chronic rheumatic diseases; 4) reported outcomes: subjective and objective sleep parameters.

Search methods

We conducted a comprehensive search of the

Results

From a total of 1644 retrieved articles, 152 titles and abstracts were identified as potentially relevant. After excluding duplicate records and screening the full text, 44 articles fulfilled the inclusion criteria. Two of the articles were duplicate reports, since they were translations from Portuguese [37], [38] to English [26], [39] (in what follows, we will reference the English ones). It should be noted that a single study can be reported in several supplementary articles. This condition

Discussion

In this systematic review, our aim was to identify the characteristics of sleep disturbances in adult women diagnosed with FMS. We found that women with FMS systematically reported more sleep symptoms (poorer sleep quality, more complaints of insufficient sleep, a great number of awakenings, and/or the experience of unrefreshing sleep) when compared to healthy controls (or other rheumatologic patients). Moreover, the effect sizes were in the “large” range (greater than 0.8 [68]), and these

Declaration of interest

The authors report no conflicts of interest.

Acknowledgments

CDP was supported by a FPU grant from the Spanish Ministry of Education (AP 2007-02965) and is currently supported by a UGR Postdoctoral Fellowship (2013 University of Granada Research Plan). LLDS is supported by the MEC-Fulbright Postdoctoral Fellowship program (grant PS-2010-0667) and the Talentia/Marie Curie Postdoctoral Fellowship program (grant Talentia Postdoc 267226). Research by GBC is funded by a Spanish Ministry of Economy and Competitiveness grant (State Secretariat for Research,

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