quantitative eeg during sleep in fibromyalgia victor rosenfeld m.d. director of neurology,...
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Quantitative EEG during Sleep in Fibromyalgia
Victor Rosenfeld M.D.Director of Neurology, SouthCoast Medical Group
Medical Director, SouthCoast Sleep CenterSavannah, GA
Disclosure InformationVictor Rosenfeld MD
Disclosure of Relevant Financial Relationships I have no financial relationships to
disclose.
Disclosure of Off-Label and/or Investigative Uses I will discuss the following off label use
and/or investigational use in my presentation: Sodium Oxybate and Pain
Sleep and FMS
Sleep Disorders are common in FMS including Non-restorative sleep, Insomnia, Hypersomnia, Sleep Apnea, and Restless Legs
Non-restorative sleep is a hallmark of FMS and can be identified using qEEG during PSG
Sleep Disorder in FMS are identifiable and treatable.
Symptoms in Fibromyalgia
SYMPTOMS Mean Severity (SD)
Morning Stiffness 7.2 (2.5)
Fatigue 7.1 (2.1)
Non-Restorative Sleep 6.8 (2.0)
Pain 6.4 (2.0)
Forgetfulness 5.9 (2.7)
Bennet et al: BMC Muscoloskeletal Disorders, 2007; 8:27
2010 Fibromyalgia Clinical Diagnostic Criteria Widespread Pain Index
(WPI)In how many areas has the
patient had pain in the last week?
Score = 0-19
Symptom Severity Scale (SS)
What was the level of symptom severity in the last week?
Score = 0-120 (no problem), 1 (slight), 2 (moderate), 3 (severe)
Patient satisfies the 2010 Fibromyalgia Clinical Diagnostic Criteria if WPI ≥7 and SS score ≥5or WPI between 3-6 and SS score ≥9
Shoulder (L/R); Upper arm (L/R); Lower am (L/R); Jaw (L/R); Neck; Buttock; Hip trochanter (L/R); Upper let (L/R); Lower leg (L/R); Upper back; Lower back; Chest; Abdomen
Fatigue; Waking unrefreshed; Cognitive disturbances; General somatic symptoms
George Beard (1869)- Neurasthenia Described “...a disease of the
nervous system characterized by enfeeblement of the nervous force. Young women appear to have been particularly susceptible to it and its onset was frequently “triggered” by an infection.”
Also described neurasthenia as a “...condition of nervous exhaustion, characterized by undue fatigue on the slightest exertions, both physical and mental. The chief symptoms are headaches, gastrointestinal disturbances, and subjective sensations of all kinds.”
Normal Sleep Architecture
After Rechtschaffen & Kale, 1968, Kalat, 2005, Weiten 2004
Sleep Architecture in FMS Non-FMS:
REM 25% Deep Sleep 20%
In FMS: REM Sleep
decreases Deep Sleep
decreases Sleep becomes
“fractured”
FMS sleep like the elderly
Sleep Basics
Deep Sleep: Normal
Deep Sleep: Alpha Intrusions
Alp h a ,#
02 .557 .51 0
De l ta ,%
01 53 04 56 0
Sp O2 ,%
5 06 07 08 09 01 0 0
HR,BPM
3 05 07 09 011 01 3 01 5 01 7 01 9 0
Sta g e
S4S3S2S1REMMVTW K
. S S
Po s
.PRSRRSLSPLPL
CA,s e c
01 02 0
OA,s e c
01 02 0
HYPO,s e c
01 02 0
L e g Mv t,s e c
01 53 0
Sn o re ,#
01234567891 0
0 0 0
11 11 1 2 1 3
IPAP,c mH2 O
051 01 52 02 53 0
0 0 0
EPAP,c mH2 O
051 01 52 02 53 0
Al l Ni g h t Hi s to g ra m
1 0 :2 2 :3 3 PM 1 2 AM 1 AM 2 AM 3 AM 4 AM
Alp h a ,#
02 .557 .51 0
De l ta ,%
01 53 04 56 0
Sp O2 ,%
5 06 07 0
8 09 01 0 0
HR,BPM
5 07 09 0
11 01 3 01 5 0
Sta g e
N3
N2
N1
R
W
R
S
R
S
Po s
.PRSRRSLSPLPL
CA,s e c
01 02 0
OA,s e c
01 02 0
HYPO,s e c
01 02 0
L e g Mv t,s e c
01 53 0
Sn o re ,#
01234567891 0
Al l Ni g h t Hi s to g ra m
11 :1 7 :5 5 PM 1 AM 2 AM 3 AM 4 AM 5 AM
1
2
3
4
5
6
7
8
9
10
Before Treatment After Treatment
1
2
3
4
5
0
5
10
15
20
25
30
Before Treatment After Treatment
1
2
3
4
5
Fig. 4: The DE/AE Ratio improved significantly for each patient after treatment with Sodium Oxybate.
Fig. 5: Improvement in DE/AE Ratio correllates correlates with improvement in VAS Pain Score
Del
ta E
vent
s/A
lpha
Eve
nts
Vis
ual A
nalo
g S
cale
Alpha/Delta qEEG during Polysomnography in five FMS patients before and after treatment with Sodium
OxybateV. Rosenfeld, MD, Sansum Clinic; D. Ngyuen, Sleepmed; J. Stern, M.D., UCLA
Variable Total GroupN = 385
Persons with Fibromyalgia
N = 133
Persons without
Fibromyalgia and Severe
OSAN = 252
Demographic characteristics/health history
Gender – Male 142 (36.9%) 5 (3.8%) 137 (54.4%)***
Taking benzodiazepines or benzodiazepine agonist
97 (25.2%) 61 (45.9%) 36 (14.3%)***
Taking antidepressants (tricyclic or SNRIs)
100 (26.0%) 56 (43.6%) 42 (16.7%)***
Age (y) 49.2 (12.8)15 - 75
48.6 (11.1) 49.5 (13.6)
Body mass index 30.1 (6.4)13.1-52.0
28.9 (5.9) 30.7 (6.6)**
Epworth Sleepiness Scale 10.5 (5.4)0-26
10.4 (5.4)n = 131
10.5 (5.4)n = 251
Sleep variables
Time spent sleeping (min) 279.3 (102.8)59.0-550.0
304.6 (95.8) 265.9 (104.1)***
Sleep efficiency (percentage) 77.9 (14.2)22.3 – 98.8
78.5 (12.6) 77.5 (15.2)
Wake after sleep onset (min) 453.1 (44.2)0-236
55.3 (42.5) 51.9 (45.1)
Apnea/Hypopnea Index 10.2 (11.0)0-80.2
9.4 (14.8) 10.7 (8.3)
Respiratory Distress Index (RDI) 14.6 (13.7)0-94.7
13.1 (17.8)n = 132
15.4 (10.9)
Periodic limb movement - yes 57 (14.8%) 16 (12.0%) 41 (16.3%)
Periodic Limb Movement Index (PLMI) 15.2 (18.3).2-99.9
12.8 (13.7)n = 48
16.5 (20.3)n = 82
Periodic Limb Movement Arousal Index (PLMAI)
9.3 (15.1).1-83.9
6.8 (14.2)n = 52
10.8 (15.5)n = 89
Narcolepsy or idiopathic hypersomnolence
25 (6.5%) 10 (7.1%) 15 (6.0%)
Delta event/alpha event ratio 13.3 (26.0)0.3-231.0
7.4 (11.1) 16.5 (30.7)**n = 251Rosenfeld et al: Journal of Clinical Neurophysiology,
2015; 32:2
Negligble Apnea
Mild Sleep Apnea
Moderate Sleep Apnea
Severe Sleep Apnea
0 10 20 30 40 50 60
FMS and Sleep Apnea (n=129)
% of Patient with OSA
Polysomnographic Variables in FMS
Narcolepsy/IH (%)
PLMA/hr
0 2 4 6 8 10 12
Non-FMS (n=394)FMS (n=129)
qEEG in PSG in pts w/wo FMS D/A ratio < 1: 98.4% specificity for
FMS
D/A ratio < 10: 85% sensitive for FMS
D/A ratio > 11: 89.1% negative predictive value for FMS
Rosenfeld et al: Journal of Clinical Neurophysiology, 2015; 32:2
qEEG in PSG in pts w/wo FMS
Non-restorative sleep is a hallmark of FMS and can be identified using qEEG during PSG
Sleep Apnea is seen in 45% of FMS patients.
Hypersomnlence is seen in 7% of FMS Patients.
PLMS is probably less common than in the non-FMS population.
Sleep Disorders in FMS are largely identifiable and treatable.