quantitative eeg during sleep in fibromyalgia victor rosenfeld m.d. director of neurology,...

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

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Sp O2 ,%

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1 0 :2 2 :3 3 PM 1 2 AM 1 AM 2 AM 3 AM 4 AM

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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

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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

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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.