Fibromyalgia (FMS) is an often misunderstood—even unrecognized—disorder that causes widespread muscle pain and tenderness which tends to come and go and move about the body. FMS affects 2-4% of the population, predominantly women and the prevalence increases with age.[sup]1[/sup]
In 1990, The American College of Rheumatology (ACR) in the Criteria for the Classification of Fibromyalgia defined FMS patients as having “chronic widespread pain” present for at least 3 months in the left and right sides of the body and above and below the waist. Axial skeletal pain (cervical spine, anterior chest, thoracic spine, or low back) must also be present.
Fatigue and sleep disturbances are of the most prevalent complaints among FMS patients and noted as symptoms that compel them to seek treatment.[sup]2[/sup] In fact, the ACR criteria for the classification of fibromyalgia identify the presence of sleep disturbances in excess of 73% of patients.[sup]3[/sup]
An increasing number of studies are showing a strong correlation between fatigue, FMS and sleep disordered breathing (SDB). It has long been appreciated that SDB symptoms include non-restorative sleep, fatigue, morning headache, lack of concentration, decline in libido, anxiety and depression,[sup]4-8[/sup] symptoms often shared by those with FMS.
A landmark study published by Moldofsky and Smythe in 1975 was the first to describe alpha-delta sleep as a possible marker for fibromyalgia, but moreover, that “fibrositis complex” might be a consequence of non-restorative sleep syndrome. The results of this study, along with recent treatment outcome data on sleep interventions, suggest that sleep should be a primary intervention target for people with FMS.[sup]9[/sup]
In a 2007 article entitled “Sleep Disturbance in Fibromyalgia,” Drs. Lineberger, Means, and Edinger, uphold the correlation stating “…it seems reasonable to speculate that sleep disturbance is mechanistically important to the etiology or symptom maintenance of FMS” and “of all FMS symptoms, sleep disturbance is among the more common, and perhaps more etiologically significant.”[sup]10[/sup]
Studies have shown the prevalence of upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA) in FMS patients in excess of 70%.[sup]4-8, 11,14[/sup] In a descriptive study of 14 consecutive female patients diagnosed with fibromyalgia, all were treated with a nasal CPAP (breathing apparatus) resulting in an improvement in functional symptoms ranging from 23% to 47%. Other studies have shown similar observations.[sup]4[/sup]
Considering the oftentimes discouraging and/or unremarkable results of efforts to treat FMS, the aforementioned findings beg to ask the question: Could FMS be a manifestation of SDB?[sup]12[/sup]
The clinical consequences of untreated sleep disorders are devastating. Serious medical conditions including (but not limited to) high blood pressure, heart attacks, stroke, ADHD, sexual dysfunction, decreased mental functions, crowded or mal-aligned teeth (too small of a mouth or no room for the teeth) all can lead to a decreased quality of life.
In the majority of cases, sleep disorders can be diagnosed and managed by qualified practitioners. According to the American Academy of Dental Sleep Medicine, dentists with post graduate education in dental sleep medicine are the first defense against SDB by diagnosing patients’ dental structures. Patients are best served by having their primary care physician work together with a qualified dental practitioner to properly diagnose and treat SDB.[sup]13[/sup]
When a case presents a past medical history of unsuccessfully managed fibromyalgia, consideration of sleep disorder breathing as part of the differential diagnosis may prove to be a positive decision.
Dr. Leonard Feld is a TMJ-TMJD Dentist with offices in Los Angeles, San Jose and Palm Desert. He is the co-founder of the TMJ & Sleep Medicine Network and is located at Southwest TMJ Specialty Group on Hwy 111 in Palm Desert (760) 341-2873.
Dr. Feld’s philosophy is always a conservative, non-invasive and no-surgical treatment.www.DocFeld.com
Resources: 1) http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/fibromyalgia.asp 2) Lineberger MD, Melanie KM, Jack DE. Sleep Disturbance in Fibromyalgia. 2007;2(1):31-39. 3) Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The american college of rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis & Rheumatism 1990;33(2):160-72. 4) Gold AR, Dipalo F, Gold MS, O’Hearn D. The Symptoms and Signs of Upper Airway Resistance Syndrome*. Chest 2003;123(1):87-95. 5) Halbower AC, Ishman SL, McGinley BM. Childhood Obstructive Sleep-Disordered Breathing*. Chest 2007;132(6):2030-41. 6) Guilleminault C, Tilkian A, Dement W. The sleep apnea syndromes. Annual Review of Medicine 1976;27(1):465-84. 7) Millman R, Fogel B, McNamara M, Carlisle C. Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure. J Clin Psychiatry 1989;50(9):348-51. 8) Thase M. Depression, sleep, and antidepressants. The Journal of clinical psychiatry 1998;59:55. 9) Hamilton NA, Afflect G, Tennen H, Karlson C, Luxton D. Preacher KJ, et al. Fibromyalgia: the role of sleep in affect and in negative event reactivity and recovery. Health psychology: official journal of the Division of Health Psychology, American Psychological Association 2008;27(4):490-97; 10) Lineberger MD, Means MK, Edinger JD. Sleep Disturbance in Fibromyalgia. Medical Disorders and Sleep 2007;2(1):31-39. 11) Dahan V, Kimoff RJ, Petrof BJ, Benedetti A, Diorio D, Trojan DA. Sleep-disordered breathing in fatigued postpoliomyelitis clinic patients. Archives of Physical Medicine and Rehabilitation 2006;87(10):1352-56. 12) Germanowicz D, Lumertz M, Martinez D, Margarites A. Sleep disordered breathing concomitant with fibromyalgia syndrome. Jornal Brasileiro de Pneumologia 2006;32:333-38.; 13) Clete A. Kushida, Timothy I. Morgenthaler, Michael R. Littner, et al. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005. SLEEP, Vol. 29, No. 2, 2006. 14) Gold AR, Dipalo F, Gold MS, Broderick J. Inspiratory airflow dynamics during sleep in women with fibromyalgia. Sleep 2004;27(3):459-66.