Journal oJP~sTchosomatic Research, Vol. 39, No. I. pp.

85 91, 1995
Copyright ~) 1995 Elsevier Science Lid
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0022-3999(94)00081

NOCTURNAL MOTOR ACTIVITY IN FIBROMYALGIA

PATIENTS WITH POOR SLEEP QUALITY

MARKKU T. H Y Y P P A a n d E R K K I K R O N H O L M

(Received for publication 6 July 1994)

Abstract Nocturnal motor activity was examined in long-term rehabilitation patients complaining of
poor sleep and having fibromyalgia syndrome (N -- 24) or other musculoskeletal disorders (N 60) and
compared with that in 91 healthy controls drawn from a random community sample. Self-reports on
sleep complaints and habits were collected. The frequency of nocturnal body movements, the "apnoea'"
index and ratio of "quiet sleep" to total time in bed were measured using the Static Charge Sensitive Bed
(SCSB) (BioMattR). As a group, patients with fibromyalgia syndrome did not differ from patients with
other musculoskeletal disorders or from healthy controls in their nocturnal motor activity. The "apnoea"
index was a little higher in the fibromyalgia group than in the healthy control group but did not differ
from that of the group of other musculoskeletal patients. Further multivariate analyses adjusted for age,
BMI, medication and "apnoea" index did not support the assumption that an increased nocturnal motor
activity characterizes patients with fibromyalgia syndrome.

Keywords: Nocturnal motor activity, Poor sleep, Fibromyalgia, Musculoskeletal disorder.

INTRODUCTION

P o o r quality o f sleep has been r e p o r t e d in chronic musculoskeletal s y n d r o m e s [1]

a n d especially in the f i b r o m y a l g i a s y n d r o m e [2 7]. Patients with f i b r o m y a l g i a have
been f o u n d to have either an a r o u s a l dysfunction, an a l p h a e l e c t r o e n c e p h a l o g r a p h y
( E E G ) a n o m a l y d u r i n g slow-wave sleep [8 10], or a p n o e a - r e l a t e d a r o u s a l s from sleep
[11].
A r o u s a l d y s f u n c t i o n s have been s u b s t a n t i a t e d in clinical r h e u m a t o l o g i c a l settings
including small p a t i e n t samples. A recent investigation showed t h a t the features and
s y m p t o m s o f the selected f i b r o m y a l g i c patients in clinical settings are n o t the same
as in the prevalence survey [12]. F o r e x a m p l e f i b r o m y a l g i a subjects in the D a n i s h
p o p u l a t i o n did n o t suffer f r o m sleep d i s t u r b a n c e s [13]. A l s o the specificity o f the
sleep E E G findings for the patients with f i b r o m y a l g i a s y n d r o m e has been d i s p u t a b l e
in some studies [9, 14, 15].
We have previously shown t h a t a heightened n o c t u r n a l m o t o r activity a n d a high
level o f physiological a c t i v a t i o n characterize m a n y patients with l o n g - t e r m nonspecific
s o m a t i c c o m p l a i n t s a n d self-perceived p o o r q u a l i t y o f sleep [16]. In this study the
n o c t u r n a l activity measures o f patients with f i b r o m y a l g i a were c o m p a r e d with o t h e r
patients. In o r d e r to test the h y p o t h e s i s o f an increased n o c t u r n a l m o t o r activity in

Research and Development, Social Insurance Institution, Finland

Address correspondence to: Dr Markku T. Hyypp/i, Research and Development, Social Insurance
Institution, Peltolantie 3, SF-20720 Turku, Finland.

85
86 M. T. H Y Y P P A and E. K R O N H O L M

fibromyalgia syndrome we used the Static Charge Sensitive Bed (SCSB) method to
measure nocturnal motor behaviour in the patients with long-term complaints of
musculoskeletal disorders, who had reported poor sleep. The nocturnal measures
were also compared with those of healthy subjects drawn from a random community
sample.

SUBJECTS A N D M E T H O D S
Setting
Patients referred to the Rehabilitation Centre (RC) of the Social Insurance Institution undergo working
capacity assessment and rehabilitation examinations. They spend over 2 weeks in the RC in the patient
dormitory, where the restrictions are the same as in Finnish hospitals in general, i.e., alcohol consumption,
illicit drugs etc. are not allowed, tobacco smoking is limited and coffee consumption is allowed. The
Rehabilitation Centre also conducts field surveys and population studies. A multidisciplinary approach
is used both for individual examinations and in epidemiological surveys.

Patients and heahhy controls

Eighty-four consecutive rehabilitation patients (41 men and 43 women, age range 23 58 yr, median
age 42.5 yr) with sleep complaints and long-term musculoskeletal disorders participated in the study.
Sleep examinations were requested by consulting physiatrists, internists or psychiatrists. Musculoskeletal
diagnoses [hzternational Classification of Diagnoses, 1975 Revision (ICD-9) 710 739] were confirmed by
a rehabilitation team of physicians. The consulting and rehabilitation team physicians were not told of
the study design.
Sciatica (7227C, ICD-9) was diagnosed in 26.7%, low back pain without sciatica (724) in 20%, neck
and shoulder syndrome (723) in 16.7%, spondylarthrosis (721) in 11.7%, myositis (728) in 10%, polymyalgia
rheumatica (725) in 3.3%, rheumatoid arthritis (714) in one and others (713,717,7292A, 738) in 10% of
the musculoskeletal patients. Fibromyalgia syndrome was classified according to the current American
College of Rheumatology 1990 criteria [6]. The exclusion criteria for fibromyalgia were other mu-
sculoskeletal causes of pain, cardiovascular or neurological disease, diabetes, and infectious or malignant
disease.
Secondary psychiatric diagnoses were confirmed by a consulting psychiatrist in a half (51.7'¼,) of the
musculoskeletal patients and in two thirds (67%) of the fibromyalgia patients. The former group consisted
of 38 male and 22 female musculoskeletal patients, aged 29 58 yr and the latter of 21 female and three
male patients, aged 23 54 yr.
Ninety-one healthy subjects (46 men and 45 women, aged 36 55 yr) without any diagnosed disease
and medication, were randomly chosen from the population register of the city of Turku, Finland, and
its surroundings (about 200,000 residents) [17]. They underwent sleep examinations similar to those for
the patients [18].
All study participants gave written consent. The study protocol and examinations were approved by
the Ethical Committee of the R C of the Social Insurance Institution.

Methods
Self-reports on sleep habits were collected and assessed for disorders of initiating and maintaining sleep
(DIMS) and for excessive daytime somnolence (EDS) [19]. D I M S was assessed as a sum score of the
replies to the following questions of the Sleep Habit Questionnaire (SHQ):
'How long (in rain) does it take for you to fall asleep?
Lessthan 5min=l,6-10min=2, 11 2 0 m i n = 3 , 2 1 30 min - 4, 3 1 4 0 min = 5, 41 5 0 m i n 6,
51 60 min = 7 or over 60 min 8.
'If your sleep is interrupted, how m a n y times do you wake up?'
Never = 0, once = 1, 2 3 times = 2 or more = 3.
"Do you suffer from sleeplessness?'
Never 0, sometimes = 1, o f t e n - 2 or almost always 3.
EDS was assessed as a sum score of the replies to lhe questions: 'How often do you take a nap?'
Never = 0, 1 2 times weekly 1, 3 4 times weekly - 2, 5 6 times weekly 3, daily - 4, m a n y times
daily = 5.
'Do you often feel that you fall asleep compulsively?'
No = 0, yes 1.
'Are you more tired than your workmates?'
 Nocturnal motor activity in fibromyalgia 87

No =0, yes = 1.
"Do you fall asleep on a bus (tram, train etc.), or in other similar situations?'
Never = 0, sometimes = 1, often = 2, or almost always = 3.
'Do you fall asleep at meetings (in cinemas, watching TV, etc.)?'
Never = 0, sometimes = 1, often = 2, or almost always = 3.
More details of SHQ including reliability and validity assessments have been published elsewhere
[1, 17, 20, 21].
Nocturnal body movements, respiratory movements and ballistogram were recorded using the SCSB
(Bio-Matt R, Turku, Finland) [18, 22 27]. The so called first-night effect of the sleep registration has been
carefully studied and no such effect has been observed in the SCSB registrations [18, 22 27]. The raw
data and computerized data were scored. Frequency of body movements (N/min), ratio of "quiet sleep",
i.e. no body movements, no marked alterations in ballistocardiographic and breathing recordings, to time
in bed [28] and "apnoea" index (the mean N of > 10 s breathing movement cessations per hr) [18, 27]
were calculated for time in bed. Body mass index (BMI, kg/m2) was measured and demographic data
were collected. Medication was assessed as the use of drugs before the onset of sleep recording (0 = no
drug; 1 = drugs). Drugs were classified as benzodiazepines, cardiovascular, analgesics and antirheumatic
nonsteroids, central nervous system drugs, antibiotics and nonprescription drugs. Organic dyssomnias,
such as narcolepsy, hypersomnia, sleep apnoea syndrome, periodic limb movement disorder or parasomnias
were neither reported by the fibromyalgia and musculoskeletal patients nor found in their medical and
sleep examinations.

Statistical treatment
The SASR version 6 program package [29] was used for all statistical analyses. Since the nocturnal
measures did not show a normal distribution (Shapiro-Wilks test for normality), the Kruskal-Wallis test
(Z2 approximation) for Wilcoxon scores was used for direct comparisons between the groups. In the
preliminary correlation analyses, age, gender, BMI, medication and "apnoea" index showed univariate
associations with the frequency of body movements and the ratio of "quiet sleep" to total time in bed.
Allocation to the fibromyalgia, other musculoskeletal disorders or healthy control group and confounding
age, gender, BMI, medication and the "apnoea index" were selected to predict nocturnal physiological
activity in multivariate analyses. In other words, the independent effect of the group on nocturnal body
movements and on "quiet sleep" was treated in the multivariate regression analyses, i.e. GLM (General
Linear Models) procedure of SASR [29]. Due to missing values statistical analyses must be done for
reduced study samples. Respective group sizes are given in the Tables.

RESULTS

I n s o m n i a a n d excessive s o m n o l e n c e w e r e c o m m o n l y r e p o r t e d b y the p a t i e n t s , a n d
the c o n t e n t s o f r e p o r t s d i d n o t differ b e t w e e n the p a t i e n t g r o u p s ( W i l c o x o n 2 - s a m p l e
test f o r s u m scores; D I M S : p = 0.20 a n d E D S : p = 0.70). U s e o f d r u g s b e f o r e
r e g i s t r a t i o n w a s s i m i l a r in the b o t h p a t i e n t g r o u p s . E x c e p t gender, age, B M I a n d
o t h e r d e m o g r a p h i c f e a t u r e s ( e d u c a t i o n a l , o c c u p a t i o n a l a n d social status) s h o w e d n o
differences a m o n g the t h r e e g r o u p s .
T h e r e w e r e significant differences a m o n g the t h r e e s t u d y g r o u p s ( K r u s k a l l - W a l l i s
test; p = 0.0001) for the m e a n f r e q u e n c y o f n o c t u r n a l b o d y m o v e m e n t s d u r i n g t i m e
in bed. It w a s h i g h e s t in the m u s c u l o s k e l e t a l g r o u p a n d l o w e s t in the h e a l t h y c o n t r o l
g r o u p . P a t i e n t s w i t h f i b r o m y a l g i a s y n d r o m e d i d n o t differ f r o m t h e h e a l t h y c o n t r o l
s u b j e c t s n o r f r o m o t h e r m u s c u l o s k e l e t a l p a t i e n t s in their n o c t u r n a l b o d y m o v e m e n t s ,
T a b l e I.
T h e m e a n " a p n o e a " i n d e x s h o w e d a significant difference a m o n g the t h r e e g r o u p s
( K r u s k a l l - W a l l i s test: p = 0.0014) b e i n g h i g h e r in p a t i e n t s t h a n in t h e i r h e a l t h y
c o n t r o l s . N o significant d i f f e r e n c e w a s seen b e t w e e n the t w o p a t i e n t g r o u p s ( T a b l e
II). T h e r a t i o o f " q u i e t sleep" to t o t a l t i m e in b e d was e q u a l in all s t u d y g r o u p s
( K r u s k a l l - W a l l i s test; p = 0.88) T a b l e III.
A significant i n d e p e n d e n t g r o u p effect w a s seen in the e x p l a n a t o r y G L M m o d e l
88 M. T. HYYPPA and E. KRONHOLM

Table I. Nocturnal body movement frequency in the patients

with fibromyalgia, in the patients with other musculoskeletal
disorders, and in the healthy control population.

N Mean 95% confidence

interval

Fibromyalgia 24 0.38 0.29 0.47

Other 55 0.50 0.44-0.56
musculoskeletal
disorders
Healthy controls 90 0.31 0.26 0.35

Significant difference (df 2; p = 0.0001, Kruskall-Wallis test, Z~

approximation, for Wilcoxon scores) is seen between the groups.

Table II. Apnoea index in the patients with fibromyalgia, in the

patients with other musculoskeletal disorders, and in the healthy
control population.

N Mean 95% confidence

interval*

Fibromylagia 24 2.1 1.(~2.6

Other 58 1.9 1.1 2.6
musculoskeletal
disorders
Healthy controls 90 1.1 0.7 1.5

Significant difference (df 2; p = 0.0014, Kruskall-Wallis test, Z2

approximation, for Wilcoxon scores) is seen between the groups.
* The confidence intervals are tentative, since the distribution of
the apnea indices is not normal.

Table III. Quiet sleep ratio (% of time in bed) in the patients

with fibromyalgia, in the patients with other musculoskeletal
disorders, and in the healthy control population.

N Mean 95% confidence

interval

Fibromyalgia 18 17.0 11.4-22.5

Other 38 17.3 13.5 21.2
musculoskeletal
disorders
Healthy controls 83 16.3 13.7 18.9

No significant difference (df 2, p - 0.71, Kruskall-Wallis test, Z~"

approximation, for Wilcoxon scores) is seen between the groups.

o f n o c t u r n a l b o d y m o v e m e n t s ( F 3.4; p = 0.04) i n d i c a t i n g t h a t t h e m u s c u l o s k e l e t a l
non-fibromyalgic group differ from the healthy control group. BMI showed a positive
i n d e p e n d e n t a s s o c i a t i o n w i t h t h e f r e q u e n c y o f n o c t u r n a l b o d y m o v e m e n t s ( F 10.6;
p = 0 . 0 0 1 4 ) a n d , as e x p e c t e d , t h e " a p n o e a " i n d e x w a s p o s i t i v e l y a s s o c i a t e d w i t h t h e
f r e q u e n c y o f n o c t u r n a l b o d y m o v e m e n t s ( F 15.0; p = 0 . 0 0 0 2 ) a n d n e g a t i v e l y a s s o c i a t e d
 Nocturnal motor activity in fibromyalgia 89

with "quiet sleep" (F 8.8; p = 0.004). No group effect was seen in the explanatory
model of "quiet sleep". Outcome variables, i.e., nocturnal body movements and
"quiet sleep", are negatively associated by definition. The model explained 35% of
total variance in nocturnal body movements and 12% of the total variance in "quiet
sleep".

DISCUSSION

No specific features of nocturnal motor activity could be found in fibromyalgia

syndrome. In their nocturnal movements fibromyalgia patients did not differ from
musculoskeletal patients without fibromyalgia or from healthy control subjects. The
"apnoea" index [18, 27] in fibromyalgia syndrome was of the same order of magnitude
as in other musculoskeletal disorders and only slightly higher than in the healthy
community sample. The "quiet sleep" ratio [28] did not show any differences among
the study groups.
In this study we did not record EEG sleep. Instead we studied other physiological
activities, such as body movements, which are controlled by the central nervous
system; and respiratory movements and ballistocardiogram, which are controlled by
the autonomic nervous system [18, 22-24, 27]. We have previously shown that an
increase in the levels of nocturnal motor activity and physiological arousal is
associated with poor sleep [16]. The SCSB method is also sensitive and specific for
the detection of hypopnoea, apnoea and subsequent arousal movements [25, 27, 30].
The "apnoea" index was slightly higher in the patients with fibromyalgia syndrome
than in the healthy community sample, but no significant difference was found
between fibromyalgia and other musculoskeletal patients. Thus, our results neither
support the assumption of sleep apnoea-related arousals in fibromyalgia syndrome
[11] nor statistically refute it.
Because of its selection criteria this study does not demonstrate the prevalence of
poor sleep among musculoskeletal patients. The experience of poor sleep was equal
in both patient groups, and all patients complained of poor sleep and insomnia.
Despite the similar experience of poor sleep, fibromyalgic patients tended to have
less nocturnal motor arousal than other musculoskeletal patients. The prevalence
of poor sleep experienced in fibromyalgia syndrome is high in the studies with
rheumatological settings (e.g., [6, 31, 32]), but in the epidemiological surveys only
25-40% of fibromyalgia patients reported sleep disorders [33, 34]. The latter figure
does not differ from the general population [12, 21].
The prominence of the alpha EEG sleep, observed in fibromyalgia patients [8-10],
has been interpreted as reflecting an increased level of arousal, which furthermore
may result in the experience of unfreshing sleep [35]. We could not verify the assumed
increased nocturnal motor arousal in fibromyalgia by the SCSB method. There are
some obvious explanations for the conflicting results. First, the definition of arousal
is important for the conclusions drawn from empirical data. "Arousal" is a com-
plicated state that cannot be reduced to brain wave patterns alone (see Ref. [36]).
Second, even if the holistic concept of arousal [36] is not considered, there are
different kinds of arousals, which are anatomically and functionally separated, e.g.,
autonomic v s cortical nervous system and motor activity v s EEG activity. Third,
conflicting results have been reported even in the EEG studies, probably due to
90 M.T. HYYPP,~ and E. KRONHOLM

small sample sizes which do n o t allow reliable statistical t r e a t m e n t [8, 10, 14, 15,
35]. H o r n e a n d Shackell [14] did n o t observe significant difference o f alpha-like E E G
activity between fibromyalgia patients a n d symptom-free controls. A p p r o x i m a t e l y
15°/,. of the healthy p o p u l a t i o n had alpha E E G activity d u r i n g slow-wave sleep in
one previous study [37]. F o u r t h , the i n t r u s i o n of alpha activity into slow-wave sleep
has n o t been standardized in previous studies [38].
The control of i m p o r t a n t c o n f o u n d i n g factors has n o t usually been considered in
earlier sleep studies o n fibromyalgia syndrome. We performed multivariate analyses
with the allocation to one o f the three study groups, age, gender, BMI, m e d i c a t i o n
a n d " a p n o e a " index as predictors, a n d n o c t u r n a l b o d y m o v e m e n t s or "quiet sleep"
as o u t c o m e variables. M u l t i v a r i a t e analyses confirmed results d r a w n from u n i v a r i a t e
c o m p a r i s o n s a m o n g the study groups, i.e., musculoskeletal disorders w i t h o u t fibro-
myalgia predict n o c t u r n a l b o d y m o v e m e n t s . Musculoskeletal disorders with or
w i t h o u t fibromyalgia do n o t i n d e p e n d e n t l y predict the a m o u n t of quiet sleep. Results
suggest a discrepancy between self-reported sleep quality a n d recorded n o c t u r n a l
m o t o r activity in fibromyalgia patients.

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