The objective of the current study was to assess the impact of sleep difficulties on HRQoL among patients with FM. Despite the research on the sleep-related symptoms experienced by those with FM, no study to our knowledge has examined the relationship of these symptoms with HRQoL, especially in comparison with a matched control group. Our results suggest sleep difficulties are pervasive among the FM population, as over 88% of patients reported some level of sleep difficulties, as defined by experiencing either difficulty falling asleep, difficulty staying asleep, or waking up too early. Nearly 63% of patients with FM reported experiencing at least two of the above symptoms. These figures were significantly higher than those without FM, even those matched with FM patients.
Replicating past literature, our sample of patients with FM reported significant decrements in both MCS (41.49) and PCS (31.29) scores relative to population norms (50 and 50, respectively). Indeed, the one and two standard deviation differences, respectively, in MCS and PCS compared with the population mean is nearly identical to the results reported by previous literature
[6, 7]. On an absolute level, these levels of HRQoL are worse than reported in the same survey for patients with severe osteoarthritis, chronic obstructive pulmonary disease, atrial fibrillation, hepatitis C, arthritis, and back pain, among others
[24–28], However, our findings suggest that the presence of sleep difficulties poses an additional burden on patients with FM. Our results suggest that sleep difficulty symptoms has an independent, and significant, clinically-meaningful effect on HRQoL among the FM population. Past research has suggested a three-point between-groups difference in MCS and PCS is often associated with a clinically-meaningful difference
. The comparison between one sleep difficulty symptom and no sleep difficulty symptoms approached this threshold while the comparison between two sleep difficulty symptoms and no sleep difficulty symptoms exceeded it, even after adjusting for confounding variables.
It is particularly important to note that these models controlled for pain severity and frequency. Naturally, severe pain and frequent pain (as confirmed in Table
2) would be expected to have a significant effect on sleep symptoms, as also demonstrated in prior research
[14, 16, 20, 22]. Yet, even accounting for the higher prevalence of pain severity and frequency among those with more sleep difficulty symptoms, worse HRQoL summary and domain scores were observed. This suggests that sleep difficulties have an independent effect on HRQoL among those with FM, beyond any potential effect of the pain experience.
Also noteworthy was that the relationship between sleep difficulties and HRQoL varied between those with FM and matched controls. In many cases, the introduction of a single sleep difficulty symptom was associated with a larger decrement in HRQoL among patients with FM, however, the introduction in a second sleep difficulty symptom was associated with larger decrement in HRQoL among matched controls. Further research may be necessary to ascertain the cause of the discrepancy. One possibility is that sleep difficulties are generally more burdensome for patients with FM, however, given the nature of the disease, a floor effect is reached upon the introduction of the second sleep difficulty symptom. In other words, patients with FM are so burdened already by their condition that the introduction of an additional sleep difficulty symptom does not affect their HRQoL as much as it would a patient without FM. Regardless, our preliminary evidence suggests that the pattern of the relationship between sleep difficulty symptoms and HRQoL is unique among those with FM.
The effect of sleep difficulty symptoms extended beyond HRQoL. In unadjusted comparisons, patients who reported sleep difficulties showed higher rates of disability than those without sleep difficulties. Although beyond the scope of the present analysis, the effect of sleep difficulties on participation in the labor force and productivity at work may also need to be considered in future research.
In sum, the results suggest patients with FM experience considerable difficulty initiating and maintaining sleep. The presence of these sleep difficulty symptoms have a significant and clinically-meaningful impact on HRQoL, even after accounting for a range of confounding variables. The study results suggest the improved management of these sleep difficulty symptoms among patients with FM may lead to clinically-relevant improvements in HRQoL. The alleviation of pain could have an important effect of improving sleep, but more research would be necessary to establish this causal pathway. Indeed, the relationship between pain and sleep does appear bidirectional
. Of course, since the effect of sleep difficulty symptoms on HRQoL was observed even after controlling for pain, the management of sleep difficulties likely extends beyond the mere alleviation of pain.
Several limitations should be noted from the results of this study. Given the cross-sectional design of the study, the causal inference cannot be determined. Although alternative explanations have been included (such as comorbidities and, demographic confounders), it is possible other unmeasured variables might explain the relationship between sleep difficulties and HRQoL. Because of the self-reported nature, recall bias may have introduced additional error into the observed associations. As described before, the sleep difficulty groups were not defined by a sleep scale but rather using three symptoms of initiating and maintaining sleep to operationalize sleep difficulty severity. It should also be emphasized that although the NHWS is demographically representative of the US population, the sample in the current study of FM patients may differ with respect to healthcare attitudes or healthcare engagement (among other variables) that could affect the size and direction of the relationships observed here.