CIRCADIAN RHYTHM IN FIBROMYALGIA SYNDROME

1. “Deciphering the role of circadian rhythm in
Fibromyalgia Syndrome patients
Dr. Ghizal Fatima
Assistant Professor
Department of Biotechnology
Era’s Medical College and Hospital
Lucknow

2. For everything there is a season and time for
every matter under heaven: a time to be born
and a time to die; a time to plant and a time
to pluck up what is planted. A time for sleep
and a time for wake up. God has made
everything beautiful in its time.
- Ecclesiastes

3. Introduction: Why we did this study
• Circadian rhythm regulates the amount of hormones and
neurotransmitters the body produces, and by this it creates circadian
rhythm in balance.
• But in fibromyalgia syndrome there is alteration in hormones and
neurotransmitters production.
• FMS patients have lower melatonin secretion during hours of darkness
which may contribute to disturbed sleep at night, fatigue and
musculoskeletal pain during the day. (Wikner et al.1998)
• Abnormal circadian rhythm of cortisol secretion in FMS patients. (Claw et
al 2003)
• Sleep disorder causes a shift in circadian pattern of cytokines level (IL-
6,TNF-alpha) which is produced less at bed time and more during the day
(Salemi et al,2003)
• The study is conducted to study the relationship of fibromyalgia syndrome
and circadian pattern of release of hormones and cytokines.

4. • 50 patents and 50 controls were enrolled for the study, all the clinical and
biochemical assessments of both patients and controls have been
completed.
• Samples were collected by admitting the patients and controls in the
Department of Rheumatology.
• Clinical assessment is done by questionnaire:-
1- General Assessment Questionnaire (self designed)
2- Fibromyalgia impact Questionnaire Revised (Bennett et al, 2009)
3- Circadian rhythm Phillip questionnaire (www.golite.philip.com)
4- Circadian rhythm symptoms of FMS questionnaire (self designed)
All the data analysis has been completed.
Clinical assessment of Patients and Controls

5. Diagnosis of patients: (FMS)
Diagnosis is based on the standardized criteria developed by the American
College of Rheumatology (1990). The criteria is-
1)-Widespread musculoskeletal pain for at least 3 months.
2)-Tenderness is found in at least 11 out of 18 anatomical sites in
making a fibromyalgia diagnosis with the application of 4 kg pressure by
palpation through first three fingers.

6. Clinical and biochemical characteristics among Study and
Control groups
Parameters FMS=50
[mean ± SD]
Controls=50
[mean ± SD]
P-value
Age [years] 36.7±9.8 32.8±10.5 >0.05
ESR 27.2±9.7 24.9±8.2 >0.05
ALT 39.8±14.1 37.6±14.4 >0.05
FIQR 91.9±8.0 5.0±8.3 <0.01
Tender Points 16.8±1.9 1.9±2.4 <0.01
CRA (Circadian Rhythm
Assessment)
40.80±16.16 14.56±24.41 <0.01

7. Variables FMS patients n=50 (%) Control n=50) (%)
Residence
Rural 17 (34) 11 (22)
Urban 33 (66) 39 (78)
Religion
Hindu 38 (76) 14 (28)
Muslim 12 (24) 36 72)
Marital Status
Married 41 (82) 31 (62)
Unmarried 9 (18) 19 (38)
Tobacco chewing
Yes 2 (4) 4 (8)
No 48 (96) 46 (92)
Widespread pain history
>3 months 14 (28) Nil
>6 months 10 (20) Nil
>1 year 26 (52) Nil

8. Clinical characteristics of women with FMS and control women:
Variables FMS patients n=50
(%)
Control n=50 (%) p-value
Weight loss
Yes 16 (32) 7 (14)
<0.05No 34 (68 43 (86)
Family history
Yes 7 (14) 0 (0)
<0.01No 43 (86) 50 (100)
Muscles twitching
Yes 50 (100) 6 (12) <0.01
No 0 (0) 44 (88)
Disequilibrium in Climbing stairs
Yes 38 (76) 3 (6) <0.01
No 12 (24) 47 (94)
Frequent awakening
Yes 42 (84) 4 (8) <0.01

9. Sleep Status
Yes (Sound sleep) 3 (6) 46 (92) <0.01
No (Disturbed sleep) 47 (94) 4 (8)
Morning Stiffness
Yes 47 (94) 3 (6) <0.01
No 3 (6) 47 (94)
Morning fatigue
Yes 48 (96) 5 (10) <0.01
No 2 (4) 45 (90)
Headache
Yes 43 (86) 24 (48) <0.01
No 7 (14) 26 (52)
Abdominal pain
Yes 28 (56) 20 (40) >0.05
No 22 (44) 30 (60)
Appetite change
Yes 18 (36) 0 (0) <0.01
No 32 (64) 50 (100)
Lack of energy
Yes 49 (98) 8 (16) <0.01
No 1 (2) 42 (84)
Jaw pain
Yes 11 (22) 46 (92) >0.05
No 39 (32) 4 (8)

10. Sampling design
First sample
collected
at 6 a.m.
Second sample
collected
At 12 noon.
Third sample
collected
At 6 p.m.
Fourth sample
collected at
12 mid-night.
Blood samples were collected at the
4 designated times of the day.
However, 6 or 7 control
Samples were collected at
11-11:30 pm and at 6 -6:30 am.
The mid-night samples of patients and
Controls were drawn
And kept for 30 min. for serum
Separation and then stored at
2-8 C. for 6 hr. and centrifuged
In the morning and stored at
-40 C.

11. Objectives: 1
Assessment of the circadian changes in cortisol, melatonin
and serotonin levels in patients with FMS

12. Circadian Rhythm of serum cortisol level in study and control group
Time of Day Study (n=50)
(Mean ± SD)
Control (n=50)
(Mean ± SD)
P-Value
Morning (6 AM)
27.91±12.81 28.30±13.63 >0.05
Afternoon (12 Noon)
14.82±5.91 13.68±6.21 >0.05
Evening (6 PM)
10.68±5.58 8.60±3.61 <0.05
Night (12 Midnight)
15.45±9.80 6.06±3.03 <0.01

14. Circadian Rhythm of serum Melatonin level in study and control group
Time of Day Study (n=50)
(Mean ± SD)
Control (n=50)
(Mean ± SD)
P-Value
Morning (6 AM)
35.18±12.75 19.73±9.98 <0.01
Afternoon(12 Noon)
14.91±6.40 13.48±5.14
>0.05
Evening (6 PM)
17.84±11.57 22.74±16.83 >0.05
Night (12 Midnight)
38.39±18.51 63.68±13.64
<0.01

16. Serum serotonin level was found high in patients but no significant circadian rhythm was
found in serum Serotonin level in study and control group.
Time of Day Study (n=50)
(Mean ± SD)
Control (n=50)
(Mean ± SD)
P-Value
Morning (6 AM)
76.53±34.02 115.54±38.68 <0.01
Afternoon(12 Noon)
86.76±47.46 113.69±28.10 <0.01
Evening (6 PM)
88.06±47.49 108.10±27.31 <0.05
Night (12 Midnight)
89.78±51.27 108.44±26.38 <0.05

18. Objective: 2
Analysis of circadian pattern of symptoms of fibromyalgia and its possible
relationship with cortisol, melatonin and serotonin

19. Symptoms Morning N=50
(%)
Afternoon N=50
(%)
Evening N=50 (%) Mid night N=50
(%)
Control Max. pain 0 (0) 0 (0) 10 4 (8)
Least pain 11 (22) 2 (4) 0 (0) 1 (2)
Patients Max. pain 19 (38) 1 (2) 12 (24) 17 (34)
Least pain 12 (24) 28 (56) 8 (16) 1 (2)
Control Max. stiffness 1 (2) 0 (0) 9 (18) 4 (8)
Least stiffness 5 (10) 7 (14) 2 (4) 0 (0)
Patients Max. stiffness 18 (36) 1 (2) 13 (26) 16 (32)
Least stiffness 11 (22) 26 (52) 9 (18) 1 (2)
Control Max. anxiety 0 (0) 13 (26) 15 (30) 5 (10)
Least anxiety 19 (38) 3 (6) 9 (18) 2 (4)
Patients Max. anxiety 15 (30) 1 (2) 15 (30) 13 (26)
Least anxiety 9 (18) 29 (58) 5 (10) 0 (0)
Control Max. numbness 1 (2) 0 (0) 0 (0) 2 (4)
Least numbness 1 (2) 2 (4) 0 (0) 0 (0)
Patients Max. numbness 7 (14) 0 (0) 7 (14) 35 (70)
Least numbness 8 (16) 37 (74) 4 (8) 0 (0)
Control Feel worst 0 (0) 1 (2) 0 (0) 1 (2)
Feel best 42 (84) 0 (0) 6 (12) 2 (4)
Circadian pattern of Fibromyalgia symptoms in patients and control

20. Patients Feel worst 20 (40) 0 (0) 10 (20) 20 (40)
Feel best 3 (6) 32 (64) 9 (18) 6 (12)
Control Max. stress 0 (0) 17 (34) 17 (34) 3 (6)
Min. stress 24 (48) 0 (0) 2 (4) 11 (22)
Patients Max. stress 10 (20) 0 (0) 19 (38) 20 (40)
Min. stress 10 (20) 34 (68) 3 (6) 2 (4)
Control Diff. conc. 2 (4) 14 (28) 20 (40) 4 (8)
No diff. conc. 23 (46) 3 (6) 14 (28) 1 (2)
Patients Diff. conc. 18 (16) 3 (6) 22 (44) 7 (14)
No diff. conc. 9 (18) 30 (60) 5 (10) 6 (12)
Control Max. Headache 2 (4) 9 (18) 8 (16) 6 (12)
Min. Headache 14 (28) 3 (6) 5 (10) 3 (6)
Patients Max. Headache 3 (6) 0 (0) 19 (38) 18 (36)
Min. Headache 14 (28) 26 (52) 0 (0) 0 (0)
Control Max. bowl 30 (60) 6 (12) 13 (26) 1 (2)
Suppress bowl 6 (12) 23 (46) 8 (16) 13 (26)
Patients Max. bowl 11 (22) 22 (44) 15 (30) 1 (2)
Suppress bowl 30 (60) 6 (12) 6 (12) 7 (14)

21. Decreased
Melatonin Level
Maximum Stress
Elevated Cortisol Level
Impaired sleep
Maximum
Numbness
Worst Stiffness
Fatigue
Least stiffness,
Anxiety and
Pain
Worst
Fibromyalgia Syndrome : Circadian
Rhythm of Symptoms
Feel good time
Day time
Sleepiness
Immense Fatigue
minimally Alert
Difficulty in
Concentration.Dizziness
12
Mid night
12
Noon
6 PM
6 AM
Headache onset
Maximum Pain,
stiffness
and Anxiety
Low Cortisol
level, High
stress
12:Midnight
High alertness
12
Noon

22. Determination of circadian changes in cytokines level (IL-6 and
TNF-alpha) and its possible relationship with melatonin,
serotonin, cortisol and symptoms of FMS.
Objective: 3

23. Time of Day Study (n=50)
(Mean ± SD)
Control (n=50)
(Mean ± SD)
P-Value
Morning (6 AM)
3.04±2.41 2.36±1.75 >0.05
Afternoon(12 Noon)
2.91±2.29 2.19±1.69
>0.05
Evening (6 PM)
2.67±2.17 2.24±1.45 >0.05
Night (12 Midnight)
2.99±2.48 2.15±1.47 >0.05
Serum IL-6 level was not found significant in patients and control group and hence there
was no significant differences observed in the circadian Rhythm of serum IL-6 level in study
and control group.

25. Time of Day Study (n=50)
(Mean ± SD)
Control (n=50)
(Mean ± SD)
P-Value
Morning (6 AM)
5.85±3.63 2.99±2.05 <0.01
Afternoon(12 Noon)
5.86±3.49 3.11±2.02
<0.01
Evening (6 PM)
5.90±3.51 2.96±2.11 <0.01
Night (12 Midnight)
5.88±3.44 2.78±1.99 <0.01
Serum TNF-alpha levels were found significant in patients group but there was no
significant circadian changes observed in serum TNF-alpha level in study and control group.

27. Conclusions
• Our results suggest that the disturbance in the circadian pattern of cortisol is found
in FMS patients. Interestingly, this increase in nocturnal serum cortisol in patients
group suggests deregulated circadian patterns which may explain in part the patient
complaint of unrefreshing sleep. In sum, our results showing lower cortisol values
in the morning, support the hypothesis of a circadian dysfunction of the cortisol
among patients group.
• Further, our results suggest that there was a weak circadian pattern of 5-HT in
patients with FMS. And this decrease in 5-HT levels, might contribute to the
pathogenesis of the disease. Interestingly, the decrease in 5-HT in patients group
throughout the day is important because it may explain in part the patients
complaint of unrefreshing sleep.
• Low melatonin level during the hours of darkness may cause disturbed sleep among
patients group. Due to which patients may complain of increased lethargy,
emotional distress, and cognitive and performance difficulties that accompany the
diffuse pain, fatigue and stiffness in the morning.
• Furthermore, our results suggest that there were no perturbations in the circadian
pattern of serum levels of IL-6 and TNF-alpha in patients with FMS.

28. • The sleep disturbance in FMS patients and that the pain is increased during night-time imply
that the ideal treatment at night hours may promote restful sleep.
• For treatment to be effective, the Chronobiological model implies that there must be a
reduction in the sleep arousal disturbance.
• Moreover, the diurnal variation of symptoms suggests that the optimal midday time for the
least pain and fatigue provides opportunities to promote and to monitor the response to
treatment programmes. For example, excessive physical exertion or energy-consuming tasks
should be discouraged in the early morning or evening.
• On the other hand, any interventional programme would be more acceptable by the patient
during the midday time. Therefore, timing may be crucial in treating FMS and this has
important implications for scheduling activities of daily living and possibly for timing the
administration of medications in FMS patients, and, therefore, these findings may lead to
novel interventions in the treatment of Fibromyalgia Syndrome.
• Future studies are important to validate the results presented here and especially to further
clarify the interplay of circadian rhythm symptoms with hormonal profiles and cytokines.

29. Relevance of the Study:
The observations of abnormalities in melatonin and cortisol which are highly regulated by circadian
pacemaker raise the possibility that there is an abnormality of circadian rhythm in FMS patients.
Moreover, the diurnal variation of symptoms suggests that the optimal midday time for the least pain
and fatigue provides opportunities to promote and to monitor the response to treatment
programmes and has important implications in the assessment of the patients. Therefore, timing
may be crucial in treating disease like FMS and this has important implications for scheduling
activities of daily living and possibly for timing the administration of medications.