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Fibromyalgia and sleep-disordered breathing: the missing link

Denis Martinez and Cristiane Maria Cassol*

Author Affiliations

Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350 – Porto Alegre, RS – Brazil – 90035-903

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Arthritis Research & Therapy 2008, 10:408  doi:10.1186/ar2538

See related review articles by Martinez-Lavin,, and Staud,, related research article by Vargas-Alarcón,, related editorial by Eisinger,, related letter by Felix and Fontonele,, and related response by Eisinger,

The electronic version of this article is the complete one and can be found online at:

Published:25 November 2008

© 2008 BioMed Central Ltd


Recently, Martinez-Lavin [1] proposed a model of sympathetically maintained neuropathic pain syndrome that has the merit of scrutinizing possible mechanisms behind the central sensitization model [2]. Eisinger [3], in an editorial comment, raises the issue of heterogeneity permeating Martinez-Lavin's proposition. Since it is difficult to establish a traumatic trigger event in all cases, Eisinger considers multicausality as more reasonable than a single post-traumatic etiology for all cases. Félix and Fontenele [4] further explored this venue, speculating that the orthostatic intolerance symptoms seen in the majority of fibromyalgia patients are a consequence of sympathetic hyperactivity. The idea that a COMT val-158-met polymorphism may cause higher cathecolamine levels has been explored [5]. Loevinger and colleagues [6] have shown that the metabolic syndrome is more common in individuals with fibromyalgia who also have higher body mass index, blood pressure, and waist-to-hip ratio than controls.

Interestingly, elevated body mass index, blood pressure, and waist-to-hip ratio are associated with sleep-disordered breathing. We recently reported in a study that 50% of the women with obstructive sleep apnea syndrome or upper airway resistance syndrome had chronic pain and more than 11 tender points when pressed with 4 kgf/cm2 [7]. Guille-minault and colleagues [8] reported orthostatic intolerance in patients with upper airway resistance syndrome. We believe that the authors investigating this theme should discuss the possibility of sleep-disordered breathing being the missing link between fibromyalgia, pain, disturbed sleep, alpha-delta sleep, hypotension, sympathetic hyperactivity, and metabolic syndrome.

We are conducting investigations into whether exposition to the typical stress of sleep-disordered breathing – with repeated arousal episodes and hypoxemia – has fibromyalgia as a possible outcome. Our preliminary results underline the need to consider and further explore this hypothesis.

Competing interests

The authors declare that they have no competing interests.


  1. Martinez-Lavin M: Biology and therapy of fibromyalgia: Stress, the stress response system, and fibromyalgia.

    Arthritis Res Ther 2007, 9:216. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  2. Staud R: Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome.

    Arthritis Res Ther 2006, 8:208. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  3. Eisinger J: Dysautonomia, fibromyalgia and reflex dystrophy.

    Arthritis Res Ther 2007, 9:105. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  4. Félix FHC, Fontenele JB: Is fibromyalgia a cardiovascular disease? A comment on Martinez-Lavin's review 'Stress, the stress response system, and fibromyalgia'.

    Arthritis Res Ther 2007, 9:404. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  5. Vargas-Alarcón G, Fragoso JM, Cruz-Robles D, Vargas A, Vargas A, Lao-Villadóniga JI, García-Fructuoso F, Ramos-Kuri M, Hernández F, Springall R, Bojalil R, Vallejo M, Martínez-Lavín M: Catechol-O-methyltransferase gene haplotypes in Mexican and Spanish patients with fibromyalgia.

    Arthritis Res Ther 2007, 9:R110. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  6. Loevinger BL, Muller D, Alonso C, Coe CL: Metabolic syndrome in women with chronic pain.

    Metabol Clin Exp 2007, 56:87-93. PubMed Abstract | Publisher Full Text OpenURL

  7. Germanowicz D, Lumertz MS, Martinez D, Margarites AF: Coexistência de transtornos respiratórios do sono e síndrome fibromiálgica.

    J Bras Pneumol 2006, 32:333-338. PubMed Abstract | Publisher Full Text OpenURL

  8. Guilleminault C, Faul JL, Stoohs R: Sleep-disordered breathing and hypotension.

    Am J Respir Crit Care Med 2001, 164:1242-1247. PubMed Abstract | Publisher Full Text OpenURL