Contributions Sommeil Neurophysiologie & autres ..

Restless leg and spinal pathology

Didier Cugy — 2022-08-23T08:54:16Z

Material and methods : From the database of 239 876 health examinations collected between 2004 and 2022 in the health examination centers of the CPAM in the Gironde, we looked for the links that may exist between sleep complaints, drowsiness, existence of a spinal pathology (neck pain, back pain, low back pain) and restless legs. The data was analyzed using the Chi2 method.
Results : A significant association (p<0.0001) was found between the presence of restless legs and sleep complaints. Surprisingly there is no association between sleep complaint and neck pain (p<0.60 )but, there is an association between sleep complaint and back pain (p<0.0001), low back pain (p<0001). restless legs being associated with a complaint of neck pain (p<0001) and unrelated to complaints concerning the dorsal (p=0.94) or lumbar (p=0.25) spine. The observed prevalence of the neck pain-restless legs association is 4.5 times higher than expected.
Discussion : restless legs, the prevalence of which is between 2 and 10% of the general population, is usually considered either as symptomatic (inflammatory syndrome, iron deficiency, etc.) or idiopathic. The results observed point in the direction of a central subcortical or high medullary origin as mentioned by Kaplan(1) or Kumru(2).
A previous report was performed in 2017 with less records. Most of the results found in 2022 confirm those already identified in 2017.
Conclusion : The association cervicalgia with restless legs is in favor of a high medullary origin
Bibliography : Kaplan Y1, Oksuz E. Association between restless legs syndrome and Chiari type 1 malformation. Clin Neurol Neurosurg. 2008 Apr ;110(4):408-10. doi : 10.1016/j.clineuro.2007.12.023. Epub 2008 Feb 20. Kumru & al. Restless leg syndrome in patients with spinal cord injury, Parkinsonism and Related Disorders (2015), doi : 10.1016/j.parkreldis.2015.10.007.

Quantitative aspects of the Sympatho Vagal Balance reported from 523 polysomnographic recordings

Didier Cugy — 2020-08-12T18:41:33Z

Objectives / Introduction : We systematically integrated the sympatho-vagal balance calculation when analyzing the sleep records. The sympathovagal balance is calculated from the analysis of the variability of the RR space obtained from the ECG signal. We relate the results of the calculations to the other sleep parameters and to the diagnosis made after polysomnography.
Methods : The computation of the sympathovagal balance is carried out from the computation of the spectral analysis of the RR variability after analysis by wavelet of the ECG signal. The standard balance (BSV) is calculated as the LF / (LF + HF) ratio. The high values correspond to the predominance of the sympathetic tone, the low values to the vagal tone. The calculation was applied systematically to all the registrations made over the past two years. The data are analyzed by age, sex, sleep stage and diagnoses.
Results : The population studied is divided into 255 men, 266 women and 2 transsexuals. 21% under 35, 28% 35 to 50, 28% 50 to 65, 19% 65 to 80 and 4% above. The mean value of BSV is 0.81, which increases significantly (increase in sympathetic tone) with age (p < 0.001), is linked to sex. the mean value is 0.82 for men and 0.795 for women (p < 0.001). The value is inversely correlated with the total sleep time (p = 0.02) and mainly with the duration of stage 2 sleep (p < 0001) and REM sleep (p = 0.003). These results are in accordance with what is known. The value of BSV is significantly lower in narcoleptic patients compared to other patients (p < 0.0083. It is also found that BSV is correlated with the index of reactivity of the pulse wave and is higher in patients with positional OSAS (p = 0.0086)
Conclusions : The sympathovagal balance is a simple parameter to calculate from the ECG signal which is known as a predictor of cardiovascular risk factors, the use of which should be integrated into the routine analysis of polysopnography.

Postural aspects and polysomnography

Didier Cugy — 2020-08-12T18:39:59Z

Objectives / Introduction : The clinical observation of patients referred for suspected sleep apnea shows similarities in different parameters. A neck circumference greater than 42cm is clearly identified. Cervical kyphosis, curling, antepulsion of the shoulder are easily assessable parameters in current clinical practice.
Methods : The postural parameters are obtained, the subject in a standing position at rest, the back aligned to a vertical plane, from the measurement of the distances inion vertical, acromion vertical and hands wall in maximum antepulsion. These parameters as well as those already known (neck circumference) are correlated with polysomnography parameters (apneas, desaturations, etc.) and autonomic parameters (RR variability, sympathovagal balance). This analysis is carried out from a database of 523 patients combining polysomnographic recordings and clinical examination. The different parameters are compared by regression calculation and analysis of variance.
Results : It is found significant correlations (p <001) with the indexes of apnea, desaturation for known parameters such as neck circumference and waist circumference, BMI. Kyphosis and shoulder curl are also correlated with the apnea index (p <0.01) as well as with RR variability. Shoulder curl correlates specifically with desaturation index (p <0.05), systolic blood pressure at rest (p <0.02) and, very surprisingly, with periodic sleep movements (p <0 , 01) as well as the RR variability (p <0.01). No significant relationship has been identified between the antepulsion and the various parameters.
Conclusions : The postural aspects of patients referred for suspected sleep pathology should be part of the clinical examination. Like neck measurement, cervical kyphosis and shoulder curl measurement should be part of the clinical observation. Taking into account postural aspects makes it possible to legitimize a type of rehabilitation approach for patients who do not justify the use of treatment with CPAP or OAM.

Uncontrollable cataplexies : -have a look to the cervical spine

Didier Cugy — 2018-09-21T06:44:14Z

Objectives / Instruction : Cataplexy is defined as episodes of sudden loss of voluntary muscle tone triggered by emotions generally lasting <2 minutes. Cataplexy is most commonly associated with and considered pathognomonic for narcolepsy. The single pharmacotherapy indicated and recommended in first-line for cataplexy is sodium oxybate. There is no consensus for second-line treatment when cataplexies are not controlled.
Methods : Case report of two patients with uncontrolled cataplexies related to narcolepsy.
Results : Patients are male, aged 62 (P1) and 68 (P2) years old. They both have a HLA DR15 / DQ0602 phenotype. They have at least one episode of cataplexy per day. Both have benefited from a combination of arousing and anti-cataplectic treatment (1,2) (SSRI, Sodium Oxybate) but these treatments were not able to control cataplexies even after a dose escalation.
Alternative causes of cataplexies or cataplexy-like were searched (3).
Physical exam showed cervical stiffness. Cervical spine MRI revealed inversion of cervical spine curvature and important staged discopathies with cervical canal stenosis. Specific management of cervical pathology was proposed in addition to the treatment of narcolepsy and cataplexy. This was efficient and we observed a better control of cataplexy.
In a very particular way, one patient described that he usually limited cataplexies frequency by walking practice.
Conclusions : In patients with uncontrolled cataplexies under Sodium Oxybate, cervical spine pathologies should be considered, especially if cervical spine is stiff or patient reports an improvement with changing posture or walking. Treatment of associated pathologies appears a consistent way to enhance narcolepsy treatment.

Polysomnographic evaluation of sleep in Chiari Type 1 malformation before surgical decision and after surgery

Didier Cugy — 2018-09-21T06:44:01Z

Objectives / Instruction : Chiari malformation is known to be associated with sleep apnea but others sleep disorders could be identified. We report here our experience of nocturnal polysomnographic performed before surgical decision and after surgery of Chiari type 1 malformation
Methods : Retrospective analysis. Since 2010, we explored patients with Chiari malformation during the pre-operative assessment, and when possible or indicated after surgery. Nocturnal video-polysomnographic were performed in the sleep laboratory. Furthermore, at each evaluation, patient completed Epworth Sleepiness Scale (ESS), Pichot ADA asthenia scale, Pichot Q2DA depression scale and Modified Essay Questions (MEQ).
Results : Seventeen patients were recorded before surgical assessment and 6 after surgery. Mean age was 43 ± 13 years old. All patients have sleep fragmentation by arousals, due to Periodic Limb Movements (PLM) for 11 patients, and significative sleep apneas (mean 18/h) for 6 patients. Mean total sleep time (TST) was 405± 19 mn, under normal data from our sleep lab (mean = 415± 2 mn). REM sleep represented only 13% of the TST.
After surgery, we observed an increase of mean TST to 432± 25 mn (vs 385± 44 mn before) and of the REM sleep (17% of the TST vs 13% ) for the 6 reevaluated patients. Sleep apnea index decreased from 18 /h to 13/h and PLM appeared to be less frequent.-Considering self-evaluation, only ESS has significative abnormal results with a mean score at 11± 3 before surgery. For the 6 patients, all scores decreased after surgery : from 12 ± 2 to 6 ± 3 for ESS, 16 ± 5 to 7 ± 2 for ADA, 8 ± 3 to 3 ± 2 for Q2DA and 4 ± 2 to 1 ± 1 for MEQ.
Conclusions : Our retrospective data showed a higher association with PLM than to apneas in Chiari malformation. Furthermore, sleep architecture parameters were altered. So polygraphy was insufficient to explore sleep and a polysomnographic study has to be preferred.
Use of Epworth Sleepiness Scale questionnaire as a screening tool appeared to be useful for sleepiness evaluation before surgery.

Pallesthesia asymetry : a new way to help diagnose of PLMS

Didier Cugy — 2016-07-21T13:49:55Z

Introduction
Periodic Leg Movements during Sleep (PLMS) is one of the sleep movement disorders that can affect the quality of sleep. Diagnostic is actually based on the association of a complaint regarding limb movements during sleep and detection of a periodic limb activity during polysomnography. But some patients could present limb activity without complaint (no bed partner for example). So clinical diagnostic orientation is difficult.

Objective
The aim of our study is to find some subjective or objective criterias to help clinicians in diagnostic, like snoring, neck circumference, macroglossia or signs of ENT obstruction in Sleep Apnea Syndrome.

Material and Method
Data is from a personal database, collected prospectively during sleep consultation. Stored data contain a systematic clinical examination including deep tendon reflexes, sensitivity with a measurement of vibration sense testing (pallesthesia), and sleep recording and diagnostics.

Pallesthesia is evaluated semi-quantitatively using a tuning fork at the ankles and wrists. The duration of perception of vibrations to the four points is recorded in the database. The barycenter of the four measurements is calculated to assess the homogeneity of the measurements.
Distribution of centroid values is analyzed to determine a threshold value above which it is considered that there is an asymmetry of perception and thus determine both groups.
The groups are compared and determined by Khi2 in groups with a syndrome of periodic movements of sleep.

Results
We found a significant association (p = 0.02) between the presence of an asymmetry of the pallesthesia and the presence of a syndrome of periodic movements during sleep.

Conclusion
Pallesthesia could be a new clinical sign to guide the diagnostic towards PLMS in patients who are consulting for a sleep disorder. This results need to be confirmed.

Erection - desaturation - apneas. A story of nose ?

Didier Cugy — 2012-06-22T18:57:26Z

Initial observation : Video Polysomnography recording allowed us to bring to light at a 59-year-old man's a characteristical sequence beginning with an erection followed by a fall of the saturation (which evolves from 97 % to 93 %) then of the appearance of obstructive respiratory events. This sequence is preceded by a period of REM sleep interrupted by an awakening followed by a passage by supine position. The analysis of the saturometry signal does not allow to put in relationship, in a simple way, the arisen of the episode of desaturation with respiratory sleep events nor with change of position.
We attempted to estimate the reproducibility of this observation on the occasion of polysomnography recordings coupled with a erectometry realized within the assessments of surgical.
Material and methods : 8 patients benefited from a coupling recording polysomnography ( MICROMED) and erectometry ( RIGISCAN).
Results : 7 patients on 8 presented episodes of night-erection. 16 episodes of erection were observed. 11 episodes of erection associated to desaturations were found at 5 patient's. Both patients who did not present these phenomena were carrier of an important SAOS (IAH of 35 / hour for one of the patients and 70 / hour for the second). All in all 10 sequences associating erection- desaturation-apneas were identified on 16 observed erections (62 %)
Discussion : the notion of congestion nasal as side effect for inhibitors of the phosphodiestérase was reported as the sidenafil (1). The nasal tissue recovering cornets answers in a similar way corpora cavernosa. He can participate in the nasal obstruction during the usually observed episodes of erection dormant paradoxical. The global mechanism of the observed events requires a detailed research
Bibliographie : (1) Trimarchi & al Nasal congestion after visual sexual stimulation with and without sildenaWl (Viagra®) : a randomized placebo-controlled study, Eur Arch Otorhinolaryngol (2008) 265:303–306 DOI 10.1007/s00405-007-0452-4

Pulse Wave Photo-plethysmogram analysis, calculation and distribution of a reactivity index over 1837 polysomnographics recordings

Didier Cugy — 2012-06-22T18:56:49Z

Pulse Wave photoplethysmography uses light absorbance technology to detect waves produced by heart pulsation. This technique associated with absoprtion spectrophotometry is at origin of SpO2 measure. Photoplethysmogram is frequently a part of signals recorded during polysomnography. For Brosh and al this signal can be considered as good indicator of coronary pathology. For Kirichenko and al normalization of the pulse photoplethysmogram amplitude can be used as indicator of anti-hypertensive efficiency.
Clinical observation allows easy individualization of the photoplethysmography signal amplitude in touch with events arising during sleep. We attempted to develop an algorithm to analyse amplitude variations of pulse photoplethysmogram , we apply it to the database of our polysomnography recordings dantabase and analyse distribution according to sleep parameters parameters and subjective scales (Epworth, ADA PICHOT, Q2DA Pichot).
Material and Methods : Amplitude variations of the photopléthysmogram are calculated from a baseline elabored on slippery average of signal amplitude and filtered. Amplitude variations superior to 50 % of basic line are deducted and associated with the current period. This allow to calculate an index of reactivity of pulse wave (Pulse Wave Reactivity:PWR). This algorithm was applied to our database of 1837 polysomnography recordings made between 2002 and 2011. Results were visually validated.
Results : Average of PWR index reported to the total sleep time is 53/h±29/h. There are significant differences of index reported to sleep stage (SS : 54/h±33/h, SW : 44/h±32/h, REM : 67/h±35/h ; p < 0.001), sex (p < 0.001), age (p < 0.001). There is significant correlations (p < 0.05) between the index and Epworth Sleepiness Score (ESS), Pichot asthenia scale (ADA) and Pichot depression scale (Q2DA).
Conclusion : Because of relations between Pulse Wave Eeactivity and others sleep elements it seems necessary to introduce this new parameter in polygraphy and polysomnography analysis.
An analysis of the reference distribution in normal population must be made.

Epworth Sleepiness Scale distribution among smokers and drinkers

Didier Cugy — 2010-11-14T17:25:00Z

Cugy D.

Since 2004 ESS is used for sleepiness screening in patient olders than 40 at Bordeaux and Cenon primary healthcare centers. Many others informations are recorded like : patient status – smoker or no, -drinkers or no. 33962 healthcare checkups were performed from 2004 to December 31, 2008. We segmented the 33962 checkups on the basis these datas : smokers (n = 16419), occasional smokers (n = 10599), non smokers (n = 6944) ; alcool drinkers (n = 3434), occasional drinkers (n = 21488), non drinkers (n = 9040). The comparison of the distribution of ESS between populations was conducted using a test khi2. There is a significant difference in distribution between smokers and non smokers (P < 0.0001). For the smokers, distribution of scores was shifted toward lower scores than that among nonsmokers. He also found a significant difference between drinkers and nondrinkers (P < 0.0001). For alcool drinkers, distribution of scores is shifted towards higher scores than that observed among non-drinkers. The increase in ESS score with alcohol is consistent with findings of Koutsourelakis et al [1] The decrease in ESS score with smoking is consistent with what is observed among drivers of trucks [2] who use tobacco against drowsiness.

References : 1. Koutsourelakis et al. Determinants of subjective sleepiness in
suspected obstructive sleep apnoea. J Sleep Res., 2008, 17 : 437–
443. Epub 2008 Aug 27.
2. Viegas, C.A. et al. Prevalence of risk factors for obstructive sleep
apnea syndrome in interstate bus drivers. J Bras Pneumol., 2006, 32 : 144–149.

Epworth Sleepiness Score distribution from 33,962 healthcare checkups

Didier Cugy — 2010-11-14T17:25:00Z

Cugy D., Lenain J-L., Balan J, Cugy S. Giordanella J-P.

Since 2004 ESS is used for sleepiness screening in patient older than 40 at Bordeaux and Cenon primary healthcare centers. 33962 healthcare checkups were performed from 2004 to December 31, 2008. The screened population in healthcare center can be considered represen- tative of the Department of the Gironde in France. We report here the characteristics of distribution of Epworth score in the subpopulation aged 40 and older. The first quartile corresponds to the ESS scores between 0 to 2, thesecond ESS=3 to 5, the thirdof ESS=6 to 8, fourth ESS= 9to24. First decile is ESS=0to1, last ESS=11 to 24. 5. 95% of the population has a score below 14. The median is between 5 and 6. The average is 6.25. The proportions for each class of Epworth score (0 .. 24) from the population (n = 33962) are : ESS = 0 (4.35%), 1 (4.75%), 2 (8, 38%), 3 (9.26%), 4 (10.35%), 5 (9.68%), 6 (9.97%), 7 (8.72%), 8 (8.40 %), 9 (6.70%), 10 (5.75%), 11 (3.81%), 12 (3.11%), 13 (2%), 14 (1.52%), 15 (1.14%), 16 (0.76%), 17 (0.44%), 18 (0.37%), 19 (0.24%), 20 (0.15%), 21 (0, 07%), 22 (0.03%), 23 (0.01%), 24 (0.04%). These results are consistent with those originally found by Johns [1] and Chervin [2] particularly as regards the average and 5% of highest scores.

References : 1. Johns, M.W. A new method for measuring daytime sleepiness : the Epworth Sleepiness Scale. Sleep, 1991, 14 : 540–545.
2. Chervin R.C., Aldrich M.S., Pickett R, Guilleminault C. Compar- ison of the results of the Epworth Sleepiness Scale and the Multiple Sleep Latency Tests. Journal of psychosomatic research, 1997, 42 :
145–155.