The association of sleep and pain: an update and a path forward

Melatonin Moderates the Triangle of Chronic Pain, Sleep Architecture and Immunometabolic Traffic

Preclinical as well as human studies indicate that melatonin is essential for a physiological sleep state, promotes analgesia and is involved in immunometabolic signaling by regulating neuroinflammatory pathways. Experimental and clinical neuromodulation studies for chronic pain treatment suggest that neurostimulation therapies such as spinal cord stimulation, vagus nerve stimulation and dorsal root ganglion stimulation have an impact on circulating inflammatory mediators in blood, cerebrospinal fluid and saliva. Herein, we provide an overview of current literature relevant for the shared pathways of sleep, pain and immunometabolism and elaborate the impact of melatonin on the crossroad of sleep, chronic pain and immunometabolism. Furthermore, we discuss the potential of melatonin as an adjunct to neurostimulation therapies. In this narrative review, we addressed these questions using the following search terms: melatonin, sleep, immunometabolism, obesity, chronic pain, neuromodulation, neurostimulation, neuroinflammation, molecular inflammatory phenotyping. So far, the majority of the published literature is derived from experimental studies and studies specifically assessing these relationships in context to neurostimulation are sparse. Thus, the adjunct potential of melatonin in clinical neurostimulation has not been evaluated under the umbrella of randomized-controlled trials and deserves increased attention as melatonin interacts and shares pathways relevant for noninvasive and invasive neurostimulation therapies.

Increased Odds of Incident Alzheimer's Disease and Related Dementias in Presence of Common Non-Cancer Chronic Pain Conditions in Appalachian Older Adults

BACKGROUND

There is a growing concern regarding the increasing prevalence of common non-cancer chronic pain conditions (NCPCs) and their possible association with Alzheimer's disease and related dementias (ADRD). However, large population-based studies are limited, especially in Appalachian and other predominantly rural, underserved populations who suffer elevated prevalence of both NCPCs and known ADRD risk factors.

OBJECTIVES

We investigated the relation of NCPC to risk of incident ADRD in older Appalachian Medicare beneficiaries and explored the potential mediating effects of mood and sleep disorders.

METHODS

Using a retrospective cohort design, we assessed the overall and cumulative association of common diagnosed NCPCs at baseline to incident ADRD in 161,573 elders ≥65 years, Medicare fee-for-service enrollees, 2013-2015. NCPCs and ADRD were ascertained using claims data. Additional competing risk for death analyses accounted for potential survival bias.

MAIN FINDINGS

Presence of any NCPC at baseline was associated with significantly increased odds for incident ADRD after adjustment for covariates [adjusted odds ratio (AOR) = 1.26 (1.20, 1.32), p < .0001]. The magnitude and strength of this association increased significantly with rising burden of NCPCs at baseline [AOR for ≥4 vs. no NCPC = 1.65 (1.34, 2.03), p-trend = .01]. The addition of depression and anxiety, but not sleep disorders, modestly attenuated these associations [AORs for any NCPC and ≥4 NCPCs, respectively = 1.16 (1.10, 1.22) and 1.39 (1.13, 1.71)], suggesting a partial mediating role of mood impairment. Sensitivity analyses, multinomial logistic regressions accounting for risk of death, yielded comparable findings.

CONCLUSION

In this large cohort of older Appalachian Medicare beneficiaries, baseline NCPCs showed a strong, positive, dose-response relationship to odds for incident ADRD; this association appeared partially mediated by depression and anxiety. Further longitudinal research in this and other high-risk, rural populations are needed to evaluate the causal relation between NCPC and ADRD.

At the intersection of sleep deficiency and opioid use: mechanisms and therapeutic opportunities

Due to the ongoing opioid epidemic, innovative scientific perspectives and approaches are urgently needed to reduce the unprecedented personal and societal burdens of nonmedical and recreational opioid use. One promising opportunity is to focus on the relationship between sleep deficiency and opioid use. In this review, we examine empirical evidence: (1) at the interface of sleep deficiency and opioid use, including hypothesized bidirectional associations between sleep efficiency and opioid abstinence; (2) as to whether normalization of sleep deficiency might directly or indirectly improve opioid abstinence (and vice versa); and (3) regarding mechanisms that could link improvements in sleep to opioid abstinence. Based on available data, we identify candidate sleep-restorative therapeutic approaches that should be examined in rigorous clinical trials.

Persistent sleep disturbance after spine surgery is associated with failure to achieve meaningful improvements in pain and health-related quality of life

BACKGROUND CONTEXT

Little is known about the effects of sleep disturbance (SD) on clinical outcomes after spine surgery.

PURPOSE

To determine the (1) prevalence of SD among patients presenting for spine surgery at an academic medical center; (2) correlations between SD and health-related quality of life (HRQoL) scores; and (3) associations between postoperative SD resolution and short-term HRQoL.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

We included 508 adults undergoing spine surgery at 1 academic center between December 2014 and January 2018.

OUTCOME MEASURES

Participants completed the Oswestry Disability Index (ODI) or Neck Disability Index (NDI) and Patient Reported Outcome Measurement System (PROMIS-29) questionnaire preoperatively, during the immediate postoperative period (6-12 weeks), and at 6, 12, and 24 months after surgery.

METHODS

Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score <55), mild disturbance (score, 55-60), moderate disturbance (score 60-70), or severe disturbance (score, 70). For the final analysis, we collapsed these categories into no/mild and moderate/severe. Pearson correlation tests were used to assess correlations between SD and HRQoL measures. Regression analysis (adjusting for age, sex, comorbidities, current opioid use, and occurrence of complications) was used to estimate the effect of postoperative resolved or continuing SD on HRQoL scores and the likelihood of achieving clinically meaningful improvements in HRQoL. Alpha = 0.05.

RESULTS

Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI and/or NDI values and worse scores in all PROMIS health domains (all, p<.001). At the immediate postoperative assessment, SD had resolved in 80 of 127 participants (63%). Compared with participants who reported no preoperative SD, those with ongoing SD were significantly less likely to achieve clinically meaningful improvements in Pain Interference (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28, 0.84), Physical Function (OR, 0.32; 95% CI, 0.13, 0.82), and Satisfaction with Participation in Social Roles (OR, 0.57; 95% CI, 0.37, 0.80).

CONCLUSION

One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQoL measures. These results highlight the importance of addressing patients' sleep disturbance both before and after surgery.

Prevalence and impact of neuropathic and non-neuropathic pain in chronic spinal cord injury

OBJECTIVE

Compare prevalence, intensity ratings, and interference ratings of neuropathic pain (NeuP) and nociceptive pain in people with chronic spinal cord injury (SCI) DESIGN: Cross-sectional survey SETTING: Six SCI Model System centers in the US PARTICIPANTS: Convenience sample of 391 individuals with traumatic SCI, aged 18 years or older, 81% male, 57% white INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: Survey based on the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) and the Spinal Cord Injury Pain Instrument (SCIPI), including 0-10 numerical ratings of pain intensity and pain interference with daily activities, mood, and sleep RESULTS: 80% of those surveyed reported having at least one pain problem; 58% reported two or more pain problems; 56% had probable NeuP; and 49% had non-NeuP. When comparing ratings for all pains (n=354 for NeuP, n=290 for non-NeuP) across subjects, probable NeuPs were significantly more intense (6.9 vs. 5.7) and interfered more with activities (5.2 vs. 3.7), mood (4.9 vs. 3.2), and sleep (5.4 vs. 3.6) than non-NeuPs (all p<0.001). However, when comparing ratings for probable NeuPs and non-NeuPs within subjects, for the subgroup of 94 participants with both pain types, only ratings for sleep interference were found to be significantly different between the pain types . Additionally, we found significantly greater prevalence of NeuP and non-NeuP for women compared to men, and of NeuP for those with paraplegia compared to those with tetraplegia.

CONCLUSIONS

Independent assessment of the pain conditions experienced by an individual with SCI is useful in understanding the differential impact that pain type has on quality of life. This is particularly important with regard to sleep interference and should be kept in mind when determining treatment strategies for meeting patient-centered outcome goals.

Sensitization in office workers with chronic neck pain in different pain conditions and intensities

OBJECTIVES

Office workers with chronic neck pain demonstrates signs of widespread hyperalgesia, less efficient descending pain modulation, which could indicate sensitization of central pain pathways. No studies have assessed a wide variety of office workers with different chronic neck pain disorders and assessed the impact of pain intensity on assessments of central pain pathways. This study aimed to assessed pressure pain thresholds (PPTs), temporal summation of pain (TSP) and conditioned pain modulation (CPM) and to associate these with pain intensity and disability in subgroups of office workers.

METHODS

One hundred-and-seventy-one office workers were distributed into groups of asymptomatic and chronic neck pain subjects. Chronic neck pain was categorized as chronic trapezius myalgia and chronic non-specific neck pain and as 'mild-pain' (Visual Analog Scale [VAS]≤3) and 'moderate-pain' (VAS>3) groups. PPTs, TSP, CPM, and Copenhagen Psychosocial Questionnaire II were assessed in all subjects. Neck Disability Index and Pain Catastrophizing Scale were assessed in all the symptomatic office workers.

RESULTS

PPTs were lower in moderate pain (n=49) and chronic trapezius myalgia (n=56) compared with asymptomatic subjects (n=62, p<0.05). TSP was facilitated in moderate pain group compared with mild pain (n=60, p<0.0001) group and asymptomatic subjects (p<0.0001). No differences were found in CPM comparing the different groups (p<0.05). Multiple regression analysis identified Neck Disability Index and TSP as independent factors for prediction of pain intensity in chronic trapezius myalgia (R²=0.319) and chronic non-specific neck pain (R²=0.208). Somatic stress, stress and sleep as independent factors in chronic non-specific neck pain (R²=0.525), and stress in moderate pain group (R²=0.494) for the prediction of disability.

CONCLUSIONS

Office workers with chronic trapezius myalgia and moderate pain intensity showed significant signs of widespread pressure hyperalgesia. Moreover, the moderate pain group demonstrated facilitated TSP indicating sensitization of central pain pathways. Neck Disability Index and TSP were independent predictors for pain intensity in pain groups. Sleep and stress were independent predictors for disability.

Cognitive behavioral therapy for insomnia (CBT-i) in patients with fibromyalgia: a systematic review and meta-analysis

PURPOSE

We aimed to evaluate the effectiveness of CBT-i in patients with fibromyalgia in comparison with other non-pharmacological treatments.

METHODS

Randomized controlled trials assessing the effects of CBT-i in adults with fibromyalgia, published in English or Spanish, were eligible. Electronic searches were performed using PubMed, Scopus, The Cochrane Library, WebOfKnowledge and Psicodoc databases in March 2021. The main outcome measures were sleep efficiency and sleep quality. Secondary outcomes included pain, depression, and anxiety.

RESULTS

Of 226 studies reviewed, five were included in the meta-analysis. CBT-i compared with non-pharmacological treatments showed no significant improvements in sleep efficiency (p = 0.05; standardized mean difference (SMD) [95% CI] 0.31 [-0.00 to 0.61]). CBT-i showed significant improvements in sleep quality (p = 0.009; SMD [95% CI] - 0.53 [-0.93 to -0.13]), pain (p = 0.002; SMD [95% CI] - 0.41 [-0.67 to -0.16]), anxiety (p = 0.001; SMD [95% CI] - 0.46 [-0.74 to 0.18]) and depression (p = 0.02; SMD [95% CI] - 0.33 [-0.61 to -0.05]), compared to non-pharmacological treatments. Effect sizes ranged from small to moderate.

CONCLUSIONS

CBT-i was associated with a significant improvement in sleep quality, pain, anxiety, and depression, although these results are retrieved from very few studies with only very low to low quality evidence. Trial registration: The review protocol was registered with PROSPERO (Record ID = CRD42016030161).IMPLICATIONS FOR REHABILITATIONCBT-i has been proven to improve sleep quality, pain, anxiety and depression, although with small effect sizes.Implementing hybrid CBT for pain and sleep or combining CBT and mindfulness may improve symptoms in people diagnosed with FM.This meta-analysis results highlight the need to enhance sleep management skills among people suffering from this health condition.

Patient and Provider Attitudes, Beliefs, and Biases That Contribute to a Marginalized Process of Care and Outcomes in Chronic Musculoskeletal Pain. A Systematic Review. Part I: Clinical Care

OBJECTIVE

Chronic musculoskeletal pain (CMP) outcomes are affected by numerous variables including the clinical conversation. When good therapeutic/working alliances are formed, congruent clinical conversations can lead to improved CMP outcomes. Identifying patient/provider attitudes, beliefs, and biases in CMP that can influence the clinical conversation, and thus clinical management decisions, is foundationally important.

DESIGN

The aims of this systematic review were to 1) summarize the evidence of the attitudes and beliefs of patients and healthcare providers (HCPs) involved in the clinical conversation of CMP; 2) examine if/how these perceptions impacted the process of care.

METHODS

A systematic search of CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used PRISMA guidelines. Included studies: vulnerable adult populations with chronic pain. Study bias was examined using the Downs and Black tool.

RESULTS

Seven retrospective studies were included. HCPs demonstrated negative implicit biases toward minorities and women when making pharmaceutical management decisions. HCPs demonstrated negative implicit biases toward lower educated women when making referrals to multidisciplinary care. Unmet patient expectations resulted in higher drop-out rates at multidisciplinary pain management programs. Patients' trust was influenced by healthcare setting and patients often had limited options secondary to health insurance type/status.

CONCLUSION

These findings suggest that patients with CMP may experience a marginalized process of care due to HCPs' negative implicit biases, unmet patient expectations, and healthcare setting. Results suggest several factors may contribute to inequitable care and the recalcitrant nature of CMP, particularly in vulnerable populations with limited healthcare choices.

Associates of Insomnia in People with Chronic Spinal Pain: A Systematic Review and Meta-Analysis

Insomnia is a major problem in the chronic spinal pain (CSP) population and has a negative impact on health and well-being. While insomnia is commonly reported, underlying mechanisms explaining the relation between sleep and pain are still not fully understood. Additionally, no reviews regarding the prevention of insomnia and/or associated factors in people with CSP are currently available. To gain a better understanding of the occurrence of insomnia and associated factors in this population, we conducted a systematic review of the literature exploring associates for insomnia in people with CSP in PubMed, Web of Science and Embase. Three independent reviewers extracted the data and performed the quality assessment. A meta-analysis was conducted for every potential associate presented in at least two studies. A total of 13 studies were found eligible, which together identified 25 different potential associates of insomnia in 24,817 people with CSP. Twelve studies had a cross-sectional design. Moderate-quality evidence showed a significantly higher rate for insomnia when one of the following factors was present: high pain intensity, anxiety and depression. Low-quality evidence showed increased odds for insomnia when one of the following factors was present: female sex, performing no professional activities and physical/musculoskeletal comorbidities. Higher healthcare use was also significantly related to the presence of insomnia. One study showed a strong association between high levels of pain catastrophizing and insomnia in people with chronic neck pain. Last, reduced odds for insomnia were found in physically active people with chronic low back pain compared to inactive people with chronic low back pain. This review provides an overview of the available literature regarding potential associates of insomnia in people with CSP. Several significant associates of insomnia were identified. These findings can be helpful to gain a better understanding of the characteristics and potential origin of insomnia in people witch CSP, to identify people with CSP who are (less) likely to have insomnia and to determine directions of future research in this area.

Cannabinoids and chronic pelvic pain in women: Focus on endometriosis

Chronic pelvic pain in women is common and frequently difficult to treat. Chronic pelvic pain often develops in the setting of endometriosis, interstitial cystitis/bladder pain syndrome, and vulvodynia. Cannabinoids are a promising treatment modality for non-cancer chronic pain, but have not been studied in women with chronic pelvic pain nor in specific chronic pelvic pain conditions. This review focuses on the interaction of the endocannabinoid system with the menstrual cycles, with endometriotic lesions, and within the bladder. Furthermore, it provides a brief overview of existing literature of the effects of endocannabinoids on chronic pain generally, with a focus on neuropathic pain. Finally, it discusses limited data available regarding the use of cannabinoids in women with chronic pelvic pain conditions. In the opinion of the authors, cannabinoids are a reasonable treatment modality for refractory chronic pelvic pain, especially if a neuropathic component is suspected. Practitioners should expect a modest effect on pain levels with an acceptable safety profile.

The relationship between pain severity and sleep quality: Posttube thoracostomy

BACKGROUND

The presence of a chest tube is a factor significantly associated with pain and pain posttube thoracostomy that negatively affects sleep quality (SQ).

AIM

To determine the relationship between the pain severity and SQ of patients who underwent the tube thoracostomy (TT).

METHODS

This was a descriptive and cross-sectional survey conducted from May 1, 2018, to December 30, 2018, in the thoracic surgery department of Sivas Cumhuriyet University Hospital in Central Anatolia/Turkey. Data were collected using a questionnaire form, a Numerical Rating Scale to determine pain severity, and the Richard-Campbell Sleep Questionnaire to assess SQ.

RESULTS

The study was carried out with 102 patients who underwent the TT. The mean age of the participants were 48.94 years. The mean scores for the scale items indicated that during the procedure and on the first day of post-TT, the pain severity of the patients was very high, their SQ was low. Pain level decreased gradually in the following days, and the SQ increased. There was a positive, strong correlation between the post-TT first day pain and first night SQ (r = 0.380, p = 0.000), second day pain and second night SQ (r = -0.537, p = 0.000), and third day pain and third night SQ (r = -0.507, p = 0.000).

CONCLUSION

The results of this study highlight that the pain severity of post-TT significantly affect the quality of the patients' night sleep.

Association Between Pain Catastrophizing and Pain and Cardiovascular Changes During a Cold-Pressor Test in Athletes

CONTEXT

Athletes are often exposed to pain due to injury and competition. Using preliminary evidence, researchers have shown that cardiovascular measures could be an objective measure of pain, but the cardiovascular response can be influenced by psychological factors, such as catastrophizing.

OBJECTIVE

To use a painful cold-pressor test (CPT) to measure the relationship among catastrophizing, pain, and cardiovascular variables in athletes.

DESIGN

Cohort study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 36 male rugby athletes (age = 24.0 ± 4.6 years, height = 180.0 ± 6.1 cm, mass = 90.5 ± 13.8 kg).

MAIN OUTCOME MEASURE(S)

We measured catastrophizing using the Pain Catastrophizing Scale and pain using a numeric pain rating scale. Cardiovascular measures were heart rate, systolic and diastolic blood pressure, and heart rate variability.

RESULTS

During the CPT, participants experienced increases in pain (from 0 to 4.1 ± 2.2), systolic blood pressure (from 126.7 ± 16.5 to 149.7 ± 23.4 mm Hg), diastolic blood pressure (from 76.9 ± 8.3 to 91.9 ± 11.5 mm Hg), and heart rate variability (from 0.0164 ± 0.0121 to 0.0400 ± 0.0323 milliseconds; all P values < .001). In addition, we observed a decrease in heart rate after the CPT (P = .04). We found a correlation between athletes' pain catastrophizing and both pain intensity and change in heart rate during the CPT (P = .02 and P = .003, respectively). Linear regression indicated that pain and catastrophizing explained 29% of the variance in the change in heart rate (P = .003).

CONCLUSIONS

Athletes who had catastrophizing thoughts were more likely to experience higher levels of pain and a greater cardiovascular response during a painful stimulus. The change in cardiovascular variables may be a good objective measure of pain in athletes in the future.

Disturbed sleep may be a core risk factor for jaw functional limitation in patients with painful temporomandibular disorders

BACKGROUND

Pain related to temporomandibular disorder (TMD) usually affects jaw function. In patients with TMD, little is known about the biopsychosocial relevance to jaw functional limitations.

OBJECTIVE

This study explored the impact of biopsychosocial risk factors on jaw functional limitation in patients with painful TMD.

METHODS

A comprehensive set of patient-reported outcomes (PROs), consisting of pain severity (Brief Pain Inventory), psychological stress (Symptom Checklist-90-Revised), catastrophising thought (Pain Catastrophizing Scale), kinesiophobia (Tampa Scale for Kinesiophobia-TMD), sleep quality (Pittsburgh Sleep Quality Index) and jaw functional limitation (Jaw Functional Limitation Scale-20), were administered, and clinical examinations were performed in patients with TMD.

RESULTS

This study included the data obtained from 131 patients with painful TMD. In the logistic regression analysis, biomedical factors (age, sex, pain duration and TMD phenotype) were not associated with jaw functional limitation. Correlations were higher in the order of sleep quality (ρ = 0.946), pain severity (ρ = 0.582), pain catastrophising (ρ = 0.535), kinesiophobia (ρ = 0.486) and emotional distress (ρ = 0.268). Multiple regression analysis demonstrated three predictors, including pain severity (p = .001), kinesiophobia (p = .023) and sleep quality (p < .001) for jaw functional limitation. In the mediation analysis, the indirect effect of pain severity on the association between sleep and limitation was significant (p < .0001).

CONCLUSION

Jaw functional limitation is associated with biopsychosocial factors. In particular, sleep may be a core risk factor for functional limitation in patients with painful TMD.

Home confinement during the COVID-19: day-to-day associations of sleep quality with rumination, psychotic-like experiences, and somatic symptoms

Due to the coronavirus disease 2019 (COVID-19) pandemic, populations from many countries have been confined at home for extended periods of time in stressful environmental and media conditions. Cross-sectional studies already evidence deleterious psychological consequences, with poor sleep as a risk factor for impaired mental health. However, limitations of cross-sectional assessments are response bias tendencies and the inability to track daily fluctuations in specific subjective experiences in extended confinement conditions. In a prospective study conducted across three European countries, we queried participants (N = 166) twice a day through an online interface about their sleep quality and their negative psychological experiences for two consecutive weeks. The focus was set on between- and within-person associations of subjective sleep quality with daytime experiences, such as rumination, psychotic-like experiences, and somatic complaints about the typical symptoms of the coronavirus. The results show that daily reports of country-specific COVID-19 deaths predicted increased negative mood, psychotic-like experiences, and somatic complaints during the same day and decreased subjective sleep quality the following night. Disrupted sleep was globally associated with negative psychological outcomes during the study period, and a relatively poorer night of sleep predicted increased rumination, psychotic-like experiences, and somatic complaints the following day. This temporal association was not paralleled by daytime mental complaints predicting relatively poorer sleep quality on the following night. Our findings show that night-to-night changes in sleep quality predict how individuals cope the next day with daily challenges induced by home confinement.

Mendelian randomization highlights insomnia as a risk factor for pain diagnoses

STUDY OBJECTIVE

Insomnia has been linked to acute and chronic pain conditions; however, it is unclear whether such relationships are causal. Recently, a large number of genetic variants have been discovered for both insomnia and pain through genome-wide association studies (GWASs) providing a unique opportunity to examine the evidence for causal relationships through the use of the Mendelian randomization paradigm.

METHODS

To elucidate the causality between insomnia and pain, we performed bidirectional Mendelian randomization analysis in FinnGen, where clinically diagnosed ICD-10 categories of pain had been evaluated. In addition, we used measures of self-reported insomnia symptoms. We used endpoints for pain in the FinnGen Release 5 (R5) (N = 218,379), and a non-overlapping sample for insomnia (UK Biobank (UKBB) and 23andMe, N = 1,331,010 or UKBB alone N = 453,379). We assessed the robustness of results through conventional Mendelian randomization sensitivity analyses.

RESULTS

Genetic liability to insomnia symptoms increased the odds of reporting pain (odds ratio (OR) [95% confidence interval (CI)] = 1.47 [1.38-1.58], p = 4.12 × 10-28). Manifested pain had a small effect on increased risk for insomnia (OR [95% CI] = 1.04 [1.01-1.07], p < 0.05). Results were consistent in sensitivity analyses.

CONCLUSIONS

Our findings support a bidirectional causal relationship between insomnia and pain. These data support a further clinical investigation into the utility of insomnia treatment as a strategy for pain management and vice versa.

Trait positive affect buffers the association between experimental sleep disruption and inflammation

BACKGROUND

Sleep disturbances and insufficient sleep are highly prevalent. Both clinical sleep disorders and multiple forms of experimental sleep loss predict heightened inflammation. As such, it is necessary to investigate potential protective factors. Given that trait positive affect (PA) is associated with reduced inflammation, and buffers the proinflammatory effects of stress, it is possible that high trait positive affect might protect individuals from an inflammatory response to sleep disruption. The present study tested this hypothesis in an experimental sleep disruption paradigm with assessment of cellular inflammation.

METHODS

Data were drawn from good sleeping adults (n = 79) who participated in a randomized, within-subjects crossover experiment comparing the effects of two nights of sleep disruption versus two nights of uninterrupted sleep. Stimulated monocytic production of intracellular proinflammatory cytokines tumor necrosis factor (TNF) and interleukin-6 (IL-6) were assayed using flow cytometric methods and indexed as the percentage of monocytes expressing TNF, IL-6, or co-expressing both. Hypotheses were evaluated using linear mixed effects models.

RESULTS

Controlling for negative affect, body mass index, age, and sex, PA significantly moderated the associations between sleep condition and stimulated monocyte production of IL-6 (b = -1.03, t = -2.02, p = .048) and its co-expression with TNF (b = -0.93, t = -2.00, p = .049), such that inflammatory responses were blunted among those high in PA with increases principally among those low in PA. The effect on TNF was similar in terms of effect size, but marginally significant.

CONCLUSIONS

Activation of cellular inflammation in response to sleep disruption is buffered by PA independent of negative affect. Interventions that promote PA might protect persons from the inflammatory activation following sleep loss, with the potential to mitigate the adverse health consequences of sleep disturbance.

Short sleep duration and physical and psychological health outcomes among adult survivors of childhood cancer

BACKGROUND

To examine associations between phenotypes of short sleep duration and clinically assessed health conditions in long-term survivors of childhood cancer.

METHODS

Survivors recruited from the St. Jude Lifetime Cohort (n = 911; 52% female; mean age 34 years; 26 years postdiagnosis) completed behavioral health surveys and underwent comprehensive physical examinations. Sleep was assessed with the Pittsburgh Sleep Quality Index. Short sleep was defined as ≤6 h per night with phenotypes of short sleep including poor sleep efficiency (<85%), prolonged sleep onset latency (SOL; ≥30 min), and wake after sleep onset (≥3 times per week). Covariates included childhood cancer treatment exposures, demographics, body mass index, and physical inactivity. Separate modified Poisson regression models were computed for each health category to estimate relative risks (RR) and 95% confidence intervals (CI). Multinomial logistic regression models examined associations between sleep and an aggregated burden of chronic health conditions.

RESULTS

Short sleep duration was reported among 44% (95% CI 41%-47%) of survivors. In multivariable models, short sleep duration alone was associated with pulmonary (RR = 1.35, 95% CI 1.08-1.69), endocrine (RR = 1.22, 95% CI 1.06-1.39) and gastrointestinal/hepatic conditions (RR = 1.46, 95% CI 1.18-1.79), and anxiety (RR 3.24, 95% CI 1.64-6.41) and depression (RR = 2.33, 95% CI 1.27-4.27). Short sleep with prolonged SOL was associated with a high/severe burden of health conditions (OR = 2.35, 95% CI 1.12-4.94).

CONCLUSIONS

Short sleep duration was associated with multiple clinically ascertained adverse health conditions. Although the temporality of these associations cannot be determined in this cross-sectional study, sleep is modifiable and improving sleep may improve long-term health in survivors.

Postoperative Pain Mediates the Association Between Peripheral Nerve Blocks and Postoperative Sleep Following Lower Extremity Arthroplasty

OBJECTIVES

Despite substantial research showing the bidrectional relationship between sleep and pain, there remains a dearth of research examining the role of perioperative pain management interventions in mitigating postoperative sleep disturbances. This secondary analysis of a prospective observational multisite study examined the association between peripheral nerve block (PNB) use during total knee or total hip arthroplasty (TKA/THA) procedures and postoperative pain and sleep outcomes.

MATERIALS AND METHODS

Adult patients undergoing TKA or THA procedures were recruited from 2 tertiary care facilities. Average pain and sleep disturbance scores were collected preoperatively and at 1- and 2-week postoperatively. Participants were not randomized to receive PNB. Postoperative outcomes were compared based on receipt of PNB during surgery. Structural equation modeling path analysis was utilized to model multiple co-occurring relationships, including mediation pathways between perioperative pain management approaches, pain, and postoperative sleep outcomes.

RESULTS

Of the 197 participants, 53% received PNB. Mediation analyses indicated that PNB was indirectly associated with 1-week sleep disturbance via its effects on 1-week pain intensity (β=-0.02, 95% confidence interval [CI] -0.04, -0.001, P=0.04). In addition, PNB was indirectly associated with 2-week sleep disturbance, via its effects on 1-week pain intensity and 1-week sleep disturbance (β=-0.04, 95% CI -0.07, -0.02, P=0.04). Lastly, PNB was indirectly associated with 2-week pain intensity via its effects on 1-week pain intensity (β=-0.10, 95% CI -0.19, -0.02, P=0.02).

CONCLUSIONS

Receipt of PNB during TKA or THA was found to be associated with improved 1-week postoperative pain intensity, which in turn was found to be associated with lower sleep disturbances at both 1- and 2-week postoperative time points. Multimodal opioid sparing pain management interventions, capable of improving postoperative sleep, are vital to improving recovery and rehabilitation following arthroplasty.

Prior Night Sleep Affects Next-Day Pain Interference Among Community-Dwelling Older Adults With Lower Extremity Chronic Pain

Emergent work suggests that sleep is a robust biobehavioral predictor of pain; however, it remains unclear how sleep is prospectively linked to pain on a day-to-day basis among older adults. The current prospective study examined how sleep duration (total sleep time), quality (sleep efficiency, wake after sleep onset), and late and irregular sleep timing influenced next-day pain perception among community-dwelling older adults (N = 10; 65 matched observations) with lower extremity chronic pain over 1 week. Multilevel modeling estimated the association between sleep (Actigraph GT9X Link) and pain perception (Brief Pain Inventory Short Form). Increased wake after sleep onset (B = 0.19, p = 0.04), sleep variability (B = 0.02, p = 0.01), and later midsleep time (B = 0.40, p < 0.05) were associated with increased pain interference the following day. Findings support the idea that timely sleep interventions may reduce the effect of poor sleep on next-day pain in older adults. [Research in Gerontological Nursing, 14(4), 173-179.].

Does pain sensitivity correlate with gastrointestinal symptoms in runners? An observational survey study

Objective:

Heightened pain sensitivity is common in functional gut disorders, but no research has examined whether it corresponds to exercise-associated gastrointestinal (GI) symptoms. We sought to explore whether scores on a questionnaire of pain sensitivity would correlate with GI symptoms during running.

Design:

This is a cross-sectional study.

Subjects:

The study involves 290 (137 male, 153 female) distance runners.

Methods:

Runners completed a survey inquiring about demographic, anthropometric and training information and rated GI symptoms at rest and during runs. In addition, the Pain Sensitivity Questionnaire (PSQ) was used to quantify pain sensitivity across all items (PSQ-Total) and on items typically rated as minor (PSQ-Minor). Spearman rho correlations were utilized to assess the associations between pain sensitivity and GI symptoms. Partial correlations were used to evaluate the associations after controlling for age, gender, running experience, body mass index and sleep problems.

Results:

PSQ scores weakly correlated with several GI symptoms at rest (rho = 0.13–0.20; p < 0.05), which remained largely intact in partial correlation analyses (partial rho = 0.12–0.18). PSQ scores weakly correlated with fullness, bloating and gas during runs (rho = 0.12–0.18; p < 0.05); fullness and bloating remained significant in the partial correlation analyses (partial rho = 0.12–0.15). These results were relatively consistent for both the PSQ-Total and PSQ-Minor.

Conclusions:

Although PSQ scores only weakly correlate with certain GI symptoms among runners, the effect sizes are similar to that of other predictors of GI distress. These results suggest a minor possible role of pain sensitivity in the development of certain GI symptoms in runners.

Treatment for patients with sleep apnea on opioids for chronic pain: results of the OpSafe trial

STUDY OBJECTIVES

Approximately 20% of North Americans are afflicted with chronic pain with 3% being opioid users. The objective was to determine whether patients on opioids for chronic pain with newly diagnosed sleep apnea attended sleep clinic review and followed treatment recommendations.

METHODS

The study was a post hoc analysis from a multicenter perspective cohort study. Inclusion criteria included adults taking opioid medications for chronic pain for >3 months. Demographic data and daily opioid dose were collected. Sleep apnea was diagnosed via level 1 polysomnography. Patients who attended sleep clinic review were grouped based on the types of treatment they received.

RESULTS

A total of 204 patients completed polysomnography and 58.8% were diagnosed to have sleep apnea (apnea-hypopnea index ≥5 events/h). Of those with sleep apnea, 58% were recommended to have an evaluation by a sleep physician. Body mass index and age were 29.5 ± 6 kg/m² and 56 ± 12 years, respectively. Of those with newly diagnosed sleep apnea, 25% received treatment, with the majority being treated with positive airway pressure therapy, whereas the rest received positional therapy and opioids/sedative reduction. The adherence rate of positive airway pressure therapy was 55% at 1 year. Over 50% of participants on opioids for chronic pain with newly diagnosed sleep apnea declined attendance for sleep clinic review or treatment.

CONCLUSIONS

There was a high refusal rate to attend clinic for treatment. Adherence to positive airway pressure therapy was low at 55%. This sheds light on the high rate of treatment nonadherence and the need for further research.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Opioid Safety Program in Pain Clinics (Op-Safe); URL: https://www.clinicaltrials.gov/ct2/show/NCT02513836; Identifier: NCT02513836.

Development of a hybrid sleep and physical activity improvement intervention for adults with osteoarthritis-related pain and sleep disturbance: a focus group study with potential users

Objective:

Suboptimal sleep and physical activity are common among people living with osteoarthritis (OA) and simultaneous improvements in both may have a beneficial impact on pain. This study aimed to gather perspectives of people living with OA on important aspects to incorporate in a hybrid sleep and physical activity improvement intervention for OA pain management.

Design:

Qualitative study using two rounds of two focus groups.

Setting and participants:

Focus groups were conducted with adults living with OA-related chronic pain and sleep disturbances. Eighteen people attended focus groups in January 2020 and, of these, 16 attended subsequent focus groups in February 2020.

Methods:

Discussion at the first round of focus groups informed generation of prototype intervention materials that were shared, discussed and refined at the second round of focus groups. Thematic analysis was used to identify themes and sub-themes from the data.

Results:

Three themes, each with three sub-themes, were identified: facilitators of engagement with the intervention (sub-themes: motivational language, accountability and education); barriers to engagement (sub-themes: suboptimal interaction with healthcare practitioners, recording behaviour as burdensome/disruptive and uncertainty about technique) and characteristics of a physical activity intervention component (sub-themes: tailored, sustainable and supported).

Conclusion:

We have identified important aspects to incorporate into the design and delivery of a hybrid sleep and physical activity improvement intervention for OA pain management. Insights will be incorporated into intervention materials and protocols, with feasibility and acceptability assessed in a future study.

Moderate to Severe Chronic Pain in Later Life: Risk and Resilience Factors for Recovery

Despite extensive research on the development and risk factors of chronic pain, the process of recovery from chronic pain in later life has been rarely studied. We estimated the recovery rate of moderate to severe chronic pain (chronic pain of moderate or severe severity or interfering with usual activities) among older adults and investigated predictors of recovery. Leveraging the longitudinal Health and Retirement Study 2006-2016 data (6 waves), we estimated the biennial national attrition-adjusted recovery rate of moderate to severe chronic pain among 6,132 US adults aged 65-75 at baseline. Generalized estimating equation Poisson models examined pain-related, sociodemographic, psychosocial and health-related factors in relation to recovery within any 2-year interval using longitudinal lagged design. Between 2006-2016, the prevalence of moderate to severe chronic pain increased from 28% to 33% with the incidence increasing from 14% to 18% and the recovery rate approximately 30%. Previous chronic pain duration, age, chronic diseases and a personality trait (agreeableness) were associated with a lower probability of recovery. Greater financial wealth and physical activity, better sleep quality and self-reported health were associated with a greater probability of recovery. Interventions that improve physical activity and sleep quality may be important avenues for reducing chronic pain burden among older adults. Perspective: Our longitudinal findings suggested that recovery from moderate to severe chronic pain is common in later life and we further identified several key factors associated with this recovery process. Future research should consider the potential of interventions that improve physical activity and sleep quality to enhance recovery among older adults.

Indirect effect of sleep on abdominal pain through daytime dysfunction in adults with irritable bowel syndrome

STUDY OBJECTIVES

Sleep deficiency, psychological distress, daytime dysfunction, and abdominal pain are common in adults with irritable bowel syndrome. Prior research on individuals with chronic pain has identified the indirect effect of sleep on pain through psychological distress or daytime dysfunction; however, this effect is less clear in irritable bowel syndrome. The purpose of this study was to examine potential indirect effects of sleep on abdominal pain symptoms simultaneously through psychological distress and daytime dysfunction in adults with irritable bowel syndrome.

METHODS

Daily symptoms of nighttime sleep complaints (sleep quality and refreshment), psychological distress, daytime dysfunction (fatigue, sleepiness, and difficulty concentrating), and abdominal pain were collected in baseline assessments from 2 randomized controlled trials of 332 adults (mean age 42 years and 85% female) with irritable bowel syndrome. Structural equation modeling was used to examine the global relationships among nighttime sleep complaints, psychological distress, daytime dysfunction, and abdominal pain.

RESULTS

The structural equation modeling analyses found a strong indirect effect of poor sleep on abdominal pain via daytime dysfunction but not psychological distress. More than 95% of the total effect of nighttime sleep complaints on abdominal pain was indirect.

CONCLUSIONS

These findings suggest that the primary impact of nighttime sleep complaints on abdominal pain is indirect. The indirect effect appears primarily through daytime dysfunction. Such understanding provides a potential avenue to optimize personalized and hybrid behavioral interventions for adults with irritable bowel syndrome through addressing daytime dysfunction and sleep behaviors. Additional study integrating symptoms with biological markers is warranted to explore the underlying mechanisms accounting for these symptoms.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov. Name: Nursing Management of Irritable Bowel Syndrome: Improving Outcomes, Nursing Management of IBS: Improving Outcomes. URLs: https://clinicaltrials.gov/ct2/show/NCT00167635, https://clinicaltrials.gov/ct2/show/NCT00907790. Identifiers: NCT00167635, NCT00907790.

Associations of frequent pain symptoms with excessive daytime sleepiness in adolescents: a longitudinal study

STUDY OBJECTIVES

Pain symptoms, sleep disturbance, and daytime sleepiness are common in adolescents. This study examined the cross-sectional and prospective associations between pain symptoms and excessive daytime sleepiness (EDS) in a large sample of adolescents.

METHODS

Participants were 7,072 adolescents (mean age = 14.6 years) in a follow-up study of behavior and health in Shandong, China. A self-administered structured questionnaire was used to assess pain symptoms (headache, stomachache, and other general pain), body weight and height, sleep, anxiety/depression, substance use, and family environment in November-December in 2015 and one year later. The Chinese adolescent daytime sleepiness scale (CADSS) was used to measure daytime sleepiness.

RESULTS

Of the sample, 19.8% and 23.2% had moderate or severe EDS at baseline and at 1-year follow-up, respectively. The prevalence and 1-year incidence rates of EDS significantly increased with the frequencies of pain symptoms. Frequent pain was significantly associated with increased risk of EDS at baseline (OR=2.01, 95% CI=1.56-2.59), incident EDS (OR=1.41, 95% CI=1.03-1.93), and persistent EDS (OR=2.17, 95% CI=1.52-3.09) while adjusting for adolescent and family covariates, including anxiety/depression, nocturnal sleep duration, insomnia symptoms, frequent snoring, body mass index, and hypnotic use. Similar associations were observed across headache, stomachache, and other pain.

CONCLUSIONS

Frequent pain is significantly and independently associated with increased risk of EDS. Our findings suggest that assessing and treating pain symptoms is important to improve healthy sleep and reduce risk of EDS in adolescents. Further research is needed to understand the underlying psychological and neurobiological mechanisms between pain and daytime sleepiness in adolescents.

Multidimensional health changes after a multimodal pain rehabilitation program: a registry-based study

Introduction

Chronic pain is treated with multimodal rehabilitation programs, targeting improvement in several health aspects. These treatments must be evaluated multidimensionally, which is a methodological challenge.

Objectives

This study investigated factors (demographic, pain-related, and individual- vs group-based treatment) predicting successful outcomes after multimodal pain rehabilitation programs.

Methods

Data from 3 outpatient clinics were retrieved from the Swedish Quality Registry for Pain Rehabilitation, for 314 patients (218 women). Outcome variables were dichotomized as binary change (improved or not improved) based on clinical thresholds. Total improvement grouped outcomes into 0 to 2, 3 to 4, and 5 to 6 improved variables. Binary logistic regression analyses investigated the association between the baseline predictors and change variables.

Results

Patients improving after treatment ranged from 34% (pain intensity) to 80% (depression) for women and 34% to 76% for men, respectively. Total improvement outcome was consistent (after treatment and 1 year) with 28% of patients improving on 5 to 6 outcomes. The baseline predictor related to most improved outcomes was pain intensity, with positive correlation to improvement in pain intensity (P < 0.001) and negative correlation with improvements in anxiety (P = 0.075) and depression (P = 0.002). Individual-based treatment, compared with group-based treatment, was associated with improvement in pain intensity (P = 0.008).

Conclusions

About a third of patients improved in several outcomes by the end of a multimodal program, with most improvement for depression and least for pain intensity. Generally, patients with more severe health status at baseline improve most directly after treatment, but these findings could not suggest treatment adjustments that would improve overall success rates.

Brainstem damage is associated with poorer sleep quality and increased pain in gulf war illness veterans

AIMS

Gulf War Illness (GWI) is manifested as multiple chronic symptoms, including chronic pain, chronic fatigue, sleep problems, neuropsychiatric disorders, respiratory, gastrointestinal, and skin problems. No single target tissue or unifying pathogenic process has been identified that accounts for this variety of symptoms. The brainstem has been suspected to contribute to this multiple symptomatology. The aim of this study was to assess the role of the brainstem in chronic sleep problems and pain in GWI veterans.

MATERIALS AND METHODS

We enrolled 90 veterans (Age = 50 ± 5, 87% Male) who were deployed to the 1990-91 Gulf War and presented with GWI symptoms. Sleep quality was evaluated using the global Pittsburgh Sleep Quality Index. Pain intensities were obtained with the Brief Pain Inventory sum score. Volumes in cortical, subcortical, brainstem, and brainstem subregions and diffusion tensor metrics in 10 bilateral brainstem tracts were tested for correlations with symptom measures.

KEY FINDINGS

Poorer sleep quality was significantly correlated with atrophy of the whole brainstem and brainstem subregions (including midbrain, pons, medulla). Poorer sleep quality also significantly correlated with lower fractional anisotropy in the nigrostriatal tract, medial forebrain tract, and the dorsal longitudinal fasciculus. There was a significant correlation between increased pain intensity and decreased fractional anisotropy in the dorsal longitudinal fasciculus. These correlations were not altered after controlling for age, sex, total intracranial volumes, or additional factors, e.g., depression and neurological conditions.

SIGNIFICANCE

These findings suggest that the brainstem plays an important role in the aberrant neuromodulation of sleep and pain symptoms in GWI.

Predictors of unacceptable pain with and without low inflammation over 5 years in early rheumatoid arthritis-an inception cohort study

Objectives

Pain is a major symptom in patients with rheumatoid arthritis (RA). In early RA, pain is usually due to synovitis, but can also persist despite effective anti-inflammatory treatment. The objective of this study was to investigate the pain course over time and predictors of unacceptable pain and unacceptable pain with low inflammation, in patients with early RA.

Methods

An inception cohort of 232 patients with early RA, recruited in 1995–2005, was followed in a structured programme for 5 years. Pain was assessed using a visual analogue scale (VAS; 0–100). Unacceptable pain was defined as VAS pain > 40 based on the patient acceptable symptom state (PASS) and low inflammation as CRP < 10 mg/l. Baseline predictors of unacceptable pain were evaluated using logistic regression analysis.

Results

Pain improved significantly during the first 6 months, but then remained basically unchanged. Thirty-four per cent of the patients had unacceptable pain 5 years after inclusion. Baseline predictors of unacceptable pain after 5 years were lower swollen joint counts [odds ratio (OR) 0.71 per standard deviation (95% confidence interval (CI) 0.51–0.99)] and higher VAS for pain and global assessment of disease activity. Unacceptable pain with low inflammation after 5 years was negatively associated with anti-CCP antibodies [OR 0.50 (95% CI 0.22–0.98)].

Conclusion

Over one third of the patients had unacceptable pain 5 years after inclusion. Lower swollen joint count was associated with unacceptable pain at 5 years. The results may be explained by the positive effects of treatment on pain related to inflammation. Non-inflammatory long-lasting pain appears to be a greater problem in anti-CCP-negative patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02550-7.

Pre-sleep cognitive arousal exacerbates sleep disturbance in chronic pain: an exploratory daily diary and actigraphy study

OBJECTIVES

Insomnia is commonly comorbid with chronic pain, and typically leads to worse outcomes. Two factors that could contribute to a cycle of pain and sleeplessness are pre-sleep cognitive arousal (repetitive thought processes) and low mood. This study aimed to examine how pain, sleep disturbance, mood, and pre-sleep cognitive arousal inter-relate, to determine whether low mood or pre-sleep cognitive arousal contribute to a vicious cycle of pain and insomnia.

METHODS

Forty seven chronic pain patients completed twice daily diary measures and actigraphy for one week. Analyses investigated the temporal and directional relationships between pain intensity, sleep quality, time awake after sleep onset, anhedonic and dysphoric mood, and pre-sleep cognitive arousal. Fluctuations in predictor variables were used to predict outcome variables the following morning using mixed-effects modelling.

RESULTS

For people with chronic pain, an evening with greater pre-sleep cognitive arousal (relative to normal) led to a night of poorer sleep (measured objectively and subjectively), lower mood in the morning, and a greater misperception of sleep (underestimating sleep). A night of poorer sleep quality led to greater pain the following morning. Fluctuations in pain intensity and depression did not have a significant influence on subsequent sleep.

CONCLUSIONS

For people with chronic pain, cognitive arousal may be a key variable exacerbating insomnia, which in turn heightens pain. Future studies could target cognitive arousal to assess effects on sleep and pain outcomes.

Interventions to improve inpatients' sleep quality in intensive care units and acute wards: a literature review

BACKGROUND

Sleep is essential for the physical and psychological restoration of inpatients, and lack of sleep results in sleep deprivation and poor sleep quality, with potentially harmful consequences.

AIM

To summarise sleep-promoting interventions in the Intensive care unit (ICU) and acute ward setting.

METHOD AND RESULTS

Six databases were searched to obtain studies for review and eight studies were selected, appraised, analysed and produced two themes: sleep-disturbing factors and sleep-promoting strategies. Sleep-disturbing factors included environmental factors (such as light and noise), illness-related factors (such as pain, anxiety and discomfort), clinical care and diagnostics. Sleep-promoting strategies included using pharmacological aids (medication) and non-pharmacological aids (reducing noise and disturbances, eye masks, earplugs and educational and behavioural changes).

CONCLUSION

The literature review showed that both ICU and acute ward settings affect patients' sleep and both use similar strategies to improve this. Nevertheless, noise and sleep disturbances remain the most critical sleep-inhibiting factors in both settings. The review recommended future research should focus on behavioural changes among health professionals to reduce noise and improve patients' sleep.

Sleep and neighborhood socioeconomic status: a micro longitudinal study of chronic low-back pain and pain-free individuals

Individuals with chronic low back pain (cLBP) frequently report sleep disturbances. Living in a neighborhood characterized by low-socioeconomic status (SES) is associated with a variety of negative health outcomes, including poor sleep. Whether low-neighborhood SES exacerbates sleep disturbances of people with cLBP, relative to pain-free individuals, has not previously been observed. This study compared associations between neighborhood-level SES, pain-status (cLBP vs. pain-free), and daily sleep metrics in 117 adults (cLBP = 82, pain-free = 35). Neighborhood-level SES was gathered from Neighborhood Atlas, which provides a composite measurement of overall neighborhood deprivation (e.g. area deprivation index). Individuals completed home sleep monitoring for 7-consecutive days/nights. Neighborhood SES and pain-status were tested as predictors of actigraphic sleep variables (e.g., sleep efficiency). Analyses revealed neighborhood-level SES and neighborhood-level SES*pain-status interaction significantly impacted objective sleep quality. These findings provide initial support for the negative impact of low neighborhood-level SES and chronic pain on sleep quality.

Application accuracy of the sleep decision tree to standardized patient cases by physiotherapists: An observational study

Background: Physiotherapists assess lifestyle factors, including sleep health, that contribute to poor health outcomes. Recommendations of sleep screening assessments have been provided; however, physical therapists' ability to successfully identify which patients would benefit from additional consultation has not been established.Objective: To determine if physiotherapists can accurately apply an evidence-based sleep decision tree to four hypothetical standardized patient cases.Methods: Participants applied the sleep decision tree to the four standardized cases via an online platform. Likert scales were used to assess perception of ease of use, likelihood of use, and how helpful they thought the sleep decision tree would be. Descriptive analyses and multiple linear regression models were conducted.Results: Eighty-eight individuals participated in the study. Most participants correctly answered the cases with 1 and 3 decision points (92% and 84%, respectively). In contrast, few participants correctly answered the cases with 4 and 5 decision points (7% and 14%, respectively). Seventy-four (84%) respondents indicated the sleep decision tree was easy to use; 57 (65%) answered they were likely to use the sleep decision tree in clinical practice; and 66 (75%) said the sleep decision tree would be helpful to their clients.Conclusions: Physiotherapists were able to accurately apply a sleep decision tree to simpler patient cases but were frequently unable to apply it to more complex patient cases. This may be due to lack of education, perceived ease of using, and relevance of the sleep decision tree to their clinical practice. The sleep decision tree may aid physiotherapists in assessing sleep health, screening for sleep disturbances, and referring for further assessment.

[On the question of a primary and secondary origin of insomnia]

Approximately 30% insomnia patients have associated somatic, neurological and psychiatric conditions. Clinician has to define causality of these conditions to determine a treatment plan. Secondary insomnia can result from the symptoms of a primary condition or form an impairment of central nervous system due to neurological disorder. Some associated conditions are characterized by high coincidence with insomnia, similar triggers and crossing genotype, neurophysiological and functional findings. This association with insomnia is observed in anxiety disorders, depression, chronic pain syndromes. The paper presents a concept of comorbid insomnia disorder which proposes the existence of a common neural structure which when affected causes the symptoms of both insomnia and comorbid disorder. Comorbid disorders can also be interconnected due to the overlap of the responsible nerve centers. Positive effect of specific pharmacological, psychotherapeutical and behavioral treatment on both conditions evidences this concept.

ASSOCIATION BETWEEN SLEEP QUALITY AND PAIN IN YOUNG AMATEUR ATHLETES

ABSTRACT Introduction: It has been shown that there is a close association between sleep quality and pain. In young athletes, sleep disorders and pain have a particularly high prevalence; however, the relationship between them has not been widely studied. Objective: To study the association between sleep quality and pain in young athletes. Methods: A cross-sectional study was conducted in which 71 young amateur athletes (39 males) were included. The mean age was 16.9 ± 1.2 years, with 6.5 ± 3.2 years of sports practice and 5.2 ± 1.2 hours of training per week. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). The participants were classified according to sleep quality, as PSQI-I = without sleep disorders, PSQI-II = requiring medical assistance and PSQI-III = requiring medical assistance and treatment. Also, pain intensity was assessed on the Numerical Rating Scale, both at rest (NRSr) and during sports activity (NRSs), along with pain duration. Results: The individuals classified as PSQI-III presented higher NRSr (Mdn = 2.0; IQR = 4.0 vs. Mdn = 0.0; IQR = 2.0; p = 0.04) and higher NRSs (Mdn = 4.0; IQR = 5.0 vs. Mdn = 0.0; IQR = 2.0; p = 0.03) than the individuals classified as PSQI-I. No differences were observed in relation to pain duration. The PSQI score was positively but weakly associated with NRSr (rs = 0.24, p=0.046) and NRSs (rs = 0.27, p = 0.03) but not with pain duration. Conclusion: Young athletes with lower levels of sleep quality show higher levels of pain at rest and during sports practice. Therefore, sleep quality and pain should be considered in the routine assessment of young athletes, by technical and health teams. Level of evidence III; type of study: Cross-sectional .

Improvements in Sleep Correlate With Improvements in Clinical Outcomes Among Adolescents Undergoing Intensive Interdisciplinary Pain Treatment

OBJECTIVES

Intensive interdisciplinary pain treatment (IIPT) programs have been shown to restore function, improve coping, and reduce pain in adolescents with chronic pain. Yet, little is known about patients' sleep during IIPT and whether or not improvements in pain treatment outcomes are associated with changes in sleep pre-to-post IIPT treatment. The objectives of the current study were to describe sleep among adolescents entering IIPT and examine associations between sleep parameters and IIPT treatment effects.

MATERIALS AND METHODS

Self-reported sleep measures and clinical outcomes (eg, functional disability, coping, average pain), were collected from 44 adolescents (mean age=14.57, 68.2% female) at admission and discharge from an inpatient IIPT program. Wrist-worn actigraphy data and sleep diaries from participants' first week and last week in the program were analyzed to characterize sleep parameters.

RESULTS

Participants self-reported poor sleep/wake patterns, high levels of insomnia symptoms, and subclinical problems with daytime sleepiness upon admission into IIPT, although actigraphic indices of sleep from the first week of IIPT admission were only just under clinical guidelines for healthy adolescent sleep. Better self-reported sleep quality assessed via aggregated sleep diaries from the first week was associated with improvement in average pain and disability over the course of the program. Furthermore, improvements in insomnia symptoms and daytime sleepiness throughout the program were positively correlated with concurrent improvements in functional disability and coping.

DISCUSSION

Taken together, results suggest that sleep may be associated with IIPT treatment effects and pave the way for future research to continue examining these relationships.

Evaluation of sleep disorder in orthopedic trauma patients: a retrospective analysis of 1129 cases

Background

In the trauma center wards, it is not unusual for patients to have sleep disorders, especially patients with an acute injury. Meanwhile, there is substantial evidence that sleep disorder is a predictor of depression and is an important feature of posttraumatic stress disorder.

Methods

All orthopedic trauma patients confined in a trauma ward in West China Hospital of Sichuan University between April 2018 and July 2019 were included in this retrospective study. Patients with mental impairment or craniocerebral injuries were excluded from the study. Basic demographic data and the Injury Severity Score (ISS) classification based on medical records were collected. The Pittsburgh sleep quality index (PSQI) was used to evaluate sleep quality, the visual analog scale (VAS) was used to evaluate physical pain, and the Barthel Index (BI) was used to evaluate activities of daily living (ADL). Univariate linear regression analysis and multivariate linear regression analysis were used to identify independently related factors.

Results

The average PSQI score was 6.3 (± 4.0). A total of 581 (51.4%) patients had a PSQI score > 5, indicating the presence of sleep disorders. The PSQI score was > 10 in 174 (15.4%) patients. Univariate statistical analysis showed that age, sex, education, ADL, and ISS classification were associated with increased PSQI scores. Marital status and pain were not associated with increased PSQI scores. When we used multivariate analysis to control for confounding variables, sex, ADL, and ISS classification remained independently associated with PSQI (P = 0.002, < 0.000, and 0.002, respectively).

Conclusions

In our study, sleep disorders were common (51.4% with PSQI > 5) and serious (15.4% with PSQI > 10) in patients with traumatic orthopedic injury. The following factors were closely associated with sleep disorders: sex, ADL, and ISS classification. Moreover, age and educational attainment have an independent impact on sleep quality. Unexpectedly, the VAS score for pain was not independently associated with the seriousness of sleep quality, which may be related to preemptive and multimodal analgesia. Further studies are required to clarify this ambiguity.

Positive airway pressure therapy for chronic pain in patients with obstructive sleep apnea-a systematic review

PURPOSE

Obstructive sleep apnea (OSA) is prevalent in patients with chronic non-cancer pain. OSA may lead to low sleep quality and an increase in pain sensitivity. Patients reporting greater sleep impairment tend to experience higher pain intensity and vice versa. Positive airway pressure (PAP) is the current gold standard treatment for OSA. This review aims to evaluate the efficacy of PAP therapy in patients with comorbid chronic pain and OSA in influencing pain outcomes like pain intensity, tolerance, threshold, and sensitivity.

METHODS

We performed a systematic literature search for studies published after 1990, utilizing the following databases: Medline, Medline In-Process/ePubs, Embase, Cochrane CENTRAL, and the Cochrane Database of Systematic Reviews. Search terms included "chronic pain," "sleep disorders," and "positive airway pressure."

RESULTS

Of 1982 initial studies, ten studies met the study inclusion criteria. Seven of these studies examined the effect of PAP therapy on chronic pain, of which five demonstrated improved pain outcomes, specifically, headache pain. The effect of PAP therapy on chronic non-headache pain was found to be inconclusive. When examining the three studies that did not involve chronic pain patients, PAP therapy effectively increased pain threshold and tolerance in two studies (p = 0.03 and p = 0.01).

CONCLUSION

An association exists between PAP therapy and decreased chronic headache outcomes in patients with OSA. Additionally, research shows that PAP therapy may increase pain tolerance and threshold. Future high-quality evidence is required to further investigate the association between PAP and non-headache chronic pain.

Short-Term and Long-Term Pain After Total Hip Arthroplasty: A Prospective Cohort Study

BACKGROUND

Postoperative pain has a major influence on older adults' rehabilitation. There is a lack of knowledge regarding how older adults return to daily living after discharge.

AIMS

The primary aim of this study was to examine the association between moderate to severe pain during the first 5 postoperative days and pain 1 year after discharge in older adults after total hip arthroplasty (THA).

DESIGN

This was a prospective cohort study.

METHODS

The study was conducted from August 2019 to February 2020, in a University Hospital in Denmark and included a 5-day diary and a telephone interview postoperatively. The following main areas were investigated: pain levels, pain management, side effects from opioids, mood, fatigue, quality of sleep, and functional level. Associations between moderate to severe pain levels at 5 days after surgery and persistent pain at 1 year were evaluated through correlation analyses.

RESULTS

A total of 70 THA older adults returned the diary postoperatively. Thereafter, 62 participated in a 1-year follow-up interview. No associations were found between pain levels 5 days postoperatively and after 1 year. Fifteen older adults reported hip pain was present still 1 year after surgery, and 14 patients still used analgesics on daily basis. No correlation was found between levels of pain and quality of sleep 1 year after surgery.

CONCLUSIONS

No association was found between older adults with moderate to severe levels of pain during the first 5 days postoperatively and 1 year after surgery. Proactive follow-up strategies for older adults after discharge following THA may be indicated to promote optimal rehabilitation.

Substituting Cannabidiol for Opioids and Pain Medications Among Individuals With Fibromyalgia: A Large Online Survey

People report substituting cannabis for pain medications, but whether cannabidiol (CBD) is used similarly remains unknown. CBD products can be CBD alone (isolate), hemp extract (containing <0.3% Δ-9-tetrahydrocannabinol [THC], other cannabinoids, and terpenes), or CBD-cannabis (containing >0.3% THC). In a secondary analysis from a cross-sectional survey, we examined substitution patterns among n = 878 individuals with fibromyalgia who currently used CBD. We sub-grouped participants by most commonly used CBD product (CBD isolate, hemp, CBD-cannabis, no preference) and whether they substituted CBD for medications. We investigated rationale for substituting, substitution-driven medication changes, CBD use patterns, and changes in pain-related symptoms (eg, sleep, anxiety). The study population was 93.6% female and 91.5% Caucasian, with an average age of 55.5 years. The majority (n = 632, 72.0%) reported substituting CBD products for medications, most commonly NSAIDs (59.0%), opioids (53.3%), gabapentanoids (35.0%), and benzodiazepines (23.1%). Most substituting participants reported decreasing or stopping use of these pain medications. The most common reasons for substitution were fewer side effects and better symptom management. Age, hemp products, past-year use of marijuana, and higher somatic burden were all associated with substituting (P's ≤ .05). Those who substituted reported larger improvements in health and pain than those who did not. Participants using CBD-cannabis reported significantly more substitutions than any other group (P's ≤ .001) and larger improvements in health, pain, memory, and sleep than other subgroups. This widespread naturalistic substitution for pain medications suggests the need for more rigorous study designs to examine this effect. PERSPECTIVE: This article shows that people with fibromyalgia are deliberately substituting CBD products for conventional pain medications despite the dearth of evidence suggesting CBD products may be helpful for fibromyalgia. CBD's medication-sparing and therapeutic potential should be examined in more rigorous study designs.

Implementation of the Uniformed Services University Pain Registry Biobank: A Military and Veteran Population Focused Biobank and Registry

OBJECTIVE

The objective of this overview is to discuss the development, implementation, data content, and structure of the Uniformed Services University Pain Registry Biobank. Additionally, procedures and policies for accessing samples for pain-related research purposes are detailed.

DESIGN

Cross-sectional overview.

SETTING

Multiple military treatment facilities.

SUBJECTS

Adult beneficiaries seeking care within the Military Health System.

METHODS

Participants complete a baseline battery of biopsychosocial survey measures, including PROMIS® measures, provide biologic samples (e.g. blood and saliva), and relevant health history, including medications and surgical history, is extracted from medical records. During the course of the next year, enrolled participants complete surveys and provide biologic samples at 3-months, 6-months, and 12-months. Thereafter, participants are contacted once annually to complete self-reported assessments and provide biologic samples.

RESULTS

In the first year alone 86 subjects have participated in the Uniformed Services University Pain Registry Biobank and provided 390 observations (e.g. biological samples and biopsychosocial patient-reported outcomes). The Uniformed Services University Pain Registry Biobank's integration of biological samples, patient-reported outcomes, and health record data over a longitudinal period across a diverse sample recruited from multiple military facilities addresses many of the limitations faced by other pain-related registries or biorepositories.

CONCLUSIONS

The Uniformed Services University Pain Registry Biobank will serve as a platform for conducting research closely aligned with the Federal Pain Research Strategy. The inclusion of active duty service members, beneficiaries, and civilians living with and without acute or chronic pain provides a unique data repository for all investigators interested in advancing pain science.

Association between sleep disturbance and low back and pelvic pain in 4-month postpartum women: A cross-sectional study

PURPOSE

Persistent low back and pelvic pain (LBPP) is a postpartum-specific health problem. Sleep disturbances' association with persistent LBPP is not yet clear. We aimed to examine the cross-sectional association between sleep disturbance and persistent LBPP at 4 months postpartum.

METHODS

We enrolled 120 women with LBPP during pregnancy (mean age, 31.8; standard deviation, 4.9 years). The primary outcome was persistent LBPP. We assessed LBPP severity at 4 months postpartum using the Numerical Rating Scale (NRS), where women with an NRS score of ≥ 4 at 4 months postpartum were allocated to the persistent LBPP group. We assessed sleep disturbance at 4 months postpartum using the Japanese version of the Pittsburgh Sleep Quality Index with a total score of ≥ 6 indicating sleep disturbance. Moreover, we performed univariate and multiple logistic regression analyses to examine the cross-sectional association of sleep disturbance with persistent LBPP. The relevant confounding variables were age, body mass index, parity, and history of LBPP before pregnancy.

RESULTS

Among the 120 women, 45 women had persistent LBPP (37.5%) with 32 (71.1%) of them reporting sleep disturbance. There was a significant association of sleep disturbance with persistent LBPP (odds ratio [OR], 2.81; 95% confidence interval [95% CI], 1.28-6.19), which remained after adjustments for confounding variables (OR, 2.98; 95% CI, 1.31-6.75).

CONCLUSION

Our findings indicate that sleep disturbance is associated with persistent LBPP at 4 months postpartum; therefore, it should be taken into consideration in postpartum women with persistent LBPP.

Sleep Well and Recover Faster with Less Pain-A Narrative Review on Sleep in the Perioperative Period

Sleep disturbance, pain, and having a surgical procedure of some kind are all very likely to occur during the average lifespan. Postoperative pain continues to be a prevalent problem and growing evidence supports the association between pain and sleep disturbances. The bidirectional nature of sleep and pain is widely acknowledged. A decline in sleep quality adds a risk for the onset of pain and also exacerbates existing pain. The risk factors for developing insomnia and experiencing severe pain after surgery are quite similar. The main aim of this narrative review is to discuss why it is important to be aware of sleep disturbances both before and after surgery, to know how sleep disturbances should be assessed and monitored, and to understand how better sleep can be supported by both pharmacological and non-pharmacological interventions.

Sex Differences, Sleep Disturbance and Risk of Persistent Pain Associated With Groin Hernia Surgery: A Nationwide Register-Based Cohort Study

Persistent pain after groin hernia repair is a major health problem. Sleep disturbance is associated with heightened pain sensitivity. The main objective of this study was to examine the role of sleep disturbance in the development and long-term maintenance of chronic postherniorrhaphy inguinal pain (CPIP), with exploration of sex differences. From 2012 to 2017, a national cohort of patients with prior groin hernia repair (n = 2084;45.8% females) were assessed for the development of CPIP 12 months after surgery. Patients then underwent long-term (median 5.0 years) follow-up to evaluate the contribution of sex and sleep disturbance on the maintenance of CPIP. Associations between pre- and postoperative sleep problems (assessed at long-term follow-up) and CPIP were tested using logistic regression. Females had higher rates of CPIP with negative impact on daily activities 12 months after surgery as compared to males (14.6 vs 9.2%, P < .0005), and were more likely to have moderate-severe CPIP in the long-term (3.1 vs 1.2%, P = .003). Preoperative sleep problems predicted development of CPIP 12 months after surgery (adjusted odds ratio [aOR] 1.76 [95%CI 1.26-2.46], P = .001) and CPIP in the long-term (aOR 2.20 [1.61-3.00] , P < .0001). CPIP was associated with insomnia and depression. Sleep disturbance may increase the risk for CPIP, and contribute to maintenance of postsurgical pain. PERSPECTIVE: Females are at heightened risk for CPIP as compared to males. Increased severity of pain symptoms are linked to poorer sleep and psychiatric morbidity. Given the robust associations between sleep disturbance and CPIP, interventions which consolidate and promote sleep, especially in females, may improve long-term pain control.

The Prevalence, Characteristics and Impact of Chronic Pain in People With Muscular Dystrophies: A Systematic Review and Meta-Analysis

Chronic pain is a frequent, yet under-recognized and under-assessed problem in people with muscular dystrophies (MDs). Knowledge of the prevalence and characteristics of chronic pain, and its impact on function and quality of life is limited and lacks systematic exploration. This article aims to systematically review and synthesize existing literature that addresses chronic pain prevalence, characteristics and impact in people with different types of MDs. The present meta-analysis showed that the estimated prevalence of chronic pain in MDs is high and appears to be similar across different diagnostic groups: 68% (95% CI: 52%-82%) in FSHD, 65% (95% CI: 51%-77%) in DM, 62% (95% CI: 50%-73%) in BMD/DMD, and 60% (95% CI: 48%-73%) in LGMD, although it should be noted that heterogeneity was high in some diagnostic groups. On average, people with FSHD and DM present with moderate pain intensity. The lumbar spine, shoulders and legs are the most frequent sites of chronic pain among people with FSHD, DM, BMD/DMD, and LGMD, with little variation. Diffuse pain across multiple body sites was reported by a notable proportion of these individuals. Chronic pain has a negative impact on daily life activities in people with MDs, and may also contribute to decreased quality of life. The protocol for this review has been published on PROSPERO (CRD42020168096). PERSPECTIVES: This is the first systematic review and meta-analysis exploring the prevalence, and nature and impact of chronic pain in people with MDs. The present study demonstrates how common chronic pain is across various MD populations and highlights the need for better recognition and understanding of the nature and impact of pain from health professionals.

Association between sleep disorders and osteoarthritis: A case-control study of 351,932 adults in the UK

This study aimed to analyse the association between sleep disorders and osteoarthritis in adults in the UK. This case-control study included patients aged ≥ 18 years who were diagnosed with osteoarthritis for the first time in one of 256 general practices in the UK between 1997 and 2016 (index date). Patients without osteoarthritis were matched (1:1) to those with osteoarthritis by sex, age, index year, general practice, observation time prior to index date (in years), obesity, injuries, and other types of arthritis. For patients without osteoarthritis, the index date was a randomly selected visit date between 1997 and 2016. The presence of sleep disorders prior to index date was assessed in the two groups. Finally, conditional logistic regression analyses were conducted to investigate the association between sleep disorders and osteoarthritis. This case-control study included 351,932 adults (61.5% women; mean [SD] age 64.9 [14.2] years). Overall, there was a significant association between sleep disorders and osteoarthritis (odds ratio = 1.25, 95% confidence interval = 1.22-1.29). This finding was corroborated in all sex and age subgroups, except in patients aged > 80 years. In terms of the type of sleep disorder, non-organic sleep disorders, hypersomnia and sleep apnea were associated to a significant extent with higher odds of developing osteoarthritis. Finally, the relationship between sleep disorders and osteoarthritis was significant in all osteoarthritis subgroups, except in that of patients with knee osteoarthritis. Based on these results, it can be concluded that sleep disorders may play a role in the development of osteoarthritis.

Enhancing sleep quality for nursing home residents with dementia: a pragmatic randomized controlled trial of an evidence-based frontline huddling program

Background

Disturbed sleep places older adults at higher risk for frailty, morbidity, and even mortality. Yet, nursing home routines frequently disturb residents’ sleep through use of noise, light, or efforts to reduce incontinence. Nursing home residents with Alzheimer’s disease and or related dementias—almost two-thirds of long-stay nursing home residents—are likely to be particularly affected by sleep disturbance. Addressing these issues, this study protocol implements an evidence-based intervention to improve sleep: a nursing home frontline staff huddling program known as LOCK. The LOCK program is derived from evidence supporting strengths-based learning, systematic observation, relationship-based teamwork, and efficiency.

Methods

This study protocol outlines a NIH Stage III, real-world hybrid efficacy-effectiveness pragmatic trial of the LOCK sleep intervention. Over two phases, in a total of 27 non-VA nursing homes from 3 corporations, the study will (1) refine the LOCK program to focus on sleep for residents with dementia, (2) test the impact of the LOCK sleep intervention for nursing home residents with dementia, and (3) evaluate the intervention’s sustainability. Phase 1 (1 year; n = 3 nursing homes; 1 per corporation) will refine the intervention and train-the-trainer protocol and pilot-tests all study methods. Phase 2 (4 years; n = 24 nursing homes; 8 per corporation) will use the refined intervention to conduct a wedge-design randomized, controlled, clinical trial. Phase 2 results will measure the LOCK sleep intervention’s impact on sleep (primary outcome) and on psychotropic medication use, pain and analgesic medication use, and activities of daily living decline (secondary outcomes). Findings will point to inter-facility variation in the program’s implementation and sustainability.

Discussion

This is the first study to our knowledge that applies a dementia sleep intervention to systematically address known barriers to nursing home quality improvement efforts. This innovative study has future potential to address clinical issues beyond sleep (safety, infection control) and expand to other settings (assisted living, inpatient mental health). The study’s strong team, careful consideration of design challenges, and resulting rigorous, pragmatic approach will ensure success of this promising intervention for nursing home residents with dementia.

Trial registration

NCT04533815, ClinicalTrials.gov, August 20, 2020. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02189-8.

Associations of loneliness and social isolation with actigraph and self-reported sleep quality in a national sample of older adults

STUDY OBJECTIVES

To examine associations of social isolation and loneliness with sleep in older adults and whether associations differ for survey and actigraph sleep measures.

METHODS

This study used data from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative study of community-dwelling older adults born 1920-1947. A random one-third of participants in 2010-2011 were invited to participate in a sleep study (N = 759) that included survey questions, 72 hours of wrist actigraphy, and a sleep log. Perceived loneliness was measured using three questions from the UCLA Loneliness Scale. An index of social isolation was constructed from nine items that queried social network characteristics and social interactions. We used ordinary least squares and ordinal logistic regression to examine whether sleep measures were associated with loneliness and social isolation adjusted for potential sociodemographic confounders.

RESULTS

Social isolation and loneliness had a low correlation (Spearman's correlation = 0.20). Both loneliness and social isolation were associated with actigraphy measures of more disrupted sleep: wake after sleep onset and percent sleep. Neither was associated with actigraph total sleep time. Increased loneliness was strongly associated with more insomnia symptoms and with shorter sleep duration assessed by a single question, but social isolation was not. More isolated individuals spent a longer time in bed.

CONCLUSIONS

We found that both loneliness and social isolation were associated with worse actigraph sleep quality, but their associations with self-reported sleep differed. Only loneliness was associated with worse and shorter self-reported sleep.

A qualitative study of the experience and impact of neuropathic pain in people living with HIV

Painful distal symmetrical polyneuropathy is common in HIV and is associated with reduced quality of life. Research has not explored the experience of neuropathic pain in people with HIV from a person-centred perspective. Therefore, a qualitative interview study was conducted to more deeply understand the experience and impact of neuropathic pain in this population. Semistructured interviews were conducted with 26 people with HIV and peripheral neuropathic pain symptoms. Interviews explored the impact of pain and participants' pain management strategies. Interviews were transcribed verbatim and analysed using thematic analysis. Four themes and 11 subthemes were identified. Theme 1 reflects the complex characterisation of neuropathic pain, including the perceived unusual nature of this pain and diagnostic uncertainty. Theme 2 centred on the interconnected impacts of pain on mood and functioning and includes how pain disrupts relationships and threatens social inclusion. Theme 3 reflects the struggle for pain relief, including participants' attempts to "exhaust all options" and limited success in finding lasting relief. The final theme describes how pain management is complicated by living with HIV; this theme includes the influence of HIV stigma on pain communication and pain as an unwanted reminder of HIV. These data support the relevance of investigating and targeting psychosocial factors to manage neuropathic pain in HIV.