A multilevel path model analysis of the relations between sleep, pain, and pain catastrophizing in chronic pain rehabilitation patients

Adolescent girls' musculoskeletal pain is more affected by insomnia than boys', and through different psychological pathways

Prior research has established that insomnia is predctive of pain in adolescents and that psychological mechanisms have a crucial role in this relationship. Adolescent girls report more insomnia and pain than boys, yet little is known of gender differences in how insomnia influences pain. This study assessed gender differences in levels and trajectories of insomnia and pain during adolescence, and whether rumination and negative mood mediated the effect of insomnia on pain. Longitudinal survey data measured on 5 annual occasions (Nbaseline = 2,767) were analyzed in a multigroup longitudinal serial mediation model. A final model was generated with insomnia as the predictor, rumination and depressed mood as mediators, pain as the outcome, and gender the grouping variable. The results showed that insomnia predicted pain in adolescents, with an effect 3.5 times larger in girls than boys. Depressed mood was the main mediator in boys. In girls, rumination was the only significant mediator. There were significant gender differences in the effects of insomnia on rumination and pain, and in the effects of rumination on depressed mood and pain, with stronger effects in girls. These results highlight that girls and boys should be considered separately when studying the relationship between insomnia and pain. PERSPECTIVE: Levels of insomnia and pain are progressively higher in adolescent girls than boys, across adolescence. The predictive strength of insomnia symptoms for future pain is 3.5 times greater in girls, with distinct gender-specific underlying pathways: rumination partially mediates this effect in girls, while depressed mood does so in boys.

Effects of sleep quality on pain, cognitive factors, central sensitization, and quality of life in patients with chronic low back pain

BACKGROUND

Sleep quality in patients with chronic low back pain (CLBP) may affect quality of life (QoL), possibly due to worsening pain, central sensitization (CS), and cognitive factors. However, causal relationship among the factors has not been confirmed yet.

OBJECTIVE

The purpose of this study was to test the hypothesis that sleep quality in patients with CLBP is attributable to pain, cognitive factors, and CS, and influences QoL, by structural covariance analysis.

METHODS

This is a cross-sectional study. Participants were recruited from six health care facilities and 101 patients with CLBP were included. Structural covariance analysis assessed the fit of data to the model using goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI), and mean squared approximation error (RMSEA).

RESULTS

The structural covariance analysis showed that the goodness-of-fit indices were high (GFI = 0.993, AGFI = 0.964, CFI = 1.00, RMSEA < 0.01). Sleep quality was not directly influenced by QoL but rather by CS and cognitive factors.

CONCLUSION

This study suggests that sleep quality in patients with CLBP is indirectly mediated through multiple pathways, including cognitive factors and CS, which may influence QoL.

Association of Sleep Disturbance With Catastrophizing and Knee Pain: Data From the Osteoarthritis Initiative

OBJECTIVE

To investigate the relationship between sleep disturbance, catastrophizing, and knee pain in middle-aged and older individuals.

METHODS

Data from the Osteoarthritis Initiative cohort from months 48 to 96 were used, where month 48 was treated as baseline. Knee pain (Western Ontario and McMaster Universities Osteoarthritis Index pain scale score ≥5 [range 0-20]), catastrophizing (extracted from Coping Strategies Questionnaire score ≥3 [range 0-6]), and sleep quality (extracted from Center for Epidemiologic Studies Depression Scale [range 1-4]) were assessed annually. We described the association of sleep disturbance with the presence and risk of knee pain and catastrophizing. The mediation effect of knee pain and catastrophizing on the sleep-catastrophizing and sleep-pain association was evaluated, respectively.

RESULTS

Catastrophizing and knee pain were reported in 346 (10%) and 917 (24%) of the 3,813 participants (mean 64.9 years, 58% female) at baseline. Participants with worse sleep disturbance were more likely to have knee pain (prevalence ratio [PR] 1.4-2.0, P for trend <0.001) and catastrophizing (PR 1.4-3.1, P for trend <0.001). Sleep disturbance at baseline predicted the risk of knee pain (risk ratio [RR] 1.1, P for trend <0.001) and catastrophizing (RR 1.2-1.7, P for trend <0.001) during follow-up. No statistically significant interactions between sleep disturbance and knee pain or catastrophizing were observed. Knee pain and catastrophizing mediated the sleep-catastrophizing and sleep-pain association, respectively, at baseline, and knee pain negatively mediated the sleep-catastrophizing association longitudinally.

CONCLUSION

Sleep disturbance was associated with the presence and risk of catastrophizing and knee pain. Sleep interventions may have a universal and independent effect in preventing incident knee pain.

Associations Among Sleep Disturbance, Pain Catastrophizing, and Pain Intensity for Methadone-maintained Patients With Opioid Use Disorder and Chronic Pain

OBJECTIVE

This study examined the cross-sectional associations among pain intensity, pain catastrophizing, and sleep disturbance among patients receiving methadone maintenance treatment (MMT) for opioid use disorder (OUD) and reporting co-occurring chronic pain.

MATERIALS AND METHODS

Participants were 89 individuals with OUD and chronic pain drawn from a larger cross-sectional study of 164 MMT patients who completed a battery of self-report measures. The authors conducted 6 mediation models to test all possible pathways (ie, each variable tested as an independent variable, mediator, or dependent variable).

RESULTS

The only significant mediation effect was an indirect effect of sleep disturbance on pain intensity through pain catastrophizing. That is, greater sleep disturbance was associated with greater pain catastrophizing, which in turn was associated with greater pain intensity.

DISCUSSION

Altogether, findings suggest that the sleep disturbance to pain catastrophizing to pain intensity pathway may be a key mechanistic pathway exacerbating pain issues among MMT patients with OUD and chronic pain. These results suggest that interventions targeting sleep disturbance may be warranted among MMT patients with OUD and chronic pain. Future work in this area with longitudinal data is warranted.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity

OBJECTIVE

Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA.

METHODS

We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity.

RESULTS

The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42).

CONCLUSIONS

Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

A Preliminary Investigation of the Underlying Mechanism Associating Daily Sleep Continuity Disturbance and Prescription Opioid Use Among Individuals With Sickle Cell Disease

BACKGROUND

There are emerging data indicating that sleep disturbance may be linked with an increase in opioid use. The majority of sickle cell disease (SCD) patients experience sleep disturbances, which can elevate pain severity and pain catastrophizing, both of which are important predictors of opioid consumption.

PURPOSE

We conducted a preliminary investigation on the association between previous night sleep disturbance and short-acting opioid use, as well as the potential mediating roles of pain severity and pain catastrophizing. Because sex is associated with sleep disturbance, pain-related experiences, and opioid use, we also explored the potential moderating role of sex.

METHODS

Participants were 45 SCD patients who were prescribed opioids. For 3 months, sleep diaries were collected immediately upon participants' awakening. Daily pain severity, pain catastrophizing, and prescription opioid use measures were collected before bedtime.

RESULTS

Multilevel structural equation modeling revealed that wake time after sleep onset (WASO) during the previous night (Time 1) predicted greater short-acting opioid use during the next day (Time 2). Pain severity and pain catastrophizing measured during the next day (Time 2) also mediated the association between the two. Sex moderation analysis showed that the positive association between WASO and pain severity was largely driven by women.

CONCLUSION

These findings provide some preliminary evidence as to the mechanism linking sleep continuity disturbance and opioid requirement in SCD patients. Future studies should replicate and extend these findings with clearer temporal information and employing more refined measures of sleep continuity and prescription opioid use in a larger sample.

Pain Catastrophizing in Older Adults with Chronic Pain: The Mediator Effect of Mood Using a Path Analysis Approach

Cognitive models of pain propose that catastrophic thinking is negatively associated with chronic pain. However, pain catastrophizing is a complex phenomenon requiring a multivariate examination. This study estimates the effects of mood variables (anxiety and depression) on pain catastrophizing in older adults with chronic pain. A postal survey addressing pain aspects was sent to 6611 people ≥ 65 years old living in south-eastern Sweden. Pain catastrophizing was measured using the pain catastrophizing scale. Anxiety and depression were assessed using two subscales of the general well-being schedule. Data were analysed using a path analysis approach. A total of 2790 respondents (76.2 ± 7.4 years old) reported chronic pain (≥three months). The mediation model accounted for 16.3% of anxiety, 17.1% of depression, and 30.9% of pain catastrophizing variances. Pain intensity, insomnia, number of comorbidities, and lifestyle factors (smoking, alcohol consumption, and weight) significantly affected both pain catastrophizing and mood. Anxiety (standardized path coefficient (b_std) = 0.324, p < 0.001) in comparison to depression (b_std = 0.125, p < 0.001) had a greater effect on pain catastrophizing. Mood mediated the relationship between pain catastrophizing and pain-related factors accounting for lifestyle and sociodemographic factors.

Linking Nonrestorative Sleep and Activity Interference Through Pain Catastrophizing and Pain Severity: An Intraday Process Model Among Individuals With Fibromyalgia

Nonrestorative sleep is a key diagnostic feature of the musculoskeletal pain disorder fibromyalgia and is robustly associated with poor physical functioning, including activity interference. However, the mechanisms through which nonrestorative sleep elicits activity interference among individuals with fibromyalgia at the within-person level remain unclear. The present study tested the following 3-path mediation model, using data gathered from a 21-day electronic daily diary in 220 individuals with fibromyalgia: previous night nonrestorative sleep → morning pain catastrophizing → afternoon pain severity → end-of-day activity interference. Results of multilevel structural equation modeling supported the 3-path mediation model. Previous night's nonrestorative sleep and morning pain catastrophizing were also directly related to end-of-day activity interference. Previous night nonrestorative sleep did not significantly predict afternoon pain severity while controlling for the effect of morning pain catastrophizing. Greater nonrestorative sleep during the previous night and a higher level of morning pain catastrophizing appear to serve as risk factors for experiencing greater daily pain and activity interference later in the day. These findings point to the potential utility of targeted interventions that improve both sleep quality and pain catastrophizing to help individuals with chronic pain engage in important daily activities despite experiencing pain. PERSPECTIVE: This study provides a better understanding of how nonrestorative sleep is associated with daily activity interference among individuals with fibromyalgia. An intervention that targets attenuating nonrestorative sleep and pain catastrophizing may help improve daily physical functioning of this population.

Chronic Pain and Sleep Disturbances: A Pragmatic Review of Their Relationships, Comorbidities, and Treatments

Objective

The objective of this review is to answer three questions: 1) How are chronic pain severity and pain duration affected in patients with chronic pain and sleep disturbances that occur simultaneously? 2) What are common comorbidities and pain-related symptoms seen in patients with chronic pain and sleep disturbances? and 3) What are potentially effective pharmacological and nonpharmacological treatment options for both conditions?

Methods

Ovid Medline and PubMed were searched. Search terms included sleep wake disorder, chronic pain, fibromyalgia, treatment outcome, psychotherapy, complementary therapies, and therapeutics. Studies that assessed outcomes between individuals with chronic pain and those with concurrent chronic pain and sleep disturbances were included. Randomized controlled clinical trials of treatments for both conditions were included.

Results

Sixteen studies indicated that patients with both chronic pain and sleep disturbances have greater pain severity, longer duration of pain, greater disability, and are less physically active than those without sleep disturbances. Patients with both conditions are more likely to have concurrent depression, catastrophizing, anxiety, and suicidal ideation. Thirty-three randomized controlled trials assessed treatment for both chronic pain and sleep disturbances. Pregabalin was the most frequently studied medication, showing improvement in pain and sleep symptoms. Cognitive behavioral therapy for insomnia showed long-term improvement in sleep for patients with chronic pain.

Conclusions

Individuals with chronic pain and sleep disturbances have greater symptom severity, longer duration of symptoms, more disability, and additional comorbidities. Pharmacological and nonpharmacological treatments may be useful in the treatment of concurrent chronic pain and sleep disturbances, but further study is needed.

Sleep disturbance in individuals with physical disabilities and chronic pain: The role of physical, emotional and cognitive factors

BACKGROUND

Sleep problems are common for individuals living with physical disabilities and chronic pain. However, the factors that influence the relationship between pain and sleep problems in these populations remain unknown.

OBJECTIVE

The aim of this study was to increase our understanding of the physical, emotional and cognitive factors associated with sleep disturbance in individuals with chronic health conditions often associated with physical disabilities.

METHODS

Participants were recruited from a database of individuals with a variety of chronic health conditions, including multiple sclerosis, spinal cord injury, back pain, osteoarthritis, and amputations. To participate in the study, they needed to report having a chronic pain problem. Participants completed an online survey using REDCap assessing average pain intensity (Numerical Rating Scale-11), pain extent (number of painful body areas), sleep disturbance (PROMIS Sleep Disturbance), depression (PROMIS Emotional Distress-Depression) and catastrophizing (Coping Strategies Questionnaire). A total of 455 participants (M_age = 58.9; SD = 11.4), of which 292 (64%) were women, provided complete data. We performed a series of four regression analyses.

RESULTS

After controlling for age and sex, the predictors explained an additional 7-16% of the variance in sleep disturbance. The final model with all of the predictors explained 22%.

CONCLUSIONS

Consistent with the study hypothesis, all the variables examined made significant and independent contributions to the variance in sleep disturbance. The findings provide additional evidence that physical, emotional and cognitive factors all play a role in the sleep quality of individuals with chronic health conditions often associated with physical disabilities.

General practitioners and management of chronic noncancer pain: a cross-sectional survey of influences on opioid deprescribing

Background

General practitioners’ (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs’ beliefs about deprescribing, including their decisions to deprescribe different types of POAs.

Aim

To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing.

Design and setting

In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken.

Methods

A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone.

Results

A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples’ long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient.

Conclusions

Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.

Predicting Responses to Pregabalin for Painful Diabetic Peripheral Neuropathy Based on Trajectory-Focused Patient Profiles Derived from the First 4 Weeks of Treatment

Introduction

Prediction of final clinical outcomes based on early weeks of treatment can enable more effective patient care for chronic pain. Our goal was to predict, with at least 90% accuracy, 12- to 13-week outcomes for pregabalin-treated painful diabetic peripheral neuropathy (pDPN) patients based on 4 weeks of pain and pain-related sleep interference data.

Methods

We utilized active treatment data from six placebo-controlled randomized controlled trials (n = 939) designed to evaluate efficacy of pregabalin for reducing pain in patients with pDPN. We implemented a three-step, trajectory-focused analytics approach based upon patient responses collected during the first 4 weeks using monotonicity, path length, frequency domain (FD), and k-nearest neighbor (kNN) methods. The first two steps were based on combinations of baseline pain, pain at 4 weeks, weekly monotonicity and path length during the first 4 weeks, and assignment of patients to one of four responder groups (based on presence/absence of 50% or 30% reduction from baseline pain at 4 and at 12/13 weeks). The third step included agreement between prediction of logistic regression of daily FD amplitudes and assignment made from kNN analyses.

Results

Step 1 correctly assigned 520/939 patients from the six studies to a responder group using a 3-metric combination approach based on unique assignment to a 50% responder group. Step 2 (applied to the remaining 419 patients) predicted an additional 121 patients, using a blend of 50% and 30% responder thresholds. Step 3 (using a combination of FD and kNN analyses) predicted 204 of the remaining 298 patients using the 50% responder threshold. Our approach correctly predicted 90.0% of all patients.

Conclusion

By correctly predicting 12- to 13-week responder outcomes with 90% accuracy based on responses from the first month of treatment, we demonstrated the value of trajectory measures in predicting pDPN patient response to pregabalin.

Trial Registration

www.clinicaltrials.gov identifiers, NCT00156078/NCT00159679/NCT00143156/NCT00553475.

Funding

Pfizer.

Plain Language Summary

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Electronic supplementary material

The online version of this article (10.1007/s12325-018-0780-3) contains supplementary material, which is available to authorized users.