Sleep and Pain: A Systematic Review of Studies of Mediation

Prevalence and predictors of sleep problems in women following a cancer diagnosis: results from the women's wellness after cancer program

PURPOSE

Using a discrete dataset from the Women's Wellness after Cancer Program (WWACP), we examine the prevalence and predictors of self-reported sleep problems in women previously treated for cancer.

METHODS

Participants were 351 women (Mage = 53.2, SD = 8.8) from the WWACP who had completed surgery, chemotherapy and/or radiotherapy for breast, gynaecological or blood cancers within the previous 24 months. Sleep problems were measured using the Pittsburgh Sleep Quality Index (PSQI). Baseline data (i.e. prior to intervention randomisation) were analysed.

RESULTS

Most women (59%) reported clinically significant sleep disturbance (PSQI > 5), 40% reported insufficient sleep duration (< 7 h), 38% self-reported poor sleep quality and 28% reported poor habitual sleep efficiency (sleep efficiency < 75%). Fewer psychological and vasomotor climacteric symptoms, age < 45 years and having a partner were associated with reduced odds (AOR < 1) of sleep problems. Higher levels of pain-related disability, and an intermediate compared to 'high' level of education, were associated with increased odds (AOR > 1) of sleep problems.

CONCLUSIONS

These findings confirm previous studies that have found a high prevalence of sleep problems in women previously treated for cancer. A range of sociodemographic, climacteric and pain-related factors were associated with sleep problems in this study.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted interventions to improve sleep quality after cancer treatment should be explored in this population. Predictors identified in this study could inform intervention targeting and development.

The role of pain intensity and depressive symptoms in the relationship between sleep quality and postural control among middle-aged and older adults with Fibromyalgia

OBJECTIVE

Fibromyalgia (FM) is a chronic pain condition often accompanied by sleep problems and depression that are each associated with reduced physical ability including postural control. Research supports a sequential association between pain intensity and depression in FM, and poor sleep quality may play a key role in this relationship. This study aimed to verify a serial pattern of associations among sleep quality, pain intensity, and depressive symptoms and quantify these effects on objective postural control.

DESIGN

Community-residing adults diagnosed with FM (n = 155; Mage = 61.08, SD = 7.70; 93% female; 79% White) were included in this cross-sectional study.

MAIN OUTCOMES

Participants self-rated sleep quality (restorative sleep, sleep waking, and sleep latency), pain intensity, and depressive symptoms, and the Fullerton Advanced Balance (FAB) scale and 8-Foot Up and Go Test (8FUPGT) measured objective postural control.

RESULTS

Findings indicated that the serial association between pain intensity and depressive symptoms fully mediated the relationship between sleep quality and both FAB (95% CI [-.125, -.013]), and 8FUPGT (95% CI [.002, .033]) performance.

CONCLUSION

Findings highlight the serial association of pain intensity and depressive symptoms with objective postural control performance and the potential for sleep and depression interventions that may maximize functional outcomes in FM.

The contribution of sleep quality and psychological factors to the experience of within-day pain fluctuations among individuals with temporomandibular disorders

We assessed the impact of day-to-day sleep quality and psychological variables (catastrophizing, negative affect, positive affect) to within-day pain fluctuations in 42 females with painful temporomandibular disorders (TMD) using electronic diaries. More specifically, we examined the contribution of these variables to the likelihood of experiencing pain exacerbations defined as: 1.1) an increase of 20 points (or more) in pain intensity on a 0-100 visual analogue scale (VAS) from morning to evening, and/or 1.2) a transition from mild-to-moderate pain over the course of the day; and pain decreases defined as: 1.3) a decrease of 20 points (or more) in pain intensity (VAS) from morning to evening, and/or 1.4) a reduction from moderate to mild pain over the day. Results indicated significantly main effects of sleep on both pain exacerbation outcomes (both p's <.05), indicating that nights with better sleep quality were less likely to be followed by clinically meaningful pain exacerbations on the next day. Results also indicated that days characterized by higher levels of catastrophizing were associated with a greater likelihood of pain exacerbations on the same day (both p's <.05). Daily catastrophizing was the only variable significantly associated with within-day pain decrease indices (both p's <.05). None of the other variables were associated with these outcomes (all p's >.05). These results underscore the importance of addressing patients' sleep quality and psychological states in the management of painful TMD. PERSPECTIVES: These findings highlight the significance of sleep quality and pain catastrophizing in the experience of within-day pain fluctuations among individuals with TMD. Addressing these components through tailored interventions may help to alleviate the impact of pain fluctuations and enhance the overall well-being of TMD patients.

Adolescent Girls' Musculoskeletal Pain is More Affected by Insomnia Than Boys, and Through Different Psychological Pathways

Prior research has established that insomnia is predictive 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 as 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.

Sleep as a prognostic factor in low back pain: a systematic review of prospective cohort studies and secondary analyses of randomized controlled trials

Sleep problems are common in individuals with low back pain (LBP) and sleep restriction seems to be associated with impaired pain processing. Our objective was to investigate whether sleep is associated with future LBP outcomes (i.e. pain intensity, disability, and recovery) in adults. We conducted a systematic review of prospective cohort studies and secondary analyses of randomized controlled trials (registration-PROSPERO CRD42022370781). In December 2022, we searched the MEDLINE, Embase, CINAHL, and PsycINFO databases. Fourteen studies, totaling 19 170 participants were included. Thirteen studies were rated as having high risk of bias (QUIPS tool). We used vote-counting and meta-analysis approaches to synthesize the data. We found associations between baseline sleep with future pain intensity, recovery, and between changes in sleep with changes in pain intensity, changes in disability, and recovery. We further synthesized outcomes as "overall LBP improvement" outcomes. Baseline poor sleep was moderately associated with non-improvement in LBP in the long-very long term (OR 1.55, 95% CI: 1.39 to 1.73; three studies providing unadjusted effect sizes), and non-improvement in sleep was largely associated with non-improvement in LBP in the short-moderate term (OR 3.45, 95% CI: 2.54 to 4.69; four studies providing unadjusted effect sizes). We found no association between baseline sleep with future disability and overall LBP improvement in the short-moderate term. Therefore, sleep may be a prognostic factor for pain intensity and recovery from LBP. All findings were supported by low to very low-quality evidence. Better-conducted studies are needed to strengthen our certainty about the evidence.

Aquatic therapy improves self-reported sleep quality in fibromyalgia patients: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the effectiveness of aquatic therapy on pain, sleep quality, psychological symptoms, quality of life, and health status in people diagnosed with fibromyalgia.

METHODS

We searched PubMed, CINAHL, The Cochrane Library, PEDro and Scopus databases. Articles were eligible if they were randomised controlled trials (RCTs) analysing the effects of aquatic therapy in adult people diagnosed with fibromyalgia, and published by October of 2022 in English or Spanish. The Cochrane Risk of Bias tool was employed to conduct the methodological quality assessment of the encompassed studies, and the overall quality of evidence for each comparison was determined using the GRADE approach.

RESULTS

Of 375 articles found, 22 met the inclusion criteria. Forest plot analysis of Pittsburgh sleep quality index at short- and mid-term follow-up showed a trend in favour of aquatic therapy, although not statistically significant, with weighted mean difference (WMD) = -1.71 (95% CI: -4.17 to -0.75, p = 0.17). Heterogeneity was substantial (χ2 = 8.74, df = 5 (p < 0.000001; I2 = 95%). Relating the pain outcome by fibromyalgia impact questionnaire (FIQ) short term showed a trend in favour of the aquatic therapy group with WMD = -5.04 (95% CI: - 9.26 to - 0.82, p =  = 0.02) with heterogeneity χ2 = 11.07, df = 4 (p = 0.03; I2 = 64%). Great heterogeneity was found between trials in medium term.

CONCLUSION

This systematic review and meta-analysis demonstrated the effectiveness of aquatic therapy as an adjunct treatment to usual care in people suffering from fibromyalgia. Aquatic therapeutic exercise improves the symptomats of sleep quality, pain, and quality of life of adults with fibromyalgia. Further research on long-term outcomes may contribute to the currently available evidence.

A perspective on a precision approach to pain in cancer; moving beyond opioid therapy

PURPOSE

Cancer-related pain is primarily treated with opioids which while effective can add significant patient burden due to side effects, associated stigma, and timely access. The purpose of this perspective discussion is to argue for a precision approach to pain in cancer based on a biopsychosocial and spiritual model which we argue can offer a higher quality of life while limiting opioid use.

CONCLUSIONS

Pain in cancer represents a heterogenous process with multiple contributing and modulating factors. Specific characterization of pain as either nociceptive, neuropathic, nociplastic, or mixed can allow for targeted treatments. Additional assessment of biopsychosocial and spiritual issues can elucidate further points of targeted intervention which can lead to overall greater pain control.

Risk of Sleep Problems in Middle-Aged and Older Adults Experiencing Bodily Pains: Serial Multiple Mediation Estimates of Emotional Distress and Activity Limitations

OBJECTIVES

Pain is increasingly becoming common among middle-aged and older adults. While research on the association between pain characteristics and sleep problems (SP) is limited in low- and middle-income countries, the underlying mechanisms of the association are poorly understood. This study examines the association of bodily pain intensity and pain interference with SP and investigates the mediating role of activity limitation and emotional distress in this association.

METHODS

We analyzed population-based data, including 1,201 individuals aged ≥50 (mean [SD] age 66.14 [11.85] years) from the 2016-2018 AgeHeaPsyWel-HeaSeeB study in Ghana. Multiple OLS regressions and serial multiple mediation modeling using bootstrapping analyses examined direct and indirect effects from pain to SP through activity limitation and emotional distress.

RESULTS

Regressions demonstrated that pain intensity and interference were significantly associated with higher levels of activity limitation, emotional distress, and SP (range: β = 0.049-0.658). Bootstrapping analysis showed that activity limitation and emotional distress serially mediated the relationship between pain intensity and SP (total effect: β = 0.264, Bootstrap 95% confidence interval [CI] = 0.165-0.362; direct effect: (β = 0.107, Bootstrap 95% CI = 0.005-0.210; total indirect effect: β = 0.156, Bootstrap 95% CI = 0.005-0.210) accounting for ∼59%. Activity limitation and emotional distress mediated pain interference and SP association (total effect: β = 0.404, Bootstrap 95% CI = 0.318-0.490; direct effect: β = 0.292, Bootstrap 95% CI = 0.201-0.384; and total indirect effect: β = 0.112, Bootstrap 95% CI = 0.069-0.156) yielding ∼28%.

CONCLUSION

Our data suggest that activity limitation and emotional distress may convey stress-related risks of pain on SP. Future research should evaluate if activity limitation and emotional distress could be effective targets to reduce the effect of pain on sleep in later-life.

Translation, cross-cultural adaptation, and validation of the 10-item spine functional index (SFI-10) in the Brazilians with musculoskeletal spine disorders

PURPOSE

To translate and cross-culturally adapt the Spine Functional Index (SFI) into Brazilian Portuguese (SFI-Br) in individuals with musculoskeletal spine disorders.

METHODS

Participants (n=194) answered the Numerical Pain Rating Scale (NPRS), 36-item Short-Form Health Survey (SF-36), Roland-Morris Disability Questionnaire for General Pain (RMDQ-g), and SFI-25 incorporating the SFI-10. Structural validity, from confirmatory factor analysis (CFA), used comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA), and chi-square/degrees of freedom (DF). The best structure was considered from the lower values of the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). Construct and criterion validity used Spearman's correlation coefficient (rho). Internal consistency used Cronbach's alpha, reliability used intraclass correlation coefficient (ICC2,1), with ceiling and floor effects determined. Error used the standard error of the measurement (SEM) and minimal detectable change, 90% level (MDC90).

RESULTS

Adequate fit indices demonstrated an unequivocal one-factor structure only for the SFI-10 (chi-square/DF <3.00, CFI and TLI >0.90, RMSEA <0.08). The SFI-10-Br correlation was high with the SFI-Br (rho=0.914, p<0.001), moderate for the RMDQ-g (rho=-0.78), SF-36 functional capacity domain (rho=0.718) and NPRS (rho=-0.526); and adequate for the remaining SF-36 domains (rho>0.30). Test-retest reliability (ICC2,1=0.826) and internal consistency (alpha=0.864) were high. No ceiling or floor effects were observed, and error was satisfactory (SEM=9.08%, MDC90=25.15%).

CONCLUSION

The SFI Brazilian version was successfully produced with the 10-item version showing an unequivocal one-factor structure, high construct and criterion validity, reliability, internal consistency, and satisfactory error. Further research on responsiveness is required.

The Impact of Sleep Disturbances on Endogenous Pain Modulation: A Systematic Review and Meta-Analysis

The bidirectional relationship between sleep and pain problems has been extensively demonstrated but despite all the accumulating evidence, their shared mechanisms are currently not fully understood. This review examined the association between sleep disturbances, defined as a broad array of sleep-related outcomes (eg, poor quality, short duration, insomnia), and endogenous pain modulation (EPM) in healthy and clinical populations. Our search yielded 6,151 references, and 37 studies met the eligibility criteria. Qualitative results showed mixed findings regarding the association between sleep disturbances and temporal summation of pain (TSP) and conditioned pain modulation (CPM), with poor sleep more commonly associated with decreased pain inhibition in both populations. Quantitative results indicated that such associations were not statistically significant, neither in healthy populations when EPM outcomes were assessed for changes pre-/post-sleep intervention (TSP: .31 [95%CI: -.30 to .92]; P = .321; CPM: .40 [95%CI: -.06 to .85] P = .088) nor in clinical populations when such association was assessed via correlation (TSP: -.00 [95%CI: -.22 to .21] P = .970; CPM: .12 [95%CI: -.05 to .29]; P = .181). For studies that reported results by sex, meta-analysis showed that experimental sleep disturbances impaired pain inhibition in females (1.43 [95%CI: .98-1.88]; P < .001) but not in males (-.30 [95%CI: -2.69 to 1.60]; P = .760). Only one study investigating the association between sleep disturbances and offset analgesia was identified, while no studies assessing spatial summation of pain were found. Overall, this review provides a comprehensive overview of the association between sleep disturbances and EPM function, emphasizing the need for further investigation to clarify specific mechanisms and phenotypic subtypes. PERSPECTIVE: This review shines a light on the association between sleep disturbances and endogenous pain modulation function. Qualitatively, we found a frequent association between reduced sleep quality and impaired pain inhibition. However, quantitatively such an association was not corroborated. Sex-specific effects were observed, with females presenting sleep-related impaired pain inhibition but not males.

Increases in Sleep Difficulties and Psychological Symptoms are Associated With the Increase of Chronic Back Pain in Adolescents: The HBSC Study 2002 to 2018

Cross-national research using data from the Health Behavior in School-aged Children (HBSC) survey showed an increase in the prevalence of chronic back pain from 2002 to 2014. However, it is unknown if this trend has persisted beyond 2014. The aims of this study were to 1) determine if the prevalence of chronic back pain in girls and boys aged 11, 13, and 15 continued to increase from 2014 to 2018 and if this was the case, 2) examine whether this increase in the prevalence of chronic back pain between 2002 and 2018 was explained indirectly by increases in sleep difficulties and psychological symptoms. Data from 7,89,596 adolescents retrieved from 5 waves of the HBSC survey conducted in 2002, 2006, 2010, 2014, and 2018 in 32 countries/regions were used. Logistic regressions and path analyses were conducted. Results showed an overall increase of .5% in the prevalence of chronic back pain between 2014 and 2018, ranging from .4% for 15-year-old girls to 1.3% for 11-year-old boys, indicating a continued overall increase in chronic back pain in adolescents beyond 2014. For 13-year-old girls and for 15-year-old girls and boys, the increase in the prevalence of chronic back pain between 2002 and 2018 was partially mediated by increases in sleep difficulties, which in turn were associated with increases in psychological symptoms. The findings provide important information that may aid stakeholders in enhancing public health initiatives to prevent or reduce the increasing trend in the prevalence of chronic back pain in adolescents. PERSPECTIVE: This study shows that chronic back pain prevalence continues to increase among adolescents, with sleep difficulties and psychological symptoms contributing significantly to this trend. The findings provide insights that may inform strategies to prevent or reduce the increasing trend of chronic back pain in adolescents.

Pain in your day? Get sleep treatment anyway! The role of pain in insomnia treatment efficacy in women veterans

Insomnia and pain disorders are among the most common conditions affecting United States adults and veterans, and their comorbidity can cause detrimental effects to quality of life among other factors. Cognitive behavioural therapy for insomnia and related behavioural therapies are recommended treatments for insomnia, but chronic pain may hinder treatment benefit. Prior research has not addressed how pain impacts the effects of behavioural insomnia treatment in United States women veterans. Using data from a comparative effectiveness clinical trial of two insomnia behavioural treatments (both including sleep restriction, stimulus control, and sleep hygiene education), we examined the impact of pain severity and pain interference on sleep improvements from baseline to post-treatment and 3-month follow-up. We found no significant moderation effects of pain severity or interference in the relationship between treatment phase and sleep outcomes. Findings highlight opportunities for using behavioural sleep interventions in patients, particularly women veterans, with comorbid pain and insomnia, and highlight areas for future research.

Chronic disease clusters are associated with prolonged, bothersome, and multisite musculoskeletal pain: a population-based study on Northern Finns

BACKGROUND

Chronic diseases often accumulate with musculoskeletal (MSK) pain. However, less evidence is available on idiosyncratic patterns of chronic diseases and their relationships with the severity of MSK pain in general MSK pain populations.

MATERIAL AND METHODS

Questionnaire-based data on physician-diagnosed chronic diseases, MSK pain and its dimensions (frequency, intensity, bothersomeness, and the number of pain sites), and confounders were collected from the Northern Finland Birth Cohort 1966 at the age of 46. Latent Class Analysis (LCA) was used to identify chronic disease clusters among individuals who reported any MSK pain within the previous year (n = 6105). The associations between chronic disease clusters, pain dimensions, and severe MSK pain, which was defined as prolonged (over 30 d within the preceding year), bothersome (Numerical Rating Scale >5), and multisite (two or more pain sites) pain, were analyzed using logistic regression and general linear regression models, adjusted for sex and educational level (n for the full sample = 4768).

RESULTS

LCA resulted in three clusters: Metabolic (10.8% of the full sample), Psychiatric (2.9%), and Relatively Healthy (86.3%). Compared to the Relatively Healthy cluster, the Metabolic and Psychiatric clusters had higher odds for daily pain and higher mean pain intensity, bothersomeness, and the number of pain sites. Similarly, the odds for severe MSK pain were up to 75% (95% confidence interval: 44%-113%) and 155% (81%-259%) higher in the Metabolic and Psychiatric clusters, respectively, after adjustments for sex and educational level.

CONCLUSIONS

Distinct patterns of chronic disease accumulation can be identified in the general MSK pain population. It seems that mental and metabolic health are at interplay with severe MSK pain. These findings suggest a potential need to screen for psychiatric and metabolic entities of health when treating working-aged people with MSK pain.Key messagesThis large study on middle-aged people with musculoskeletal pain aimed to examine the idiosyncratic patterns of chronic diseases and their relationships with the severity of musculoskeletal pain. Latent class cluster analysis identified three chronic disease clusters: Psychiatric, Metabolic, and Relatively Healthy. People with accumulated mental (Psychiatric cluster) or metabolic diseases (Metabolic cluster) experienced more severe pain than people who were relatively healthy (Relatively Healthy cluster). These findings suggest a potential need to screen for psychiatric and metabolic entities of health when treating working-aged people with MSK pain.

Dexamethasone with aggressive warming facilitates pain reduction, reduced blood loss, and quicker recovery after total hip arthroplasty

This study aimed to evaluate the optimal frequency of dexamethasone (DEX) administration and the efficacy of DEX with aggressive warming in total hip arthroplasty (THA), which remains unclear. A total of 150 patients were treated with DEX (10 mg) once before and once or twice after surgery with or without intraoperative aggressive warming. On postoperative day 3, the dynamic visual analogue scale scores and C-reactive protein (CRP) and interleukin-6 (IL-6) levels in participants administered with DEX twice after surgery were significantly lower than those who did not receive the second dose. The range of motion (ROM), postoperative fatigue based on Identity-Consequence-Fatigue Scale, average temperature at different stages, intraoperative blood loss, and postoperative drainage volume in patients who were subjected to warming were significantly higher than those who were not. The degree of satisfaction was also higher in the patients who received both second dose and warming than those who received neither. No differences in complications were observed based on the treatments. An additional dose of DEX at 48 h post-surgery has short-term advantages in terms of analgesia, anti-inflammatory effects, and accelerated rehabilitation after THA. DEX combined with aggressive warming further optimises short-term ROM and fatigue and improves the degree of satisfaction.Clinical trial was registered in the International Clinical Trial Registry, and the date of registration is 2/12/2020 (ChiCTR2000040560).

Are physical therapy interventions effective in improving sleep in people with chronic pain? A systematic review and multivariate meta-analysis

Chronic pain exerts an enormous personal and economic burden, with sleep disturbances being one of the most reported problems by adults with chronic pain. The aim of this study was to analyse whether different physical therapy interventions could lead to improvements in sleep quality and pain intensity in individuals with chronic pain, as well as if there is any association. A systematic review and a univariate and multivariate meta-analysis were carried out according to the PRISMA guidelines. A search in PubMed, Scopus and Web of Science databases was performed. Six randomised controlled trials were included in the review and four of them were included in the meta-analysis; all of them with a moderate to high methodological quality. Data from adult participants with chronic pain after different physical therapy interventions was extracted. For the meta-analysis, the Insomnia Severity Index and the Numerical Rating Scale were considered. Results from the qualitative and quantitative analysis showed that most of the physical therapy interventions included had higher improvements in the intervention group than in the control group, although the effect size was not statistically significant (univariate for sleep quality: -0.08 [-0.34, 0.18], p = 0.46; univariate for pain intensity: -0.47 [-1.24, 0.30], p = 0.18; multivariate for both outcomes: -0.27). More studies are still needed to determine which physical therapy interventions are effective to improve sleep in people with chronic pain and if there are patients with specific characteristics who may benefit more than others.

Pain Assessment in Oral Medicine through Its Different Dimensions: A Comprehensive Review

Orofacial pain is a complex experience made up of different features and involving various aspects of life. It has demonstrated a connection, especially when chronic, with conditions such as anxiety, depression, and sleep disorders, through paths that still have not been completely clarified. A deep understanding of orofacial pain and its impact on an individual's life is critical for planning accurate diagnostic and therapeutic approaches. This review seeks to provide a comprehensive overview of the components constituting the pain experience, its implications in an individual's life, the different tools for multidimensional pain assessment, and the specific applications for each tool. A comprehensive review was performed using the PubMed, Scopus, and Web of Science electronic databases. Ninety-five studies, including observational studies, clinical trials, case-control studies, and case reports, were included and analyzed in this review. Orofacial pain assessment exploits several methods, ranging from clinical evaluation to rating scales, questionnaires, and daily diaries. The choice of the correct instrument requires an evaluation of the type of pain experienced, of the patient's characteristics and abilities to complete particular tasks, and finally, of the assessment tool features.

The Role of Physical Activity on the Relationships Between Pain, Anxiety, and Sleep Quality in Older Age

BACKGROUND

Sleep quality is associated with a range of negative outcomes in older adults, including a higher risk for cognitive decline, greater disability, and poorer quality of life. Pain and anxiety are both important factors associated with poor sleep quality. Physical activity (PA) is frequently recommended to enhance sleep quality and may have additional benefits for pain and anxiety symptoms. However, current models have not examined the interplay among these factors in relation to sleep quality in older adults.

METHODS

We examined survey data from a community sample of 281 older adults (aged 55-98 years). Bootstrapped mediation and moderated mediation models using the PROCESS macro in SPSS were used to analyze indirect pathways from pain and anxiety to sleep quality and the conditional effects of exercise.

RESULTS

Higher levels of pain and anxiety were significantly and independently associated with poorer sleep quality in older adults. The effect of pain on sleep quality was partially mediated by anxiety symptoms. PA significantly moderated the effects of anxiety on sleep quality, while it did not significantly impact the relationship between pain and sleep quality. The overall indirect effect was not moderated by PA.

CONCLUSION

Pain and anxiety are both significant predictors of sleep quality in older adults, and pain influences sleep quality in older adults partially through its influence on anxiety symptoms. PA may be beneficial for sleep quality for individuals with high anxiety, but patients may see fewer benefits from PA if sleep problems are primarily related to pain.

Lengthening sleep reduces pain in childhood arthritis: a crossover randomised controlled trial

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is a common chronic childhood disease and chronic pain is a debilitating feature. A strong link has been shown between poor sleep and pain in JIA. However, the causal direction is unknown. This study's aim was to determine if, in adolescents with JIA, a recommended healthful sleep duration leads to reductions in pain when compared with the restricted sleep (RS) duration that is commonly seen.

METHODS

Patients with JIA (12-18 years old; pain score of ≥1 on a visual analogue scale) participated in a randomised, crossover sleep manipulation protocol. The 3-week protocol comprised a baseline week (BL), a week with healthy sleep duration (HSD; 9.5 hours in bed/night) and a RS week (RS; 6.5 hours in bed/night). After BL, participants were randomly assigned to either HSD or RS, and then crossed over to the other condition. Pain was self-assessed using the iCanCope with Pain app. We used Bayesian hierarchical models to estimate the effect of sleep duration on pain.

RESULTS

Participants (n=31; mean age=15.0±1.8 years) averaged 1.4 (95% credible interval (CrI) 1.2-1.6) more hours of sleep per night during HSD relative to RS. Compared with RS, HSD resulted in a favourable effect on pain scores (OR 0.61, 95% CrI 0.39-0.95).

CONCLUSION

It is possible to have adolescents with childhood arthritis get a healthier sleep duration, and this longer sleep results in reduced pain. These findings complement prior correlational studies and confirm a causal relationship between reduced sleep duration and increased pain.

TRIAL REGISTRATION NUMBER

NCT04133662.

Sleep disturbances are associated with pain intensity and pain-related functional interference in patients experiencing orofacial pain

BACKGROUND

Sleep and pain have a reciprocal relationship, interacting with psychosocial aspects including depression, anxiety, somatization and significant stressful events.

OBJECTIVE

The aim of this study was to assess patients with oro-facial pain (OFP) and related sleep disturbances and determine the strongest psychosocial correlates.

METHODS

A cross-sectional study of anonymized data of consecutive patients with OFP {January 2019 and February 2020} were analysed. Diagnostic and Axis-II data were integrated to assess the relationship between sleep disturbances, measured using Chronic Pain Sleep Inventory, and demographic factors, clinical comorbidities, recent stressful events, pain severity and pain- and psychological-related function.

RESULTS

Five out of six patients with OFP were presented with pain-related sleep disturbances. Sleep problems were enhanced in patients with primary oro-facial headache compared with other OFP conditions. However, once the level of pain intensity and interference was accounted for, primary headache, was not a significant correlate of pain-related sleep disturbances. Multivariate analysis revealed (average) pain severity and pain interference were both significantly associated with sleep problems. There were also significant independent associations of sleep problems with somatization levels and reported experience of recent stressful events.

CONCLUSION

Identifying sleep problems as a part of OFP management may be beneficial and could result in better management outcomes.

Catastrophizing and acceptance are mediators between insomnia and pain intensity-an SQRP study of more than 6,400 patients with non-malignant chronic pain conditions

Background

Sleep problems (insomnia) and chronic pain are associated. Chronic pain and insomnia/insufficient sleep quality share similar symptoms and features. Although they have a bidirectional relationship, more research is needed to understand how they interact via mediators and how moderators influence this relationship.

Aims

In this large clinical registry-based cohort study (N = 6,497), we investigate important mediators between insomnia and pain intensity in a cross-sectional sample of chronic pain patients using advanced path analysis. In addition, we investigate whether some background variables were moderators of the identified important paths or not and the correlation patterns between insomnia and pain intensity in relation to the mediators.

Methods

This study includes a cohort of adult patients with chronic non-cancer pain from the Swedish Quality Registry for Pain Rehabilitation (SQRP) with data on patient-reported outcome measures (PROMs) (2008-2016). The PROMs cover the background, pain aspects, psychological distress, pain-related cognitions, activity/participation, and health-related quality of life variables of the patients. Partial least squares structural equation modeling was used to explore the direct and indirect (via mediators) relationships between insomnia and pain intensity at baseline.

Results

In this cohort study, insomnia was prevalent at 62.3%, and both direct and indirect mediating paths were present for the insomnia-pain intensity relationship. All of the mediating effects combined were weaker than the direct effect between insomnia and pain intensity. The mediating effects via catastrophizing and acceptance showed the strongest and equal mediating paths, and mediating effects via fear avoidance were the second strongest. Insomnia showed stronger direct significant correlations with psychological distress, catastrophizing, and acceptance compared with those of pain intensity. Sex, age, education level, spatial extent of pain, or body mass index did not moderate the mediating paths.

Discussion and conclusion

This study confirms the existence of significant direct and mediating paths between reported insomnia and pain intensity. Future studies should focus on illuminating how sleep interventions influence pain intensity and other important key factors that contribute to the distress of chronic pain patients.

Efficacy of combined strategies of physical activity, diet and sleep disorders as treatment in patients with chronic shoulder pain. A systematic review

Introduction: The objective of this systematic review was to analyze the existing scientific evidence on the influence of dietary strategies, exercise, and sleep disorders on the symptomatology of patients with chronic shoulder pain, as well as to assess the methodological quality of the literature collected. Methods: The selection criteria were as follows: we included randomized controlled clinical trials written in English that investigated the effects of such interventions in patients with chronic shoulder pain and excluded studies where pre-operative rehabilitation or rehabilitation combined with corticosteroid injections was performed. We searched six databases Pubmed, Cochrane Library, Web of Science, CINAHL, Sportdiscus and Scopus, using the keywords "shoulder pain," "fasting," "physical therapy modalities," "rehabilitation," "exercise," "circadian clocks," and "chronic pain" to select randomized controlled clinical trials conducted in humans and written in English. The last search was conducted on 24/01/2023. (PROSPERO:CRD42023379925). Results: We used the tool proposed by the Cochrane Handbook to assess the risk of bias in the included studies of the 17 studies included, nine had a high risk of bias, two studies had an unclear risk of bias, and the remaining six studies had a low risk of bias. A total of 17 articles were selected, including 10 studies that showed a positive influences of exercise on chronic shoulder pain and five studies that showed a negative influence of sleep disorders on this patient profile. The remaining two articles analyzed the influence of nutritional strategies and metabolic problems in patients with chronic shoulder pain. The total sample size of the 17 included articles amounted to 9,991 individuals. Discussion: Studies confirm that exercise generates a hypoalgesic effect that improves chronic shoulder pain, functionality, and quality of life. Although dietary strategies and sleep disorders are known to influence chronic shoulder pain, there is a lack of studies that conduct interventions on these problems to assess how chronic shoulder pain varies.

The bidirectional association between chronic musculoskeletal pain and sleep-related problems: a systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis synthesizes the evidence on prospective bidirectional associations between sleep-related problems (SRP) and chronic musculoskeletal pain (CMP).

METHODS

A literature search for cohort studies available in the PubMed, Scopus, Web of Science, PsycINFO and Cochrane Library databases as of 19 July 2022 was performed. Pooled odds ratios and effect sizes were calculated through random effects meta-analysis. Subgroup and meta-regression analyses were performed to explore differences by follow-up time, proportion of each sex and mean age. The Meta-analysis Of Observational Studies in Epidemiology guidelines were strictly followed.

RESULTS

Twenty studies with a total of 208 190 adults (aged 34.4-71.7 years) were included, with 17 of them being used in the meta-analysis. Individuals with SRP at baseline had a 1.79-fold higher incidence (odds ratio [OR] = 1.79; 95% CI: 1.55, 2.08; I2 = 84.7%; P < 0.001) and a 2.04-fold higher persistence (OR = 2.04; 95% CI: 1.42, 2.94; I2 = 88.5%; P < 0.005) of CMP than those without SRP. In the subgroup analysis of the association between SRP and CMP, the longer the follow-up time of the studies, the higher the heterogeneity between them. In the corresponding meta-regression, no significant effect was observed for follow-up time, sex proportion or age. Individuals with CMP at baseline had a 2.02-fold higher incidence of SRP (OR = 2.02; 95% CI: 1.62, 2.53; I2 = 90.0%; P < 0.001) than those without CMP.

CONCLUSION

This study provides robust evidence concerning the longitudinal association between SRP and incidence-persistence of CMP in adults. In addition, the available prospective studies support the existence of a bidirectional relationship between CMP and SRP.

PROSPERO REGISTRATION NUMBER

CRD42020212360.

Brain-predicted age difference mediates the association between PROMIS sleep impairment, and self-reported pain measure in persons with knee pain

Knee pain, the most common cause of musculoskeletal pain (MSK), constitutes a severe public health burden. Its neurobiological causes, however, remain poorly understood. Among many possible causes, it has been proposed that sleep problems could lead to an increase in chronic pain symptomatology, which may be driven by central nervous system changes. In fact, we previously found that brain cortical thickness mediated the relationship between sleep qualities and pain severity in older adults with MSK. We also demonstrated a significant difference in a machine-learning-derived brain-aging biomarker between participants with low-and high-impact knee pain. Considering this, we examined whether brain aging was associated with self-reported sleep and pain measures, and whether brain aging mediated the relationship between sleep problems and knee pain. Exploratory Spearman and Pearson partial correlations, controlling for age, sex, race and study site, showed a significant association of brain aging with sleep related impairment and self-reported pain measures. Moreover, mediation analysis showed that brain aging significantly mediated the effect of sleep related impairment on clinical pain and physical symptoms. Our findings extend our prior work demonstrating advanced brain aging among individuals with chronic pain and the mediating role of brain-aging on the association between sleep and pain severity. Future longitudinal studies are needed to further understand whether the brain can be a therapeutic target to reverse the possible effect of sleep problems on chronic pain.

Hospitalized Patients' Sleep Quality Compared Between Multioccupancy Rooms and Single-Patient Rooms

OBJECTIVES

To evaluate patients' sleep quality in a former hospital with two-and four-bedded rooms compared to a new hospital that incorporated evidence-based design features, including exclusively single-patient rooms (SPRs).

BACKGROUND

Hospitalized patients often report poor sleep quality due to both patient-related factors and hospital environmental factors. It is unclear if staying in an SPR in a hospital designed as a healing environment is associated with better sleep quality.

METHODS

In a before-after study, sleep quality, duration, and efficiency over 72 hr were measured with a sleep diary, GENEActiv accelerometer, and the Richards-Campbell Sleep Questionnaire (RCSQ) with scores ranging from 0 to 100, with higher scores reflecting better sleep. Participants were either staying alone in the former hospital with two-and four-bedded rooms (Group 1), sharing a room with one to three fellow patients (Group 2), or staying alone in a newly designed hospital with 100% SPRs (Group 3).

RESULTS

We included 17 patients in Group 1, 32 patients in Group 2, and 56 patients in Group 3. Univariable linear mixed model analysis, controlling for night number, revealed that the RCSQ total score was lowest in Group 2 compared to the other two groups. In the multivariable analysis, the RCSQ score was also the lowest in Group 2, with a significant effect from covariate "use of night medication."

CONCLUSION

Self-reported sleep quality of hospitalized patients in a hospital with 100% SPRs designed as a healing environment was slightly better than that of patients staying in multioccupancy rooms with fellow patients.

Efficacy and Safety of Preoperative Melatonin for Women Undergoing Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

Background: Cesarean section (CS) has been linked to a number of negative effects, such as pain, anxiety, and sleeping problems. The aim of this systematic review and meta-analysis was to investigate the safety and efficacy of preoperative melatonin on postoperative outcomes in pregnant women who were scheduled for elective CS. Methods: We systemically searched 4 electronic databases (PubMed, Scopus, Web of Science, and Cochrane Library) from inception until 10 March 2023. We included randomized controlled trials (RCTs) comparing melatonin and placebo for postoperative outcomes in CS patients. For risk of bias assessment, we used the Cochrane Risk of Bias 2 tool. Continuous variables were pooled as mean difference (MD), and categorical variables were pooled as a risk ratio (RR) with a 95% confidence interval (CI). Results: We included 7 studies with a total of 754 pregnant women scheduled for CS. The melatonin group had a lower pain score (MD = -1.23, 95% CI [-1.94, -0.51], p < 0.001) and longer time to first analgesic request (MD = 60.41 min, 95% CI [45.47, 75.36], p < 0.001) than the placebo group. No difference was found regarding hemoglobin levels, heart rate, mean arterial pressure, total blood loss, or adverse events. Conclusions: Preoperative melatonin may reduce postoperative pain in CS patients without side effects. This research offers a safe and affordable pain management method for this population, which has clinical consequences. Further research is needed to validate these findings and determine the best melatonin dosage and timing.

The interplay between symptoms of insomnia and pain in people with osteoarthritis: A narrative review of the current evidence

Osteoarthritis (OA) is a leading cause of disability worldwide and clinical pain is the major symptom of OA. This clinical OA-related pain is firmly associated with symptoms of insomnia, which are reported in up to 81% of people with OA. Since understanding the association between both symptoms is critical for their appropriate management, this narrative review synthesizes the existing evidence in people with OA on i) the mechanisms underlying the association between insomnia symptoms and clinical OA-related pain, and ii) the effectiveness of conservative non-pharmacological treatments on insomnia symptoms and clinical OA-related pain. The evidence available identifies depressive symptoms, pain catastrophizing and pain self-efficacy as mechanisms partially explaining the cross-sectional association between insomnia symptoms and pain in people with OA. Furthermore, in comparison to treatments without a specific insomnia intervention, the ones including an insomnia intervention appear more effective for improving insomnia symptoms, but not for reducing clinical OA-related pain. However, at a within-person level, treatment-related positive effects on insomnia symptoms are associated with a long-term pain reduction. Future longitudinal prospective studies offering fundamental insights into neurobiological and psychosocial mechanisms explaining the association between insomnia symptoms and clinical OA-related pain will enable the development of effective treatments targeting both symptoms.

Sleep quality and polysomnographic changes in patients with chronic pain with and without central sensitization signs

BACKGROUND

Insufficient sleep is common nowadays and it can be associated with chronic pain.

OBJECTIVE

To describe the main polysomnographic findings in patients with chronic musculoskeletal pain and to estimate the association between sleep quality, polysomnography variables and chronic musculoskeletal pain.

METHODS

This cross-sectional research analyzed a database from polysomnography type 1 exams results and then collected data via an electronic form from these patients. The form collected sociodemographic data and presented clinical questionnaires for measuring sleep quality, sleepiness, pain intensity and central sensitization signs. Pearson's correlation coefficient and odds ratio were used to estimate the associations.

RESULTS

The mean age of the respondents was 55.1 (SD 13.4) years. The mean score of the Central Sensitization Inventory showed signs of central sensitization (50.1; SD 13.4) in the participants. Most patients (86%) had 1 or more nocturnal awakenings, 90% had one or more episodes of sleep apnea, 47% had Rapid Eye Movement sleep phase latency greater than 70-120 min and the mean sleep efficiency among all participants was 81.6%. The Pittsburgh Sleep Quality Index score was correlated with the CSI score (r = 0.55; 95% CI: 0.45, 0.61). People with central sensitization signs have 2.6 times more chance to present sleep episodes of blood oxygen saturation below 90% (OR = 2.62; 95% CI:1.23, 6.47).

CONCLUSION

Most people with central sensitization signs had poor sleep quality, night waking episodes and specific disturbances in sleep phases. The findings showed association between central sensitization, sleep quality, nocturnal awakening, and changes in blood oxygen saturation during sleep.

Sleep quality as a mediator of the relation between depression and chronic pain: a systematic review and meta-analysis

BACKGROUND

Chronic pain and depression represent two global health problems with considerable economic consequences. Although existing literature reports on the relation between depression and pain conditions, meta-analytic evidence backing the mediating role of sleep disturbance as one of the main symptoms of depression is scarce. To examine the extent to which sleep disturbance mediates the depression-chronic pain association, we conducted a systematic review and meta-analysis of the associations of chronic pain, depression, and sleep quality.

METHODS

We systematically searched for literature in MEDLINE and other relevant databases and identified cohort and case-control studies on depression, sleep disturbance, and chronic pain. Forty-nine studies were eligible, with a total population of 120 489 individuals. We obtained direct and indirect path coefficients via two-stage meta-analytic structural equation modelling, examined heterogeneity via subgroup analyses, and evaluated primary studies quality.

RESULTS

We found a significant, partial mediation effect of sleep disturbance on the relation between depression and chronic pain. The pooled path coefficient (coef.) of the indirect effect was 0.03 (95% confidence interval [CI]: 0.01-0.05) and accounted for 12.5% of the total effect of depression on chronic pain. This indirect effect also existed for cohort studies (coef. 0.02; 95% CI: 0.002-0.04), European studies (coef. 0.03; 95% CI: 0.004-0.05), and studies that adjusted for confounders (coef. 0.04; 95% CI: 0.01-0.09).

CONCLUSIONS

Sleep disturbance partially mediates the association between depression and pain. Although plausible mechanisms could explain this mediation effect, other explanations, including reverse causation, must be further explored.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022338201.

Investigation of pain sensitivity following 3 nights of disrupted sleep in healthy individuals

BACKGROUND

Poor quality sleep is a common complaint among people with chronic pain. The co-occurrence of poor sleep quality and chronic pain often comes with increased pain intensity, more disability and a higher cost of healthcare. Poor sleep has been suggested to affect measures of peripheral and central pain mechanisms. To date, sleep provocations are the only models proven to affect measures of central pain mechanisms in healthy subjects. However, there are limited studies investigating the effect of several nights of sleep disruption on measures of central pain mechanisms.

METHODS

The current study implemented three nights of sleep disruption with three planned awakenings per night in 30 healthy subjects sleeping at home. Pain testing was conducted at the same time of day at baseline and follow-up for each subject. Pressure pain thresholds were assessed bilaterally on the infraspinatus and gastrocnemius muscles. Using handheld pressure algometry, suprathreshold pressure pain sensitivity and area were also investigated on the dominant infraspinatus muscle. Cuff-pressure pain detection and tolerance thresholds, temporal summation of pain and conditioned pain modulation were investigated using cuff-pressure algometry.

RESULTS

Temporal summation of pain was significantly facilitated (p = 0.022), suprathreshold pain areas (p = 0.005) and intensities (p < 0.05) were significantly increased, and all pressure pain thresholds were decreased (p < 0.005) after sleep disruption compared to baseline.

CONCLUSIONS

The current study found that three consecutive nights of sleep disruption at home induced pressure hyperalgesia and increased measures of pain facilitation in healthy subjects, which is consistent with previous findings.

SIGNIFICANCE

Poor quality of sleep is often experienced by patients with chronic pain, with the most common complaint being nightly awakenings. This exploratory study is the first to investigate changes in measures of central and peripheral pain sensitivity in healthy subjects after sleep disruptions for three consecutive nights without any restrictions on total sleep time. The findings suggest that disruptions to sleep continuity in healthy individuals can induce increased sensitivity to measures of central and peripheral pain sensitization.

A nationwide study on pain manifestations and sleep problems in community-dwelling older adults: findings from ELSI-Brazil

PURPOSE

Sleep problems are common and affect approximately 36-70% of older adults worldwide and can be associated with negative outcomes such as pain. There is believed to be a bidirectional relationship between sleep problems and pain, modulated by inflammation and stress. The objective was to investigate the association between self-reported sleep problems and pain manifestations.

METHODS

A cross-sectional study using data from the second wave of the Brazilian Longitudinal Study of Aging (2019-2021) was conducted. The exposure variables were self-reported sleep problems: poor sleep quality, insomnia (initial, intermediate, and final), and daytime sleepiness. The outcomes were self-reported pain manifestations: frequent pain, moderate/intense/strong pain, and pain-related disability. Logistic regressions were performed to verify the association between exposures and outcomes.

RESULTS

A total of 6875 community-dwelling older adults participated in this study (71.1 ± 8.3 years; 54.4% female). Older adults with self-reported poor sleep quality, initial, intermediate and final insomnia, and daytime sleepiness had, respectively, 1.99 (95% CI 1.57-2.53), 1.47 (95% CI 1.11-1.97), 1.65 (95% CI 1.27-2.14), 1.69 (95% CI 1.29-2.22), and 1.76 (95% CI 1.35-2.29) greater odds of reporting frequent pain. The odds of moderate/intense/strong pain were higher in older adults that reported poor sleep quality (OR: 2.21; 95% CI 1.08-4.51). Older adults with self-reported poor sleep quality, initial, intermediate and final insomnia, and daytime sleepiness had, respectively, 1.84 (95% CI 1.11-3.02), 1.73 (95% CI 1.14-2.62), 1.80 (95% CI 1.19-2.73), 1.58 (95% CI 1.07-2.34), and 1.63 (95% CI 1.11-2.39) greater odds of reporting pain-related disability.

CONCLUSION

Self-reported sleep problems are associated with pain manifestations in older adults. The results may help in the proposition of programs and public health policies.

Transdermal buprenorphine improves overall quality of life and symptom severity in cancer patients with pain

AIM AND OBJECTIVES

This study explored the effect of transdermal buprenorphine on quality of life and six symptoms in cancer patients with pain.

BACKGROUND

Transdermal opioids offer advantages over traditional routes of administration. The impact of transdermal buprenorphine on quality of life for patients with cancer in Asian populations is unknown.

DESIGN

This study employed a single-arm observational repeated measures design. Cancer patients with pain were evaluated prior to treatment (baseline). Over a 4-week treatment period, quality of life and symptoms were assessed at 2 and 4 weeks. This study adhered to the recommendations of STROBE guidelines.

METHODS

This multi-site study was conducted in six hospitals located across northern, middle and southern Taiwan. Adult cancer patients whose pain was previously stable with opioid analgesics and, based on clinical judgement, were able to convert to transdermal buprenorphine treatment were invited to participate. Quality of life was measured with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30).

RESULTS

Generalised estimating equations showed participants who completed at least one follow-up measurement (N = 80) over 4-weeks had a significant improvement in overall quality of life. Functional status only improved for social functioning. However, symptom severity decreased significantly for nausea/vomiting, pain, insomnia and constipation.

CONCLUSIONS

The study provides initial evidence supporting transdermal buprenorphine for providing beneficial effects of improving quality of life and reducing severity of symptoms in Asian patients with cancer.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can inform the clinical practice that the use of transdermal buprenorphine in cancer patients with pain may also reduce the severity of other symptoms and improve overall quality of life.

TRIAL REGISTRATION DETAILS

This study was registered in ClinicalTrials.gov. Identifier: NCT04315831.

The complexities of the sleep-pain relationship in adolescents: A critical review

Chronic pain is a common and disabling condition in adolescents. Disturbed sleep is associated with many detrimental effects in adolescents with acute and chronic pain. While sleep and pain are known to share a reciprocal relationship, the sleep-pain relationship in adolescence warrants further contextualization within normally occurring maturation of several biopsychological processes. Since sleep and pain disorders begin to emerge in early adolescence and are often comorbid, there is a need for a comprehensive picture of their interrelation especially related to temporal relationships and mechanistic drivers. While existing reviews provide a solid foundation for the interaction between disturbed sleep and pain in youth, we will extend this review by highlighting current methodological challenges for both sleep and pain assessments, exploring the recent evidence for directionality in the sleep-pain relationship, reviewing potential mechanisms and factors underlying the relationship, and providing direction for future investigations. We will also highlight the potential role of digital technologies in advancing the understanding of the sleep and pain relationship. Ultimately, we anticipate this information will facilitate further research and inform the management of pain and poor sleep, which will ultimately improve the quality of life in adolescents and reduce the risk of pain persisting into adulthood.

A bidirectional study of the association between insomnia, high-sensitivity C-reactive protein, and comorbid low back pain and lower limb pain

OBJECTIVES

To examine the possible bidirectional association between insomnia and comorbid chronic low back pain (LBP) and lower limb pain and to explore whether high-sensitivity C-reactive protein (hsCRP) amplifies these associations.

METHODS

We calculated adjusted risk ratios (RR) with 95% confidence intervals (CI) for the development of insomnia and mild-to-severe chronic LBP and lower limb pain at 11 years follow-up in participants aged ≥32 years and with hsCRP ≤10 mg/L at baseline in 2007-2008: 3,714 without chronic LBP or lower limb pain (sample 1) and 7,892 without insomnia (sample 2).

RESULTS

Compared to participants without chronic pain, participants with comorbid chronic LBP and lower limb pain had a RR of insomnia of 1.37 (95% CI 1.12-1.66). Compared with participants without insomnia, participants with insomnia did not have an increased risk of comorbid chronic LBP and lower limb pain (RR: 1.06, 95% CI 0.76-1.46); however, participants with insomnia had a RR of chronic LBP of 1.20 (95% CI 1.02-1.42). There was no strong amplifying effect of elevated hsCRP (3.00-10.0 mg/L) on these associations.

CONCLUSIONS

These findings suggest that elevated hsCRP does not amplify the associations between insomnia and mild-to-severe chronic LBP and lower limb pain. Further research using data on the temporal relation between insomnia, chronic pain, and inflammatory responses are required to fully understand the causal pathways.

Predicting Intention to Participate in Community Physical Activities for Adults with Physical Disabilities

Structural equation modeling was used to derive a relationship predicting the intention to participate in community physical activity among community-dwelling adults with a physical disability in Xiamen, China. The data were collected in a cross-sectional survey. The structural equation modeling combined biomedicine and the theory of planned behavior. It integrated ratings using the rehabilitation set from the international classification of functioning, disability, and health and role-physical scores from the short form 36 health survey questionnaire instrument. The model demonstrated a good ability to predict self-reported participation intentions, explaining 62% of the variance. The standard coefficients showed that activity limitation (27%), role-physical score (21%) and body impairment (14%) were the most influential predictors. ICF-RS ratings and role-physical ratings together can usefully predict physically disabled adults' intention of participating in community physical activities. Suggestions are presented for multidisciplinary intervention and improving this portion of the WHO's classification system.

Application of dexamethasone combined with tranexamic acid in perioperative period of total hip arthroplasty

OBJECTIVE

To evaluate the efficacy and safety of dexamethasone (DEXA) combined with tranexamic acid (TXA) in the perioperative period of total hip arthroplasty.

MATERIALS AND METHODS

A total of 100 cases were randomly divided into 2 groups (50 cases per group). All patients were given 15 mg/kg TXA before skin incision and 3 hours later. Patients in the intervention group (TXA + DEXA group) were given 20 mg dexamethasone intravenously after the onset of anesthesia, and the same dose of DEXA was administered again 24 hours later. Patients in the placebo group (TXA group) were only given the same dose of normal saline. Postoperative c-reactive protein and interleukin-6, postoperative nausea and vomiting, fatigue visual analogue scale score, postoperative length of stay, range of motion, and consumption of analgesic and antiemetics were statistically analyzed in the 2 groups.

RESULTS

The levels of c-reactive protein and interleukin-6 in the TXA + DEXA group were lower than those in the TXA group at 24, 48, 72 hours post-operatively (P < .001). Walking pain scores in the TXA + DEXA group were also significantly lower than those in the TXA group at 24 and 48 hours (P < .001); rest pain scores were lower at 24 hours (P < .001). Compared with the TXA group, the incidence of nausea VAS, postoperative nausea and vomiting, fatigue, analgesia and antiemetics consumption, postoperative length of stay, and range of motion were lower in the TXA + DEXA group (all P < .05), while there were no significant differences in postoperative hematocrit, total blood loss, and complications (P > .05).

CONCLUSION

The combination of TXA (15 mg/kg; before skin incision and 3 hours later) and DEX (20 mg dexamethasone intravenously after the onset of anesthesia, and again 24 hours later) is an effective and safe strategy for patients undergoing total hip arthroplasty.

Microglial Responses and Pain Behaviors Are Exacerbated by Chronic Sleep Deprivation in Rats with Chronic Pain Via Neuroinflammatory Pathways

The inflammatory response of central nervous system (CNS) and microglial activation is important in the development of pain behaviors induced by sleep deprivation. We found that chronic sleep deprivation (CSD) aggravated pain behaviors in rats with chronic pain by upregulating expression of Toll-like receptor 4 (TLR4), NOD-like receptor pyrin domain containing 3 (NLRP3), and interleukin 1β (IL-1β), which promoted microglial activation in the brain. We also found that CSD increased numbers of Iba1⁺ and TLR4⁺ cells, as well as neuronal apoptosis. Inhibitors of TLR4 and NLRP3 (TAK-242 and MCC950, respectively) reduced expression levels of inflammatory factor proteins and M1-related factor mRNA, decreased microglial activation, and relieved the hyperalgesia caused by CSD. These results suggest that CSD aggravated pain behavior in rats with chronic pain through the TLR4/NLRP3/IL-1β signaling pathway, which mediates microglial activation and promotes CNS inflammation and neuronal apoptosis.

Independent and combined associations of depressive symptoms and sleep disturbance with chronic pain in community-dwelling older adults

Supplemental Digital Content is Available in the Text.

The combination of depressive symptoms and sleep disturbance was positively associated with chronic pain, but there were no additive interactions in community-dwelling older adults.

Introduction:

There is limited evidence regarding whether depressive symptoms and sleep disturbance are independently or synergistically associated with chronic pain.

Objectives:

We investigated the independent and combined associations of depressive symptoms and sleep disturbance with chronic pain and its severity (and the additive interactions) in community-dwelling older adults.

Methods:

This cross-sectional study analyzed the data of 1374 individuals who were 65 to 75 year old, not in need of long-term care, and completed questionnaires assessing sociodemographic factors, depressive symptoms, sleep disturbance, and chronic pain. The severity of chronic pain was assessed based on pain intensity, pain distribution, and pain type. The participants' status of depressive symptoms and sleep disturbance were categorized in the following 4 groups: neither condition, depressive symptoms alone, sleep disturbance alone, and both conditions.

Results:

Among the 1374 participants, 849 (61.8%) had chronic pain. The multivariable-adjusted odds ratios and 95% confidence intervals of the presence of chronic pain in those with depressive symptoms alone, sleep disturbance alone, and both conditions were 1.40 (0.97–2.03), 1.98 (1.41–2.78), and 2.12 (1.39–2.23), respectively, compared with the neither-condition group. Similar associations were observed for severe chronic pain. However, there were no significant additive interactions. In addition, only sleep disturbance was significantly associated with chronic pain, after adjusting for depressive symptoms.

Conclusions:

Our analyses did not reveal a synergistic effect of depressive symptoms and sleep disturbance on chronic pain and its severity, suggesting that most of the effects of depressive symptoms on chronic pain may be mediated by sleep disturbance.

Effect of percutaneous electrical nerve field stimulation on mechanosensitivity, sleep, and psychological comorbidities in adolescents with functional abdominal pain disorders

BACKGROUND

Percutaneous electrical nerve field stimulation (PENFS) improves symptoms in adolescents with functional abdominal pain disorders (FAPDs). However, little is known about its impact on sleep and psychological functioning. We evaluated the effects of PENFS on resting and evoked pain and nausea, sleep and psychological functioning, and long-term outcomes.

METHODS

Patient ages 11-19 years with FAPD requiring PENFS as standard care were recruited. Evoked pain was elicited by a Water Load Symptom Provocation Task (WL-SPT) before and after four weeks of treatment. Pain, gastrointestinal symptoms, sleep, somatic symptoms, and physical and psychological functioning were assessed. Actigraphy was used to measure daily sleep-wake patterns.

KEY RESULTS

Twenty patients (14.3 ± 2.2 years old) with FAPD were enrolled. Most patients were females (70%) and white (95%). During pain evoked by WL-SPT, visual analog scale (VAS) pain intensity and nausea were lower following PENFS compared with baseline (p = 0.004 and p = 0.02, respectively). After PENFS, resting VAS pain unpleasantness (p = 0.03), abdominal pain (p < 0.0001), pain catastrophizing (p = 0.0004), somatic complaints (0.01), functional disability (p = 0.04), and anxiety (p = 0.02) exhibited significant improvements, and some were sustained long-term. Self-reported sleep improved after PENFS (p's < 0.05) as well as actigraphy-derived sleep onset latency (p = 0.03).

CONCLUSIONS AND INFERENCES

We demonstrated improvements in resting and evoked pain and nausea, sleep, disability, pain catastrophizing, somatic complaints, and anxiety after four weeks of PENFS therapy. Some effects were sustained at 6-12 months post-treatment. This suggests that PENFS is a suitable alternative to pharmacologic therapy.

Comorbidity and familial aggregation of back/neck pain in the NIMH Family Study of Affective Spectrum Disorders

OBJECTIVE

Back pain is associated with substantial Global Burden of Disease and is highly comorbid with mood and anxiety symptoms and syndromes. However, mechanisms underlying this association have not been well-elucidated. Here we apply data from the NIMH Family Study of Affective Spectrum Disorders to investigate the comorbidity, familial aggregation, and cross-aggregation of back/neck pain with mood disorder subtypes.

METHODS

The sample includes 519 probands and 560 interviewed first-degree relatives. Lifetime DSM-IV Bipolar I, Bipolar II, and Major Depressive Disorder [MDD] were derived from semi-structured diagnostic interviews. Lifetime history of back or neck pain and its age of onset were self-reported retrospectively. Familial aggregation and cross-aggregation were estimated via mixed effects models in probands and interviewed first-degree relatives, while heritability and co-heritability (endophenotypic ranking value [ERV]) were estimated using full pedigrees.

RESULTS

Over 45% of participants endorsed a history of back/neck pain. Back/neck pain was familial (adjusted odds ratio [aOR] 1.5, p = 0.04; h2 = 0.24, p = 0.009). Back/neck pain in probands was associated with MDD in relatives (aOR 1.5, p = 0.04; ERV = 0.17, p = 0.024), but not with bipolar disorder. Onset of back/neck pain occurred earlier in those with bipolar disorder compared to controls.

CONCLUSION

Findings suggest common familial risk factors underlying back/neck pain with MDD, whereas there was within-individual comorbidity of bipolar with back/neck pain. Future studies that identify common factors that lead to either back/neck pain or MDD can inform prevention and interventions.

Mediators of socioeconomic inequalities in preterm birth: a systematic review

BACKGROUND

Rates of preterm birth are substantial with significant inequalities. Understanding the role of risk factors on the pathway from maternal socioeconomic status (SES) to preterm birth can help inform interventions and policy. This study therefore aimed to identify mediators of the relationship between maternal SES and preterm birth, assess the strength of evidence, and evaluate the quality of methods used to assess mediation.

METHODS

Using Scopus, Medline OVID, "Medline In Process & Other Non-Indexed Citation", PsycINFO, and Social Science Citation Index (via Web of Science), search terms combined variations on mediation, socioeconomic status, and preterm birth. Citation and advanced Google searches supplemented this. Inclusion criteria guided screening and selection of observational studies Jan-2000 to July-2020. The metric extracted was the proportion of socioeconomic inequality in preterm birth explained by each mediator (e.g. 'proportion eliminated'). Included studies were narratively synthesised.

RESULTS

Of 22 studies included, over one-half used cohort design. Most studies had potential measurement bias for mediators, and only two studies fully adjusted for key confounders. Eighteen studies found significant socioeconomic inequalities in preterm birth. Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions. There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth. Significant residual inequalities frequently remained. Difference-of-coefficients between models was the most common mediation analysis approach, only six studies assessed exposure-mediator interaction, and only two considered causal assumptions.

CONCLUSIONS

The substantial socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators that have been studied, particularly maternal smoking in pregnancy. There is, however, a large residual direct effect of SES evident in most studies. Despite the mediation analysis approaches used limiting our ability to make causal inference, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is probably necessary to address inequalities in preterm birth, alongside action on mediating pathways.

[Psychosomatics in Pain Therapy - Challenges of Chronic Pain]

Although there is growing awareness among physicians regarding chronic pain, the patient with chronic pain is often considered a complex, if not "difficult" patient in practice. Patients with chronic pain are thus at increased risk of being hastily dismissed and sent on their way. At the same time, therapeutic options are often limited and therapeutic successes not satisfying.

Subjective Sleep Complaints were Associated with Painful Temporomandibular Disorders in Adolescents: the Epidor-Adolescere Study

BACKGROUND

Sleep disturbances in adolescents has received a lot of attention in the literature and it is recognized as a serious health concern. The association between pain and sleep disturbances in adolescents has been extensively studied. However, to the best of our knowledge, there is a lack of studies investigating the association between various subjective sleep variables and painful TMD in adolescents.

OBJECTIVES

to investigate the association between painful TMD and subjective sleep variables in adolescents' non-clinical sample. We conducted a cross-sectional study. TMD was classified according to the RDC/TMD criteria. The Revised Face Scale evaluated TMD pain intensity, and pressure pain thresholds (PPTs) were assessed in trigeminal and extra-trigeminal areas. The subjective sleep variables were assessed according to the Sleep Disturbance Scale for Children and Sleep Behavior Questionnaire.

RESULTS

The final sample consisted of 690 adolescents (12.7±0.76 years), with 16.2% of them presenting painful TMD. Adolescents who frequently reported waking up more than twice per night and feeling tired when awake were more likely to present painful TMD symptoms [OR= 1.7 (95% CI: 1.04-2.90); p=0.034 and OR= 1.6 (95% CI: 1.01-2.48); p=0.046, respectively]. The intensity of TMD pain was negatively associated with sleep quality (p=0.015). Also, PPT values in the trigeminal and extra-trigeminal areas were negatively associated with total sleep time (p= 0.048 and p=0.042, respectively).

CONCLUSIONS

the present results point out the importance of considering sleep complaints associated with painful TMD in adolescents.

Occupational therapists’ perspectives on current practice in chronic pain and sleep disturbances

Background

Chronic pain and sleep disturbances are often co-morbid. Sleep disturbances can negatively affect self-care occupations, cognition, mood, emotional functioning and physical wellbeing.

Aim

To explore occupational therapists’ experience working with clients with chronic pain and sleep difficulties.

Method

Semi-structured interviews were conducted with 11 occupational therapists with experience working with clients with sleep disturbances and chronic pain.

Findings

The relationship between sleep disturbances and chronic pain was described as being complex and multifaceted. Participants believed they were uniquely placed to work with clients experiencing these two conditions. They felt inadequately equipped to treat sleep disturbances and chronic pain. Participants indicated that best practice required multiple interventions and a team-based approach. Finally, the participants noted that sleep disturbances and chronic pain are a growing area of practice.

Conclusion

The findings suggest that occupational therapists tailor their intervention strategies to be early, multi-pronged and individualised. Institutional barriers need to be addressed to further develop occupational therapists’ skill set when working in the areas of sleep and chronic pain. Further research to support the interventions currently used in practice to treat these two conditions is needed.

Pain Catastrophizing Mediates the Relationship Between Pain Intensity and Sleep Disturbances in U.S. Veterans With Chronic Pain

INTRODUCTION

Veterans with chronic pain frequently report comorbid disruptions in sleep and psychological dysfunction. The purpose of this study was to investigate whether psychological function variables mediate the sleep-pain relationship. Knowledge regarding such contributing factors can inform the development and optimization of treatments for sleep disturbances and pain.

MATERIALS AND METHODS

In an IRB-approved, registered clinical trial, we collected objective sleep data from U.S. military Veterans with chronic pain (N = 184, ages 23-81) using wrist actigraphy for 7 days and self-reported survey data assessing sleep quality, pain intensity, and psychological function (depression, anxiety, post-traumatic stress disorder, and pain catastrophizing). We investigated the associations between objectively measured and self-reported sleep quality and self-reported pain intensity. In addition, using parallel mediation analyses, we examined whether psychological function variables mediated these associations.

RESULTS

Actigraphy showed suboptimal sleep duration (less than 7 hours) and sleep fragmentation for most participants. Self-reported poor sleep quality and pain intensity were significantly correlated. Pain catastrophizing was found to mediate the association between self-reported sleep quality and pain intensity.

CONCLUSIONS

Sleep disturbances in this sample of Veterans with chronic pain included insufficient sleep, fragmented sleep, and perceived poor sleep quality. Analyses suggest that poor perceived sleep quality and pain intensity are mediated via pain catastrophizing. The finding highlights the potential importance of pain catastrophizing in Veterans with chronic pain. Future longitudinal research is needed to determine the extent to which treatments that reduce pain catastrophizing might also improve both sleep and pain outcomes.

Sleep phase and pre-sleep arousal predicted co-developmental trajectories of pain and insomnia within adolescence

The onset of both chronic pain and insomnia is high during adolescence. Although a bidirectional relationship between pain and insomnia has support, how pain and sleep co-develop throughout adolescence remains unknown. Sleep–wake patterns, pre-sleep behavior and pre-sleep arousal may influence the co-development of pain and insomnia. Four waves of longitudinal self-report data were used (N^baseline = 2767, Age^baseline M = 13.65 years, SD = 0.65). Multidimensional growth mixture modeling was used to identify four subgroups of adolescents with different concurrent trajectories of pain and insomnia. The trajectories followed each other across time in all classes: one class of consistently low pain and insomnia (68.7%), one class with persistent high symptoms (4.9%), as well as one class of increasing (13.9%), and one of decreasing (12.5%), trajectories. Later sleep–wake patterns and more pre-sleep cognitive-emotional arousal predicted both increasing and decreasing trajectories of concurrent pain and insomnia. The current study showed that developmental trajectories of pain and insomnia follow each other within adolescents and across adolescence. Both sleep-phase focused interventions as well as psychological interventions that focus on pre-sleep cognitive-emotional arousal may prove beneficial for adolescents with comorbid pain and insomnia.