Impaired sleep predicts onset of low back pain and burnout symptoms: evidence from a three-wave study

Correlation between anxiety, sleep disturbance and clinical outcomes in a lumbar decompression cohort

BACKGROUND

Patients with lumbar spinal pathology often suffer from anxiety and sleep disturbance, but correlations between anxiety and sleep disturbance and other patient-reported outcome measures (PROMs) before and after surgical intervention have not been explored. The purpose of this study is to analyze the correlations between patient-reported anxiety, sleep disturbance, and PROMs before and after lumbar decompression.

METHODS

All patients undergoing elective, primary, lumbar decompression were retrospectively queried from a prospectively-maintained single spine surgeon database. Demographic and perioperative data and pre- and postoperative PROMs were extracted. Patient-Reported Outcome Measure Information System (PROMIS)-Anxiety, PROMIS-Sleep Disturbance (SD), PROMIS-Physical Function (PF), 9-Item Patient Health Questionnaire (PHQ-9), Visual Analog Scale (VAS)-Back, VAS-Leg, Oswestry Disability Index (ODI) were obtained preoperatively and through two years postoperatively. Pearson's correlation coefficients were calculated between PROMIS-Anxiety, PROMIS-SD, and the other PROMs of interest.

RESULTS

PROMIS-Anxiety was positively correlated with PROMIS-SD (range: r = 0.473-0.828, p ≤ 0.006, all), PHQ-9 (range: r = 0.613--0.890, p ≤ 0.006, all), VAS-Back (range: r = -0.410-0.798, p ≤ 0.039, all), and ODI (range: r = 0.503-0.732, p ≤ 0.033, all) at all timepoints. PROMIS-Anxiety was negatively correlated with PROMIS-PF through 1 year postoperatively (range: r = -0.323- -0.729p ≤ 0.033, all). PROMIS-Anxiety was positively correlated to VAS-Leg at preoperative, 6-week, 12-week, and 2-year postoperative timepoints (range: r = 0.333--0.707, p ≤ 0.022, all). PROMIS-SD was positively correlated with PHQ-9 (range: r = 0.600-0.836), VASBack (range: r = 0.383-0.734), VAS-Leg (range: r = 0.399-0.811), and ODI (range: r = 0.404-0.812) at all timepoints (p ≤ 0.031, all). PROMIS-SD was negatively correlated with PROMIS-PF at all timepoints (range: r = -0.339-0.665, p ≤ 0.035, all).

CONCLUSION

Patient-reported anxiety and sleep disturbance are significantly correlated with depressive burden, back pain, disability, and physical function, before and after lumbar decompression. Future studies should aim to determine the directionality of the associations and test interventions to improve health-related quality of life following lumbar decompression.

Just-in-Time Adaptive Intervention for Stabilizing Sleep Hours of Japanese Workers: Microrandomized Trial

BACKGROUND

Sleep disturbance is a major contributor to future health and occupational issues. Mobile health can provide interventions that address adverse health behaviors for individuals in a vulnerable health state in real-world settings (just-in-time adaptive intervention).

OBJECTIVE

This study aims to identify a subpopulation with vulnerable sleep state in daily life (study 1) and, immediately afterward, to test whether providing mobile health intervention improved habitual sleep behaviors and psychological wellness in real-world settings by conducting a microrandomized trial (study 2).

METHODS

Japanese workers (n=182) were instructed to collect data on their habitual sleep behaviors and momentary symptoms (including depressive mood, anxiety, and subjective sleep quality) using digital devices in a real-world setting. In study 1, we calculated intraindividual mean and variability of sleep hours, midpoint of sleep, and sleep efficiency to characterize their habitual sleep behaviors. In study 2, we designed and conducted a sleep just-in-time adaptive intervention, which delivered objective push-type sleep feedback messages to improve their sleep hours for a subset of participants in study 1 (n=81). The feedback messages were generated based on their sleep data measured on previous nights and were randomly sent to participants with a 50% chance for each day (microrandomization).

RESULTS

In study 1, we applied hierarchical clustering to dichotomize the population into 2 clusters (group A and group B) and found that group B was characterized by unstable habitual sleep behaviors (large intraindividual variabilities). In addition, linear mixed-effect models showed that the interindividual variability of sleep hours was significantly associated with depressive mood (β=3.83; P=.004), anxiety (β=5.70; P=.03), and subjective sleep quality (β=-3.37; P=.03). In study 2, we found that providing sleep feedback prolonged subsequent sleep hours (increasing up to 40 min; P=.01), and this effect lasted for up to 7 days. Overall, the stability of sleep hours in study 2 was significantly improved among participants in group B compared with the participants in study 1 (P=.001).

CONCLUSIONS

This is the first study to demonstrate that providing sleep feedback can benefit the modification of habitual sleep behaviors in a microrandomized trial. The findings of this study encourage the use of digitalized health intervention that uses real-time health monitoring and personalized feedback.

Validity and reliability of the sleep health index among patients with spinal degenerative diseases

OBJECTIVE

To test the validity and reliability of the Sleep Health Index (SHI) in a Chinese clinical sample, and thereby provide more evidence for the assessment of sleep health in future research and clinical practice.

METHODS

This study used a cross-sectional design. A convenient sample of 265 participants with spinal degenerative diseases was recruited from outpatient clinics. The SHI, Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Patient Health Questionnaire-9 (PHQ-9), Visual Analogue Scale (VAS), and EuroQoL 5-Dimension 5-Level (EQ-5D-5L) were administered via REDCap. Structural, concurrent, convergent, known-group validity, internal consistency, and test-retest reliability were evaluated.

RESULTS

Confirmatory factor analysis confirmed a 3-factor structure (sleep duration, sleep quality, and disordered sleep). The overall SHI score had a high correlation with PSQI and ISI (r = -0.62 and -0.70, respectively) as well as a moderate correlation with PHQ-9 (r = -0.50, p<0.001). The overall SHI was significantly associated with VAS, ESS, and EQ-5D-5L (r = -0.15 to -0.23, p<0.05). Participants with pain had a lower score on the sleep quality sub-index than those without (p<0.001). Those with chronic diseases had a significantly lower score on the sleep duration sub-index than those without (p<0.05). Those with depression, poor sleep quality, and insomnia had lower scores on the overall scale and the three sub-indices than those without (p<0.05). The overall SHI showed acceptable internal consistency (Cronbach's α = 0.74) and test-retest reliability (intraclass correlation coefficient = 0.73).

CONCLUSIONS

The Chinese version of SHI showed good validity and acceptable reliability and could be used to assess sleep health among clinical populations.

Sleep Quality as a Mediator of Burnout, Stress and Multisite Musculoskeletal Pain in Healthcare Workers: A Longitudinal Study

This study aimed to verify whether sleep quality is a mediator of the relationship between burnout, stress and multisite pain in healthcare workers in a longitudinal study with 12 months of follow-up during the COVID-19 pandemic. Online questionnaires were used for data collection. The sociodemographic questionnaire contained personal and occupational data. The short version of the Copenhagen Psychosocial Questionnaire (COPSOQ II-Br) was used to assess burnout and stress. The Pittsburgh Sleep Quality Index (PSQI-Br) assessed sleep quality over one month. The Nordic Musculoskeletal Questionnaire (NMQ) aimed to identify the presence of multisite musculoskeletal pain in the last 12 months and the last 7 days. Mediation analysis was used to verify whether the effect of the predictor variables (burnout and stress) on the dependent variable (number of pain sites in the last 12 months and 7 days) was due to an intervening variable (sleep quality). Stress and burnout were associated with multisite pain in healthcare workers in the last 12 months and the last 7 days. Sleep quality was a significant mediator of this association in the last 12 months, indicating that some of the association between burnout, stress and multisite pain can be explained by poor sleep quality. Thus, a comprehensive approach to long-term multisite pain should consider psychosocial aspects such as burnout, stress and sleep quality.

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.

Subjective and Objective Consequences of Stress in Subjects with Subjectively Different Sleep Quality-A Cross-Sectional Study

BACKGROUND

Restful sleep plays an important role in long-term health and occupational safety. Heart rate variability (HRV) is used as stress indicator. The aim of this study was to determine whether HRV at rest or during sleep, as an objective indicator of stress, reflects subjectively assessed sleep quality.

METHODS

84 subjects (37.3 ± 15.6 years) were classified into good sleepers and poor sleepers based on the results of the Pittsburgh Sleep Quality Index (PSQI). The cut-off value to distinguish between good and bad sleepers recommended by Buysse et al. 1989 is >5. Mental health status was determined using the 12-Item General Health Questionnaire (GHQ-12). A 24 h electrocardiogram (ECG) was recorded for HRV analysis (total and 6 h night phase).

RESULTS

The poor sleepers showed a significantly lower mental health status (p = 0.004). The multifactorial variance analysis of the total phase time parameters Min HR (p = 0.032, η² = 0.056) and SI (p = 0.015, η² = 0.072) showed significant interaction effects. In the 6h night phase, significant interaction effects were found for SDNN (p = 0.036, η² = 0.065) and SD2 (p = 0.033, η² = 0.067). In addition, there was a significant negative correlation between HRV and stress and a positive correlation between HRV and mental health.

CONCLUSIONS

Although this study did not demonstrate a direct relationship between sleep quality and HRV, it was shown that there are important connections between sleep quality and mental health, and between HRV and mental health.

The effect of long-term poor sleep quality on risk of back-related disability and the modifying role of physical activity

Sleep problems and regular leisure time physical activity (LTPA) are interrelated and have contrasting effects on risk of back pain. However, no studies have investigated the influence of long-term poor sleep quality on risk of back-related disability, or if LTPA modifies this association. The study comprised data on 8601 people who participated in three consecutive surveys over ~ 22 years, and who reported no chronic back pain at the two first surveys. Adjusted risk ratios (RRs) for back-related disability were calculated at the last survey, associated with the joint effect of changes in sleep quality between the two first surveys and meeting physical activity guidelines at the second survey. Compared to people with long-term good sleep, people with long-term poor sleep had nearly twice the risk of back-related disability (RR 1.92, 95% CI 1.48-2.49). There was no statistical interaction between sleep and LTPA but people who reported long-term poor sleep and meeting the physical activity guidelines had 35% lower risk of back-related disability compared to people with same level of sleep problems, but who not met the guidelines. These findings suggest that long-term poor sleep quality contributes to a substantially increased risk of chronic and disabling back pain irrespective of LTPA.

Evaluation of Absenteeism, Pain, and Disability in Nurses With Persistent Low Back Pain Following Cognitive Functional Therapy: A Case Series Pilot Study With 3-Year Follow-Up

OBJECTIVE

Persistent low back pain (PLBP) is a common and costly health problem worldwide. Better strategies to manage it are required. The purpose of this study was to longitudinally evaluate absenteeism, pain, and disability in nurses with PLBP following a cognitive functional therapy (CFT) intervention.

METHODS

In this case series pilot study, 33 eligible nurses with PLBP were recruited. During the baseline phase (phase A; no intervention), outcome measures were collected on 2 occasions 6 months apart (A1 and A2). During phase B, participants received an individualized CFT intervention for 14 weeks. During phase C (no intervention), outcomes were measured immediately after the intervention, as well as 3, 6, 9, 12, and 36 months after the intervention (secondary outcomes only until 12 months). LBP-related work absenteeism, pain intensity (numerical pain rating scale) and disability (Oswestry Disability Index) were the primary outcomes. Health care seeking, a range of psychological and lifestyle variables, and global perceived effect were secondary outcomes.

RESULTS

Days of absenteeism due to LBP were significantly reduced in the first and second calendar years after the CFT intervention but not the third and fourth. Disability was significantly reduced immediately after (-4.4; 95% CI = -6.5 to -2.2) and at 3 months (-4.3; 95% CI = -6.6 to -2.0), 9 months (-6.0; 95% CI = -8.1 to -3.9), and 12 months (-4.9; 95% CI = -7.0 to -2.8) after the intervention. Pain was significantly reduced immediately after (-1.2; 95% CI = -1.7 to -0.8) and at 3 months (-1.5; 95% CI = -2.0 to -0.9), 9 months (-1.1; 95% CI = -1.9 to -0.3), and 12 months (-0.9; 95% CI = -1.5 to -0.2) after the intervention. Total health care seeking (consults and proportion of participants) was significantly reduced after the intervention. All psychosocial variables, except for 1, demonstrated significant improvements at all follow-up assessments.

CONCLUSIONS

This case series pilot study demonstrated significant reductions in LBP-related absenteeism, pain intensity, disability, health care seeking, and several psychological and lifestyle behaviors until the 1-year follow-up among nurses with PLBP following an individualized CFT intervention. Further evaluation of the efficacy of CFT in high-quality randomized clinical trials among nurses is recommended.

Vacation's lingering benefits, but only for those with low stress jobs

BACKGROUND

Vacationing provides potential recovery from work stress and is associated with cardiovascular disease morbidity and mortality. This study considered psychological variables that might change as a vacation is approaching (fade-in) or after a vacation ends (fade-out) and how these associations might vary as a function of ongoing work stress. Methods: Sixty workers eligible for paid time off were recruited from the community. Multiple assessments occurred during an 8- to 10-week period spanning the period before and after a vacation. A piecewise random coefficient model compared changes over time (slopes) for pre- and post-vacation periods. Outcomes included affect, aggression, social support, and work stress. Results: Hostile affect, negative affect, stress, and physical aggression all declined significantly during the post-vacation period (relative to no change during the pre-vacation period). In addition, these changes in pre- versus post-vacation periods differed as a function of work stress, with some vacation benefits observed specifically among workers with low work stress. Conclusions: Findings indicate that vacations produced psychological benefits that persist beyond the vacation period. Vacation-associated benefits may serve as mechanisms underlying associations between vacations and slow developing disease. However, work stress appears to spillover and can thereby undermine a vacation's fade-in and fade-out benefits.

Self-assessment of medical students and young physicians in training : Self-confidence of clinical competencies and working or learning environment

BACKGROUND

In 2015 medical training regulations have been restructured for postgraduate medical training in Austria resulting in a significant shortening of the training period. Furthermore, a restriction of working hours for physicians to 48 h per week was implemented affecting the framework of postgraduate medical training. The aim of this study was to obtain a self-assessment of students and young physicians in Austria regarding their self-confidence in clinical skills and their working and learning environment.

METHODS

In this study 6th year medical students, physicians in their basic training (common trunk), physicians in family medicine training, and residents in their first 18 months of training were asked to participate in a survey. Self-reported data were collected for five different prespecified domains (communication, motor skills, knowledge, documentation, and emergency).

RESULTS

In all domains, self-confidence increased significantly during medical training. Analysis further revealed better results of residents compared with all other groups in all domains, whereas physicians in family medicine training only rated themselves better in the documentation domain (p = 0.010); however, the interest in family medicine was low, even among physicians in family medicine training. The workload significantly increased during medical education, with the highest stress levels for physicians in family medicine training and residents (p = 0.001).

CONCLUSIONS

Self-confidence of young physicians but also their stress levels increased during the medical training. Further studies are needed to answer the question why the interest in family medicine was so unexpectedly low in this cohort.

Emotional exhaustion and sleep-related worry as serial mediators between sleep disturbance and depressive symptoms in student nurses: A longitudinal analysis

OBJECTIVE

The multi-wave longitudinal study was to explore the underlying mechanisms between sleep disturbance and depressive symptoms for up to 9.5 months among student nurses and to examine whether emotional exhaustion and sleep-related worry could be the mediators.

METHODS

856 student nurses aged 15-24 years (mean age = 17.8 years; all female) were recruited from a nursing school. Participants reported demographic variables (age, sibling, location, health condition, family monthly income and parents' marital quality) at baseline (Time1), Body Mass Index, weekly exercise, sleep disturbance and depressive symptoms at 3-month into internship (Time2), emotional exhaustion and sleep-related worry at 6-month into internship (Time3), and depressive symptoms at 9.5-month follow-up (Time4). Mediation analyses with bootstrapping were conducted to investigate the mediating role of emotional exhaustion and sleep-related worry in the relationship between sleep disturbance and depressive symptoms.

RESULTS

Adjusted analyses suggested that the direct effect of sleep disturbance on depressive symptoms was not significant (β = 0.026, SE = 0.069, p = .71). Mediation analyses revealed two significant indirect effects between Time2 sleep disturbance and Time4 depressive symptoms with the mediating effect of emotional exhaustion (β = 0.019, SE = 0.009, BC95%CI [0.0036,0.0405]) and sleep-related worry (β = 0.016, SE = 0.008, BC95%CI [0.0026,0.0337]) respectively. When testing serial multiple mediation, the specific indirect effect of sleep disturbance on depressive symptoms through both emotional exhaustion and sleep-related worry was significant (β = 0.005, SE = 0.003, BC95%CI [0.0004,0.0123]).

CONCLUSIONS

Emotional exhaustion and sleep-related worry were positively associated with sleep disturbance and depressive symptoms.

SOS-Appreciation overboard! Illegitimacy and psychologists' job satisfaction

In the globalized and rapidly evolving work environment, deficiencies in job design are a common reason that employees must sometimes complete tasks that are not directly connected to their occupational role. Individuals with a clear vision of their occupational role and duties in particular, such as psychologists, might consider such tasks as an offense to self. According to the "Stress-as-Offense-to-Self" (SOS) concept, so-called "illegitimate tasks" do not respect a person's occupational identity-threatening the self through disrespect. We investigated perceived appreciation as an underlying mechanism mediating between illegitimate tasks and reduced job satisfaction after one year through three studies conducted in two European countries. Using data from 50 psychologists who graduated from a German university, Study 1 revealed that perceived appreciation explained the relationship between illegitimate tasks and job satisfaction after one year. Studies 2 and 3 confirmed this finding using data from 67 and 183 Swiss employees working in fields of psychology. In particular, illegitimate tasks affected the perception of appreciation immediately and in the long term, which in turn affected the psychologists' job satisfaction (contagion model). Our results illustrate the importance of perceived appreciation as a mechanism that mediates between illegitimate tasks and job satisfaction of psychologists.

The Global Problem of Insufficient Sleep and Its Serious Public Health Implications

Good sleep is necessary for good physical and mental health and a good quality of life. Insufficient sleep is a pervasive and prominent problem in the modern 24-h society. A considerable body of evidence suggests that insufficient sleep causes hosts of adverse medical and mental dysfunctions. An extensive literature search was done in all the major databases for “insufficient sleep” and “public health implications” in this review. Globally, insufficient sleep is prevalent across various age groups, considered to be a public health epidemic that is often unrecognized, under-reported, and that has rather high economic costs. This paper addresses a brief overview on insufficient sleep, causes, and consequences, and how it adds to the existing burden of diseases. Insufficient sleep leads to the derailment of body systems, leading to increased incidences of cardiovascular morbidity, increased chances of diabetes mellitus, obesity, derailment of cognitive functions, vehicular accidents, and increased accidents at workplaces. The increased usage of smart phones and electronic devices is worsening the epidemic. Adolescents with insufficient sleep are likely to be overweight and may suffer from depressive symptoms. The paper concludes by emphasizing sleep quality assessments as an important early risk indicator, thereby reducing the incidence of a wide spectrum of morbidities.