Does Disordered Sleep Moderate the Relationship Between Pain, Disability and Downstream Health Care Utilization in Patients With Low Back Pain?: A Longitudinal Cohort From the US Military Health System

A Functional Restoration Program for Active Duty Service Members With Chronic Pain: Examining the Impact of Co-occurring PTSD on Treatment Response

INTRODUCTION

Standard medical intervention for chronic pain may be less effective in the presence of co-occurring PTSD. Functional restoration programs (FRPs), which combine psychological interventions and progressive exercise rehabilitation, represent an alternative to standard medical intervention for chronic pain. The objective of the current study is to evaluate a FRP serving Active Duty Service Members with chronic pain and to examine whether co-occurring PTSD symptoms are associated with differential treatment response.

METHODS

This is a retrospective observational study of data previously collected at Naval Medical Center San Diego approved by the Naval Medical Center San Diego Institutional Review Board. The study included 81 Active Duty Service Members, primarily Sailors and Marines, who completed a FRP, and examined pre- to post-treatment changes in Pain Impact Score-a composite measure of pain intensity, pain interference, and physical functioning-as well as measures of mental health and pain cognitions. Co-occurring PTSD symptoms were examined as a potential moderator of treatment response.

RESULTS

Twenty-three patients (28.4%) screened positive for PTSD during baseline assessments. Repeated measures analysis of variance showed statistically significant improvement in Pain Impact Score for the full sample (P <.001). Although no significant interactions with probable PTSD were demonstrated for measures of pain intensity and physical functioning (both Ps >.05), patients screening positive for PTSD demonstrated a lesser decrease in pain interference compared to patients screening negative for PTSD (P <.01). Improvements in measures of mental health and pain cognitions were also statistically significant for the full sample (all P values <.05) and did not differ as a function of PTSD symptoms (all P values >.05).

CONCLUSION

This FRP primarily serving Sailors and Marines contributed to broad overall improvements in the domains of pain and functioning as well as mental health and pain cognitions. Co-occurring PTSD symptoms were not associated with poorer treatment response on most measured outcomes.

Preferences and Avoidance of Sleeping Positions Among Patients With Chronic Low Back Pain: A Cross-Sectional Study

Background Chronic low back pain (CLBP) is a common issue among the working-age population. Sleeping position may affect CLBP, with the prone position commonly suggested to be avoided. This study aims to examine the relationship between preferred and avoided sleeping positions and to explore the frequency of increased pain in various sleeping positions among patients with nonspecific CLBP and pain and disability levels. Methods This cross-sectional study included all adult patients referred for specialist consultation for CLBP at the outpatient clinic of the Central Hospital of Central Finland's spine department. Pain intensity was measured using a visual analog scale (VAS), and disability was assessed with the Oswestry Disability Index (ODI). Patients completed a questionnaire detailing the main sleeping positions and positions avoided due to low back pain (LBP). Results The study enrolled 375 consecutive patients, with a mean age of 51 ± 17 years; 64% (n=240) were female. The mean VAS score was 63 ± 24, and the mean Oswestry Index was 38 ± 18%. The majority of patients (87%, n=327) reported sleeping in a side-lying position, followed by supine (47%, n=176) and prone (22%, n=82) positions. A negative correlation was found between age and the preference for sleeping in the prone position. No significant gender differences in sleep positions were observed (p=0.69). Sleep was disturbed in 77% of patients (n=289) due to LBP, and 87% (n=327) reported difficulties due to LBP when getting up. Overall, 92% of participants (n=345) experienced difficulties sleeping or getting up in the morning due to LBP. Many patients avoided certain positions due to pain: 42% (n=157) avoided the prone position, 35% (n=131) the back, 15% (n=56) the left side, and 13% (n=49) the right side. Although the prone position was most commonly linked with pain, especially among women, our findings suggest that any sleeping position could potentially exacerbate pain in individuals with CLBP. Conclusions This study highlights the variability in how sleeping positions affect pain in patients with nonspecific CLBP. While the prone position is most frequently associated with increased pain, individual preferences and responses vary significantly, and often sidelying and supine positions provoke pain. The diversity in sleeping positions that exacerbate pain highlights the need for tailored advice in the management of patients with CLBP.

Mental Health Predictors of Response to Standard Medical Intervention at a Military Pain Specialty Clinic

INTRODUCTION

Chronic pain among active duty service members can negatively impact operational readiness and contributes to significant health care costs within military treatment facilities. Response to standard medical intervention (SMI) for chronic pain is highly variable. The objective of the current study was to examine whether mental health indicators predict individual variation in response to SMI for chronic pain in a military pain specialty clinic.

METHODS

This is a retrospective observational study of data previously collected at the Pain Medicine Center at Naval Medical Center San Diego (NMCSD) approved by the NMCSD Institutional Review Board. We included 286 ADSMs who completed the Pain Assessment Screening Tool and Outcomes Registry (PASTOR) at two assessment points (mean = 118.45 days apart, SD = 37.22) as part of standard care. Hierarchical linear regression analyses were conducted to examine whether pretreatment mental health measures predict changes in the pain impact score (PIS)-a composite measure of pain intensity, pain interference, and physical functioning-over the course of treatment.

RESULTS

After controlling for pretreatment PIS, pretreatment PTSD symptoms, fatigue, and anger were all significant predictors of posttreatment PIS: Higher PTSD symptoms, higher fatigue, and lower anger predicted poorer response to treatment (all Ps < .05).

CONCLUSION

Higher pretreatment PTSD and fatigue symptoms may portend poorer response to SMI for chronic pain. Poor response to treatment may also be predicted by lower pretreatment anger. Further investigation is warranted to identify the best strategies for treating chronic pain in military treatment facilities when these conditions are identified during initial evaluation.

Does poor sleep quality lead to increased low back pain the following day?

OBJECTIVES

This study explored the relationship between sleep quality and next-day pain intensity for people with low back pain and investigated whether there was any evidence that this relationship was causal.

METHODS

We conducted a secondary analysis of an observational study that investigated sleep quality in people with low back pain. People with low back pain were recruited from primary care and the community. Sleep quality was measured with subjective (self-report) and objective (polysomnography (PSG)) measures. PSG analysis classifies sleep into stages, of which slow-wave sleep (SWS) is thought to have a key role in maintaining or increasing pain intensity. We drew directed acyclic graphs to identify possible confounders of the relationship between both measures of sleep quality, and pain intensity. We constructed two linear regression models to explore the effect of subjective and objective sleep quality on next-day pain intensity before and after confounder adjustment.

RESULTS

Thirty-nine participants were included in the study. For participants with low back pain, self-reported better quality sleep β=-0.38 (95% CI -0.63 to -0.13), or spending a greater proportion of time in SWS β=-0.12 (95% CI -0.22 to -0.02) was associated with lower next day pain intensity. After confounder adjustment, the effect reduced and was no longer significant for either self-reported β=-0.18 (95% CI -0.46 to 0.10), or SWS β=-0.08 (95% CI -0.18 to 0.03).

CONCLUSIONS

Sleep quality, whether measured by self-report or proportion of time in SWS, was associated with next day pain intensity for people with low back pain. However, this relationship is likely to be confounded and therefore not likely to be causal.

Low back pain is associated with sleep disturbance: a 3-year longitudinal study after the Great East Japan Earthquake

BACKGROUND

Low back pain and sleep disturbance are common health problems worldwide which are also commonly observed among people after natural disasters. These symptoms are well known to coexist, and recent reports have indicated that sleep disturbance is a risk factor for low back pain. However, the influence of low back pain on sleep disturbance has rarely been assessed; therefore, this study aimed to clarify the association of low back pain with sleep disturbance, especially focusing on the frequency of low back pain, using 3-year cohort data after the Great East Japan Earthquake.

METHODS

This study used the data obtained from people living in the disaster-affected areas after the Great East Japan Earthquake (n = 2,097). Low back pain and sleep disturbance were assessed at 4, 5, 6, and 7 years after the disaster. The frequency of low back pain was defined as the number of low back pain episodes at and before the evaluation time point and categorized into five groups such as absence, 1, 2, 3, and 4 at the fourth time point and four groups such as absence, 1, 2, and 3 at the third time point. Multivariate logistic regression analyses were conducted to assess the association of low back pain with sleep disturbance.

RESULTS

Low back pain was significantly associated with sleep disturbance, and the association was stronger in participants with more frequent low back pain (adjusted odds ratios [95% confidence intervals],1.46 [1.10-1.95] in "1"; 2.02 [1.49-2.74] in "2"; 2.38 [1.67-3.40] in "3"; and 4.08 [2.74-6.06] in "4" in the frequency of low back pain) (P for trend < 0.001). Furthermore, antecedent low back pain was significantly associated with new-onset sleep disturbance, and the association was robust in more frequent low back pain (adjusted odds ratios [95% confidence intervals],1.60 [1.05-2.44] in "1"; 1.96 [1.20-3.21] in "2"; and 2.17 [1.14-4.14] in "3" in the frequency of low back pain) (P for trend = 0.007).

CONCLUSION

Our study showed that low back pain is strongly associated with sleep disturbance. Attention should be paid to low back pain to prevent and treat sleep disturbance, especially focusing on chronicity of low back pain.

Prevalence of non-specific chronic low-back pain and risk factors among male soldiers in Saudi Arabia

Background

Non-specific chronic low back pain (NSCLBP) is the most common musculoskeletal disorder affecting health and work among the military population. NSCLBP is a complex disorder with several risk factors contributing to its occurrence. Therefore, the objective of our study was to estimate the prevalence and contribution of risk factors towards NSCLBP among male soldiers in Saudi Arabia.

Methods

A cross-sectional study was conducted from March 2020 to January 2021 among the military personnel at Hafar Al-Batin military base, Saudi Arabia. The entire population (n = 62, 000) at the military base were invited to participate in the study. The participants were invited to participate in the study either through direct referral from in-patient and out-patient departments of the military hospital or by invitation through pamphlets, email, and advertisement across the offices and residential areas. Soldiers reporting lower back pain for at least 12 weeks were screened for inclusion criteria at the physical therapy department of the military hospital. Inclusion criteria included pain or discomfort originating from the lower back without any known spinal diseases. Participants with a systemic inflammatory disorder, trauma, neurological symptoms, and recent spinal surgery were excluded. All eligible participants were assessed for demographic variables and risk factors and complete the Rolland Morris Disability Questionnaire and WHO-Five Well-Being Index.

Results

This study identified a 46.3% prevalence of pain originating from the spine with a 2.7% prevalence of NSCLBP. Spearman's rho correlation between the severity of disability due to NSCLBP was strongly associated with age (r_s = 0.834, p < 0.01), quality of sleep (r_s = 0.790, p < 0.01), body mass index (BMI) (r_s = 0.617, p < 0.01), smoking (r_s = 0.520, p < 0.01), co-morbidity (r_s = 0.357, p < 0.01), but not with the level of physical activity (r_s = 0.044, p = 0.07).

Conclusion

There was a high prevalence of pain originating from the spine among male Saudi soldiers with a relatively low prevalence of NSCLBP. However, the prevalence of disability due to NSCLBP was strongly associated with age, sleep quality, BMI, smoking habit, and co-morbidity.

How sleep can help maximize human potential: The role of leaders

OBJECTIVE

During multi-domain operations (MDO), soldiers need the physical supremacy, cognitive dominance, and emotional resilience to help defend and win our nation's wars. Optimal sleep has been shown to boost physical performance and cognitive processing. This manuscript will discuss how recent advances in sleep science strongly argue for the integration of sleep planning into military operations.

DESIGN

Review article.

METHODS

We reviewed the current understanding of how sleep affects Soldier readiness, how sleep and pain are interrelated, and unique challenges to obtaining adequate sleep in military training environments. We then address solutions that can be implemented by leaders and individuals to manage warfighter fatigue and optimize unit performance.

RESULTS

Since sleep is foundational to soldier health and readiness, improving warfighter fatigue management is a priority for leaders.

CONCLUSION

To succeed in MDO, military personnel require physical supremacy, cognitive dominance, and emotional resilience to fight and win. Sleep science is a rapidly emerging field, and the clear implications for maximizing human performance argue strongly for more deliberate integration into military training and operations. Leaders that incorporate sleep and fatigue management into the planning and execution phases of operations will help facilitate mission priorities and prove a powerful force multiplier.

Perceived benefits of a brief acupuncture for sleep disturbances in post-deployment military service members

STUDY OBJECTIVES

The purpose of this study was to describe the perceived benefits of a manual standardized stress acupuncture (MSSA) for sleep disturbances (SD) in service members with deployment exposure.

METHODS

This qualitative study was imbedded in a two-arm randomized controlled trial, mixed-methods research that evaluated the effect of weekly MSSA for four weeks as an adjunct treatment with an abbreviated cognitive behavioral therapy for insomnia (CBTi) for SD in service members. Participants were randomized to either the experimental group (CBTi and MSSA) and control group (CBTi only). CBTi consisted of one group psychotherapy for 60 minutes, a follow-up telephone therapy for 30 minutes, and additional four 30-minute follow-up sessions via telephone. Participants provided written journal entries by answering five open-ended questions about their treatment experiences at week five during the posttreatment assessment. Journal log entries were transcribed verbatim in the Dedoose software. A thematic content analysis method was used to code emerging themes.

RESULTS

Three overarching categories were found from the qualitative data: personal challenges in implementing the CBTi sleep strategies, no perception of improvement from treatment, and perceived benefits of treatment. The CBTi/MSSA group reported greater benefits in sleep and in other life areas including mental, physical, and social functioning using thematic content analysis.

CONCLUSIONS

Findings of this study showed greater improvements in participants' sleep, mood, physical health, and occupational and social functioning after receiving the combination of CBTi and MSSA. Future research that investigates the long-term effects of CBTi and MSSA may be beneficial among post-deployment service members.

CLINICAL TRIAL REGISTRATION

Our study was conducted as part of a mixed-methods study registered with clinicaltrials.gov identifier: NCT04031365.

Factors associated with seeking medical care for low back pain in a twin adult sample

BACKGROUND

Previous studies have only investigated how symptom presentation and socio-demographic factors influence care-seeking for low back pain (LBP). However, the influence of health and lifestyle factors remains unclear, and the potential confounding effects of aggregated familial factors (including genetics and the early shared environment) has not been considered extensively.

METHODS

A cross-sectional analysis was performed on 1605 twins enrolled in the Murcia Twin Registry (Spain). The outcome was seeking medical care for LBP and various self-reported demographic, health and lifestyle factors were considered predictors. All variables except sleep quality and diabetes were collected in 2013, which were cross-referenced from 2009 to 2010. A multivariate logistic regression model was performed on the total sample, followed by a co-twin case-control analysis.

RESULTS

The only significant factor found to increase the odds of seeking medical care for LBP without being affected by familial factors was poor sleep quality (total sample OR = 1.58, 95%CI 1.24-2.01; case-control OR = 1.75, 95%CI 1.14-2.69). The factors that were associated with reduced odds of seeking medical care for LBP and not confounded by familial factors were male sex (case-control OR = 0.55, 95%CI 0.33-0.93), alcohol intake (case-control OR = 0.90, 95%CI 0.82-0.99) and a history of diabetes (case-control OR = 0.50, 95%CI 0.25-0.97). No other factors significantly influenced medical care-seeking for LBP.

CONCLUSIONS

People reporting poor sleep quality are more likely to seek medical care for LBP in the long term, with this relationship being independent from aggregated familial factors. Conversely, males, people reporting higher alcohol intake, and people with a history of diabetes are less likely to seek medical care for LBP.

SIGNIFICANCE

This is the first study investigating the factors that influence seeking medical care for LBP, while adjusting for the influence of familial factors using a co-twin control design. Poor sleep quality is associated with seeking medical care for LBP in the long term and does not appear to be confounded by familial factors. Early screening for indicators of poor sleep quality and appropriate referral to interventions for improving sleep quality or reducing pain in sleep may improve LBP management.