Comorbid insomnia in patients with chronic pain: a study based on the Swedish quality registry for pain rehabilitation (SQRP)

Trajectories of pain intensity, pain catastrophizing, and pain interference in the perinatal and postpartum period

Introduction

Chronic pain (pain >3 months) is a growing epidemic. Normal pregnancy may give rise to recurrent and sometimes constant pain for women. Women with worse pain symptoms are more likely to report symptoms of anxiety, depression, and/or insomnia during the perinatal period, which may impact labor and delivery outcomes. We examined the relationship between demographic and psychological predictors of pain throughout pregnancy and into the postpartum.

Objectives

To examine trajectories of pain intensity, pain catastrophizing, and pain interference during pregnancy and the early postpartum, and associated sociodemographic predictors of trajectory membership.

Methods

One hundred forty-two pregnant women were assessed at 4 time points for measures of pain intensity, pain catastrophizing, pain interference, and symptoms of insomnia, depression, and generalized anxiety. Women completed the first survey before 20 weeks' gestation and were reassessed every 10 weeks. Surveys were completed on average at 15 weeks', 25 weeks', and 35 weeks' gestation, and at 6-week postpartum. Using latent class mixed models, trajectory analysis was used to determine trajectories of pain intensity, pain catastrophizing, and pain interference.

Results

A 1-class pain intensity model, 2-class pain catastrophizing model, and 3-class pain interference model were identified. Adaptive lasso and imputation demonstrated model robustness. Individual associations with trajectories included baseline symptoms of anxiety, depression, and insomnia, and pain symptomology.

Conclusion

These findings may help to identify women who are at high risk for experiencing pain symptoms during pregnancy and could aid in developing targeted management strategies to prevent mothers from developing chronic pain during their pregnancy and into the postpartum period.

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.

Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia

Determining the most effective insomnia medication for patients may require therapeutic trials of different medications. In addition, medication side effects, interactions with co-administered medications, and declining therapeutic efficacy can necessitate switching between different insomnia medications or deprescribing altogether. Currently, little guidance exists regarding the safest and most effective way to transition from one medication to another. Thus, we developed evidence-based guidelines to inform clinicians regarding best practices when deprescribing or transitioning between insomnia medications. Five U.S.-based sleep experts reviewed the literature involving insomnia medication deprescribing, tapering, and switching and rated the quality of evidence. They used this evidence to generate recommendations through discussion and consensus. When switching or discontinuing insomnia medications, we recommend benzodiazepine hypnotic drugs be tapered while additional CBT-I is provided. For Z-drugs zolpidem and eszopiclone (and not zaleplon), especially when prescribed at supratherapeutic doses, tapering is recommended with a 1–2-day delay in administration of the next insomnia therapy when applicable. There is no need to taper DORAs, doxepin, and ramelteon. Lastly, off-label antidepressants and antipsychotics used to treat insomnia should be gradually reduced when discontinuing. In general, offering individuals a rationale for deprescribing or switching and involving them in the decision-making process can facilitate the change and enhance treatment success.

EEG Beta functional connectivity decrease in the left amygdala correlates with the affective pain in fibromyalgia: A pilot study

Fibromyalgia (FM) is a major chronic pain disease with prominent affective disturbances, and pain-associated changes in neurotransmitters activity and in brain connectivity. However, correlates of affective pain dimension lack. The primary goal of this correlational cross-sectional case-control pilot study was to find electrophysiological correlates of the affective pain component in FM. We examined the resting-state EEG spectral power and imaginary coherence in the beta (β) band (supposedly indexing the GABAergic neurotransmission) in 16 female patients with FM and 11 age-adjusted female controls. FM patients displayed lower functional connectivity in the High β (Hβ, 20-30 Hz) sub-band than controls (p = 0.039) in the left basolateral complex of the amygdala (p = 0.039) within the left mesiotemporal area, in particular, in correlation with a higher affective pain component level (r = 0.50, p = 0.049). Patients showed higher Low β (Lβ, 13-20 Hz) relative power than controls in the left prefrontal cortex (p = 0.001), correlated with ongoing pain intensity (r = 0.54, p = 0.032). For the first time, GABA-related connectivity changes correlated with the affective pain component are shown in the amygdala, a region highly involved in the affective regulation of pain. The β power increase in the prefrontal cortex could be compensatory to pain-related GABAergic dysfunction.

Mental health among patients with chronic musculoskeletal pain and its relation to number of pain sites and pain intensity, a cross-sectional study among primary health care patients

BACKGROUND

Chronic musculoskeletal pain (CMP) is characterised by pain related to the muscles or the joints with a duration of three months or more and is associated with high symptomatic burden in patients in primary health care. CMP is commonly associated with impaired mental health, which may affect the rehabilitation process. The primary aim of this study was to compare symptoms of anxiety, depression, fatigue, and insomnia in patients in primary health care with and without CMP. The secondary aim was to assess difference in mental health symptoms related to number of pain sites and pain intensity.

METHODS

This cross-sectional study was conducted in Trondheim, Norway. All patients aged 21-58 from randomly selected general practitioners (GPs) were invited to participate. Participants were classified into two groups according to presence of CMP. Symptoms of anxiety, depression, fatigue, and insomnia were assessed by the Hospital Anxiety and Depression Scale (HADS), Chalder Fatigue Questionnaire (CFQ), and Insomnia Severity Index (ISI), respectively, using an online survey system.

RESULTS

From the patient lists of six GPs, we included 969 patients. Mean age 46 years (SD: 10.1), and 517 reported CMP. CMP patients reported higher mean symptom score for anxiety (5.4 vs 3.7), depression (3.4 vs 2.0), fatigue (14.2 vs 11.2), and insomnia (8.1 vs 4.4), all p < 0.01 compared to no-CMP patients. Symptoms of impaired mental health increased with increasing number of pain sites and pain intensity (p < 0.001).

CONCLUSIONS

Primary health care patients with CMP reported significantly more symptoms of anxiety, depression, fatigue, and insomnia than patients without CMP. The higher number of pain sites and pain intensity, the more mental health symptoms, especially of anxiety. Primary health care personnel have to address mental health issues when treating patients with CMP.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT02020772, 25/12/2013).

The treatment lottery of chronic back pain? A case series at a multidisciplinary pain centre

OBJECTIVES

Despite the number of people affected by chronic back pain, and the many available treatment options, even the best modalities provide limited pain reduction on a group level, often without simultaneous improvements in functioning or health-related quality of life. The objective was to provide an overview of the treatment of chronic back pain in clinical practice at a multidisciplinary pain centre, and to study patient and pain characteristics in different treatment groups.

METHODS

104 chronic back pain patients (primary ICD-10-SE-diagnosis M53.0-M54.9 excluding M54.1 and M54.3), referred to the Pain and Rehabilitation Centre, University Hospital, Linköping in 2015, were studied using data from the Swedish Quality Registry for Pain Rehabilitation, self-reported medication data, and a retrospective medical record review.

RESULTS

The following treatment groups were identified: rehabilitation (n=21), analgesics (n=33), invasive intervention (n=14), and no treatment (n=35). Significant differences between groups were found with regards to age, sick leave, education level, persisting pain duration, punishing responses by significant other, previous invasive intervention, receiving sub-clinic, physician speciality and referring care level.

CONCLUSIONS

Overall, patient demographics were associated with treatment strategy to a higher degree than patient-reported outcome measures. Moreover, physician speciality and organisational factors seemed to play a role in treatment choice.

Identify novel, shared and disorder-specific genetic architecture of major depressive disorder, insomnia and chronic pain

Major depressive disorder (MDD), insomnia (INS) and chronic pain (CP) often have high comorbidity and show high genetic correlation. Here we aimed to better characterize their novel, shared and disorder-specific genetic architecture. Based on genome-wide association study (GWAS) summary data, we applied the conditional false discovery rate (condFDR) and conjunctional FDR (conjFDR) approach to investigate the novel and overlapped genetic loci for MDD, INS and CP. In addition, putative disorder-specific SNP associations were analyzed by conditioning the other two traits. The functions of the identified genomic loci were explored by performing gene set enrichment analysis (GSEA) for the loci mapped genes. We identified 22, 43 and 91 novel risk loci for MDD, INS and CP. GSEA for the loci mapped genes highlighted olfactory signaling pathway for MDD novel loci, breast cancer related gene set for both INS and CP novel loci, and nervous system related development, structure and activity for CP. Furthermore, we identified three loci jointly associated with the three disorders, including 13q14.3 locus with nearby gene OLFM4, 14q21.1 locus with nearby gene LRFN5 and 5q21.2 locus located in intergenic region. In addition, we identified one specific loci for MDD, 7 for INS and 11 for CP respectively by conditioning the other two traits, which were mapped to 68 genes for MDD, 85 for INS and 100 for CP. The MDD specific genes are enriched in immune system related pathways. This study increases understanding of the genetic architectures underlying MDD, INS and CP. The shared underlying genetic risk may help to explain the high comorbidity rates of the disorders.

Internet-Delivered Cognitive Behavioral Therapy for Insomnia Comorbid With Chronic Pain: Randomized Controlled Trial

Background

Patients with chronic pain often experience insomnia symptoms. Pain initiates, maintains, and exacerbates insomnia symptoms, and vice versa, indicating a complex situation with an additional burden for these patients. Hence, the evaluation of insomnia-related interventions for patients with chronic pain is important.

Objective

This randomized controlled trial examined the effectiveness of internet-based cognitive behavioral therapy for insomnia (ICBT-i) for reducing insomnia severity and other sleep- and pain-related parameters in patients with chronic pain. Participants were recruited from the Swedish Quality Registry for Pain Rehabilitation.

Methods

We included 54 patients (mean age 49.3, SD 12.3 years) who were randomly assigned to the ICBT-i condition and 24 to an active control condition (applied relaxation). Both treatment conditions were delivered via the internet. The Insomnia Severity Index (ISI), a sleep diary, and a battery of anxiety, depression, and pain-related parameter measurements were assessed at baseline, after treatment, and at a 6-month follow-up (only ISI, anxiety, depression, and pain-related parameters). For the ISI and sleep diary, we also recorded weekly measurements during the 5-week treatment. Negative effects were also monitored and reported.

Results

Results showed a significant immediate interaction effect (time by treatment) on the ISI and other sleep parameters, namely, sleep efficiency, sleep onset latency, early morning awakenings, and wake time after sleep onset. Participants in the applied relaxation group reported no significant immediate improvements, but both groups exhibited a time effect for anxiety and depression at the 6-month follow-up. No significant improvements on pain-related parameters were found. At the 6-month follow-up, both the ICBT-i and applied relaxation groups had similar sleep parameters. For both treatment arms, increased stress was the most frequently reported negative effect.

Conclusions

In patients with chronic pain, brief ICBT-i leads to a more rapid decline in insomnia symptoms than does applied relaxation. As these results are unique, further research is needed to investigate the effect of ICBT-i on a larger sample size of people with chronic pain. Using both treatments might lead to an even better outcome in patients with comorbid insomnia and chronic pain.

Trial Registration

ClinicalTrials.gov NCT03425942; https://clinicaltrials.gov/ct2/show/NCT03425942

[Pain syndromes and insomnia: the role of association with comorbid mental disorders (on the model of glossalgia)]

OBJECTIVE

To test the association between pain severity and anxiety, depression, and somatoform symptoms in burning sleep syndrome (BMS).

MATERIAL AND METHODS

The study included 36 patients (33 women, 3 men), mean age 58.0±14.8 years. Psychopathological, clinical-dermatological, parametric, statistical methods were used. Psychometric examination included the Visual Analogue Scale (VAS) for assessment of pain (severity of glossalgia), PHQ-4 for self-assessment of severity of anxiety (GAD-2) and depression (PHQ-2), the Hospital Anxiety and Depression Scale (HADS), the Screening for Somatoform Symptoms-2 (SOMS-2), the Pittsburgh Sleep Quality Index (PSQI), the EQ-5D-5L quality of life assessment scale.

RESULTS AND CONCLUSION

Insomnia in chronic pain is very common. On the one hand, studies show that sleep deprivation can enhance pain perception. On the other hand, chronic pain can trigger a variety of sleep disorders. One of the localizations of chronic pain syndrome is the oral mucosa. Somatoform pain disorder related to oral mucosa called «glossalgia» or «burning mouth syndrome» (BMS). The prevalence of insomnia in the study sample was 61.1%. The statistically significant positive correlation was found between the severity of insomnia (PSQI) and the severity of anxiety on both GAD-2 and HADS, while insomnia showed no correlation with depression and pain severity. At the same time, the severity of anxiety showed statistically significant positive correlation with the severity of pain assessed by VAS.

Insomnia symptoms and chronic pain: Outcomes of an interdisciplinary pain rehabilitation program

OBJECTIVES

Insomnia is a highly prevalent problem among patients with chronic pain. Interdisciplinary pain rehabilitation programs (IPRPs) are a leading treatment option for chronic pain; however, research is limited and existing findings are mixed on the impact of insomnia symptoms on IPRP outcomes and the extent to which insomnia symptoms improve as a result of IPRP treatment.

METHODS

In this study, insomnia and pain-related outcomes following a 10-week IPRP were examined from a relatively large sample (N = 393) of adult patients with varying chronic pain conditions who completed the Insomnia Severity Index (ISI) at program admission and discharge. Both group- and individual-level changes in insomnia severity were examined to evaluate statistically and clinically significant changes in insomnia symptoms, along with the impact of insomnia symptoms on measures of pain, emotional distress, and functioning. Participants were categorized as having no clinically significant insomnia symptoms (NCSI), mild, moderate, or severe insomnia based on ISI scores.

RESULTS

Higher levels of insomnia severity were associated with worse pain, functioning, and emotional distress. Most patients reporting mild, moderate, or severe insomnia symptoms at program admission moved to a lower insomnia symptom category at the time of discharge (62%); however, only 33% of these patients reported a meaningful score reduction (i.e., ISI change ≥8 points). In addition, insomnia symptoms had a negative impact on treatment gains related to pain interference and physical health-related quality of life.

DISCUSSION

These findings suggest that usual IPRP care confers overall treatment benefit for individuals with chronic pain and insomnia. However, insomnia symptoms may negatively impact pain treatment outcomes and usual care appears insufficient to address elevated insomnia symptoms for many patients. Additional insomnia-specific treatment may be warranted for patients with comorbid chronic pain.

Insomnia Symptoms and Chronic Pain among Patients Participating in a Pain Rehabilitation Program-A Registry Study

Insomnia and chronic pain are prevalent health complaints. Previous research has shown that they are closely associated, but their interaction and causality are not completely understood. Further research is needed to uncover the extent to which a treatment strategy focusing on one of the conditions affects the other. This study aimed to map the prevalence of insomnia symptoms among patients in interdisciplinary pain rehabilitation program (IPRP) and investigate associations between the degree of insomnia at baseline and the treatment outcome regarding pain intensity, physical function, social function, mental well-being, anxiety, and depression. Of the 8515 patients with chronic pain, aged 15–81 who were registered in the Swedish Quality Registry for Pain Rehabilitation during 2016–2019 and participated in IPRP, 7261 had follow-up data after treatment. Logistic regression analysis was used to investigate associations. The prevalence of clinical insomnia, according to Insomnia Severity Index (ISI), among chronic pain patients in IPRP was 66%, and insomnia symptoms were associated with both country of birth and educational level. After IPRP, the prevalence of clinical insomnia decreased to 47%. There were statistically significant associations between the degree of insomnia symptoms before IPRP and physical function (p < 0.001), social function (p = 0.004) and mental well-being (p < 0.001). A higher degree of insomnia symptoms at baseline was associated with improvement after IPRP. In conclusion, IPRP seem to have beneficial effects on insomnia symptoms in chronic pain patients. Nevertheless, almost half of the patients still suffer from clinical insomnia after IPRP. The possible effect of systematic screening and treatment of insomnia for improving the effect of IPRP on pain is an important area for future research.

Mendelian randomization highlights insomnia as a risk factor for pain diagnoses

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lose Pain, Lose Weight, and Lose Both: A Cohort Study of Patients with Chronic Pain and Obesity Using a National Quality Registry

Background

It is known that chronic pain makes it difficult to lose weight, but it is unknown whether obese patients (body mass index ≥30 kg/m²) who experience significant pain relief after interdisciplinary multimodal pain rehabilitation (IMMPR) lose weight.

Objective

This study investigated whether obese patients with chronic pain lost weight after completing IMMPR in specialist pain units. The association of pain relief and weight change over time was also examined.

Methods

Data from obese patients included in the Swedish Quality Registry for Pain Rehabilitation for specialized pain units were used (N=224), including baseline and 12-month follow-up after IMMPR from 2016 to 2018. Patients reported body weight and height, pain aspects (eg, pain intensity), physical activity behaviours, psychological distress, and health-related quality of life (HRQoL). A reduction of at least 5% of initial weight indicates clinically significant weight loss. Patients were classified into three groups based on the pain relief levels after IMMPR: pain relief of clinical significance (30% or more reduction of pain intensity); pain relief without clinical significance (less than 30% reduction of pain intensity); and no pain relief. Linear mixed regression models were used to examine the weight changes among the groups with different pain relief levels.

Results

A significant reduction of pain intensity was found after IMMPR (p < 0.01, effect size Cohen’s d = 0.34). A similar proportion of patients in the three groups with different pain relief levels had clinically significant weight loss (20.2%~24.3%, p = 0.47). Significant improvements were reported regarding physical activity behaviour, psychological distress, and HRQoL, but weight change was not associated with changes of pain intensity.

Conclusion

About one-fifth of obese patients achieved significant weight reduction after IMMPR. Obese patients need a tailored pain rehabilitation program incorporating a targeted approach for weight management.

Sleep disturbance in patients attending specialized chronic pain clinics in Denmark: a longitudinal study examining the relationship between sleep and pain outcomes

OBJECTIVES

Sleep disturbances are highly prevalent in patients with chronic pain. However, the majority of studies to date examining sleep disturbances in patients with chronic pain have been population-based cross-sectional studies. The aims of this study were to 1) examine the frequency of sleep disturbances in patients referred to two interdisciplinary chronic pain clinics in Denmark, 2) explore associations between sleep disturbances and pain intensity, disability and quality of life at baseline and follow-up, and 3) explore whether changes in sleep quality mediated the relationships between pain outcomes at baseline and pain outcomes at follow-up.

METHODS

We carried out a longitudinal observational study, examining patients enrolled in two chronic pain clinics assessed at baseline (n=2,531) and post-treatment follow-up (n=657). Patients reported on their sleep disturbances using the sleep quality subscale of the Karolinska Sleep Questionnaire (KSQ), their pain intensity using 0-10 numerical rating scales, their pain-related disability using the Pain Disability Index (PDI), and quality of life using the EuroQol-VAS scale. The average time between baseline and follow-up was 207 days (SD=154).

RESULTS

At baseline, the majority of patients reported frequent sleep disturbances. We found a significant association at baseline between self-reported sleep disturbances and pain intensity, pain-related disability, and quality of life, where greater sleep disturbance was associated with poorer outcomes. At follow-up, patients reported significant improvements across all pain and sleep outcomes. In two mediation models, we showed that changes in sleep disturbances from baseline to follow-up were significantly associated with (i) pain intensity at follow-up, and (ii) pain disability at follow-up. However, baseline pain intensity and disability scores were not associated with changes in sleep disturbances and, we did not find evidence for significant mediation of either pain outcome by changes in sleep disturbances.

CONCLUSIONS

Self-reported sleep disturbances were associated with pain outcomes at baseline and follow-up, with greater sleep disturbances associated with poorer pain outcomes. Changes in sleep quality did not mediate the relationships between baseline and follow-up scores for pain intensity and disability. These findings contribute to a growing body of evidence confirming an association between sleep and chronic pain experience, particularly suggestive of a sleep to pain link. Our data following patients after interdisciplinary treatment suggests that improved sleep is a marker for a better outcome after treatment.

Daily associations between sleep and pain in patients with chronic musculoskeletal pain

Patients with chronic pain commonly report sleep problems, and the evidence for a relationship between sleep disturbance and pain seems robust. The day-to-day associations between these constructs are less well studied, particularly with objective sleep measures such as actigraphy. Moreover, the concurrent presence of negative affective symptoms, as well as seasonality effects at extreme latitudes may complicate it further. Here, we studied 56 patients with chronic primary musculoskeletal pain conditions, contributing data in two separate 7-day data-collection periods during the summer and winter, respectively. The effect of self-reported sleep quality, and actigraphy measured sleep duration, efficiency and timing on next-day pain, as well as the effect of pain on the same sleep indices were estimated by generalised linear mixed regression models. The models were additionally adjusted for age, sex, education, data collection period, weekend, season and mental distress, with the latter two also specified as moderators. We observed a significant effect of pain as a predictor of next-night sleep quality (p = .003) and marginally of next-night sleep duration (p = .079). Conversely, sleep quality tentatively predicted next-day pain (p = .063). No other day-to-day associations were present. Mental distress was the strongest predictor of pain, but it did not modify the sleep-pain associations, nor did season. In conclusion pain, sleep quality and mental distress are closely related, underscoring the importance of encompassing this complexity in assessment and treatment of patients with chronic pain.

What factors are associated with health-related quality of life among patients with chronic musculoskeletal pain? A cross-sectional study in primary health care

BACKGROUND

Chronic musculoskeletal pain (CMP) affects daily life function and is the most prevalent disorder in primary health care. The primary objective was to examine demographic factors and pain characteristics associated with reduced health-related quality of life (HRQoL) among patients in primary care reporting CMP. Our secondary objective was to compare HRQoL in patients with and without CMP.

METHOD

This cross-sectional study was conducted in Trondheim, Norway. Twenty randomly selected GPs, and their listed patients aged 21-58 were invited to participate. Self-reported CMP data was collected using online questionnaires. HRQoL was measured by the 15D questionnaire, total score of 0.9 was used as cut-off for clinical reduced HRQoL.

RESULTS

A total of 969 patients (650 females) were recruited from six GPs' patient lists, mean age 45.6 (SD 10.1). CMP was reported by 517 (53%). Factors significantly associated with reduced HRQoL were gender (OR 2.0, 95% CI 1.2, 3.4), disability pension (OR 26.6, 95% CI 3.1, 228.0), mood (OR 1.3, 95% CI 1.1, 1.6), relations with other people (OR 0.8, 95% CI 0.6, 0.9), sleep (OR 1.2, 95% CI 1.0, 1.3) and enjoyment (OR 1.2, 95% CI 1.0). CMP patients had significantly lower total HRQoL score compared to patients without CMP (Between group difference 0.08, 95% CI 0.07-0.09). Half of the CMP patients reported a HRQoL score < 0.9 compared to 14% in the no CMP group.

CONCLUSIONS

Being female, receiving disability pension, and several psychosocial factors were found highly associated with reduced HRQoL in CMP patients, whereas pain characteristics were not. Patients with CMP reported statistically and clinically significant lower HRQoL than patients without CMP. Due to low response rate the conclusions must be handled with caution.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT02020772).

Insomnia is Associated with the Effect of Inpatient Multimodal Occupational Rehabilitation on Work Participation in Workers with Musculoskeletal or Mental Health Disorders: Secondary Analyses of a Randomized Clinical Trial

STUDY OBJECTIVES

Insomnia is common among people with musculoskeletal and/or mental health disorders. This study aimed to assess whether insomnia is associated with the favorable effect from inpatient multimodal occupational rehabilitation on future work participation among individuals with these conditions.

METHODS

Insomnia was measured at baseline through a randomized clinical trial that compared the effect of inpatient multimodal occupational rehabilitation with a less-comprehensive program of outpatient acceptance and commitment therapy on future work participation. The inpatient multimodal program lasted 3.5 weeks at the rehabilitation center, comprising psychoeducational sessions (including sleep education), fixed schedules, acceptance and commitment therapy, physical exercise and work-related problem-solving, whereas the outpatient program comprised mainly six weekly acceptance and commitment therapy sessions. Both programs were group-based. The study tracked cumulative sick leave during the 12 months of follow-up using national registry data.

RESULTS

Among the 163 adults included in this subgroup analysis, 56% (n=91) reported insomnia. Overall, we found statistical evidence of interaction between the occupational program and insomnia concerning cumulative sick leave (p=0.03). Compared with people without insomnia in the comprehensive inpatient multimodal program, people with insomnia had 12 (95% CI: -48 to 24) fewer days with sick leave if they participated in the inpatient program and 46 (95% CI: 8 to 83) more days if they participated in the outpatient program.

CONCLUSION

These findings suggest that insomnia should be addressed specifically before individuals on sick leave are considered for participation in occupational rehabilitation and that individuals with insomnia may benefit in particular from inpatient rehabilitation.

The Context Matters: A Retrospective Analysis of Life Stage at Chronic Pain Onset in Relation to Pain Characteristics and Psychosocial Outcomes

BACKGROUND

Developmental life stage at chronic pain onset differs among chronic pain patients. Although pain affects multiple life domains, it is unknown whether the timing of chronic pain onset relates to pain characteristics and psychosocial outcomes. The purpose of this retrospective study was to investigate differences in pain characteristics and psychosocial outcomes in patients at different developmental life stages at chronic pain onset.

METHODS

Cross-sectional baseline data from the Swedish Quality Registry for Pain Rehabilitation (2009 to 2016) were used, selecting the middle-aged patients (45-65 years, n=6225) reporting chronic nonmalignant pain. Patients were categorized into three groups, depending on their developmental life stage at chronic pain onset: early onset (age ≤30 years), intermediate onset (age 31-45 years), and late onset (age ≥46 years). Pain characteristics and psychosocial outcomes were assessed with validated self-reported measures.

RESULTS

One-way MANCOVA indicated differences in number of pain locations and psychosocial outcomes among the groups. Post hoc analysis showed differences in the trends for how groups differed on outcome domains. Overall, patients with earlier chronic pain onset showed significantly poorer psychosocial outcomes and more spreading of pain.

CONCLUSION

Developmental life stage at chronic pain onset is associated with different pain outcomes. Pain onset early in life is linked to worse outcomes in multiple domains, pointing to a need for identifying these patients early.

Facing obesity in pain rehabilitation clinics: Profiles of physical activity in patients with chronic pain and obesity-A study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Background

The obesity epidemic has influenced pain rehabilitation clinics. To date, little is known about baseline level of physical activity (PA) in patients referred to pain rehabilitation clinics. We aimed to investigate the PA levels of patients referred to pain rehabilitation clinics and to evaluate the effect of excess weight on PA level.

Methods and findings

Data were obtained from the Swedish Quality Registry for Pain Rehabilitation between 2016 and 2017. These data included PA time (everyday PA and physical exercise per week), Body Mass Index (BMI), sociodemographic factors, chronic pain and psychological aspects (e.g., pain intensity, depressive and anxiety symptoms and insomnia problems). Insufficient PA was defined as less than 150 minutes per week. We performed logistic regressions as well as orthogonal partial least square regression to estimate the effects of excess weight on PA. Over one-fourth of the patients were classified as obese (BMI ≥30 kg/m², 871/3110, 25.3%) and nearly one-third of these patients were classified as severely obese (BMI ≥35 kg/m², 242/871, 27.8%). Time estimations for physical exercise varied among the BMI groups, but patients in the higher BMI category were more likely to spend less time on everyday PA. Compared to normal weight, mild obesity [odds ratio (OR) 0.65, 95% confidence interval (CI) 0.53–0.81] and severe obesity (OR 0.56, 95% CI 0.42–0.74) were associated with less PA. Mild obese patients had an elevated risk of 65% and severe obese patients had an elevated risk of 96% for insufficient PA. Increased pain intensity was positively related to insufficient PA (OR 1.17, 95% CI 1.06–1.29) among the obese patients.

Conclusion

Having low PA is very common for patients referred to pain rehabilitation clinics, especially for those with comorbid obesity. As a first step to increase PA, obese patients need to be encouraged to increase the intensity and amount of less painful daily PA.

Analysis of the evidence of related factors, associated conditions and at-risk populations of the NANDA-I nursing diagnosis insomnia

Objectives

To summarize evidence in the literature on the predictors of insomnia in adults and to determine correspondences with diagnostic indicators of the NANDA-I diagnosis Insomnia.

Methods

An integrative review performed in Pubmed, Virtual Health Library and CINAHL. Forty-eight articles published in Portuguese, English or Spanish from 2011 to 2018 were included. An analysis of correspondence between the predictors and the NANDA-I related factors and associated conditions for Insomnia was performed.

Results

There was a correspondence of the predictors found in this review with NANDA-I related factors and associated conditions, except for grieving and frequent naps during the day. Smoking, caffeine intake, dysfunctional sleep beliefs, obesity and caregiver role strain are possible new related factors; chronic illness is a possible new associated condition and individuals going through changes in marital status, economically disadvantaged, female gender, increasing age and night shift worker are possible new at-risk populations.

Conclusion

The predictors of insomnia that had a correspondence with the NANDA-I elements can support the evidence base of the nursing diagnosis. The predictors found without a correspondence with the diagnosis can be considered for inclusion in the NANDA-I classification, thereby supporting the clinical reasoning of nurses and students.

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

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

Factors Associated With Sleep Quality in Patients With Chronic Widespread Pain Attending Multidisciplinary Treatment

PURPOSE

(1) To investigate the prevalence of poor sleep quality and (2) to explore the associations between clinical, cognitive, and emotional factors and quality of sleep in patients with chronic widespread pain (CWP) receiving multidisciplinary treatment.

METHOD

Baseline data were used from 163 patients with CWP referred for multidisciplinary treatment. Linear regression models were used to assess the relationship of clinical (pain, fatigue, pain interference, and disability), emotional (anxiety, depression, and psychological distress), and cognitive factors (catastrophizing, acceptance, self-efficacy, kinesiophobia and illness beliefs) with sleep quality, as measured using the Pittsburgh Sleep Quality Index.

RESULTS

Poor sleep quality was found in 92% of the patients. The multivariable model showed that a higher level of fatigue (b = 1.77, standard error [SE] = 0.62, β = 0.21, t = 2.87, P < 0.01), psychological distress (b = 0.02, SE = 0.01, β = 0.27, t = 3.50, P < 0.01), and more concerns about the illness (b = 0.46, SE = 0.18, β = 0.20, t = 2.57, P = 0.01) were independently associated with poorer quality of sleep. The overall linear regression model explains 27.9% of sleep quality.

CONCLUSIONS

The high prevalence of poor sleep quality in patients with CWP referred for multidisciplinary treatment emphasizes the need to target sleep during treatment. Further research is needed to disentangle the cause-effect relationship between fatigue, psychological distress, and concerns about the illness and poor sleep (note: this abstract has been published before [Ann Rheum Dis. 2018;77:A1788]).

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

Objective

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

Methods

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

Results

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

Conclusions

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

Identification of novel common variants associated with chronic pain using conditional false discovery rate analysis with major depressive disorder and assessment of pleiotropic effects of LRFN5

Chronic pain is a complex trait that is moderately heritable and genetically, as well as phenotypically, correlated with major depressive disorder (MDD). Use of the conditional false discovery rate (cFDR) approach, which leverages pleiotropy identified from existing GWAS outputs, has been successful in discovering novel associated variants in related phenotypes. Here, genome-wide association study outputs for both von Korff chronic pain grade and for MDD were used to identify variants meeting a cFDR threshold for each outcome phenotype separately, as well as a conjunctional cFDR (ccFDR) threshold for both phenotypes together. Using a moderately conservative threshold, we identified a total of 11 novel single nucleotide polymorphisms (SNPs), six of which were associated with chronic pain grade and nine of which were associated with MDD. Four SNPs on chromosome 14 were associated with both chronic pain grade and MDD. SNPs associated only with chronic pain grade were located within SLC16A7 on chromosome 12. SNPs associated only with MDD were located either in a gene-dense region on chromosome 1 harbouring LINC01360, LRRIQ3, FPGT and FPGT-TNNI3K, or within/close to LRFN5 on chromosome 14. The SNPs associated with both outcomes were also located within LRFN5. Several of the SNPs on chromosomes 1 and 14 were identified as being associated with expression levels of nearby genes in the brain and central nervous system. Overall, using the cFDR approach, we identified several novel genetic loci associated with chronic pain and we describe likely pleiotropic effects of a recently identified MDD locus on chronic pain.

Genome-wide association study of multisite chronic pain in UK Biobank

Chronic pain is highly prevalent worldwide and represents a significant socioeconomic and public health burden. Several aspects of chronic pain, for example back pain and a severity-related phenotype 'chronic pain grade', have been shown previously to be complex heritable traits with a polygenic component. Additional pain-related phenotypes capturing aspects of an individual's overall sensitivity to experiencing and reporting chronic pain have also been suggested as a focus for investigation. We made use of a measure of the number of sites of chronic pain in individuals within the UK general population. This measure, termed Multisite Chronic Pain (MCP), is a complex trait and its genetic architecture has not previously been investigated. To address this, we carried out a large-scale genome-wide association study (GWAS) of MCP in ~380,000 UK Biobank participants. Our findings were consistent with MCP having a significant polygenic component, with a Single Nucleotide Polymorphism (SNP) heritability of 10.2%. In total 76 independent lead SNPs at 39 risk loci were associated with MCP. Additional gene-level association analyses identified neurogenesis, synaptic plasticity, nervous system development, cell-cycle progression and apoptosis genes as enriched for genetic association with MCP. Genetic correlations were observed between MCP and a range of psychiatric, autoimmune and anthropometric traits, including major depressive disorder (MDD), asthma and Body Mass Index (BMI). Furthermore, in Mendelian randomisation (MR) analyses a causal effect of MCP on MDD was observed. Additionally, a polygenic risk score (PRS) for MCP was found to significantly predict chronic widespread pain (pain all over the body), indicating the existence of genetic variants contributing to both of these pain phenotypes. Overall, our findings support the proposition that chronic pain involves a strong nervous system component with implications for our understanding of the physiology of chronic pain. These discoveries may also inform the future development of novel treatment approaches.

Biobehavioral Mechanisms Associated With Nonhealing Wounds and Psychoneurologic Symptoms (Pain, Cognitive Dysfunction, Fatigue, Depression, and Anxiety) in Older Individuals With Chronic Venous Leg Ulcers

The prevalence and incidence of chronic venous leg ulcers (CVLUs) are increasing worldwide, as are the associated financial costs. Although it has long been known that their underlying etiology is venous insufficiency, the molecular aspects of healing versus nonhealing, as well as the psychoneurologic symptoms (PNS; pain, cognitive dysfunction, fatigue, depression, and anxiety) associated with CVLUs remain understudied. In this biobehaviorally focused review, we aim to elucidate the complex mechanisms that link the biological and molecular aspects of CLVUs with their PNS. Innovations in "omics" research have increased our understanding of important wound microenvironmental factors (e.g., inflammation, microbial pathogenic biofilm, epigenetic processes) that may adversely alter the wound bed's molecular milieu so that microbes evade immune detection. Although these molecular factors are not singularly responsible for wound healing, they are major components of wound development, nonhealing, and PNS that, until now, have not been amenable to systematic study, especially over time. Further, this review explores our current understanding of the molecular mechanisms by which the immune activation that contributes to the development and persistence of CVLUs also leads to the development, persistence, and severity of wound-related PNS. We also make recommendations for future research that will expand the field of biobehavioral wound science. Biobehavioral research that focuses on the interrelated mechanisms of PNS will lead to symptom-management interventions that improve quality of life for the population burdened by CVLUs.

Impact of Sleep Disorders and Other Factors on the Quality of Life in General Population: A Cross-Sectional Study

The study objective was to assess if insomnia, along with other factors, can impact the physical and mental quality of life (QOL) of the Lebanese general population. This cross-sectional study, conducted between November 2017 and March 2018, enrolled 756 community-dwelling participants. A first linear regression, using the SF-12 PCS score as the dependent variable, showed that having a family history of insomnia problems (β = 1.107, p = 0.026) was significantly associated with higher physical QOL (higher SF-12 PCS score), whereas increased stress (β = 0.048, p = 0.015) was significantly associated with lower physical QOL. A second linear regression, using the SF-12 MCS score as dependent variable, showed that having increased age (β = -0.079, p < 0.001) was significantly associated with lower mental QOL. Despite its cross-sectional design and the modest sample size, this study adds to the evidence that insomnia, along with other factors (including sociodemographic and psychological factors), can have a detrimental impact on both physical and mental QOL of participants.

The role of pain in chronic pain patients’ perception of health-related quality of life: a cross-sectional SQRP study of 40,000 patients

Background and aims

Health-related quality of life (Hr-QoL) reflects the burden of a condition on an overarching level. Pain intensity, disability and other factors influence how patients with chronic pain perceive their condition, e.g. Hr-QoL. However, the relative importance of these factors is unclear and there is an ongoing debate as to what importance pain measures have in this group. We investigated the importance of current pain level and mood on aspects of Hr-QoL in patients with chronic pain and investigated whether such relationships are influenced by demographics.

Methods

Data was obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP), between 2008 and 2016 on patients ≥18 years old who suffered from chronic pain and were referred to participating specialist clinics. Dependent variables were general Hr-QoL [using two scales from European Quality of Life instrument: EQ5D Index and the European Quality of Life instrument health scale (EQ thermometer)] and specific Hr-QoL [from the Short Form Health Survey (SF36) the physical component summary (SF36-PCS) and the mental (psychological) component summary (SF36-MCS)]. Independent variables were sociodemographic variables, pain variables, psychological distress and pain attitudes. Principal component analysis (PCA) was used for multivariate correlation analyses of all investigated variables and Orthogonal Partial Least Square Regression (OPLS) for multivariate regressions on health aspects.

Results

There was 40,518 patients (72% women). Pain intensity and interference showed the strongest multivariate correlations with EQ5D Index, EQ thermometer and SF36-PCS. Psychological distress variables displayed the strongest multivariate correlations with SF36-MCS. Demographic properties did not significantly influence variations in the investigated Hr-QoL variables.

Conclusions

Pain, mood and pain attitudes were significantly correlated with Hr-QoL variables, but these variables cannot explain most of variations in Hr-QoL variables. The results pinpoint that broad assessments (including pain intensity aspects) are needed to capture the clinical presentation of patients with complex chronic pain conditions.

Is sleep disturbance in patients with chronic pain affected by physical exercise or ACT-based stress management? - A randomized controlled study

BACKGROUND

Most people suffering chronic pain are plagued by sleeping difficulties. Cognitive behaviour therapy has produced promising results for insomnia comorbid with chronic pain, but the access to such treatment is often limited. Over the last ten years, interventions aiming to increase cognitive flexibility and physical activity have been assumed to be effective treatments for a variety of conditions, including insomnia and chronic pain. If proven effective, these treatments could constitute the first steps in a stepped care model for chronic pain and insomnia.

METHODS

Two hundred ninety-nine chronic pain subjects were randomized to Exercise, ACT-based stress management (ACT-bsm), or an active control group. Two hundred thirty-two participants (78%) received their allocated intervention at least to some extent. These participants were evaluated using mixed model analyses for changes in sleep (Insomnia Severity Index, ISI), pain intensity, depression, and anxiety immediately after treatment, six months and twelve months after treatment.

RESULTS

The mixed model analyses revealed that Exercise had a positive effect on insomnia compared with the control group and the effect remained after 12 months. No clear effect (i.e., both for completers and for completers together with treatment non-completers) upon ISI was found for the ACT-bsm. Pain intensity decreased significantly both in the exercise group and in the control group. For the two psychological variables (i.e., symptoms of anxiety and depression) were found significant improvements over time but no group differences. The treatment effects for ISI and pain intensity did not reach clinical significance per definitions presented in other relevant studies.

CONCLUSIONS

Beneficial significant effects on insomnia was confirmed in the exercise condition. However, these changes were probably not clinically important. For pain intensity a general decrease was found in the Exercise condition and in the control condition, while no change occurred in ACT-bsm. No group differences were found for the two psychological variables.

TRIAL REGISTRATION

The study was registered in Clinical Trials (Trial registration: ClinicalTrials.gov Id: NCT02399644 , 21 January 2015, retrospectively registered).

Insomnia Really Hurts: Effect of a Bad Night's Sleep on Pain Increases With Insomnia Severity

Insomnia and chronic pain are highly prevalent conditions and are often comorbid. Somatic complaints other than pain are also often observed in insomnia. Poor sleep and pain are known to mutually reinforce each other. However, it is unknown whether the habitual severity of insomnia modulates the acute effect of a particularly bad night's sleep on the next day's pain severity, and whether it modulates the acute effect of pain on the following night's sleep quality. Using data from 3,508 volunteers (2,684 female, mean age 50.09 y), we addressed these questions in addition to the associations between the habitual severity of insomnia, somatic complaints, and pain. Results indicated that people suffering from more severe habitual insomnia showed stronger mutual acute within-day reactivity of pain and poor sleep quality. The same increased reactivity was found in people with more severe habitual pain. Interestingly, the acute within-day mutual reactivity of pain and sleep quality showed consistent asymmetry. Pain worsened more after a particularly bad night's sleep than it improved after a particularly good night's sleep. Likewise, sleep worsened more after a day with more-than-usual pain than it improved after a day with less-than-usual pain. Future interventions may profit from addressing this asymmetric mutual reactivity especially in people with severe comorbid insomnia and chronic pain.

Association of insomnia severity with well-being, quality of life and health care costs: A cross-sectional study in older adults with chronic pain (PainS65+)

BACKGROUND

Insomnia is one of the most common complaints in chronic pain. This study aimed to evaluate the association of insomnia with well-being, quality of life and health care costs.

METHODS

The sample included 2790 older individuals (median age = 76; interquartile range [IQR] = 70-82) with chronic pain. The participants completed a postal survey assessing basic demographic data, pain intensity and frequency, height, weight, comorbidities, general well-being, quality of life and the insomnia severity index (ISI). Data on health care costs were calculated as costs per year (€ prices) and measured in terms of outpatient and inpatient care, pain drugs, total drugs and total health care costs.

RESULTS

The overall fraction of clinical insomnia was 24.6% (moderate clinical insomnia: 21.9% [95% CI: 18.8-23.3]; severe clinical insomnia: 2.7% [95% CI: 1.6-3.2]). Persons who reported clinical insomnia were more likely to experience pain more frequently with higher pain intensity compared to those reported no clinically significant insomnia. Mean total health care costs were € 8469 (95% CI: €4029-€14,271) for persons with severe insomnia compared with € 4345 (95% CI: €4033-€4694) for persons with no clinically significant insomnia. An association between severe insomnia, well-being, quality of life, outpatient care, total drugs costs and total health care costs remained after controlling for age, sex, pain intensity, frequency, body mass index and comorbidities using linear regression models.

CONCLUSIONS

Our results determine an independent association of insomnia with low health-related quality of life and increased health care costs in older adults with chronic pain.

SIGNIFICANCE

The concurrence and the severity of insomnia among older adults with chronic pain were associated with decreased well-being and quality of life, and increased health care costs to society.

A nonpharmacologic approach to managing insomnia in primary care

Insomnia, or inadequate or poor sleep leading to significant distress or impairment in functioning, is a prevalent disorder treated by primary care providers (PCPs). With millions of people across the United States suffering from insomnia, PCPs must understand the disorder's pathophysiology, perpetuating factors, and treatment, as well as its effect on patient health and the economy. Although PCPs traditionally treat insomnia with pharmaceuticals, behavioral measures are effective and should be used whenever possible. This article reviews clinically relevant principles of diagnosing and treating insomnia, highlighting nonpharmacologic treatments.

Insomnia severity and its relationship with demographics, pain features, anxiety, and depression in older adults with and without pain: cross-sectional population-based results from the PainS65+ cohort

BACKGROUND

Insomnia is a major cause of concern in the elderly with and without pain. This study set out to examine the insomnia and its correlates in a large sample of community adults aged ≥65 years.

METHODS

A cross-sectional postal survey was completed by 6205 older individuals (53.8% women; mean age = 76.2 years; SD = 7.5). The participants also completed the Insomnia Severity Index (ISI) and questionnaires assessing pain intensity, pain spreading, anxiety, depression, and basic demographic information. The sample was divided into three groups based on the presence and duration of pain: chronic pain (CP; n = 2790), subacute pain (SP; n = 510), and no pain (NP; n = 2905).

RESULTS

A proportion of each of the groups had an ISI score of 15 or greater (i.e., clinical insomnia): CP = 24.6%; SP = 21.3%; and NP = 13.0%. The average scores of ISI differed significantly among CP, SP, and NP groups (p < 0.001). Stratified regression analyses showed that pain intensity, pain spreading, anxiety, and depression were independently related to insomnia in the CP group. Anxiety and depression were independently related to insomnia in the SP group, but only anxiety was significantly associated with insomnia in the NP group. Age and sex were not associated with insomnia.

CONCLUSIONS

This study confirms that insomnia is not associated with chronological aging per se within the elderly population. Although the possible associations of insomnia with pain are complex, ensuing from pain intensity, pain spreading, anxiety, and depression, our results highlighted that anxiety was more strongly associated with insomnia in all groups than the depression and pain characteristics. Therapeutic plans should consider these relations during the course of pain, and a comprehensive assessment including both pain and psychological features is essential when older people are seeking primary health care for insomnia complaints.

Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain

BACKGROUND AND AIMS

Pain is one of the most common reasons for patients to seek primary health care. Pain relief is likely to be achieved for patients suffering from acute pain, but for individuals with chronic pain it is more likely that the condition will persist. These patients have the option of being referred to specialised pain clinics. However, the complexity surrounding chronic pain patients is not well studied in these settings. This study aimed to describe patients with chronic pain referred to a pain clinic by using the information submitted during their first visit and one year later and also to identify associations between baseline characteristics and improvements in health-related quality of life in the follow-up.

METHODS

This was a longitudinal observational study of a sample consisting of 318 patients referred to a pain clinic. One group of patients containing 271 individuals (median age 48, 64% females) was assessed and received conventional pain treatment (CPT group) and a second group of 47 patients (median age 53, 64% females) was assessed by a pain specialist and referred back to their physician with a treatment recommendation (assessment only, AO group). Patient-reported outcome measures in health-related quality of life (EQ-5D), pain intensity (VAS), mental health (HADS), insomnia (ISI), pain-related disability (PDI), kinesiophobia (TSK) and sense of coherence (SOC) were collected at the first visit and one year later.

RESULTS

At baseline, the CPT group reported a low EQ-5D Index (median (md) 0.157) and EQ VAS (md 40) as well as considerable high, current pain intensity VAS (md 58), HADS anxiety (md 8), ISI (md 17), PDI (md 36) and TSK (md 39). The AO group showed similar problems (no significant differences compared to the CPT group), except for ISI, where the AO group reported less severe problems. At the one-year follow-up, the CPT group had a statistically significant improvement in EQ-5D, VAS, ISI, PDI and TSK. In the AO group no significant changes were observed. In the CPT group there was an association between a high ISI level at baseline and an improved EQ-5D Index in the follow-up.

CONCLUSIONS

The study describes rarely explored groups of patients with chronic pain at a pain clinic. Severe pain problems were present in both groups at their first visit. A statistically significant improvement could be seen in the group that was conventionally treated while this was not the case among those subjects who were assessed and referred. The results imply, that relatively limited treatment strategies were helpful for the patients' health-related quality of life. Despite these improvements, the patients were not fully recovered, pointing to the chronicity of pain conditions and the need of support for many patients.

IMPLICATIONS

Increased knowledge about assessment, selection and treatment at pain clinics is important to improve the quality of the work performed at these clinics. Despite limited resources, further efforts should be made to collect comparable, valid data on a regular base from pain clinics in order to develop recommendation models.

Patient Satisfaction with Spanish Pain Centers: Observational Study with More than 3,000 Patients

Chronic pain is a serious problem in Spain. This multicenter, epidemiological 3-month follow-up study investigates pain management efficacy in Spanish centers using patient satisfaction criteria. 3,414 eligible adult patients (65,6% female) with moderate to severe chronic pain from 146 pain centers were included. Patient satisfaction was assessed based onto question 18 of Spanish healthcare barometer-CSI. Pain evolution (Brief Pain Inventory-Short Form (BPI-SF) and visual analog scale (VAS)), quality of life/EuroQol-5, and pain control expectations fulfillment were also assessed. Mean age was 61.3 years. 64.4% of participating centers employed multidisciplinary pain management approach. After 3 months, mean patient satisfaction was 7.8 (1-10) on the CIS barometer. Medical staff received the highest scores, whereas waiting for tests, appointment request to appointment date time, and waiting times at the center the lowest. Mean pain decreased from 7.4 to 4.0; BPI-SF intensity decreased from 6.5 to 3.8; pain control expectations were met in 78.7% of patients; EuroQoL-5D utility index increased from 0.37 to 0.62, p < 0.001, and health status (VAS) from 40.6 to 61.9, p < 0.001. Chronic pain patients (90%) are satisfied with Spanish centers care; 80% had their pain control expectations met. Quality of life improved remarkably: 71% felt moderately to significantly better. However, waiting times need improvement.

Patients with chronic pain: One-year follow-up of a multimodal rehabilitation programme at a pain clinic

BACKGROUND AND AIMS

Multimodal rehabilitation (MMR) programmes, including, physical training, educational and psychological interventions by an interdisciplinary team are found to be more successful for patients with disabling chronic pain compared with less comprehensive treatments. MMR programmes are based on the biopsychosocial model and the goal is usually to improve function, quality of life and facilitate and enable return to work. As pain clinics traditionally offer conventional medical pain treatment, there is limited knowledge about MMR given in this context. The aim of our study was to describe characteristics of patients with chronic pain, treated with a MMR programme at a conventional pain clinic, to evaluate patient-reported outcome measures (PROM) from start to one year after, and to study possibly associated factors for the improvement of health-related quality of life after one year.

METHODS

A prospective, observational study with a one-year follow-up was performed.

SUBJECTS

A total of 42 individuals (38 females, age 44.0±12.3 years and 4 men age 40±8.5 years) with different pain diagnoses were included. After a team assessment, the patients began a programme that lasted about three months. The MMR programme contained coordinated, individually adapted treatments administered individually or in groups, and was based on cognitive behavioural principles. Questionnaires regarding health-related quality of life (HRQoL) (EQ-5D), insomnia (ISI), mental health (HADS), pain-related disability (PDI), kinesiophobia (TSK), current pain intensity (VAS) and sense of coherence (SOC) were used at the start of the MMR and at follow-up. Demographic data were collected from the patient records.

RESULTS

The PROM at baseline showed substantial pain problems with low HRQoL (EQ-5D index of 0.1±0.282, and EQ VAS of 32.67±20.1), moderate insomnia (ISI 18.95±6.7), doubtful cases of depression and anxiety (HADS-depression 9.35±4.1 and HADS-anxiety 9.78±3.95), presence of pain-related disability (PDI 39.48 ±12.64), kinesiophobia (TSK 40.8±9.8), as well as moderate current pain (VAS 61.31±20.4). The sense of coherence was weak (SOC of 51.37±14). At one-year follow-up, significant (p≤0.05) improvement occurred on the EQ-5D index, EQ VAS, ISI, PDI and TSK. In the logistic regression analysis, no significant associations could be identified.

CONCLUSIONS

MMR for patients with complex pain problems can be a successful treatment alternative at conventional pain clinics.

IMPLICATIONS

Since access to rehabilitation clinics in Sweden may be limited, the availability of MMR can increase by providing this type of intervention in pain clinics. Increased knowledge of MMR in different settings can also contribute to increased understanding and collaboration between pain clinics and rehabilitation units.

Modeling community integration in workers with delayed recovery from mild traumatic brain injury

Background

Delayed recovery in persons after mild traumatic brain injury (mTBI) is poorly understood. Community integration (CI) is endorsed by persons with neurological disorders as an important outcome. We aimed to describe CI and its associated factors in insured Ontario workers with delayed recovery following mTBI.

Methods

A cross-sectional study of insured workers in the chronic phase following mTBI was performed at a rehabilitation hospital in Ontario, Canada. Sociodemographic, occupational, injury-related, clinical, and claim-related data were collected from self-reports, medical assessments, and insurers’ referral files. Community Integration Questionnaire (CIQ) scores were compared using analysis of variance or Spearman’s correlation tests. Stepwise multivariable linear regression models were used to evaluate the associations with CI.

Results

Ninety-four workers with mTBI (45.2 ± 9.9 years old, 61.2 % male) at 197 days post-injury (interquartile range, 139–416 days) were included. The CIQ total and subscale scores were similar to those reported in more severe TBI samples. The CIQ scores were moderately to strongly correlated with various sociodemographic, claim-related, and clinical variables. In the multivariable regression analysis, several covariates accounted for 36.4 % of the CIQ variance in the final fully adjusted model.

Discussion

This study evaluated CI in workers with mTBI, and analyzed its associated variables. Analysis revealed insomnia, head or neck pain, being married or in a relationship, time since injury, and a diagnosis of possible/probable malingering were independently associated with limited CI.

Conclusions

Workers with delayed recovery from mTBI experience difficulty with CI. Insomnia is a particularly relevant covariate, explaining the greater part of its variance. To enhance participation, care should focus on clinical and non-clinical covariates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0432-z) contains supplementary material, which is available to authorized users.

The Swedish version of the Insomnia Severity Index: Factor structure analysis and psychometric properties in chronic pain patients

Objective

Insomnia is the most commonly diagnosed comorbidity disorder among patients with chronic pain. This circumstance requests brief and valid instruments for screening insomnia in epidemiological studies. The main object of this study was to assess the psychometric properties and factor structure of the Swedish version of the Insomnia Severity Index (ISI). The ISI is a short instrument designed to measure clinical insomnia and one of the most common used scales both in clinical and research practice. However there is no study in Sweden that guarantees neither its factor structure nor its feasibility in chronic pain patients. We further examined the measurement invariance property of the ISI across the two sexes.

Methods

The ISI was administered to 836 (269 men and 567 women) chronic pain patients from the Swedish Quality Registry for Pain Rehabilitation. This study used demographic data, the Hospital Anxiety and Depression Scale (HADS), the Mental Summary Component (MSC) of the Health Survey (SF-36) and the item 7 from Multidimensional Pain Inventory (MPI). The sample was divided into two random halves: exploratory factor analysis (EFA) was performed in the first sample (N1 = 334, 40%) and confirmatory factor analysis (CFA) in the second half of the sample (N2 = 502, 60%). The measurement and structural invariance of the proposed structure (4-item version) between the two sexes as well as reliability and validity indexes were further assessed.

Results

Exploratory factor analysis using the principal axis factoring method generated one global factor structure for the ISI, explaining 63.1% of the total variance. The one factor solution was stable between the two sexes. Principal component analysis was also applied and indicated almost identical results. The structure was further assessed by CFA, resulting in an adequate fit only after omitting three items. The difference on structural and measurement invariance in the loadings by participants’ sex was not significant (Δχ 2 = 10.6; df = 3; p = .69 and Δχ 2 = 2.86; df = 3; p = 41 respectively). The shorter version four-item Insomnia Severity Index (ISI-4) was analysed further. The Chronbach’s alpha for the global ISI-4 score was 0.88. The construct validity of the ISI-4 was also supported by the, Hospital Anxiety and Depression Scale, the Mental Summary Component of quality of life and quality of sleep data. Pain intensity was significantly associated with the ISI-4 score (beta = .29, p < 001) whereas no significant correlation between four-item Insomnia Severity Index score and age was observed (p > 05).

Conclusions and implications

Although short, the four-item Insomnia Severity Index (ISI-4) version seemed to effectively assess insomnia in chronic pain patients. An important clinical implication is that the four-item Swedish Insomnia Severity Index can be used in chronic pain cohorts when screening for insomnia problems. Its measurement and structural invariance property across the two sexes shows that the ISI-4 is a valid measure of the insomnia across groups of chronic patients. Our results also suggest its utility both in pain clinical practice and research purposes.

Increased risks of healthcare-seeking behaviors of anxiety, depression and insomnia among patients with bladder pain syndrome/interstitial cystitis: a nationwide population-based study

PURPOSE

To explore the association between bladder pain syndrome/interstitial cystitis (BPS/IC) and the risk of subsequent healthcare-seeking behavior for common mental disorders in Taiwan using a population-based administrative database.

MATERIALS AND METHODS

Both BPS/IC subjects and their age- and sex-matched non-BPS/IC control subjects who had no previous insomnia and mental diseases, including anxiety, depression, were subsequent serviced for these mental disorders by psychiatrists from the recruited date between 2002 and 2010. The risk of outcomes was assessed with Kaplan-Meier curves; and the impact of BPS/IC was estimated with Poisson regression analysis and Cox proportional hazards models.

RESULTS

We included 16,185 BPS/IC subjects and 32,370 non-BPS/IC subjects, with a mean age of 46 years and 73.5 % of women. Difference of the prevalence of hypertension, diabetes, chronic kidney disease, and hyperlipidemia between groups was not significant difference. Subjects with BPS/IC had a significant higher incidence rate of anxiety, depression, and insomnia than the matched controls (92.9 vs 38.4, 101.0 vs 42.2, 47.5 vs 23.0; per 10,000 person-year). After adjusting for age, sex, and common comorbidities in multivariable analysis, BPS/IC remained a significant predictor with hazard ratio and 95 % confidence incidence, 2.4 (2.2-2.7), 2.4 (2.2-2.6), and 2.1 (1.8-2.4) for anxiety, depression, and insomnia, respectively.

CONCLUSION

Patients with BPS/IC are at risk of development of anxiety, depression, and insomnia. These findings can help guide urologists, urogynecologists, and psychiatrists toward early identification and treatment of psychological complications that may develop in BPS/IC patients.

Wen-dan decoction improves negative emotions in sleep-deprived rats by regulating orexin-a and leptin expression

Wen-Dan Decoction (WDD), a formula of traditional Chinese medicine, has been clinically used for treating insomnia for approximately 800 years. However, the therapeutic mechanisms of WDD remain unclear. Orexin-A plays a key role in the sleep-wake cycle, while leptin function is opposite to orexin-A. Thus, orexin-A and leptin may be important factors in sleep disorders. In this study, 48 rats were divided into control, model, WDD-treated, and diazepam-treated groups. The model of insomnia was produced by sleep deprivation (SD) for 14 days. The expressions of orexin-A, leptin, and their receptors in blood serum, prefrontal cortex, and hypothalamus were detected by enzyme-linked immunosorbent assay, immunohistochemistry, and real time PCR. Open field tests showed that SD increased both crossing movement (Cm) and rearing-movement (Rm) times. Orexin-A and leptin levels in blood serum increased after SD but decreased in brain compared to the control group. mRNA expressions of orexin receptor 1 and leptin receptor after SD were decreased in the prefrontal cortex but were increased in hypothalamus. WDD treatment normalized the behavior and upregulated orexin-A, leptin, orexin receptor 1 and leptin receptor in brain. The findings suggest that WDD treatment may regulate SD-induced negative emotions by regulating orexin-A and leptin expression.