The role of sleep problems in the development of depression in those with persistent pain: a prospective cohort study

The Combined Influence of Sleep Disturbance and Depression on 12-month Outcomes After Lumbar Spine Surgery

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To examine the combined influence of preoperative sleep disturbance and depression on 12-month patient-reported outcomes after lumbar spine surgery (LSS).

SUMMARY OF BACKGROUND DATA

Psychological and behavioral factors are considered major risk factors for poor outcomes after LSS. However, there is a need to explore the combined effects of preoperative factors such as sleep disturbance and depression. Understanding the influence of sleep disturbance and depression can inform evidence-based preoperative assessment and shared-decision making of preoperative and postoperative treatment.

METHODS

Data from 700 patients undergoing LSS were analyzed. Preoperative sleep disturbance and depression were assessed with PROMIS subscales. Established thresholds defined patients with moderate/severe symptoms. Outcomes for disability (Oswestry Disability Index) and back and leg pain (Numeric Rating Scales) were assessed preoperatively and at 12 months. Separate multivariable linear regressions examined the influence of each factor on 12-month outcomes with and without accounting for the other and in combination as a 4-level variable: (1) moderate/severe sleep disturbance alone, (2) moderate/severe depression alone, (3) both moderate/severe sleep disturbance and depression, (4) no moderate/severe sleep disturbance or depression.

RESULTS

Preoperative sleep disturbance and depression were associated with 12-month disability and pain ( P <0.05). After accounting for depression, preoperative sleep disturbance remained associated with disability, while preoperative depression adjusting for sleep disturbance remained associated with all outcomes ( P <0.05). Patients reporting both moderate/severe sleep disturbance and moderate/severe depression had 12.6 points higher disability and 1.5 points higher back and leg pain compared with patients without moderate/severe sleep disturbance or depression.

CONCLUSIONS

The combination of sleep disturbance and depression impacts postoperative outcomes considerably. The high-risk group of patients with moderate/severe sleep disturbance and depression could benefit from targeted treatment strategies.

LEVEL OF EVIDENCE

Level II.

Pain-Insomnia-Depression Syndrome: Triangular Relationships, Pathobiological Correlations, Current Treatment Modalities, and Future Direction

Pain-insomnia-depression syndrome (PIDS) is a complex triad of chronic pain, insomnia, and depression that has profound effects on an individual's quality of life and mental health. The pathobiological context of PIDS involves complex neurobiological and physiological mechanisms, including alterations in neurotransmitter systems and impaired pain processing pathways. The first-line therapeutic approaches for the treatment of chronic pain, depression, and insomnia are a combination of pharmacological and non-pharmacological therapies. In cases where patients do not respond adequately to these treatments, additional interventions such as deep brain stimulation (DBS) may be required. Despite advances in understanding and treatment, there are still gaps in knowledge that need to be addressed. To improve our understanding, future research should focus on conducting longitudinal studies to uncover temporal associations, identify biomarkers and genetic markers associated with PIDS, examine the influence of psychosocial factors on treatment responses, and develop innovative interventions that address the complex nature of PIDS. The aim of this study is to provide a comprehensive overview of these components and to discuss their underlying pathobiological relationships.

Fear of progression, depression, and sleep difficulties in people experiencing endometriosis-pain: A cross-sectional study

OBJECTIVE

Endometriosis is a chronic condition generally characterised by severe pain. Recent findings demonstrate disproportionately elevated rates of insomnia and fatigue among people with endometriosis, particularly among those with associated pain. Yet there is little understanding of the psychological factors that might contribute to these sleep and fatigue related difficulties. We investigated whether fear of progression and depression interacted with pain to influence fatigue and insomnia among people with endometriosis-related pain.

METHODS

A total of 206 individuals with endometriosis were included in this cross-sectional, online survey in January 2022. Participants provided relevant demographics and endometriosis characteristics. The BPI-SF, FoP-Q-SF, DASS-21, CFS and ISI were used to assess pain intensity, fear of progression, depression, fatigue, and insomnia symptoms, respectively. Associations between key variables were assessed with correlations. A path analysis determined whether the relationships between pain and fatigue, and pain and insomnia, depended on levels of fear of progression and depression.

RESULTS

Controlling for age, fear of progression was uniquely associated with worse fatigue (β = 0.348, p < .001) and insomnia (β = 0.389, p < .001), and moderated the relationship between pain and fatigue (β = 0.155, p = .009). Specifically, with increasing pain severity, the effects of fear of progression on fatigue were exacerbated. Depression was uniquely associated with fatigue (β = 0.360, p < .001), but did not elicit any moderation effects.

CONCLUSION

These results highlight the role of fear of progression and depression in endometriosis-related fatigue and insomnia, paving the way for future interventions targeting these constructs to be tested.

Analysis of the Risk Factors for Negative Emotions in Patients with Esophageal Cancer During the Peri-Radiotherapy Period and Their Effects on Malnutrition

Background

Esophageal cancer has a high incidence in China. Many patients also have a heavy psychological burden due to clinical features such as wasting and choking on food. This study analyzed the risk factors of negative emotions in esophageal cancer patients during the peri-radiotherapy period and its effects on malnutrition.

Methods

We retrospectively analyzed 339 patients with esophageal cancer during the peri-radiotherapy who received treatment at our hospital from April 2017 to April 2020, and followed up for 3 years. t test and Chi-square test were used to analyze the relationship between patients' negative emotions and clinical data. Binary logistics regression was performed to analyze the independent risk factors for the occurrence of negative mood and malnutrition in the patients. Kaplan-Meier survival curves were used to analyze survival rates.

Results

Our results showed that 18.3% of patients undergoing radiotherapy for esophageal cancer had negative emotions, and 41.9% suffered from malnutrition. The results of the binary logistic regression analysis showed that monthly household income (OR = 0.470, P = 0.022), the TNM stage (OR = 2.030, P = 0.044), concomitant gastrointestinal symptoms (OR = 2.071, P = 0.024), sleep status (OR = 2.540, P = 0.003), swallowing disorders (OR = 1.919, P = 0.048), and post-radiotherapy complications were independent risk factors for the development of negative emotions in patients. Negative emotions (OR = 2.547, P = 0.038) were also a risk factor for malnutrition in patients with esophageal cancer.

Conclusion

Many patients with esophageal cancer suffer from anxiety and depression in the peri-radiotherapy period, which might lead to complications such as malnutrition or aggravate and affect the prognosis of patients. Therefore, psychological care should be provided based on conventional care to effectively relieve their psychological pressure, and improve their prognosis and quality of life.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022338201.

Disrupted sleep and risk of depression in later life: A prospective cohort study with extended follow up and a systematic review and meta-analysis

BACKGROUND

Sleep difficulties increase the risk of current and future depression, but it is unclear if this relationship is causal.

METHODS

Prospective cohort study of a community sample of men aged 70-89 years followed for up to 17 years. Initial assessments occurred between 2001 and 2004. Participants were followed until death or 31 December 2018. Patient Health Questionnaire (PHQ-9) ≥ 10 at subsequent waves of assessments (every 2-3 years) or the recorded diagnosis of a depressive disorder in the Western Australian Data Linkage System marked the onset of depression during follow up. We excluded from follow up men with prevalent depression. The systematic review of longitudinal studies examining the association between disrupted sleep and depression in later life followed PRISMA guidelines.

RESULTS

3441 of 5547 older men reported sleep difficulties at study entry. Current or past depression affected 437 of 5547 participants. Of the 4561 older men free of depression, 2693 reported sleep difficulties. The hazard ratio (HR) of incident depression among participants with sleep problems was 1.67 (95%CI = 1.39-2.00). Statistical adjustments for age, place of birth, education, smoking and physical frailty did not change the effect-size of this association. The systematic review identified another 14 studies, and the meta-analysis yielded an overall risk ratio of depression of 1.82 (95%CI = 1.69-1.97), although the overall quality of available evidence was sub-optimal.

CONCLUSIONS

Disrupted sleep increases the risk of depression in later life and this seems unlikely to be due to reverse causality. Older adults with sleep difficulties are legitimate targets of interventions to prevent depression.

The interplay between multisite pain and insomnia on the risk of anxiety and depression: the HUNT study

BACKGROUND

Chronic musculoskeletal pain and insomnia frequently co-occur and are known independent risk factors for anxiety and depression. However, the interplay between these two conditions on the risk of anxiety and depression has not been explored.

METHODS

A population-based prospective study of 18,301 adults in the Norwegian HUNT Study without anxiety or depression at baseline (2006-2008). We calculated adjusted risk ratios (RRs) with 95% confidence intervals (CIs) for anxiety and/or depression at follow-up (2017-2019), associated with i) number of chronic pain sites, and ii) chronic pain and insomnia symptoms jointly.

RESULTS

At follow-up, 2155 (11.8%) participants reported anxiety and/or depression. The number of pain sites was positively associated with risk of anxiety and/or depression (P_trend, < 0.001). Compared to people without chronic pain and insomnia symptoms, people with ≥5 pain sites and no insomnia symptoms had a RR of 1.52 (95% CI: 1.28 to 1.81) for anxiety and/or depression, those with no chronic pain but with insomnia had a RR of 1.78 (95% CI: 1.33 to 2.38), whereas the RR among people with both ≥5 pain sites and insomnia was 2.42 (95% CI: 1.85 to 3.16). We observed no synergistic effect above additivity for the combination of ≥5 pain sites and insomnia on risk of anxiety and/or depression.

CONCLUSIONS

This study shows that people with multisite chronic pain who also suffer from insomnia are at a particularly high risk for anxiety and/or depression, suggesting that insomnia symptoms are important contributors to the association between multisite pain and common mental health problems.

Sleep disorders and non-sleep circadian disorders predict depression: a systematic review and meta-analysis of longitudinal studies

Patients with depression often suffer from sleep disorders and non-sleep circadian disorders. However, whether they precede and predict subsequent depression is unclear. We conducted a meta-analysis of studies on sleep disorders and non-sleep circadian disorders. We found insomnia, hypersomnia, short and long sleep duration, obstructive sleep apnea, restless legs syndrome and eveningness orientation at baseline all led to subsequent depression. Those with propensity to late meal patterns, heightened levels of cortisol in awakening response and low robustness of rest-activity rhythm at baseline had higher risks for later depression. Among insomnia subtypes, difficulty initiating sleep and difficulty maintaining sleep predicted future depression. Notably, persistent insomnia at baseline contributed to more than two-fold risk of incident depression compared to insomnia. Moreover, insomnia symptom numbers showed dose-dependent relationship with the incident depression. In conclusion, different types of sleep disorders and non-sleep circadian disorders were proven to be risk factors of subsequent depression, and mechanisms underlying the relationship between sleep disorders, non-sleep circadian disorders and subsequent depression should be further elucidated in the future.

Pain, Sleep, and Health-Related Quality of Life after Multidisciplinary Intervention for Chronic Pain

Multidisciplinary pain-management programs have the potential to decrease pain intensity, improve health-related quality of life (HRQOL), and increase sleep quality. In this longitudinal prospective cohort study, the aim was to investigate the long-term effects of multidisciplinary pain rehabilitation interventions in Iceland. More precisely, we (a) explored and described how individuals with chronic pain evaluated their pain severity, sleep, and HRQOL at pre-treatment and at one-year follow-up and (b) examined what predicted the participants' one-year follow-up HRQOL. Seventy-nine patients aged 20-68 years, most of whom were women (85%), responded. The participants scored their pain lower at one-year follow-up (p < 0.001). According to their response, most of them had disrupted sleep, mainly because of pain. One year after the treatment, more participants slept through the night (p = 0.004), and their HRQOL increased. Higher pre-treatment mental component summary (MCS) scores and having pursued higher education predicted higher MCS scores at one-year follow-up, and higher pre-treatment physical component summary (PCS) scores predicted higher PCS scores at one-year follow-up. Sleep problems, being a woman, and having children younger than 18 years of age predicted lower MCS scores at one-year follow-up. These findings are suggestive that patients should be examined with respect to their mental status, and it could be beneficial if they received some professional support after completing the intervention.

Positive Encounters as a Buffer: Pain and Sleep Disturbances in Older Adults' Everyday Lives

Objectives: To test whether older adults' pain was bidirectionally associated with nighttime sleep disturbances and whether daily positive encounters attenuated these associations. Methods: Participants (N = 292, mean = 73.71 years old) from the Daily Experiences and Well-being Study indicated pain and positive encounters with close partners (e.g., family and friends) and nonclose partners (e.g., acquaintances and service providers) every 3 hours throughout each day across 4-6 days. They also reported nighttime sleep disturbances the following morning. Results: Multilevel models revealed that participants with more prior nighttime sleep disturbances reported more severe pain the next day. This link was attenuated on days when participants had a greater proportion of positive encounters or viewed encounters as more pleasant, especially when these encounters occurred with close partners. Discussion: This study identifies benefits of positive encounters to older adults and sheds light on ways that may alleviate their pain from a social perspective.

The Effect of Pain Catastrophizing on Depression among Older Korean Adults with Chronic Pain: The Mediating Role of Chronic Pain Interference and Sleep Quality

Pain catastrophizing is a notable concept associated with change in chronic pain interference and depression. Sleep quality is also one of the important factors affecting geriatric depression. This study examined the mediating effects of chronic pain interference and sleep quality on the relationship between pain catastrophizing and depression. This study is a secondary data analysis that analyzed a total of 138 older Korean adults with chronic pain. The participants were selected from a single elderly daycare center in a city in South Korea. Also, the multiple regression analysis and PROCESS macro with bootstrapping were used. The results revealed that chronic pain interference and sleep quality mediated the relationship between pain catastrophizing and depression, respectively. Furthermore, chronic pain interference and sleep quality sequentially and dually mediated the effect of pain catastrophizing on depression. In the management of depression in the elderly, persistent complaints of pain should not be disregarded, irrespective of the intensity of their chronic pain. Psychological intervention is needed to alleviate negative thoughts about chronic pain and to increase the ability to cope with chronic pain. In addition, it is important to assess sleep patterns and to develop interventions to improve sleep quality, because depression in the elderly could appear as a symptom of a sleep problems.

BMI influences relationships among health factors for adults with persistent pain who use prescription opioids

BACKGROUND

Long-term use of prescription opioids for pain results in negative health outcomes. Overweight and pain are related, and adults with either condition commonly report poor sleep quality, high levels of depression, low levels of self-efficacy, and high pain interference and intensity. Insufficient research exists regarding how weight may influence pain outcomes in the context of common symptoms.

PURPOSE

To investigate how body mass index (BMI) influences relationships between health factors and pain outcomes among adults with pain prescribed opioids.

METHODS

The sample included 226 adults. Linear regression models tested relationships among variables and outcomes of pain intensity and pain interference.

FINDINGS

BMI significantly strengthened relationships between health factors and pain interference but not pain intensity.

DISCUSSION

Adults with persistent pain suffer worsened pain interference in the context of increased weight status. Nurses should consider addressing BMI as part of a holistic pain management care plan.

Consequences of Chronic Non-Cancer Pain in adulthood. Scoping Review

OBJECTIVE

To examine and map the consequences of chronic pain in adulthood.

METHOD

Documents addressing the impact of chronic pain on the psychological and social spheres of people suffering from chronic pain, published in Spanish and English between 2013 and 2018, were included. Those who addressed pharmacological treatments, chronic pain resulting from surgical interventions or who did not have access to the full text were excluded. Finally, 28 documents from the 485 reviewed were included

RESULTS

Studies show that pain is related to high rates of limitation in daily activities, sleep disorders and anxiety-depression spectrum disorders. People in pain have more problems to get the workday done and to maintain social relationships. Chronic pain is also associated with worse family functioning.

CONCLUSIONS

This review shows that limitations in the ability to perform activities of daily living, sleep, psychological health, social and work resources and family functioning are lines of interest in published articles. However, knowledge gaps are detected in areas such as the influence of having suffered pain in childhood or adolescence, the consequences of non-fulfillment of working hours and gender inequalities.

Association of sleep quality with telomere length, a marker of cellular aging: A retrospective cohort study of older adults in the United States

BACKGROUND

Sleep quality is a risk factor for age-related diseases, and although the underlying mechanisms remain unclear, the effects of poor sleep quality on telomere length (TL) may play a role.

OBJECTIVE

The objective of the study was to evaluate the independent association between sleep quality and salivary TL in a large sample of older adults.

DESIGN

We adopted a retrospective cohort design, and participants comprised 5,268 adults drawn from the Health and Retirement Study. We used the 2006 (baseline) and 2008 (follow-up) waves. Baseline sleep quality was assessed using 4 Likert scale questions (trouble falling asleep, waking up during the night, waking up too early and not being able to fall sleep again, and feeling well rested in the morning). The TL was assessed using the T/S ratio, a continuous variable. The associations between sleep quality and T/S were assessed using multivariable ordinary least squares regressions. All analyses were adjusted for demographics, lifestyle characteristics, psychosocial, and other factors.

RESULTS

Overall, 16% reported never feeling well rested in the morning; 25.7% of respondents always had trouble waking during the night; and 12.8% always had trouble waking up too early in the morning. Respondents who never felt rested in the morning had significantly shorter TL than those who always felt rested in the morning (adjusted beta = -0.08, standard error = 0.03, P < .01). The composite sleep measure was not significantly associated with shorter TL.

CONCLUSIONS

In this cohort of older adults, not feeling well rested in the morning was significantly and inversely associated with TL; however, the composite measure of sleep quality was not significantly associated with TL. These findings suggest a potential connection between one of the measures of impaired sleep and reduction in TL, a marker of cellular aging that has been linked to multiple chronic conditions.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Sleep problems increase the risk of musculoskeletal pain in boys but not girls: a prospective cohort study

Adults with sleep problems are at higher risk for onset of musculoskeletal pain, but the evidence is less clear for children. This prospective cohort study investigated whether children with sleep problems are at higher risk for onset of musculoskeletal pain and explored whether sex is a modifier of this association. In a prospective cohort study of Australian schoolchildren (n = 1239, mean age 9 years), the associations between sleep problems at baseline and new onset of both musculoskeletal pain and persistent musculoskeletal pain (pain lasting > 3 months) 1 year later were investigated using logistic regression. The potential modifying effect of sex was also assessed. One-year incidence proportion for musculoskeletal pain onset is 43% and 7% for persistent musculoskeletal pain. Sleep problems were associated with musculoskeletal pain onset and persistent musculoskeletal pain onset in boys, odds ratio 2.80 (95% CI 1.39, 5.62) and OR 3.70 (1.30, 10.54), respectively, but not girls OR 0.58 (0.28, 1.19) and OR 1.43 (0.41, 4.95), respectively.Conclusions: Rates of musculoskeletal pain are high in children. Boys with sleep problems are at greater risk of onset of musculoskeletal pain, but girls do not appear to have higher risk. Consideration of sleep health may help prevent persistent musculoskeletal pain in children. What is Known: • Sleep problems are associated with the onset of musculoskeletal pain in adults. • It is not clear if the association between sleep problems and the onset of musculoskeletal pain is present also in children and if sex plays a role in this association. What is New: • This is the first large population-based study that has prospectively investigated the relationship between sleep problems and onset of musculoskeletal pain in school-aged children. • Children, especially boys with sleep problems, were at increased risk for the development of persistent musculoskeletal pain.

Chronic pain: a review of its epidemiology and associated factors in population-based studies

Chronic pain is a common, complex, and distressing problem that has a profound impact on individuals and society. It frequently presents as a result of a disease or an injury; however, it is not merely an accompanying symptom, but rather a separate condition in its own right, with its own medical definition and taxonomy. Studying the distribution and determinants of chronic pain allows us to understand and manage the problem at the individual and population levels. Targeted and appropriate prevention and management strategies need to take into account the biological, psychological, socio-demographic, and lifestyle determinants and outcomes of pain. We present a narrative review of the current understanding of these factors.

Can patients with low health literacy be identified from routine primary care health records? A cross-sectional and prospective analysis

Background

People with low health literacy (HL) are at increased risk of poor health outcomes, and receive less benefit from healthcare services. However, healthcare practitioners can effectively adapt healthcare information if they are aware of their patients’ HL. Measurements are available to assess HL levels but may not be practical for use within primary care settings. New alternative methods based on demographic indicators have been successfully developed, and we aim to test if such methodology can be applied to routinely collected consultation records.

Methods

Secondary analysis was carried out from a recently completed prospective cohort study that investigated a primary care population who had consulted about a musculoskeletal pain problem. Participants completed questionnaires (assessing general health, HL, pain, and demographic information) at baseline and 6 months, with linked data from the participants’ consultation records. The Single Item Literacy Screener was used as a benchmark for HL. We tested the performance of an existing demographic assessment of HL, whether this could be refined/improved further (using questionnaire data), and then test the application in primary care consultation data. Tests included accuracy, sensitivity, specificity, and area under the curve (AUC). Finally, the completed model was tested prospectively using logistic regression producing odds ratios (OR) in the prediction of poor health outcomes (physical health and pain intensity).

Results

In total 1501 participants were included within the analysis and 16.1% were categorised as having low HL. Tests for the existing demographic assessment showed poor performance (AUC 0.52), refinement using additional components derived from the questionnaire improved the model (AUC 0.69), and the final model using data only from consultation data remained improved (AUC 0.64). Tests of this final consultation model in the prediction of outcomes showed those with low HL were 5 times more likely to report poor health (OR 5.1) and almost 4 times more likely to report higher pain intensity (OR 3.9).

Conclusions

This study has shown the feasibility of the assessment of HL using primary care consultation data, and that people indicated as having low HL have poorer health outcomes. Further refinement is now required to increase the accuracy of this method.

Predictors of pain interference and potential gain from intervention in community dwelling adults with joint pain: A prospective cohort study

INTRODUCTION

There is little research on identifying modifiable risk factors that predict future interference of pain with daily activity in people with joint pain, and the estimation of the corresponding population attributable risk (PAR). The present study therefore investigated modifiable predictors of pain interference and estimated maximum potential gain from intervention in adults with joint pain.

METHODS

A population-based cohort aged ≥50 years was recruited from eight general practices in North Staffordshire, UK. Participants (n = 1878) had joint pain at baseline lasting ≥3 months and indicated no pain interference. Adjusted associations of self-reported, potentially modifiable prognostic factors (body mass index, anxiety/depressive symptoms, widespread pain, inadequate joint pain control, physical inactivity, sleep problems, smoking and alcohol intake) with onset of pain interference 3 years later were estimated via Poisson regression, and corresponding PAR estimates were obtained.

RESULTS

Inadequate joint-specific pain control, insomnia and infrequent walking were found to be independently significantly associated with the onset of pain interference after 3 years, with associated PARs of 6.3% (95% confidence interval -0.3, 12.4), 7.6% (-0.4, 15.0) and 8.0% (0.1, 15.2), respectively, with only the PAR for infrequent walking deemed statistically significant. The PAR associated with insomnia, infrequent walking and inadequate control of joint pain simultaneously was 20.3% (8.6, 30.4).

CONCLUSIONS

There is potential to reduce moderately the onset of pain interference from joint pain in the over-50s if clinical and public health interventions targeted pain management and insomnia, and promoted an active lifestyle. However, most of the onset of significant pain interference in the over-50s, would not be prevented, even assuming that these factors could be eliminated.

Asthma and allergy as risk factors for suicidal behavior among young adults

An association between allergic disease, depression and suicidality has been reported.

OBJECTIVE

To explore the relationships between suicidality and asthma, allergy, internet addiction, stress, sleep quality, pain/discomfort, and depression, among emerging adults.

PARTICIPANTS

929 college students completed an online survey between October 2015 and April 2017.

METHODS

A cross-sectional study using multivariate analysis techniques was implemented.

RESULTS

Using structural equation modeling, we found that allergies and stress were directly related to pain/discomfort; pain/discomfort was associated to poor sleep, depression, and suicidality. Sleep quality was also affected by stress; while sleep, stress, pain/discomfort, and internet addiction were directly related to depression (all p < .05). Ultimately, four factors impacted suicidality: stress, pain/discomfort, depression, and, indirectly, sleep quality (all p < .05). Although allergy had some effects, these did not reach statistical significance (p < .09).

CONCLUSION

Findings suggest that allergy might impact suicidality indirectly through increased pain/discomfort, poor sleep, and depression.

Cognitive behavioural therapy in pain and psychological disorders: Towards a hybrid future

Cognitive Behavioural Therapy (CBT) is a form of evidence-based talking therapy that emphasises the importance of behaviour and conscious thoughts in shaping our emotional experiences. As pain becomes increasingly accepted as not only a sensory but also an emotional experience, success in using CBT to treat emotional disorders has resulted in the incorporation of cognitive-behavioural principles into the management of chronic pain. Outcomes of CBT-informed interdisciplinary pain management programmes are modest at best, despite rapid methodological improvements in trial design and implementation. Whilst the field searches for new treatment directions, a hybrid CBT approach that seeks to simultaneously tackle pain and its comorbidities shows promise in optimising treatment effectiveness and flexibility. This article provides a brief description of the core characteristics of CBT and the transformation this therapeutic model has brought to our understanding and management of chronic pain. Current evidence on efficacy of CBT for chronic pain is then reviewed, followed by a critical consideration of the advantages and disadvantages of the new hybrid treatment approach that conceptualises and treats chronic pain in connection with its comorbidities. Recent progress made in the area of pain and insomnia is highlighted as an example to project therapeutic innovations in the near future.

Incident Chronic Spinal Pain and Depressive Disorders: Data From the National Comorbidity Survey

This study examined pre-existing depression as a risk factor for the development of chronic spinal pain, and pre-existing chronic spinal pain as a risk factor for the development of depression. Data from the National Comorbidity Survey, a stratified sample of 5,001 participants evaluated in 1990 to 1992 (NCS-1) and again in 2000 to 2001 (NCS-2) were used to address these associations. Cox regression was used to estimate hazard ratios and time-to-incidence after NCS-1. Participants with antecedent acute or chronic depressive disorders at NCS-1 were more likely to develop chronic spinal pain in the ensuing 10 years compared with participants without depressive disorders. Those with antecedent chronic spinal pain at NCS-1 were more likely to develop dysthymic disorder than subjects without chronic spinal pain at NCS-1; however, antecedent chronic spinal pain was not associated the subsequent development of major depressive disorder. These results suggest that both pain and depression are associated with the development of the other condition. In particular, chronic depression is more strongly linked to chronic spinal pain than is acute depression. The results are discussed in terms of the need to assess the presence of both disorders given the presence of one. PERSPECTIVE: Chronic spinal pain and depressive disorders, especially chronic depression, increase the likelihood for the subsequent development of the other condition. The results underscore the need to routinely assess for the presence of both disorders given the presence of one to mitigate the effects of developing comorbid conditions.

Sleep problems and fatigue as predictors for the onset of chronic widespread pain over a 5- and 18-year perspective

BACKGROUND

Previous research suggests that sleep problems may be an important predictor for chronic widespread pain (CWP). With this study we investigated both sleep problems and fatigue as predictors for the onset of CWP over a 5-year and an 18-year perspective in a population free from CWP at baseline.

METHODS

To get a more stable classification of CWP, we used a wash-out period, including only individuals who had not reported CWP at baseline (1998) and three years prior baseline (1995). In all, data from 1249 individuals entered the analyses for the 5-year follow-up and 791 entered for the 18-year follow-up. Difficulties initiating sleep, maintaining sleep, early morning awakening, non-restorative sleep and fatigue were investigated as predictors separately and simultaneously in binary logistic regression analyses.

RESULTS

The results showed that problems with initiating sleep, maintaining sleep, early awakening and non-restorative sleep predicted the onset of CWP over a 5-year (OR 1.85 to OR 2.27) and 18-year (OR 1.54 to OR 2.25) perspective irrespective of mental health (assessed by SF-36) at baseline. Also fatigue predicted the onset of CWP over the two-time perspectives (OR 3.70 and OR 2.36 respectively) when adjusting for mental health. Overall the effect of the sleep problems and fatigue on new onset CWP (over a 5-year perspective) was somewhat attenuated when adjusting for pain at baseline but remained significant for problems with early awakening, non-restorative sleep and fatigue. Problems with maintaining sleep predicted CWP 18 years later irrespective of mental health and number of pain regions (OR 1.72). Reporting simultaneous problems with all four aspects of sleep was associated with the onset of CWP over a five-year and 18-yearperspective, irrespective of age, gender, socio economy, mental health and pain at baseline. Sleep problems and fatigue predicted the onset of CWP five years later irrespective of each other.

CONCLUSION

Sleep problems and fatigue were both important predictors for the onset of CWP over a five-year perspective. Sleep problems was a stronger predictor in a longer time-perspective. The results highlight the importance of the assessment of sleep quality and fatigue in the clinic.

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda

A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.

Efficacy of Mirogabalin (DS-5565) on Patient-Reported Pain and Sleep Interference in Patients with Diabetic Neuropathic Pain: Secondary Outcomes of a Phase II Proof-of-Concept Study

Objective

To evaluate the effects of mirogabalin on patient-reported pain and sleep interference in diabetic peripheral neuropathic pain (DPNP).

Subjects

Adults (≥18 years) with type 1 or 2 diabetes, glycosylated hemoglobin of 10% or less at screening, and DPNP for six months or more were eligible for participation.

Methods

Subjects (N = 452) were randomly assigned (2:1:1:1:1:1:1) to receive placebo, dose-ranging mirogabalin (5, 10, 15, 20, 30 mg/day), or pregabalin (300 mg/day) for five weeks. Secondary efficacy end points studied here included patient global impression of change (PGIC), modified brief pain inventory (BPI), and average daily sleep interference score (ADSIS). Correlation plots were generated to examine the relationship between ADSIS and average daily pain score (ADPS).

Results

At week 5, significant reductions in ADSIS were observed in the mirogabalin 15, 20, and 30 mg/day groups, compared with placebo (P < 0.05). Baseline ADSIS and ADPS were strongly correlated (R2 = 0.4407), as were mean changes from baseline in ADSIS and ADPS at week 5 (R2 = 0.6694). The mirogabalin 30 mg/day group showed significant improvement compared with placebo in four of six BPI subscales at end point; the mirogabalin 15 mg/day group showed significant improvement in three of six BPI subscales (P < 0.05). At end of treatment, the percentage of subject with PGIC status of "much improved or better" was greater in all mirogabalin dose groups than in the placebo group (P < 0.05). A low incidence of treatment-related adverse events was reported for mirogabalin.

Conclusions

Results support the effectiveness of mirogabalin in improving patient-reported pain and sleep interference in DPNP.

Effects of sleep changes on pain-related health outcomes in the general population: A systematic review of longitudinal studies with exploratory meta-analysis

Emerging longitudinal research has highlighted poor sleep as a risk factor of a range of adverse health outcomes, including disabling pain conditions. In establishing the causal role of sleep in pain, it remains to be clarified whether sleep deterioration over time is a driver of pain and whether sleep improvement can mitigate pain-related outcomes. A systematic literature search was performed using PubMed MEDLINE, Ovid EMBASE, and Proquest PsycINFO, to identify 16 longitudinal studies involving 61,000 participants. The studies evaluated the effect of sleep changes (simulating sleep deterioration, sleep stability, and sleep improvement) on subsequent pain-related outcomes in the general population. A decline in sleep quality and sleep quantity was associated with a two- to three-fold increase in risk of developing a pain condition, small elevations in levels of inflammatory markers, and a decline in self-reported physical health status. An exploratory meta-analysis further revealed that deterioration in sleep was associated with worse self-reported physical functioning (medium effect size), whilst improvement in sleep was associated with better physical functioning (small effect size). The review consolidates evidence that changes in sleep are prospectively associated with pain-related outcomes and highlights the need for further longitudinal investigations on the long-term impact of sleep improvements.

The pain, depression, disability pathway in those with low back pain: a moderation analysis of health locus of control

Low back pain (LBP) is common, impacts on the individual and society, and is a major health concern. Psychological consequences of LBP, such as depression, are significant barriers to recovery, but mechanisms for the development of depression are less well understood. One potential mechanism is the individual’s health locus of control (HLoC), that is, perception of the level of control an individual has over their health. The objective of this study is to investigate the moderation effect of HLoC on the pain–depression–disability pathway in those with LBP. The design is a nested cross-sectional analysis of two existing cohorts of patients (n=637) who had previously consulted their primary care physician about LBP. Measures were taken of HLoC, pain intensity and interference, depression, disability, and bothersomeness. Structural Equation Modeling analysis was applied to two path models that examined the pain to depression to disability pathway moderated by the HLoC constructs of Internality and Externality, respectively. Critical ratio (CR) difference tests were applied to the coefficients using pairwise comparisons. The results show that both models had an acceptable model fit and pathways were significant. CR tests indicated a significant moderation effect, with stronger pathway coefficients for depression for those who report low Internality (β 0.48), compared to those with high Internality (β 0.28). No moderation effects were found within the Externality model. HLoC Internality significantly moderates the pain–depression pathway in those with LBP, meaning that those who have a low perception of control report greater levels of depression. HLoC may signify depression among people with LBP, and could potentially be a target for intervention.

Does physical activity buffer insomnia due to back and neck pain?

INTRODUCTION

Musculoskeletal pain is highly prevalent and a burden to society, recurrent and persistent low back pain (LBP) and neck pain (NP) being the most common conditions. They are associated with other poor health outcomes such as sleep problems. Physical activity (PA) prevents LBP and NP, but the direct effect on sleep is unclear. This study explored the effect of pain on insomnia, and examined if adherence to moderate-to-high intensity levels of PA influenced this relationship.

METHODS

In this prospective observational study, 1821 workers were followed over 3 years. Data included self-rated measures of LBP and NP, insomnia and level and amount of PA. Pain variables were used in a "risk profile" for future sick-listing, insomnia was categorized into those with and without such problems, and adherence to PA was defined as reporting moderate-to-high levels in two consecutive years. In Poisson regression models, individuals with pain risk profiles were analysed according to PA adherence for the outcome insomnia. Repeated measurements allowed control for prior pain.

RESULTS

In this mainly male working population, individuals with a risk profile for LBP and NP had a significant increased risk (RR = 1.5) of developing insomnia one year later when not adhering to moderate-to-high levels of PA. Among those not reporting prior pain, the risk was even larger (RR = 2.5). Generalizability may be restricted to relatively healthy males. The individuals who reported a pain risk profile two consecutive years did not get the buffer effect from adhering to moderate-to-high levels of PA in terms of developing insomnia.

Interplay among pain intensity, sleep disturbance and emotion in patients with non-specific low back pain

Background

Low back pain (LBP) is the most common problem worldwide. There are several negative consequences of LBP, such as sleep disorders, work leave, disability, depression, anxiety, and poor quality of life. In this study, we designed to evaluate the prevalence of sleep disturbance in patients with non-specific LBP(NSLBP), and cross-correlation among sleep disorder, anxiety, depression and pain intensity in patients with NSLBP.

Aim

In this study, we designed to evaluate the prevalence of sleep disturbance in patients with NSLBP, and cross-correlation among sleep disorder, anxiety, depression and pain intensity in patients with NSLBP.

Methods

A cross-sectional self-assessment questionnaire survey was carried out in an outpatient clinic. Anonymous assessments were used to characterize the presence of NSLBP, PSQI, VAS, SF-36 form, ODI, BAI and BDI. Cross-correlation among the severity of NSLBP and sleep disturbance, anxiety, depression and life quality were evaluated.

Results

Patients with NSLBP have a higher incidence of sleep disorder, anxiety and depression, and higher ODI scores than healthy people without LPB (P < 0.01). NSLBP patients with sleep disorders have more severe anxiety, depression, an increased VAS score and poor daily living (P < 0.05). NSLBP patients with anxiety have declined sleep quality, poor daily living, decreased work and social skills, and increased LBP severity (P < 0.05). NSLBP patients with depression have declined sleep quality, poor daily living, decreased work and social skills (P < 0.05). Significant associations were found between the severity of NSLBP and sleep disorders, anxiety and ODI scores.

Conclusion

Psychological and social factors play an important role in the development of NSLBP. NSLBP leads to sleep disorders, which decrease the sleep quality and increase the unpleasant emotions and memories in return; these can exacerbate the severity of LBP, with the cycle repeating to form a vicious circle.

Causal Mediation in the Development of Painful Temporomandibular Disorder

We explored causal mediation of sleep quality and perceived stress in development of painful temporomandibular disorder (TMD). Sleep quality and perceived stress were assessed at baseline and quarterly intervals thereafter in 2,737 initially TMD-free adults in the Orofacial Pain Prospective Evaluation and Risk Assessment study (OPPERA) prospective cohort study. During follow-up, incident TMD cases were classified using research diagnostic criteria. Mediation analysis was conducted using a weighted Cox proportional hazards regression model that estimated hazard ratios (HRs) and 95% confidence limits (CL) of first-onset TMD. Models determined whether: 1) poor sleep quality during follow-up mediated the effect of baseline perceived stress on first-onset TMD, and 2) perceived stress during follow-up mediated the effect of baseline poor sleep quality on first-onset TMD. In both analyses, the total effect was decomposed into natural direct and indirect effects. Poor baseline sleep quality led to heightened perceived stress that then contributed to TMD development. When the total effect of poor sleep quality (HR = 2.10, CL = 1.76, 2.50) was decomposed, 34% of its effect was mediated by perceived stress (indirect effect HR = 1.29, CL = 1.06, 1.58). The effect of perceived stress on first-onset TMD was not mediated by sleep quality. Improving sleep may avert escalation of stress, limiting effects of both factors on TMD development.

PERSPECTIVE

Causal mediation analysis highlights mechanisms by which poor sleep quality promotes development of TMD. First, poor sleep quality exerts a direct effect on pain. Second, it triggers a heightened perception of stress, which acts as an intermediate factor in the causal pathway between poor sleep quality and first-onset TMD pain.

Cooccurrence and bidirectional prediction of sleep disturbances and depression in older adults: Meta-analysis and systematic review

The present study pooled the prevalence of sleep disturbances and depression in community-dwelling older adults (mean age≥60years) and quantified the strength of evidence of the relationship between these two problems. From 23 cross-sectional studies and five sets of baseline data, a high pooled prevalence of sleep disturbances (30.5%), depressive symptoms (18.1%) and coexisting disorders (10.6%) were found. In the 23 cohort studies, self-reported sleep disturbances increased the risk of the onset of depression (relative risk [RR]=1.92). Persistent sleep disturbances increased the risk of the development (RR=3.90), recurrence (RR=7.70), and worsening (RR=1.46) of depression in older adults. Little support was found for a predictive role for objective sleep characteristics in the development of depression. Older adults with depression had a higher risk of developing (RR=1.72) and worsening (RR=1.73) symptoms of sleep disturbances. This review emphasizes the importance of timely interventions in incipient sleep disturbances and depression among older adults, preventing the development of more serious comorbidities.

Insomnia and the risk of depression: a meta-analysis of prospective cohort studies

BACKGROUND

Observational studies suggest that insomnia might be associated with an increased risk of depression with inconsistent results. This study aimed at conducting a meta-analysis of prospective cohort studies to evaluate the association between insomnia and the risk of depression.

METHODS

Relevant cohort studies were comprehensively searched from the PubMed, Embase, Web of Science, and China National Knowledge Infrastructure databases (up to October 2014) and from the reference lists of retrieved articles. A random-effects model was used to calculate the pooled risk estimates and 95 % confidence intervals (CIs). The I ² statistic was used to assess the heterogeneity and potential sources of heterogeneity were assessed with meta-regression. The potential publication bias was explored by using funnel plots, Egger's test, and Duval and Tweedie trim-and-fill methods.

RESULTS

Thirty-four cohort studies involving 172,077 participants were included in this meta-analysis with an average follow-up period of 60.4 months (ranging from 3.5 to 408). Statistical analysis suggested a positive relationship between insomnia and depression, the pooled RR was 2.27 (95 % CI: 1.89-2.71), and a high heterogeneity was observed (I ²  = 92.6 %, P < 0.001). Visual inspection of the funnel plot revealed some asymmetry. The Egger's test identified evidence of substantial publication bias (P <0.05), but correction for this bias using trim-and-fill method did not alter the combined risk estimates.

CONCLUSIONS

This meta-analysis indicates that insomnia is significantly associated with an increased risk of depression, which has implications for the prevention of depression in non-depressed individuals with insomnia symptoms.

The pain-depression dyad and the association with sleep dysfunction in chronic rhinosinusitis

BACKGROUND

Depression, pain, and sleep disturbance is a symptom cluster often found in patients with chronic illness, exerting a large impact on quality of life (QOL). A wealth of literature exists demonstrating a significant association between depression, pain, and sleep dysfunction in other chronic diseases. This relationship has not been described in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-eight adult patients with CRS were prospectively enrolled. Patients at risk for depression were identified using the Patient Health Questionnaire-2 (PHQ-2) using a cut-off score of ≥1. Pain experience was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short Form McGill Pain Questionnaire (SF-MPQ). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Forty-seven patients were at risk for depression. Significant positive correlations were found between total PSQI scores and all pain measures (R = 0.38-0.61, p ≤ 0.05) and between total PSQI scores and PHQ-2 scores (R = 0.46, p < 0.05). For patients at risk for depression, significant, positive correlations were found between pain measures, the total PSQI score, and the 3 PSQI subdomains (sleep latency, sleep quality, and daytime dysfunction; R = 0.31-0.61, p < 0.05). The relationship between pain and sleep dysfunction scores was not seen in the absence of depression.

CONCLUSION

Depression, pain, and sleep dysfunction are interrelated in patients with CRS. In the absence of depression, significant correlations between pain and sleep are not observed, suggesting that depression plays a key role in this interaction. Further research is needed to investigate the complex relationship between depression, pain, and sleep dysfunction in CRS.

Pain grade and sleep disturbance in older adults: evaluation the role of pain, and stress for depressed and non-depressed individuals

OBJECTIVE

The aim of this paper was to assess the relationship between pain and sleep in older adults taking depression, stress, and medical comorbidities into account.

METHODS

A cross-sectional analysis was performed using Einstein Aging Study, a community-based cohort study of adults aged 70 years and older. Ratings of pain intensity and interference from the Medical Outcomes Study (MOS) Short-Form 36 were used to assign individuals to low-pain versus high-pain severity. Sleep disturbance was assessed using the nine-item sleep problems index from the Medical Outcomes Study Sleep Scale. Other measures included the Geriatric Depression Scale and Perceived Stress Scale (PSS). Linear regression models were used to assess the association between pain grade and sleep disturbance adjusted for demographics, PSS, Geriatric Depression Scale, and other comorbidities.

RESULTS

Five hundred sixty-two eligible participants with a mean age of 78.22 years (standard deviation = 5.43) were included; 64% were women. Pain grade [β = 5.40, 95% confidence interval (CI) 2.56-8.21, p < 0.001] was associated with sleep disturbance after adjusting for demographic variables. In models including pain grade (β = 3.08, 95% CI 0.32-5.85, p = 0.03) and PSS (β = 0.57, 95% CI 0.39-0.75, p < 0.001), both were associated with sleep disturbance, although the PSS attenuated the relationship between pain and sleep by 34%. Depression, when added to previous model, was also associated with sleep (β = 2.17, 95% CI 1.48-2.85, p < 0.001) and attenuated the relationship between pain (β = 2.41, 95% CI -0.25 to 5.08, p = 0.07) and sleep by 22%. Stratified for depression, we found that pain, stress, and other medical comorbidities were significantly associated with sleep disturbance in non-depressed individuals but not individuals with depression.

CONCLUSIONS

Pain, stress, and medical comorbidities are associated with sleep disturbance, especially in non-depressed older adults.

The Unhappy Triad: Pain, Sleep Complaints, and Internalizing Symptoms

There is limited understanding of the etiology and temporal relations of chronic pain, sleep complaints, and depression/anxiety. Several models have been proposed by which sleep disruption represents a common mechanism for the comorbidity of these symptoms. The goals of this study were to 1) clarify the boundaries of these domains and to 2) examine the relations of these symptoms over time following exposure to stressful and potentially traumatic experiences during a combat deployment. We found support for three distinct domains of sleep complaints, internalizing symptoms, and physical complaints. We tested two competing models that have been proposed in the literature, controlling for negative and positive emotionality. Internalizing symptoms strongly mediated the relation between sleep complaints and pain (total effect = .15, direct effect = -.05). The study suggests that increases in sleep complaints immediately following deployment increase the risk of internalizing symptoms and pain several years after deployment.

The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial

OBJECTIVE

The goal of this study was to examine the bidirectional relationship of sleep and pain to determine whether changes in sleep complaints over the course of a chronic pain treatment trial predict pain outcomes and vice versa, controlling for changes in depression and anxiety.

METHODS

Data were analyzed from a 12-month randomized, controlled trial that tested the effectiveness of a collaborative care intervention for veterans with chronic musculoskeletal pain. Participants were 250 veterans from 5 primary care clinics in a Veteran Affairs (VA) medical center. Measures of pain, sleep, and depression/anxiety symptoms were collected at baseline, 3 months, and 12 months. Factor analysis was used to clarify the boundaries of these domains, and structural equation modeling was used to examine whether changes in sleep complaints and depression/anxiety during the trial predicted pain at the end of the trial, controlling for covariates. An alternative model was also tested in which changes in pain predicted sleep complaints.

RESULTS

Changes in sleep complaints at 3 months significantly predicted changes in pain at 12 months (standardized path coefficient = .29, p < .001). To a lesser extent, changes in pain predicted changes in sleep (standardized path coefficient = .15, p < .05). Changes in depression/anxiety did not significantly predict changes in pain or sleep. There was also evidence of differential relations of specific sleep complaints with pain.

CONCLUSIONS

This work helps to further disentangle the complex relationship between pain and sleep. This bidirectional relationship may need to be considered to improve pain outcomes.

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.

The effects of daily mood and couple interactions on the sleep quality of older adults with chronic pain

We examined the effect of daily negative and positive mood on the sleep quality of knee osteoarthritis (OA) patients (N = 152) and whether a partner's daily responses to a patient's pain behaviors moderated these associations. Patients and their partners completed a baseline interview and 22 daily diary assessments. After controlling for demographic characteristics, OA severity, comorbidities, medication use, relationship satisfaction, and depressed mood, multilevel modeling analyses demonstrated main effects of negative and positive mood on sleep quality indicators. Mood and partner responses interacted such that high solicitous and punishing responses strengthened the association between negative mood and worse sleep. Further, high solicitous responses increased the degree of association between low positive mood and poor sleep, and empathic responses combined with positive mood were associated with better sleep. Results demonstrate that daily negative and positive mood fluctuations can interact with partner responses to affect sleep quality among older adults with chronic pain.