ArticleLiterature Review

Postoperative sleep disruptions: A potential catalyst of acute pain?

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... These papers agree that sleep alterations are mainly changes in sleep pattern/cycles in the first postoperative days. The changes in sleep cycles are sleep fragmentation, reduced total sleep time and loss of time spend in slow wave sleep (SWS) and rapid eye movement (REM) sleep [12][13][14][15][16]. Suppressed REM sleep is compensated with rebound REM sleep in following nights which is correlated with apnoea, ventricular tachycardia, severe bradycardia [17]. ...
... Sleep quality is one of the postoperative complications that has been less studied [3,17]. Sleep quality impairment may affect patient's recovery and well-being after surgery, so it should be routinely evaluated [8][9][10]12,[14][15][16]. Certain postoperative symptoms and signs are already analysed and treated before discharge like pain, nausea, hemodynamic stability, bleeding and dizziness [4,6,13,14,16,20]. ...
... Sleep quality is one of the postoperative complications that has been less studied [3,17]. Sleep quality impairment may affect patient's recovery and well-being after surgery, so it should be routinely evaluated [8][9][10]12,[14][15][16]. Certain postoperative symptoms and signs are already analysed and treated before discharge like pain, nausea, hemodynamic stability, bleeding and dizziness [4,6,13,14,16,20]. Pain and nausea are the most common side effects in the postoperative recovery period [4,6,20]. ...
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Evaluate the postoperative quality of sleep in patients submitted to ambulatory surgery and additionally compare who spent the first night at the hospital and those who returned home.
... These conditions amplify each other, increase postoperative complications, and affect well-being and recovery of patients. For example, pain after surgery can lead to stress or anxiety (Desborough, 2000), altered sleep (Chouchou et al., 2014;Rosenberg-Adamsen et al., 1996), functional decline (Gan, 2017;Peters et al., 2007), and respiratory complications due to ineffective breathing (Chouchou et al., 2014). Inversely, disrupted sleep and anxiety may contribute to increased pain perception and hinder effective pain management (Chouchou et al., 2014;Vaughn et al., 2007). ...
... These conditions amplify each other, increase postoperative complications, and affect well-being and recovery of patients. For example, pain after surgery can lead to stress or anxiety (Desborough, 2000), altered sleep (Chouchou et al., 2014;Rosenberg-Adamsen et al., 1996), functional decline (Gan, 2017;Peters et al., 2007), and respiratory complications due to ineffective breathing (Chouchou et al., 2014). Inversely, disrupted sleep and anxiety may contribute to increased pain perception and hinder effective pain management (Chouchou et al., 2014;Vaughn et al., 2007). ...
... For example, pain after surgery can lead to stress or anxiety (Desborough, 2000), altered sleep (Chouchou et al., 2014;Rosenberg-Adamsen et al., 1996), functional decline (Gan, 2017;Peters et al., 2007), and respiratory complications due to ineffective breathing (Chouchou et al., 2014). Inversely, disrupted sleep and anxiety may contribute to increased pain perception and hinder effective pain management (Chouchou et al., 2014;Vaughn et al., 2007). Moreover, psychological stress is associated with the disruption of biomarkers associated with wound healing (Walburn et al., 2009). ...
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Objectives Gaining an understanding of postoperative patients’ environmental needs, barriers, and facilitators for optimal healing. Background An optimal hospital environment (the “healing environment”) can enhance patients’ postoperative recovery and shorten length of stay. However, insights lack into patients’ lived environmental needs for optimal healing after surgery and how these needs are being met. Method A qualitative study was conducted between August 2016 and August 2017 with 21 patients who underwent elective major abdominal surgery in a Dutch university hospital. Data were collected through context-mapping exercises and interviews to capture patients’ lived experiences and explore the meaning of these experiences. Data were systematically analyzed according to the principles of thematic content analysis. Results Three themes were identified. First, participants want a sense of control over their treatment, ambient features, privacy, nutrition, and help requests. Participants described the need for positive distractions: personalizing the room, connecting with the external environment, and the ability to undertake activities. Finally, participants expressed the importance of functional, practical, and emotional support from professionals, peers, and relatives. According to participants, the hospital environment often does not meet their healing needs while being hospitalized. Conclusion The hospital environment often does not meet patients’ needs. Needs fulfillment can be improved by practical adjustments to the physical and interpersonal environment and considering patient’s individual preferences and changing needs during recovery. Patient narratives, pictures, and drawings are valuable sources for hospital managers in their efforts to design evidence-based environments that anticipate to patient-specific needs for achieving early recovery.
... Following major operations, patients commonly report poor sleep quality [11]. Almost half (42%) of patients report unsatisfactory sleep after orthopaedic, vascular and general surgery [12]. Poor sleep quality is commonly managed with hypnotic medicines, including z-drugs, melatonin and benzodiazepines. ...
... Midazolam was more effective than placebo at reducing pain intensity up to 12 The trials in which the hypnotic medicines were delivered intranasally or intramuscularly were not compared to a placebo so were not included in the metaregression. ...
Article
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Background: This systematic review aimed to investigate whether the administration of hypnotic medicines, z-drugs, melatonin or benzodiazepines, reduced pain intensity postoperatively. Methods: Medline, Embase, Cinahl, Psych info, Central and PubMed databases were searched, from inception to February 2020 to identify relevant trials. The search was extended, post hoc, to include meta-Register of Controlled Trials, the Web of Science and the conference booklets for the 14th, 15th, and 16th International Association for the Study of Pain conferences. Two independent reviewers screened titles and abstracts and cross-checked the extracted data. Results: The search retrieved 5546 articles. After full-text screening, 15 trials were included, which had randomised 1252 participants. There is moderate-quality evidence that in the short-term [WMD - 1.06, CI - 1.48 to - 0.64, p ≤ .01] and low-quality evidence that in the medium-term [WMD - 0.90, CI - 1.43 to - 0.37, p ≤ .01] postoperative period oral zolpidem 5/10 mg with other analgesic medicines reduced pain intensity compared to the same analgesic medicines alone. There is low-quality evidence that melatonin was not effective on postoperative pain intensity compared to placebo. The results of benzodiazepines on pain intensity were mixed. The authors reported no significant adverse events. Conclusions: There is promising evidence that the hypnotic medicine zolpidem, adjuvant to other analgesics, is effective at achieving a minimally clinically important difference in pain intensity postoperatively. There is no consistent effect of melatonin or benzodiazepines on postoperative pain intensity. Readers should interpret these results with some caution due to the lack of data on safety, the small number of trials included in the pooled effects and their sample sizes. Systematic review registration: The protocol for this systematic review was registered with PROSPERO ID= CRD42015025327 .
... However, perioperative sleep is frequently disrupted by many factors, including postoperative pain, environmental and surgical stress, anesthesia, and other factors that lead to discomfort (Whitlock et al., 2017;Su and Wang, 2018). Postoperative sleep disruptions manifest as sleep fragmentation and reduced slow-wave and REM sleep durations (Chouchou et al., 2014). In particular, REM sleep disorder may significantly negatively affect postoperative cognition (Lazic et al., 2017). ...
... Postoperative pain remains a significant health care issue that disturbs sleep in the postoperative period, and sleep disturbances may, in turn, exacerbate postoperative pain (Chouchou et al., 2014). Anesthesia is substantially different from natural sleep, sometimes interfering with the circadian rhythm and disrupting the sleep cycle, subsequently affecting glymphatic clearance (Lazic et al., 2017). ...
Article
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Perioperative neurocognitive disorder (PND) frequently occurs in the elderly as a severe postoperative complication and is characterized by a decline in cognitive function that impairs memory, attention, and other cognitive domains. Currently, the exact pathogenic mechanism of PND is multifaceted and remains unclear. The glymphatic system is a newly discovered glial-dependent perivascular network that subserves a pseudo-lymphatic function in the brain. Recent studies have highlighted the significant role of the glymphatic system in the removal of harmful metabolites in the brain. Dysfunction of the glymphatic system can reduce metabolic waste removal, leading to neuroinflammation and neurological disorders. We speculate that there is a causal relationship between the glymphatic system and symptomatic progression in PND. This paper reviews the current literature on the glymphatic system and some perioperative factors to discuss the role of the glymphatic system in PND.
... Endoscopic nasal surgery is a common type of otolaryngology procedure that can minimize surgical invasiveness; however, surgical trauma and nasal packing may still cause moderate pain [1,2] and sleep disturbances [3] postoperatively. This may have additive deterioration effects [4] and prolong the rehabilitation process [5]. When the expected postoperative pain ranges from moderate to serious, routine analgesic treatment is usually provided through non-opioid analgesics with rescue opioids [6]; unfortunately, the current pain management situation has been poor overall. ...
... Second, postoperative pain plays an important role in the change of sleep quality after surgery. The relationship between pain and sleep quality is reciprocal; poor sleep leads to heightened sensitivity to pain, and high levels of pain are significant predictors of poor sleep [4,5]. Effective postoperative pain management might break the cycle and promote sleep improvement. ...
Article
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Study objectiveBilateral endoscopic nasal surgery is usually associated with pain and sleep disturbance. The aim of this study was to evaluate the effects of dexmedetomidine-soaked nasal packing on analgesia and improvement of sleep quality in patients undergoing this surgery.Method Eighty patients were enrolled and randomly allocated into 4 groups. At the end of surgery, dexmedetomidine-soaked nasal packings were applied to three groups with a dosage of 1 μg kg−1 (D1), 2μg kg−1 (D2), 4 μg kg−1 (D4) and normal saline-soaked nasal packing (NS) was applied to a fourth group. The primary outcome was postoperative pain scores using a visual analog scale (VAS) recorded at six time points: before the surgery (T1); 2 h (T2), 8 h (T3), 24 h (T4), 48 h (T5) after surgery; and at the moment of nasal packing removal (T6). Secondary outcomes were postoperative sleep status evaluated by the Pittsburgh sleep quality index (PSQI) and subjective sleep quality value (SSQV). Factors affecting sleep, hemodynamic changes, and adverse events were also recorded.ResultsCompared with the NS group, dexmedetomidine-soaked nasal packing significantly relieved postoperative pain and improved sleep quality. The effect was similar between D2 and D4, which was greater than in D1. However, D2 was associated with fewer adverse events.Conclusions Dexmedetomidine-soaked nasal packing not only offers effective analgesia but also improves postoperative sleep quality in patients undergoing bilateral endoscopic nasal surgery. Taking effect and adverse events into consideration, a dosage of 2μg kg−1 may be optimal.Trial registrationwww.chictr.org.cn/index.aspx (ChiCTR1900025692) Retrospectively registered 5 September 2019
... Psychologically, the patient expects postsurgical pain and therefore worry, anxiety, and pain anticipation are inevitably part of the acute pain experience. Knowledge about factors relating to both pain experience and sleep disturbances reveals similarities in the development of both, such as negative expectations and psychological distress [10][11][12][13][14][15]. The physiological processes behind postsurgery healing may not be as efficient if the patient also suffers from insomnia [15,16]. ...
... Sleep disturbances are quite frequent in patients in the postsurgical setting, and sleep patterns have been shown to be affected in several ways. Typical postoperative sleep disturbances include decreased total sleep time with several arousals, leading to decreased REM and non-REM sleep [10]. Patients may also report worse sleep quality and nightmares [42]. ...
Article
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Sleep disturbance, pain, and having a surgical procedure of some kind are all very likely to occur during the average lifespan. Postoperative pain continues to be a prevalent problem and growing evidence supports the association between pain and sleep disturbances. The bidirectional nature of sleep and pain is widely acknowledged. A decline in sleep quality adds a risk for the onset of pain and also exacerbates existing pain. The risk factors for developing insomnia and experiencing severe pain after surgery are quite similar. The main aim of this narrative review is to discuss why it is important to be aware of sleep disturbances both before and after surgery, to know how sleep disturbances should be assessed and monitored, and to understand how better sleep can be supported by both pharmacological and non-pharmacological interventions.
... The disturbances include obstructive sleep apnea (OSA), reduced total sleep time, sleep fragmentation, circadian rhythm disruption, and so on (6)(7)(8). Over 40% of patients complained about poor sleep quality during the first night following surgery, and the sleep problems continued several days postoperation (9). Some observational studies reported that patients with poor sleep quality were predisposed to mental disorders including delirium and cognitive dysfunction (10)(11)(12). ...
... It arises as the combined effect of multiple factors, which include advanced age, low education level, preoperative impaired cognition, alcohol abuse, smoking, cardiac or macrovascular surgery, major non-cardiac surgeries, perioperative administration of sedative and analgesic drugs, and postoperative imperfect analgesia, among others (53)(54)(55). Sleep problems are a hot topic in current clinical research due to their prevalence and potential negative impact on cognitive functions, including learning, memory, spatial orientation, behavioral capacity, and so on (9,(56)(57)(58). Furthermore, long-term sleep disturbances are intimately associated with major depression and dementia in adult populations, especially the aged (59,60). ...
Article
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Background: The aim of this systematic review and meta-analysis of clinical trials was to investigate the effects of perioperative sleep disturbances on postoperative delirium (POD). Methods: Authors searched for studies (until May 12, 2020) reporting POD in patients with sleep disturbances following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: We identified 29 relevant trials including 55,907 patients. We divided these trials into three groups according to study design: Seven retrospective observational trials, 12 prospective observational trials, and 10 randomized controlled trials. The results demonstrated that perioperative sleep disturbances were significantly associated with POD occurrence in observational groups [retrospective: OR = 0.56, 95% CI: [0.33, 0.93], I2 = 91%, p for effect = 0.03; prospective: OR = 0.27, 95% CI: [0.20, 0.36], I2 = 25%, p for effect < 0.001], but not in the randomized controlled trial group [OR = 0.58, 95% CI: [0.34, 1.01], I2 = 68%, p for effect = 0.05]. Publication bias was assessed using Egger's test. We used a one-by-one literature exclusion method to address high heterogeneity. Conclusions: Perioperative sleep disturbances were potential risk factors for POD in observational trials, but not in randomized controlled trials.
... One of the nonmedical therapies available is acupressure, which is an easy and safe procedure for symptom management, but requires experts to perform. [1][2][3][4][5][6][7][8][9][10][11][12][13] Acupressure is a noninvasive massage technique that has existed since ancient times and used for symptom management. 14 In addition, it is also recognized by the World Health Organization as a complementary medicine method. ...
... Therefore, in addition to medical treatment, the importance of complementary methods should be considered as well. [1][2][3][4][5][6][7][8][9][10][11][12][13] Acupressure and Anxiety ...
Article
Purpose: To determine the effect of acupressure on anxiety and sleep quality after cardiac surgery. Design: A randomized pre-post test control group design. Methods: Patients after cardiac surgery were divided into two groups: the intervention group (n = 50), who received acupressure on four different acupoints plus standard care, and the control group (n = 50), who received only standard care. Patients were admitted to the surgical clinic from the intensive care unit after 3 or 4 days of surgery. The levels of anxiety and sleep quality were evaluated during three postoperative days starting from their first day in the surgical clinic. Findings: Among the patients in the intervention group, the usage of acupressure decreased the level of anxiety and increased the sleep quality significantly compared with the control group (P < .05). Conclusions: Our findings showed that acupressure decreased the level of anxiety and improved the sleep quality in the surgical clinic after cardiac surgery.
... Trong một nghiên cứu gần đây của Wylde (28) báo cáo rằng giấc ngủ của bệnh nhân thường bị đánh thức giữa đêm khoảng 47 -52% bệnh nhân phẫu thuật chấn thương chỉnh hình từ đêm hậu phẫu đầu tiên đến đêm thứ ba. Những nghiên cứu thống kê trước đây (6,8,14) cũng cho thấy rằng hầu hết bệnh nhân thường xuyên phàn nàn không thỏa mãn về chất lượng giấc ngủ do khó ngủ, giảm thời gian ngủ, tăng số giờ ngủ ban ngày, thức dậy sớm vào buổi sáng ở đêm hậu phẫu đầu tiên. Những bệnh nhân này cũng cho rằng chất lượng giấc ngủ của họ kém kéo dài đến ngày thứ tư sau phẫu thuật. ...
... cho thấy chất lượng giấc ngủ kém là triệu chứng phổ biến ở bệnh nhân nhập viện, hầu hết bệnh nhân thường phàn nàn về chất lượng giấc ngủ kém. Một nghiên cứu khác (6), cho thấy 42% bệnh nhân thường xuyên phàn nàn về giấc ngủ không đạt yêu cầu sau phẫu thuật và 23% trường hợp có chất lượng giấc ngủ không đạt yêu cầu cho đến Chất lượng giấc ngủ = 146,07 -3,06 (đau sau phẫu thuật) -4,62 (mệt mỏi) -1,04 (lo lắng) -0,58 (ảnh hưởng từ chăm sóc môi trường). ngày thứ 4 sau phẫu thuật. ...
Article
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Objectives: To examine the factors that predicts quality of sleep among patients after receiving major orthopedic surgery in Vietnam. Methods: The simple random technique was used to recruit 82 patients who were received major orthopedic surgery at Traumatology-Orthopedic department in Hue University Hospital, Vietnam. Data were analyzed by using descriptive statistic and multiple regression analysis. Results: The results indicated that mean score of quality of sleep was at a moderate level (M = 83.24, SD = + 15.17) during the second postoperative night. The standard multiple regression analysis revealed that postoperative pain, fatigue, anxiety, and disturbances from environment of care could explain 59.4% of variance of quality of sleep (R2 = 0.594, F (4,77) = 28.22, p < 0.001). The best predictor of quality of sleep was disturbances from environment of care (β = -0.35, p < 0.001). Conclusions: These findings provide a better understanding of quality of sleep. Moreover, nursing care for patients in postoperative period should manage influencing factors in order to promote patient’s sleep quality. Key works: Quality of sleep, predictors, influencing factors, major orthopedic surgery, Vietnam.
... 1,2 A previous study reported that more than 40% of patients complained of poor sleep quality the first night before surgery and that their sleep problems usually last a few days after surgery. 3 Ruyi 4 compared the sleep conditions of perioperative patients and healthy volunteers and found that the incidence of sleep disturbances in perioperative patients was 17% higher than that in healthy volunteers. Preoperative negative moods, hormone levels, personality characteristics, general anesthetics, surgical trauma, and pain are all factors affecting sleep conditions and circadian rhythm in perioperative patients. ...
... Ketamine can reduce the production of NO by inhibiting NO synthase, thereby inhibiting inflammatory pain. 116 3) In the case of ischemia, hypoxia, and trauma, nerve cells release a large amount of excitatory amino acids such as glutamate, which act on NMDA receptors and cause nerve cell damage. Ketamine can inhibit the activation of NMDA receptors and reduce the concentration of glutamate to protect nerve cells. ...
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Bijia Song, Junchao Zhu Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of ChinaCorrespondence: Junchao ZhuDepartment of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of ChinaEmail zhujunchao1@hotmail.comAbstract: Perioperative sleep disturbances are commonly observed before, during, and after surgery and can be caused by several factors, such as preoperative negative moods, general anesthetics, surgery trauma, and pain. Over the past decade, the fast-acting antidepressant effects of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine represent one of the most attractive discoveries in the field of psychiatry, such as antidepressant and anxiolytic effects. It is also widely used as a short-acting anesthetic and analgesic. Recent research has revealed new possible applications for ketamine, such as for perioperative sleep disorders and circadian rhythm disorders. Here, we summarize the risk factors for perioperative sleep disturbances, outcomes of perioperative sleep disturbances, and mechanism of action of ketamine in improving perioperative sleep quality.Keywords: perioperative sleep disturbances, ketamine, antidepressant, anxiolytic, anti-inflammation
... Wu and Raja 2011)). Sleep patterns in the postoperative period can be severely disrupted and shortened with a suppression of both slow-wave and rapid-eye-movement (REM) sleep(Chouchou et al. 2014). The quantity and quality of sleep after surgery are influenced by a multitude of factors, including hospital-related environmental factors (e.g., noise, light), interruptions in sleep due to nurse checks or other medical interventions, the extent of tissue injury, the effectiveness of the analgesics, and the activation of the surgical stress response, as well as pain(Wesselius et al. 2018).Patients experiencing postsurgical pain are often provided with analgesic medication.Opioids, while a potentially effective form of short term pain management, have significant risks for both dependence and mortality(Rudd et al. 2016), and additionally are associated with opioid induced hyperalgesia after surgery related to short and ultra-short acting opioids and theduration of administration (reviewed in (Fletcher and Martinez 2014). ...
Article
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Pain can be both a cause and a consequence of sleep deficiency. This bidirectional relationship between sleep and pain has important implications for clinical management of patients, but also for chronic pain prevention and public health more broadly. The review that follows will provide an overview of the neurobiological evidence of mechanisms thought to be involved in the modulation of pain by sleep deficiency, including the opioid, monoaminergic, orexinergic, immune, melatonin, and endocannabinoid systems; the hypothalamus-pituitary-adrenal axis; and adenosine and nitric oxide signaling. In addition, it will provide a broad overview of pharmacological and non-pharmacological approaches for the management of chronic pain comorbid with sleep disturbances and for the management of postoperative pain, as well as discuss the effects of sleep-disturbing medications on pain amplification.
... This may be especially true after hip surgery, which often comes with positional restrictions that affect sleep (e.g., activity restricted by physician; cannot sleep in certain positions, and others). Improved sleep before surgery has been shown to reduce pain intensity after surgery (8), and disrupted sleep after surgical procedures has been postulated as a catalyst for pain (9). ...
Article
Background: There is a relationship between sleep, pain, and chronic opioid utilization. This has been poorly explored in general, and especially in patients undergoing orthopaedic surgery. Fewer studies have investigated this relationship based on a sleep diagnosis present both before and after surgery. Objectives: To identify the association between insomnia and sleep apnea and downstream opioid use and medical utilization (visits and cost) in the 2 years following arthroscopic hip surgery. Study design: A retrospective cohort. Setting: The US Military Health System. Methods: This was a consecutive cohort of individuals undergoing hip arthroscopy in the Military Health System (MHS). Medical utilization data were abstracted from the MHS Data Repository between 2003 and 2015, representing 1 year prior and 2 years after surgery for every individual. Sleep disorder diagnoses (insomnia and sleep apnea) were identified using International Classification of Disease codes, and opioid utilization was determined from pharmacy data based on American Hospital Formulary Service codes 280808 and 280812. Sleep disorders present before surgery were used as predictors in multivariate logistic regression, and sleep disorders present after surgery were examined for associations with the outcomes using the Chi-square tests. The dependent variables in both cases were downstream medical utilization (costs, visits, and opioid use). Results: Of 1870 eligible patients (mean age 32.3 years; 44.5% women), 165 (8.8%) had a diagnosis of insomnia before surgery and 333 (17.8%) after surgery; whereas 93 (5.0%) had a diagnosis of apnea before surgery and 268 (14.3%) after surgery. A diagnosis of insomnia before surgery predicted having at least 3+ opioids prescriptions after surgery (adjusted odds ratio, 1.97 [95% confidence interval, 1.39, 2.79]) and greater downstream total medical visits and costs in the 2 years after surgery. However, the number of individuals with a diagnosis of insomnia or apnea after surgery more than doubled, and was significantly associated with chronic opioid use, all-cause medical and all hip-related medical downstream visits and costs in the 2 years after surgery. Limitations: The use of observational data and claims data are only as good as how it was entered. Conclusions: Sleep disorders prior to surgery predicted chronic opioid use and medical utilization after surgery. However, a much higher rate of individuals had sleep apnea and insomnia present after surgery, which were significantly associated with chronic opioid use and greater total and hip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery may be important, but an even higher rate of sleep disorders may be developed after surgery, and continued screening after surgery may have greater clinical merit. Assessing quality of sleep during perioperative management may provide a unique opportunity to decrease pain and chronic opioid use after surgery. Key words: Pain, opioid use, insomnia, sleep apnea, orthopaedic surgery, military medicine, health care utilization.
... In human and animal models, sleep disturbances pre-and post-surgery have been shown to be associated with prolonged postoperative recovery time and increased pain (reviewed in Refs. 110,229,571), one of the cardinal signs of inflammation. Hence, pre-and post-operative sleep management will likely reduce postoperative pain and accelerate recovery processes. ...
Article
Sleep and immunity are bidirectionally linked. Immune system activation alters sleep, and sleep in turn affects the innate and adaptive arm of our body's defense system. Stimulation of the immune system by microbial challenges triggers an inflammatory response, which, depending on its magnitude and time course, can induce an increase in sleep duration and intensity, but also a disruption of sleep. Enhancement of sleep during an infection is assumed to feedback to the immune system to promote host defense. Indeed, sleep affects various immune parameters, is associated with a reduced infection risk, and can improve infection outcome and vaccination responses. The induction of a hormonal constellation that supports immune functions is one likely mechanism underlying the immune-supporting effects of sleep. In the absence of an infectious challenge, sleep appears to promote inflammatory homeostasis through effects on several inflammatory mediators, such as cytokines. This notion is supported by findings that prolonged sleep deficiency (e.g., short sleep duration, sleep disturbance) can lead to chronic, systemic low-grade inflammation and is associated with various diseases that have an inflammatory component, like diabetes, atherosclerosis, and neurodegeneration. Here, we review available data on this regulatory sleep-immune crosstalk, point out methodological challenges, and suggest questions open for future research.
... Sleep disturbances and fatigue are associated with overall health functioning [94] and postsurgical outcomes [95][96][97][98][99]. Per the original PROMIS domain structure, Fatigue loaded onto both Physical and Mental Health domains [67]. ...
Article
Objectives: The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) is a multidimensional screening system evaluating biopsychosocial factors affecting pain and functioning. Using a military sample, the current study 1) examined the structure and domains of the PROMIS, the Defense and Veterans Pain Rating Scale 2.0 (DVPRS), and the Pain Catastrophizing Scale (PCS) within a presurgical setting and 2) examined the relationship of these variables to pre- and postsurgical opioid use. Methods: This cross-sectional study included 279 adult patients scheduled for surgery at the Walter Reed National Military Medical Center and a validation sample of 79 additional patients from the Naval Medical Center, San Diego. PROMIS, DVPRS, PCS, and opioid use data were collected before surgery. Exploratory factor analysis and confirmatory factor analysis identified the latent structure for the measures. A structural equation model (SEM) examined their relationship to pre- and postsurgical opioid use. Results: Two latent factors represented Psychosocial Functioning (PROMIS Depression, PROMIS Anxiety, and PROMIS Social Isolation) and Pain Impact (DVPRS, PROMIS Pain Interference, PROMIS Physical Functioning). The remaining PROMIS scales did not load onto a single factor. In the SEM, the two latent factors and PCS were significantly related to pre- and postsurgical opioid use. Conclusions: This study highlights the utility and relative ease of using a convenient multidimensional assessment in presurgical settings. Using such an assessment can help provide targeted interventions for individuals who may be at greatest risk for negative postsurgical outcomes.
... Yapılan çalışmalar sonucunda postoperatif ağrının uyku kalitesini önemli derecede etkilediği bildirilmiştir. 20 Büyükyılmaz ve ark. ortopedik cerrahi hastalarında postoperatif uyku kalitesini değerlendirdikleri çalışmalarında, ağrının uyku kalitesini etkileyen en önemli faktör olduğunu bildirmişlerdir. ...
... It is a common clinical problem for major surgery patients to experience severe postoperative sleep disturbance including sleep deprivation, disruption, and abnormal architecture, which could be caused by different factors such as anxiety, pain, or maladaptation to the ward environment. [1][2][3][4][5][6][7][8][9][10] Postoperative sleep disturbance may worsen a patients' physical condition by increasing the risk of postoperative delirium or cognitive dysfunction, and delaying recovery. 3,4,[10][11][12] Numerous attempts have been made to relieve severe sleep disturbances after surgery through eliminating noise and light in surgical wards with blinders or earplugs, the consolidation of patient care interactions. ...
Article
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Objective: The study aimed to investigate the effects of intraoperative dexmedetomidine on postoperative sleep disturbance for different surgical patients and compare such effects between different dose of dexmedetomidine. Methods: A total of 7418 patients undergoing nine types of non-cardiac major surgeries were retrospectively studied. Patients were separated into DEX (dexmedetomidine) or Non-DEX (Non-dexmedetomidine) groups based on the use of dexmedetomidine during surgery. The patients who reported they could not fall asleep during the night or woke up repeatedly during the most of the night at the day of the surgery and whose NRS were >6 were defined as cases with severe sleep disturbance. Propensity score matched analysis based on all preoperative baseline data was performed along with logistic regression analysis including different surgery types and dosage of dexmedetomidine use. Results: In both of the unmatched cohort (OR, 0.49 [95% CI: 0.43-0.56]) and matched cohort (0.49 [95% CI: 0.42-0.58]), the DEX group had a significantly lower incidence of severe sleep disturbance than the Non-DEX group. In the subgroup analysis, for gynecological and urological surgery population, the ORs for DEX-group reached 0.21 (95% CI, 0.13-0.33; P<0.0001) and 0.30 (95% CI,0.19-0.47; P<0.0001), respectively. In addition, low-dose dexmedetomidine (0.2-0.4 μg·kg-1·h-1) showed the greatest effect with an odds ratio of 0.38 (95% CI: 0.31-0.44; P<0.0001), and the incidence of severe sleep disturbance in the low-dose group was significantly lower (11.5% vs. 17.7% vs. 16.5%, P<0.0001) than that in the medium- (0.4-0.6 μg·kg-1·h-1) and high-dose (0.6-0.8 μg·kg-1·h-1) groups. Conclusion: Intraoperative dexmedetomidine use can significantly decrease the incidence of severe sleep disturbance on the day of surgery for patients undergoing non-cardiac major surgery, and the effects were most significant in patients receiving gynecological and urological surgery. Furthermore, low-dose dexmedetomidine (0.2-0.4 μg·kg-1·h-1) is most effective for prevention of postoperative sleep disturbance.
... Furthermore, there is a relationship between pain perception and sleep, that involves various unidirectional or bidirectional interactions (Tang et al., 2012). It has been reported that SD diminishes the pain threshold (Chouchou et al., 2014). However, the relationship between sleep and pain is not exactly recognized. ...
Article
Sleep deprivation (SD) is a common issue in today’s society. Sleep is essential for proper cognitive functions, including learning and memory. Furthermore, sleep disorders can alter pain information processing. Meanwhile, hippocampal nicotinic receptors have a role in modulating pain and memory. The goal of this study is to investigate the effect of dorsal hippocampal (CA1) nicotinic receptors on behavioral changes induced by Total (TSD) and REM Sleep Deprivation (RSD). A modified water box and multi-platform apparatus were used to induce TSD and RSD, respectively. To investigate the interaction between nicotinic receptors and hippocampus-dependent memory, nicotinic receptor agonist (nicotine) or antagonist (mecamylamine) was injected into the CA1 region. The results showed, nicotine at the doses of 0.001 and 0.1 µg/rat and mecamylamine at the doses of 0.01 and 0.1 µg/rat decreased memory acquisition, while both at the doses of 0.01 and 0.1 µg/rat enhanced locomotor activity. Additionally, all doses used for both drugs did not alter pain perception. Also, 24h TSD or RSD attenuated memory acquisition with no effect on locomotor activity and only TSD induced an analgesic effect. Intra-CA1 administration of subthreshold dose of nicotine (0.0001 µg/rat) and mecamylamine (0.001 µg/rat) did not alter memory acquisition, pain perception and locomotor activity in sham of TSD/RSD rats. Both drugs reversed all behavioral changes induced by TSD. Furthermore, both drugs reversed the effect of RSD on memory acquisition, while only mecamylamine reversed the effect of RSD on locomotor activity. In conclusion, CA1 nicotinic receptors play a significant role in TSD/RSD-induced behavioral changes.
... It is also important to note that the relationship between sleep and sensory processing is bidirectional: sensory discomfort increases the risk of sleep problems and sleep problems influence sensory processing. [63,64]. ...
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Purpose of Review Melatonin is used to treat sleep difficulties associated with autism spectrum disorder (ASD). There are growing evidence that melatonin could have an effect on other symptoms than sleep, such as anxiety, depression, pain, and gastrointestinal dysfunctions. Interestingly, these symptoms frequently are found as comorbid conditions in individuals with ASD. We aimed to highlight the potential effect of melatonin on these symptoms. Recent Findings Animal and human studies show that melatonin reduces anxiety. Regarding the effect of melatonin on pain, animal studies are promising, but results remain heterogeneous in humans. Both animal and human studies have found that melatonin can have a positive effect on gastrointestinal dysfunction. Summary Melatonin has the potential to act on a wide variety of symptoms associated with ASD. However, other than sleep difficulties, no studies exist on melatonin as a treatment for ASD comorbid conditions. Such investigations should be on the research agenda because melatonin could improve a multitude of ASD comorbidities and, consequently, improve well-being.
... Delirium is very common in ICU patients for a multitude of reasons including postoperative sleep disturbance. Multimodal interventions to prevent delirium in older hospitalized patients, which include minimizing sleep disruption, appear effective in reducing its incidence [56][57] . ...
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Postoperative sleep disturbance is a common occurrence with significant adverse effects on patients including delayed recovery, impairment of cognitive function, pain sensitivity and cardiovascular events. The development of postoperative sleep disturbance is multifactorial and involves the surgical inflammatory response, the severity of surgical trauma, pain, anxiety, the use of anesthetics and environmental factors such as nocturnal noise and light levels. Many of these factors can be managed perioperatively to minimize the deleterious impact on sleep. Pharmacological and non-pharmacological treatment strategies for postoperative sleep disturbance include dexmedetomidine, zolpidem, melatonin, enhanced recovery after surgery (ERAS) protocol and controlling of environmental noise and light levels. It is likely that a combination of pharmacological and non-pharmacological therapies will have the greatest impact; however, further research is required before their use can be routinely recommended.
... The pain itself disrupts sleep quality, which in turn intensifies pain sensitivity. 63 Although pharmacologic agents administered as epidural, intraspinal, or intrapleural anesthesia, or as patient controlled analgesia (PCA) provide effective postoperative pain relief in most instances, analgesic drugs (especially opioids) are associated with drowsiness, respiratory depression, and sleep disruption. Reduced SWS, dose-dependent REM suppression, variability in total sleep time, and awakening or arousal episodes during sleep may be problematic. ...
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Man Luo,1,* Bijia Song,1,2,* Junchao Zhu1 1Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China; 2Department of Anesthesiology, Friendship Hospital of Capital Medical University, Beijing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Junchao Zhu Department of AnesthesiologyShengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of ChinaEmail zhujunchao1@hotmail.comAbstract: General anesthesia produces a state of drug-induced unconsciousness that is controlled by the extent and duration of administered agents. Whether inhalation or intravenous in formulation, such agents may interfere with normal sleep–wake cycles, impairing postoperative sleep quality and creating complications. Electroacupuncture is a new approach widely applied in clinical practice during recent years. This particular technology helps regulate neurotransmitter concentrations in the brain, lowering norepinephrine and dopamine levels to improve sleep quality. It also alleviates surgical pain that degrades postoperative sleep quality after general anesthesia by downregulating immune activity (SP, NK-1, and COX-1) and upregulating serotonin receptor (5-HT1AR, 5-HT2AR) and endocannabinoid expression levels. However, large-scale, multicenter studies are still needed to determine the optimal duration, frequency, and timing of electroacupuncture for such use.Keywords: general anesthesia, sleep quality, acupoints, electroacupuncture
... somehow, it has been described that these disorders can be caused by multiple factors, including surgical stress, environmental factors, medical treatments [9][10][11][12][13][14] and comorbidities such as obesity, hypertension, diabetes, cardiovascular disease, and postoperative pain, the latter being a major risk factor for sleep disorders that acts in a bidirectional way since the administration of opioids for easing the pain also alters the sleep cycle [15,16] Therefore, for the proper management of these disorders during the early postoperative period a careful approach must be done and the effectiveness of the available treatments and their potential side effects must be considered, since sometimes drugs may be effective, but they can cause sedation so that patients are at risk of having respiratory distress, aspiration pneumonitis, and experiencing confusion, falls and delirium [7]. In nonsurgical patients, Z-drugs, non-benzodiazepines hypnotic agents, (Zolpidem, Zopiclone, Eszopiclone, Zaleplon) and benzodiazepines have been reported to be effective in the short-term for the treatment of sleep disorders; ...
... We used a pharmacological REM sleep deprivation (REMSD) design with the alpha-2 adrenergic receptor agonist clonidine (see Fig. 5). REMSD is particularly relevant for examining the relationship between sleep and placebo analgesia, because sleep disruptions (e.g., total and partial sleep restriction, awakenings during sleep) are known to alter pain sensitivity the next day (Chouchou, Khoury, et al. 2014;Lavigne et al. 2011). A pharmacological REMSD model is more suitable than the usual awakening from REM sleep method for investigating pain perception and placebo analgesia, without change in sleep duration or sleep fragmentation (Autret et al. 1976;Gentili et al. 1996;Nelly Huynh et al. 2006b). ...
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The placebo effect is a psychobiological phenomenon producing clinical benefits attributed to a wide range of neurobiological mechanisms. Independently from placebo effects, these mechanisms may also be under the influence of processes that can take place during sleep. The relationship between sleep and placebo effects has received very little attention. Three experimental studies, conducted on healthy subjects, have examined sleep changes following placebo conditioning associated with analgesic suggestions and the effects of sleep deprivation on placebo effects. A relation between rapid eye movement (REM) sleep, expectations of relief and placebo analgesia was observed in which REM sleep deprivation seems to improve placebo-induced expectations and analgesia. Moreover, analgesic expectations developed before sleep produced a reduction in cortical arousals evoked by noxious stimuli during REM sleep. In this article, we describe sleep and pain/analgesia interactions, the relationship between sleep and placebo analgesia, and finally the potential mechanisms underlying this relationship.
... For instance, sleep quality is linked to the development of chronic pain [20,21]. Sleep deprivation and sleep disruption can lead to pain and hyperalgesia [22][23][24][25][26]. In addition, many studies have shown that pain and sleep have bidirectional interactions; that is, pain may lead to sleep disturbances that result in poor sleep quality, and, in turn, sleep disturbances can cause increased pain and hyperalgesia [22,27,28]. ...
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Methods: A prospective, randomized study was conducted with 88 patients undergoing laparoscopic colorectal surgery. The experimental group (S group, n = 44) was given 10 mg of zolpidem tartrate one night before the surgical procedure, while no medication was given to the control group (C group, n = 44). The primary outcome was the intraoperative remifentanil consumption. Sufentanil consumption, average patient-controlled analgesia (PCA) effective press times, the visual analog scale (VAS) scores, and incidences of postoperative nausea and vomiting (PONV) were recorded at 6 h (T1), 12 h (T2), and 24 h (T3) postoperatively. Results: The intraoperative remifentanil consumption was significantly lower in the S group than that in the C group (p < 0.01). Sufentanil consumption at 6 h and 12 h postoperatively was significantly lower in the S group than that in the C group (p < 0.05); average PCA effective press times and VAS scores, at 6 h and 12 h postoperatively, were significantly lower in the S group than those in the C group (p < 0.01); differences between groups 24 h postoperatively were not significant. No significant between-group difference was noted in the incidence of nausea and vomiting. Conclusion: Improving patients' sleep quality the night before surgical procedure by zolpidem can decrease the usage of intraoperative analgesics and reduce postoperative pain.
... Specific mechanisms underlying adverse neurophysiological changes may involve increased activation of NMDA receptors (Holst et al., 2017;Kopp et al., 2006), and altered regulation of adenosinergic, dopaminergic and endogenous opioidergic systems (Sardi et al., 2018;Ukponmwan et al., 1984). Notably, several factors contribute to sleep disturbance during the postoperative period, including surgical stress response-systemic inflammation (Imeri & Opp, 2009;Menger & Vollmar, 2004), endocrine abnormalities (Morgan & Tsai, 2016) and increased sympathetic outflow (Desborough, 2000)-as well as anesthesia (Moote & Knill, 1988), analgesics (Dimsdale et al., 2007), affective state and environmental conditions (Chouchou et al., 2014; T A B L E 2 Linear regression models: BPI pain severity 6 months postoperative (primary outcome measure) -Adamsen et al., 1996). Given this multitude of mechanisms, we believe that it is important to explore the relative importance of perioperative sleep disturbance on postoperative pain control in the context of different surgical procedures. ...
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Background Sleep disturbance is thought to aggravate acute postoperative pain. The influence of preoperative sleep problems on pain control in the long‐term and development of chronic postsurgical pain is largely unknown. Methods This prospective, observational study aimed to examine the links between preoperative sleep disturbance (Pittsburgh Sleep Quality Index, PSQI) and pain severity (Brief Pain Inventory, BPI) 6 months postoperative (primary outcome), objective measures of pain and postoperative pain control variables (secondary outcomes). Patients (n=52) with disabling osteoarthritis (OA) pain undergoing total hip arthroplasty (THA) were included. Quantitative sensory testing (QST) was performed preoperatively on the day of surgery to evaluate pain objectively. Clinical data, as well as measures of sleep quality and pain, were obtained preoperatively and longitudinally over a six‐month period. Results Preoperatively, sleep disturbance (i.e., PSQI score >5) occurred in 73.1% (n=38) of THA patients, and pain severity was high (BPI pain severity 5.4±1.3). Regression models, adjusting for relevant covariates, showed that preoperative PSQI score predicted pain severity 6 months postoperative (β=0.091 (95% CI 0.001‐0.181), p=0.048, R²=0.35). Poor sleep quality was associated with increased pressure pain sensitivity and impaired endogenous pain inhibitory capacity (R² range 0.14‐0.33, all p´s <0.04). Moreover, preoperative sleep disturbance predicted increased opioid treatment during the first 24 hours after surgery (unadjusted β=0.009 (95% CI 0.002‐0.015) mg/kg, p=0.007, R²=0.15). Conclusions Preoperative sleep disturbance is prevalent in THA patients, is associated with objective measures of pain severity, and independently predicts immediate postoperative opioid treatment and poorer long‐term pain control in patients who have undergone THA.
... Except other factors (body temperature regulation and metabolism), the circadian oscillation in HR is the primary source of the ULF power (Laborde et al., 2017). Circadian rhythm disruption was deemed to contribute to the development of POD by itself or by interacting with pain and inflammation (Chouchou et al., 2014;Scott, 2015;Fadayomi et al., 2018). Therefore, the lower ULF indices may manifest circadian rhythm disruption of delirium patients. ...
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Background Postoperative delirium (POD) is a common complication after orthopedic surgery in elderly patients. The elderly may experience drastic changes in autonomic nervous system (ANS) activity and circadian rhythm disorders after surgery. Therefore, we intend to explore the relationship between postoperative long-term heart rate (HR) variability (HRV), as a measure of ANS activity and circadian rhythm, and occurrence of POD in elderly patients.Methods The study population of this cohort was elderly patients over 60 years of age who scheduled for orthopedic surgery under spinal anesthesia. Patients were screened for inclusion and exclusion criteria before surgery. Then, participants were invited to wear a Holter monitor on the first postoperative day to collect 24-h electrocardiographic (ECG) data. Parameters in the time domain [the standard deviation of the normal-to-normal (NN) intervals (SDNN), mean of the standard deviations of all the NN intervals for each 5-min segment of a 24-h HRV recording (SDNNI), and the root mean square of successive differences of the NN intervals (RMSSD)] and frequency domain [heart rate (HR), high frequency (HF), low frequency (LF), very low frequency (VLF), ultra low frequency (ULF), and total power (TP)] were calculated. Assessment of delirium was performed daily up to the seventh postoperative day using the Chinese version of the 3-Min Diagnostic Interview for CAM-defined Delirium (3D-CAM). The relationship between HRV and POD, as well as the association between HRV and duration of POD, was assessed.ResultsOf the 294 cases that finally completed the follow-up, 60 cases developed POD. Among the HRV parameters, SDNNI, VLF, and ULF were related to the occurrence of POD. After adjustment for potential confounders, the correlation between HRV indices and POD disappeared. Through stratified analysis, two significant negative correlations emerged: ULF in young-old participants and SDNNI, VLF, and ULF in male patients.Conclusion The lower HRV parameters may be related to the occurrence of POD, and this correlation is more significant in young-old and male patients. ANS disorders and rhythm abnormalities reflected by HRV changes may represent a possible mechanism that promotes POD.
... Patients may present with reduced sleep duration, increased awakenings, reduced sleep quality, and frequent nightmares. 1 Clinical and experimental studies suggest that sleep disturbances may exacerbate pain. Surgical stress appears to be the main cause of sleep disruption. ...
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In this article, we conduct a systematic review of the literature to explore the specific role of dexmedetomidine (DEX) on postoperative sleep and its associated mechanisms at present. The electronic database Embase, MEDLINE/PubMed, the Cochrane Library, Web of Science, and Google Scholar were searched. The restriction terms included "dexmedetomidine", "sleep" and "surgery". The inclusion criteria were as following: 1) patients 18 years old or older; 2) DEX used in the perioperative period not just for critically ill patients in the intensive care unit (ICU); 3) prospective or retrospective studies. The review articles, conference abstracts, and animal studies were excluded. Out of the 22 articles which met the above criteria, 20 of them were randomized controlled studies and 2 of them were retrospective cohort studies. Infusion of DEX including during the surgery and after surgery at a low or high dose was shown to improve subjective and objective sleep quality, although 2 studies showed there is no evidence that the use of DEX improves sleep quality and 1 showed less sleep efficiency and shorter total sleep time in the DEX group. Other postoperative outcomes evaluated postoperative nausea and vomiting, pain, postoperative delirium bradycardia and hypotension. Outcomes of our systematic review showed that DEX has advantages in improving patients' postoperative sleep quality. Combined with the use of general anesthetic, DEX provides a reliable choice for procedural sedation.
... Postoperative sleep disturbances frequently occur in patients after general anesthesia. Sleep patterns are seriously disturbed on the first night after surgery with the total sleep time, slowwave sleep (SWS), and REM significantly reduced, while the sleep arousal time frequently increases [13]. Sleep interruptions may last for three to four nights or longer-up to several weeks after surgery [14]. ...
Article
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The cerebellum is widely regarded as a brain region involved in motor processing, non-motor processing, and even sleep-wake cycles. Cerebellar dysfunction may cause changes in the sleep-wake cycle, leading to sleep disturbances. At present, there is limited research on its effect on postoperative sleep after general anesthesia, despite the suspicion of its implication in postoperative sleep disturbances. With this review, we aim to provide a clear and comprehensive review of the cerebellar activity during the normal sleep-wake cycle, the correlation between cerebellar dysfunction and postoperative sleep disturbances, and the effects of general anesthesia on cerebellar dysfunction. Future large-scale multicenter trials are needed to objectively support the present results, identify the initial cerebellar dysfunction to prevent postoperative sleep disturbances, and develop new therapeutic measures targeting sleep disturbances with possible far-reaching implications for neurodegenerative diseases in general.
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Objectives: The aim of our study was to compare the effect of using dexmedetomidine (DEX) during the daytime operation or the nighttime operation under general anesthesia on postoperative sleep quality and pain of patients. Methods: Seventy-five patients scheduled for elective laparoscopic abdominal surgeries under general anesthesia were randomly assigned to receive operation in the Day Group (8:00-12:00) and the Night Group (18:00-22:00). The Portable Sleep Monitor (PSM) was performed on the following 3 nights: the night before surgery (Sleep 1), the first night after surgery (Sleep 2), and the third night after surgery (Sleep 3). Postoperative pain scores using visual analogue scoring scale, subjective sleep quality using the Athens Insomnia Scale, total dose of general anesthetics and PCA pump press numbers were also recorded. Results: Intraoperative administration of DEX for patients in the Day Group could improve sleep quality with a higher sleep efficiency and a lower AIS subjective sleep quality than patients in the Night Group at Sleep 2 (P < 0.001 and P = 0.001, respectively) and Sleep 3 (P < 0.001, respectively). There were marked lower rapid eye movement (REM) sleep and Stable sleep in the Night Group than that in the Day Group at Sleep 2 (P < 0.001 and P = 0.032, respectively) and Sleep 3 (P < 0.001, respectively). Patients in the Day Group have better pain relief and less PCA pump press numbers than patients in the Night Group. Conclusion: Using dexmedetomidine during the daytime operation can better improve postoperative sleep quality and pain than nighttime operation in patients undergoing laparoscopic abdominal surgeries.
Article
Postoperative sleep disorder frequently occurs in patients after surgery. Sleep disturbance aggravates pain, anxiety, and delirium, which is an important risk factor for poor recovery. Circadian rhythm disorder induced by general anesthesia plays important role in postoperative sleep disorders. A large number of clinical studies have shown that various forms and duration of general anesthesia can lead to postoperative sleep disorders. In this study, the effect of prolonged propofol anesthesia on biological rhythm was comprehensively evaluated by wireless physiological telemetry system, and the therapeutic effect of exogenous melatonin pretreatment was further investigated. The results showed that prolonged propofol anesthesia had significant impacts on the circadian rhythm of sleep, body temperature, locomotor activity and endogenous melatonin secretion within 24 h following anesthesia, resulting in diminished oscillation amplitude. In hypothalamus, the expression of circadian factor PER and CRY were inhibited by propofol, possibly through activation of CAMK-CREB signaling pathway. Post-translational factors GSK-3β, SIRT1, AMPK were also involved in the regulation of circadian factors after propofol anesthesia. Melatonin pretreatment could restore circadian rhythm process by regulating circadian factor expression through post-translational modulation and prohibit the over-synthesis of melatonin in pineal gland. This study verified the effects of anesthetics on circadian rhythm and further evaluated the potential therapeutic effect of melatonin on postoperative circadian rhythm and sleep disorders.
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Objective: To explore the frequency, severity and variances in patient-reported symptoms of calm, irritated and infected skeletal pin sites. Methods: A cross-sectional within-subjects repeated-measures study was conducted, employing a self-report questionnaire. Patients (n = 165) treated with lower limb external fixators at 7 English hospitals completed a designed questionnaire. Three sets of retrospective repeated-measures data were collected relating to calm, irritated and infected pin sites. Results: Significant differences were revealed between each of the three pin site states (calm, irritated & infected) in the degree of: redness, swelling, itchiness, pain, wound discharge, heat/burning, shiny skin and odour. In relation to difficulty or pain using the affected arm or leg, difficulty weight bearing on the leg, nausea and/or vomiting, feeling unwell or feverish, shivering, tiredness/lethargy and disturbed sleep, significant differences were demonstrated between infected and irritated states and infected and calm states, but not between irritated and calm. Conclusions: The findings provide greater depth of understanding of the symptoms of pin site infection and irritation. Patients may be able to differentiate between different pin site states by comparing the magnitude of the inflammatory symptoms and the presence of other specific symptoms that relate solely to infection and no other clinical state. The irritated state is probably caused by a different pathological processother than infection and may be an indication of contact dermatitis.
Article
Background Sleep macrostructure is commonly disturbed after surgery. Postoperative pain control remains challenging. Given the bidirectional interaction between sleep and pain, understanding the role of modulation of sleep during the perioperative period on postoperative pain is needed. Methods Systematic review. Controlled trials examining the effects of perioperative sleep‐promoting pharmacological agents on postoperative pain and analgesic consumption were identified through a systematic search strategy utilizing multiple electronic databases. Results Fourteen studies (9 melatonin, 5 zolpidem) involving 921 patients (melatonin n=586, zolpidem n=335) were included. Compared to placebo, melatonin reduced postoperative pain scores ≥30% and significantly decreased opioid consumption in 3 studies (postoperative day (POD) 1‐2), whereas 4 studies reported no significant effect of melatonin on postoperative pain. Compared to placebo, zolpidem reduced postoperative pain scores during POD1‐7/POD1‐14 in two studies, but only one trial suggested clinically meaningful improvement (i.e., relative reduction of pain score ≥30%). Whereas 3 zolpidem trials showed no significant differences regarding postoperative pain ratings, zolpidem treatment was associated with decreased analgesic consumption in 4 out of 5 trials. Several limitations of the included studies were identified; only 1 study out of 14 was deemed low risk of bias, and heterogeneity of study design and outcome assessment precluded meta‐analysis. Conclusion Perioperative addition of a sleep‐promoting pharmacological agent may improve pain control, but underlying evidence is weak and results are inconsistent. Only 5 of the 14 studies objectively evaluated changes in sleep (polysomnography – 2 zolpidem studies; actigraphy – 3 melatonin studies) which complicates conclusions regarding links between perioperative sleep and pain. This article is protected by copyright. All rights reserved.
Chapter
Sleep is essential for our health, for our regeneration, and for our daily functioning. A physical therapist is a protagonist in promoting wellness, mobility, and independence, in a broad range of diseases. Why not sleep? Physical therapists can work with different anamnesis and examination options and there exist many treatment approaches for sleep disorders in physiotherapy. They are evidence-based and often should be applied complementary to other treatments. The physical therapist role includes the following: to screen for sleep dysfunction; to identify impairments related to sleep dysfunction; and to implement and progress therapeutic interventions to address impairments that interfere with sleep. In addition, their role is to educate society, patients and clients, caregivers, and providers on healthy sleep behaviors and the relationship between sleep, pain, physical activity, function, health, and well-being. They monitor and, if indicated, manage sleep quality and quantity in patients and clients to enhance physical therapy outcomes and refer to sleep medicine professionals when necessary.
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This overview provides a brief summary of the complex interactions that link sleep, pain, and analgesic medications. Sleepscientists and clinicians are well aware of these relationships and understand that maintaining healthy pain-free subjects in a stable environment is essential to generating interpretable data and valid conclusions. However, these concepts and the data that support bidirectional interactions between sleep and pain may be less known to those who are not sleep scientists yet need such information to protect and advance both animal wellbeing and research validity (for example, veterinarians,IACUC members). Abundant human evidence supports the disruptive effect of pain and the modulatory effects of analgesic drugs on sleep; however, analgesic drugs can alter both sleep and the electroencephalogram, which is the primary objectivemeasure for identifying sleep and evaluating sleep properties in both humans and animals. Consideration of the modulatory and interactive relationships of sleep, pain, and analgesic medications is essential to designing and conducting valid and reproducible sleep research using animal subjects.
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Background: Attention to factors that may affect patients' ability to experience enhanced recovery after surgery is essential in planning for postoperative care. Aims: To create models of predefined pre,- peri-, and postoperative variables in order to analyze their impact on patients' physical recovery on postoperative days 1 and 2 after major orthopedic and general surgery. Design: An exploratory design with repeated measures was used, including 479 patients who had undergone orthopedic (289) or general surgery (190) at three hospitals. Methods: Pain, nausea, and level of physical ability were measured preoperatively and on postoperative days 1 and 2 by using the Numerical Rating Scale and items from the Postoperative Recovery Profile. Structural equation modeling was used to explore the impact of the predefined variables on patients' physical recovery. Results: The orthopedic group contained significantly more women and significantly more patients with pain and opioid use. Although the models showed good fit, "traditional" preoperative (pain, nausea, physical abilities, chronic pain, opioid use) and perioperative variables (anesthesia, length of surgery) constituted few (orthopedic) or no (general surgery) predictive properties for physical recovery. Postoperative average pain intensity, average nausea intensity, and physical ability explained physical recovery on day 1, and physical recovery on day 1 predicted physical recovery on day 2. Conclusions: "Traditional" predictors had little effect on patients' postoperative physical recovery, while associations with common postoperative symptoms were shown. Further research is needed to explore additional variables affecting early physical recovery and to understand how soon patients are physically ready to return home.
Article
Purpose: To evaluate the outcomes of the different drug combination and infusion techniques for patient-controlled analgesia (PCA). Methods: Ninety-seven patients who had undergone spinal tumor surgery were randomized to 4 groups with different PCA drugs and infusion techniques: subcutaneous sufentanil (SS) group; (n=25), subcutaneous sufentanil and dexmedetomidine (SDS) group (n=24), intravenous sufentanil (SI) group (n=23), and intravenous sufentanil and dexmedetomidine (SDI) group (n=25). The primary outcome measured the cumulative amount of sufentanil delivered to the patients through PCA 24 and 48 hours after the surgery. Secondary outcomes measured the visual analog scale pain scores 24 and 48 hours after the surgery, Pittsburgh Sleep Quality Index before and 1 month after surgery, Athens Insomnia Score before and the first 2 nights after surgery, and the rate of adverse events within 48 hours after surgery. Findings: At 24 and 48 hours after surgery, the cumulative amount of sufentanil in the SDS group (mean [SD], 76.44 [10.75] at 24 hours and 151.96 [20.92] at 48 hours) and the SDI group (mean [SD], 75.08 [9.00] at 24 hours and 149.56 [18.22] at 48 hours) were significantly lower than in SS group (mean [SD] 95.52 [12.40] at 24 hours and 183.23 [23.06] at 48 hours) and the SI group (mean [SD], 97.25 [10.80] at 24 hours and 186.67 [20.14] at 48 hours; P < 0.001). The visual analog scale pain scores and Athens Insomnia Scale scores were also lower in the SDS and SDI groups than in the SS and SI groups 24 and 48 hours after surgery (P < 0.05). The Pittsburgh Sleep Quality Index was lower in the SDS and SDI groups 1 month after surgery. Lastly, the rate of nausea and vomiting was higher in the SI group than in the SS, SDS, and SDI groups (P = 0.018). Implications: Dexmedetomidine in PCA could decrease sufentanil intake and improve analgesic effect and sleep quality. Subcutaneous PCA can provide the same benefit with a lower rate of nausea and vomiting. ClinicalTrials.gov identifier: NCT04111328. (Clin Ther. 2021;XX:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
Article
Objective: Despite the bidirectional relationship between sleep and pain, there remains a dearth of research examining the role of perioperative pain management interventions in mitigating postoperative sleep disturbances. This secondary analysis of a prospective observational multi-site study examined the association between peripheral nerve block (PNB) use during total knee or total hip arthroplasty procedures and postoperative pain and sleep outcomes. Methods: Adult patients undergoing total knee or total hip arthroplasty procedures were recruited from two tertiary care facilities. Average pain and sleep disturbance scores were collected preoperatively and at 1- and 2-weeks postoperatively. Participants were not randomized to receive PNB. Postoperative outcomes were compared based on receipt of PNB during surgery. Structural equation modeling path analysis was utilized to model multiple co-occurring relationships, including mediation pathways between perioperative pain management approaches, pain, and postoperative sleep outcomes. Results: Of the 197 participants, 53% received PNB. Mediation analyses indicated that PNB was indirectly associated with 1-week sleep disturbance via its effects on 1-week pain intensity (β=-0.02, 95% CI -0.04, -0.001, P=0.04). Additionally, PNB was indirectly associated with 2-week sleep disturbance, via its effects on 1-week pain intensity and 1-week sleep disturbance (β=-0.04, 95% CI -0.07, -0.02, P=0.04). Lastly, PNB was indirectly associated with 2-week pain intensity via its effects on 1-week pain intensity (β=-0.10, 95% CI -0.19, -0.02, P=0.02). Conclusion: Receipt of PNB during total knee or total hip arthroplasty was found to be associated with improved 1-week postoperative pain intensity, which in turn was found to be associated with lower sleep disturbances at both 1- and 2-week postoperative time points. Multimodal opioid sparing pain management interventions, capable of improving postoperative sleep, are vital to improving recovery and rehabilitation following arthroplasty.
Article
Adequate sleep is essential to health and well-being. Adverse effects of sleep loss are evident acutely and are cumulative in their effect. These include impairment of cognition, psychomotor function, and mood, as well as cardiovascular, metabolic, and immune dysfunction including proinflammatory effects and increased catabolic propensity. Such effects are counterproductive to recovery from illness and operation, yet hospitalization challenges sleep through the anxieties, discomforts, and sleep environmental challenges faced by patients, the inadequate attention given to the needs of patients with preexisting sleep disorders, and the lack of priority these issues receive from hospital staff and their leaders. Mitigation of the adverse effects of noise, light, uncomfortable bedding, intrusive observations, anxiety, and pain together with attention to specific sleep needs and monitoring of sleep quality are steps that would help address the issue and potentially improve patient outcomes.
Chapter
Inadequate sleep is prevalent during school or workdays, and it creates a need to “catch up” on sleep during leisure time. This phenomenon creates negative effects on cognition, mood, focus, and impact health. Traffic accidents are more common when sleep deprived, and prevalence of hypertension, type 2 diabetes, arrhythmias are similarly on the rise. This article will explore practices that limit healthy sleep, and suggestions to improve both the quantity and quality of sleep.
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Background: The clinical relevance of inpatient step counts after lung surgery remains unknown. Objective: The aim of this study was to identify those factors related to physical activity measured by step count, during the inpatient stay, and its relationship with symptom severity and perceived health status at hospital admission, discharge, and 1 month after discharge. Methods: We studied the inpatient step count of 73 participants who underwent lung resection surgery. The number of steps was measured using a triaxial accelerometer. The health status and the severity of symptoms were examined at hospital admission, discharge, and 1 month after discharge. Results: Of the 73 participants, 35 were active and 38 were sedentary during the hospitalization. The mean number of steps walked during 3 inpatient days was 6689 ± 3261 and 523 ± 2273 (P < .001) for the active and sedentary groups, respectively. The dyspnea and fatigue scores in the sedentary group across data collection points (hospital admission, discharge, and follow-up) were significantly worse (P < .01). In regard to pain, the sedentary group presented worse results, than the active group, at discharge and follow-up (P < .01). The correlation analysis indicated significant but weak correlations (r < 0.500) between inpatient steps per day and symptom severity at 1-month follow-up (T2) after surgery. Conclusion: Inpatient step count may be a risk factor for symptom severity and perceived health status during hospitalization and within the first month after lung resection surgery. Implications for practice: Nurses should consider recommending physical activity during hospitalization for patients after lung resection.
Article
Introduction Sufentanil is a selective µ-opioid agonist, used intravenously and intrathecally for moderate to severe acute pain. Sublingual sufentanil nanotablets have been developed; 15 mcg tablet for a patient-controlled analgesia device and 30-mcg tablet for a single-dose device administered by a healthcare professional. Dosing interval is a minimum of 20 min for a 15 mcg tablet and a treatment duration of up to 72 hours. The single 30-mcg nanotablet dosing interval is 1 hour. Mean plasma elimination half-life is 13 hours and bioavailability 47–57% after the first sublingual sufentanil tablet. Areas covered This review focuses on the effectiveness, safety, and feasibility of sublingual sufentanil 30-mcg single dose suspended by a healthcare professional for the management of moderate to severe acute pain. A few Phase 4 studies concerning the sublingual sufentanil tablet system containing 15-mcg nanotablets are also reviewed. Expert opinion Sufentanil sublingual 30-mcg nanotablets provide effective pain relief in various acute moderate to severe pain states. The safety profile of sublingual sufentanil 30 mcg is typical to opioids nausea, vomiting, and sedation being the most common ones. Sublingual sufentanil 30-mcg nanotablet has the potential for efficient moderate to severe pain management in supervised healthcare facilities.
Article
Background The 15-item Quality of Recovery (QoR-15) scale is a validated patient-reported outcome questionnaire that measures the quality of postoperative recovery. This study aimed to validate a translated Korean version of QoR-15 (QoR-15K) in a broad range of surgical patients. Methods After Korean translation of the original English version of the QoR-15, we performed psychometric validation of the QoR-15K to evaluate the quality of recovery after surgery. The validity, reliability, responsiveness, and clinical feasibility of the QoR-15K were evaluated. A subgroup analysis in patients with video-assisted lung resection was performed. Results Among 193 patients, 188 (97.4%) completed the QoR-15K after surgery. We found good convergent validity between the postoperative QoR-15K and the global QoR visual analogue scale (ρ=0.61, P<0.001). The negative correlation between the QoR-15K score and the extent of surgery (ρ=–0.33, P<0.001), the duration of surgery (ρ=–0.33, P<0.001), and the severity of postoperative pain (ρ=–0.40, P<0.001) supported construct validity. The postoperative QoR-15K showed good internal consistency (Cronbach α=0.90), split-half reliability (0.81), and test–retest reliability (0.95; 95% confidence interval [CI], 0.94–0.96). The QoR-15K score decreased from 140 (preoperative, inter-quartile range [IQR] 128–146) to 100 (postoperative day 1, IQR 75–122), median difference –36.5 (95% CI, –41 to –32.5; P<0.0001). The QoR-15K indicated excellent responsiveness with Cliff's effect size –0.78 (95% CI, –0.84 to –0.71). Subgroup analysis yielded similar results. Conclusions The QoR-15K is valid and has excellent reliability, a high degree of responsiveness, and clinical feasibility as a metric of quality of recovery in Korean surgical population. Clinical trial registration NCT04169087.
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Background: Poor sleep leads to poor health outcomes. Inpatient sleep disturbance has been studied primarily in the ICU. Minimal research exists on sleep in surgical populations. Methods: We recruited patients undergoing elective, inpatient general surgery. Participants wore Fitbit trackers while inpatient to measure total sleep time (CDC Recommendation ≥7hrs/night). At discharge, patients completed the Richards-Campbell Sleep Questionnaire (RCSQ) to measure inpatient sleep quality. The RCSQ combines five domains into a cumulative score (0-100); a higher score means better sleep quality. Patients also completed the outpatient Pittsburgh Sleep Quality Index (PSQI) preoperatively and postoperatively. The primary outcome was percentage of patients with Total Sleep Score ≥ 50. Secondary outcomes included mean RCSQ domain scores, Fitbit Total Sleep Time (TST), and percentage with PSQI Score indicating poor sleep. Results: We included 64 patients (Mean±SD age = 55.0±14.1). Mean±SD RCSQ Total Sleep Score was 49±20.5 with 53.1% with Total Sleep Score < 50. Mean±SD RCSQ domain scores, Awakenings: 40.4±22.8, Sleep Quality: 49.1±27.9, Sleep Latency: 49.2±25.3, Sleep Depth: 50.2±26.5, Returning to Sleep: 55.9±28.1, and Noise Disturbance: 59.1±27.9. On Night 1, 25 devices (40%) had recorded sleep data due to enough sleep. Mean TST± SD on Night 1 was 4.7±2.8 hrs. Mean TST for Nights 2, 3 and 4 remained below 7 hrs. Percentage each night achieving the CDC goal of ≥ 7 hrs, Night 1: 10.9%, Night 2: 32.8%, Night 3: 35.3%, Night 4: 27.6%. 88.1% of patients were poor sleepers preoperatively per the PSQI, while 84.5% were poor sleepers at follow up (p = 0.6). Conclusions: Elective general surgery patients experience a severe inpatient sleep disturbance, worse than in similarly studied ICU cohorts. This disturbance is driven primarily by nighttime awakenings.
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Purpose: As tau pathology is involved in impaired postoperative learning and memory in rats, we attempted to identify the possible mechanisms by which tau pathology affects postoperative sleep deprivation. Methods: Adult male Sprague-Dawley rats were randomly assigned into six groups as follows: the Control group, Anaesthesia group, Surgery group, Sleep deprivation (SD) group: 24-h SD with the modified multiple platform method (MMPM), Anaesthesia and SD (ASD) group, and Surgery and SD (SSD) group. Tau396 and FOXQ1 protein expression levels in the hippocampal neurons of all groups were analysed. Changes following co-culture of hippocampal neurons with IL-6 were detected by flow cytometry. Results: Twenty-four hours of acute SD decreased the error scores on postoperative day 5 in the ASD and SSD groups compared with the Anaesthesia and Surgery groups. Compared with the tau levels in the Control group, tau levels in the Anaesthesia and Surgery groups were increased, but SD decreased the expression of tau in the ASD and SSD groups. The expression levels of tau and FOXQ1 were inversely regulated. When hippocampal neurons were co-cultured with IL-6, the same changes were observed. Conclusion: Postoperative 24-h acute SD improves learning and memory through inhibition of tau phosphorylation and increases IL-6-induced expression of FOXQ1 in the hippocampal neurons of splenectomized rats.
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Background Pain is a leading cause of disability worldwide. Pain assessments are an essential part of evidence-based care and management. Among comparable care providers, there is variation in how nurses document assessments as well as the content in them, and there is a notable associated administrative burden. Aims This study evaluated the impact and significance of a new, structured, digitised pain assessment form from quality, safety and efficiency standpoints. Methods Samples of pain assessments were examined at three consecutive stages: first, the pre-existing form was used, then the new structured form was introduced and, finally, the structured form was taken away and nurses went back to completing the original form. Assessments were scored by two clinical analysts against 18 clinically defined pain-related characteristics and factors. The time taken to extract and interpret the assessments was also recorded. Statistically significant changes were assessed using Welch's t-tests and Fisher's exact tests. Findings There was a significant improvement in data quality using the new structured form compared with the pre-existing template, including an increase in the capture of five safety-related variables. Less time was needed to extract and interpret data with the new form. Conclusion Intelligent structured forms are highly effective for documenting pain assessments, and offer notable benefits in quality, safety, and efficiency.
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Purpose: General anesthesia may affect the quality of postoperative sleep, especially after surgery on elderly patients. The decline of postoperative sleep quality may produce harmful effects on the postoperative recovery of patients. In this review, we summarized the efficacy and potential mechanism of acupuncture on postoperative sleep quality. Methods: We review the effect of general anesthesia on circadian sleep rhythm. In addition, to provide evidence about the impairment of decreased postoperative sleep quality, we also emphasize the mechanism of acupuncture alleviates factors that affect sleep quality after general anesthesia. Results: The application of acupuncture technology has been helpful to improve sleep quality and alleviate postoperative complications affecting postoperative sleep quality after general anesthesia. Conclusion: Acupuncture at different acupoints could effectively improve body's neurotransmitter levels and regulate biological clock genes through various mechanisms, and then improve postoperative sleep quality. Large-scale multi-center trials are needed to verify these findings.
Article
Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.
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Sleep disturbances are highly prevalent in chronic pain patients. Understanding their relationship has become an important research topic since poor sleep and pain are assumed to closely interact. To date, human experimental studies exploring the impact of sleep disruption/deprivation on pain perception have yielded conflicting results. This inconsistency may be due to the large heterogeneity of study populations and study protocols previously used. In addition, none of the previous studies investigated the entire spectrum of nociceptive modalities. To address these shortcomings, a standardized comprehensive quantitative sensory protocol was used in order to compare the somatosensory profile of 14 healthy subjects (6 female, 8 male, 23.5 ± 4.1 yr; mean ± SD) after a night of total sleep deprivation (TSD) and a night of habitual sleep in a cross-over design. One night of TSD significantly increased the level of sleepiness (p<0.001) and resulted in higher scores of the State Anxiety Inventory (p<0.01). In addition to previously reported hyperalgesia to heat (p<0.05) and blunt pressure (p<0.05), study participants developed hyperalgesia to cold (p<0.01) and increased mechanical pain sensitivity to pinprick stimuli (p<0.05) but no changes in temporal summation. Paradoxical heat sensations or dynamic mechanical allodynia were absent. TSD selectively modulated nociception, since detection thresholds of non-nociceptive modalities remained unchanged. Our findings show that a single night of TSD is able to induce generalized hyperalgesia and to increase State Anxiety scores. In the future, TSD may serve as a translational pain model to elucidate the pathomechanisms underlying the hyperalgesic effect of sleep disturbances.
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To determine whether an extended bedtime in sleepy and otherwise healthy volunteers would increase alertness and thereby also reduce pain sensitivity. Outpatient with sleep laboratory assessments. Healthy volunteers (n = 18), defined as having an average daily sleep latency on the Multiple Sleep Latency Test (MSLT) < 8 min, were randomized to 4 nights of extended bedtime (10 hr) (EXT) or 4 nights of their diary-reported habitual bedtimes (HAB). On day 1 and day 4 they received a standard MSLT (10:00, 12:00, 14:00, and 16:00 hr) and finger withdrawal latency pain testing to a radiant heat stimulus (10:30 and 14:30 hr). During the four experimental nights the EXT group slept 1.8 hr per night more than the HAB group and average daily sleep latency on the MSLT increased in the EXT group, but not the HAB group. Similarly, finger withdrawal latency was increased (pain sensitivity was reduced) in the EXT group but not the HAB group. The nightly increase in sleep time during the four experimental nights was correlated with the improvement in MSLT, which in turn was correlated with reduced pain sensitivity. These are the first data to show that an extended bedtime in mildly sleepy healthy adults, which resulted in increased sleep time and reduced sleepiness, reduces pain sensitivity. CITATION: Roehrs TA; Harris E; Randall S; Roth T. Pain sensitivity and recovery from mild chronic sleep loss. SLEEP 2012;35(12):1667-1672.
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Because insomnia is a common comorbidity of chronic pain, scientific and clinical interest in the relationship of pain and sleep has surged in recent years. Although experimental studies suggest a sleep-interfering property of pain and a pain-enhancing effect of sleep deprivation/fragmentation, the temporal association between pain and sleep as experienced by patients is less understood. The current study was conducted to examine the influence of presleep pain on subsequent sleep and sleep on pain reports the next day, taking into consideration other related psychophysiologic variables such as mood and arousal. A daily process study, involving participants to monitor their pain, sleep, mood, and presleep arousal for 1 wk. Multilevel modeling was used to analyze the data. In the patients' natural living and sleeping environment. One hundred nineteen patients (73.9% female, mean age = 46 years) with chronic pain and concomitant insomnia. An electronic diary was used to record patients' self-reported sleep quality/efficiency and ratings of pain, mood, and arousal at different times of the day; actigraphy was also used to provide estimates of sleep efficiency. Results indicated that presleep pain was not a reliable predictor of subsequent sleep. Instead, sleep was better predicted by presleep cognitive arousal. Although sleep quality was a consistent predictor of pain the next day, the pain-relieving effect of sleep was only evident during the first half of the day. These findings challenge the often-assumed reciprocal relationship between pain and sleep and call for a diversification in thinking of the daily interaction of these 2 processes.
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Disturbances of sleep are hypothesized to contribute to pain. However, experimental data are limited to healthy pain-free individuals. This study evaluated the effect of sleep loss during part of the night on daytime mood symptoms and pain perceptions in patients with rheumatoid arthritis in comparison with control subjects. A between-groups laboratory study with assessment of mood symptoms and pain perception before and after partial night sleep deprivation (PSD; awake 23:00 hr to 03:00 hr). General clinical research center. Patients with rheumatoid arthritis (n = 27) and volunteer comparison control subjects (n = 27). Subjective reports of sleep, mood symptoms and pain, polysomnographic assessment of sleep continuity, and subjective and objective assessment of rheumatoid arthritis-specific joint pain. PSD induced differential increases in self-reported fatigue (P < 0.09), depression (P < 0.04), anxiety (P < 0.04), and pain (P < 0.01) in patients with rheumatoid arthritis compared with responses in control subjects, in whom differential increases of self-reported pain were independent of changes in mood symptoms, subjective sleep quality, and objective measures of sleep fragmentation. In the patients with rheumatoid arthritis, PSD also induced increases in disease-specific activity as indexed by self-reported pain severity (P < 0.01) and number of painful joints (P < 0.02) as well as clinician-rated joint counts (P < 0.03). This study provides the first evidence of an exaggerated increase in symptoms of mood and pain in patients with rheumatoid arthritis after sleep loss, along with an activation of rheumatoid arthritis-related joint pain. Given the reciprocal relationship between sleep disturbances and pain, clinical management of pain in patients with rheumatoid arthritis should include an increased focus on the prevention and treatment of sleep disturbance in this clinical population.
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Most patients with chronic musculoskeletal pain report poor-quality sleep. The impact of chronic pain on sleep can be described as a vicious circle with mutual deleterious influences between pain and sleep-associated symptoms. It is difficult, however, to extract quantitative or consistent and specific sleep variables (eg, total sleep time, slow-wave sleep, sleep stage duration) that characterize the pain-related disruption of sleep. Comorbidity (eg, fatigue; depression; anxiety, sleep, movement, or breathing disorders) often confounds the reading and interpretation of sleep traces. Furthermore, many other methodologic issues complicate our ability to generalize findings (low external validity) to first-line medicine. Because sleep alterations in common musculoskeletal pain are neither specific nor pathognomonic, the aim is to provide a critical overview of the current understanding of pain and sleep interaction, discussing evidence-based and empiric knowledge that should be considered in further research and clinical applications.
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The autonomic nervous system (ANS) reacts to nociceptive stimulation during sleep, but whether this reaction is contingent to cortical arousal, and whether one of the autonomic arms (sympathetic/parasympathetic) predominates over the other remains unknown. We assessed ANS reactivity to nociceptive stimulation during all sleep stages through heart rate variability, and correlated the results with the presence of cortical arousal measured in concomitant 32-channel EEG. Fourteen healthy volunteers underwent whole-night polysomnography during which nociceptive laser stimuli were applied over the hand. RR intervals (RR) and spectral analysis by wavelet transform were performed to assess parasympathetic (HF(WV)) and sympathetic (LF(WV) and LF(WV)/HF(WV) ratio) reactivity. During all sleep stages, RR significantly decreased in reaction to nociceptive stimulations, reaching a level similar to that of wakefulness, at the 3rd beat post-stimulus and returning to baseline after seven beats. This RR decrease was associated with an increase in sympathetic LF(WV) and LF(WV)/HF(WV) ratio without any parasympathetic HF(WV) change. Albeit RR decrease existed even in the absence of arousals, it was significantly higher when an arousal followed the noxious stimulus. These results suggest that the sympathetic-dependent cardiac activation induced by nociceptive stimuli is modulated by a sleep dependent phenomenon related to cortical activation and not by sleep itself, since it reaches a same intensity whatever the state of vigilance.
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Acute postoperative pain is a complex phenomenon that baffles the staff involved in both its prevention and treatment. Acute postoperative pain varies even among patients who underwent the same type of surgery, and it is now known to be caused by different factors, including genetic background. This review will focus on the most important genes correlated with inter-patient differences in both pain sensitivity and analgesic response. Pain therapy is often administered to patients who are also taking other types of medication; therefore, drug interactions must be considered. A genetic analysis of receptors, of drug transporters, and of metabolizing enzymes may be needed to establish the effective doses of each drug in the individual patient to prevent side effects and also to achieve pain relief in a shorter period of time, which may prevent acute pain from becoming chronic. The etiology of chronic pain has not been elucidated yet, but we know that genetic predisposition comes into play, together with other clinical factors. Clinical trials including genetic analysis could be extremely useful in optimizing the management of postoperative pain therapy.
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Extensive research into circadian rhythms and their influence on biological systems has given rise to the science of chronobiology and subsequently chronotherapy, the science of delivering drugs in synchrony with biological rhythms. The field of chronotherapeutics paves the way for advances and complexities in current drug delivery technology. The ultimate goal of current chronopharmaceutical research strives to design ideal chronotherapeutic drug delivery systems that respond to such therapeutic needs. Considering the fact that physiological events such as heart rate, blood pressure, plasma concentration of hormones, plasma proteins and enzymes display constancy over time, drug delivery systems with constant release profiles have thus been favored. However, due to circadian rhythms, the conventional paradigm of constant drug delivery may not be what is needed. Instead, precisely timed drug delivery systems are required in order to correlate drug delivery with circadian rhythms to provide maximum therapeutic efficacy for chronotherapeutic diseases when most needed. The aim of this review paper is to outline the concepts in designing chronopharmaceuticals from a clinical viewpoint of major chronotherapeutic diseases such as asthma, allergic rhinitis, cardiovascular disorders, rheumatoid arthritis and cancer as well as relatively minor niche areas of interest such as in glaucoma, diabetes, immunity, pain, gastric ulcers, epilepsy and even HIV/AIDS that would require chronotherapy. In addition this review paper attempts to concisely assimilate and explicate the role of circadian rhythms in these various disease states and provide a focused overview of the current state-of-the-art in designing strategies for chronopharmaceutical formulations employed for treating chronotherapeutic diseases.
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Although the impact of sleep on cognitive function is increasingly well established, the role of sleep in modulating affective brain processes remains largely uncharacterized. Using a face recognition task, here we demonstrate an amplified reactivity to anger and fear emotions across the day, without sleep. However, an intervening nap blocked and even reversed this negative emotional reactivity to anger and fear while conversely enhancing ratings of positive (happy) expressions. Most interestingly, only those subjects who obtained rapid eye movement (REM) sleep displayed this remodulation of affective reactivity for the latter 2 emotion categories. Together, these results suggest that the evaluation of specific human emotions is not static across a daytime waking interval, showing a progressive reactivity toward threat-related negative expressions. However, an episode of sleep can reverse this predisposition, with REM sleep depotentiating negative reactivity toward fearful expressions while concomitantly facilitating recognition and ratings of reward-relevant positive expressions. These findings support the view that sleep, and specifically REM neurophysiology, may represent an important factor governing the optimal homeostasis of emotional brain regulation.
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The experiment investigated the impact of sleep restriction on pain perception and related evoked potential correlates (laser-evoked potentials, LEPs). Ten healthy subjects with good sleep quality were investigated in the morning twice, once after habitual sleep and once after partial sleep restriction. Additionally, we studied the impact of attentional focussing on pain and LEPs by directing attention to (intensity discrimination) or away from the stimulus (mental arithmetic). Laser stimuli directed to the hand dorsum were rated as 30% more painful after sleep restriction (49+/-7 mm) than after a night of habitual sleep (38+/-7 mm). A significant interaction between attentional focus and sleep condition suggested that attentional focusing was less distinctive under sleep restriction. Intensity discrimination was preserved. In contrast, the amplitude of the early parasylvian N1 of LEPs was significantly smaller after a night of partial sleep restriction (-36%, p<0.05). Likewise, the amplitude of the vertex N2-P2 was significantly reduced (-34%, p<0.01); also attentional modulation of the N2-P2 was reduced. Thus, objective (LEPs) and subjective (pain ratings) parameters of nociceptive processing were differentially modulated by partial sleep restriction. We propose, that sleep reduction leads to an impairment of activation in the ascending pathway (leading to reduced LEPs). In contradistinction, pain perception was boosted, which we attribute to lack of pain control distinct from classical descending inhibition, and thus not affecting the projection pathway. Sleep-restricted subjects exhibit reduced attentional modulation of pain stimuli and may thus have difficulties to readily attend to or disengage from pain.
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In order to assess the quality of sleep in surgical patients the amount of self-rated postoperative insomnia and its predisposing factors, we conducted a three-fold questionnaire survey in 176 consecutive patients undergoing elective orthopaedic, vascular or abdominal surgery. The first questionnaire was completed the day preceding surgery, the second at the day of discharge and the third two weeks later. This survey concerned the patient's general status, his usual sleep profile and factors which could interfere with sleep (hypnotics, pain, environmental factors) throughout the study period. It allowed quantification of these parameters and the assessment of their time-course. Perioperative insomnia appeared to be a long-lasting phenomenon which persisted after discharge. Factor analysis and multiple regression models showed that postoperative, self-rated insomnia was multifactorial and mainly explained by the amount of postoperative pain (p = 0.035).
Article
Sleep disruption by painful stimuli is frequently observed both in clinical and experimental conditions. Nociceptive stimuli produce significantly more arousals (30% of stimuli) than non-nociceptive ones. However, even if they do not interrupt sleep, they can trigger a variety of other reactions. Reflex behaviours in response to nociceptive stimuli can be observed during all sleep stages, and are more likely to occur in association with an arousal than alone. Cardiac activation represents a robust sympathetically driven effect preserved whatever the state of vigilance, even if its magnitude can be modulated by a concomitant cortical arousal. Not withstanding these reactions, incorporation of nociceptive stimuli into dream content remains limited. At cortical level, laser-evoked potential studies demonstrate that the processing of nociceptive stimulations is partly conserved during all sleep stages. Furthermore, when nociceptive stimulations interrupt sleep, the cortical response presents a late component suggesting that the stimulation has to be cognitively processed in order to produce a subsequent arousal. More complex reactions to nociceptive stimulations were occasionally reported. In this context, an epileptic patient with intracerebral electrodes implanted for therapeutic purposes allowed us extending these observations. This patient exhibited finger lifts in response to stimulations delivered during paradoxical (REM) sleep. This motor reaction was previously used during wakefulness to indicate that the stimulation had been perceived. When these finger lifts occurred a systematic re-activation of the anterior cingulate preceded each movement. This observation suggests that during PS, not only the processing of sensory inputs but also the capacity for the sleeper to intentionally indicate his perception could be preserved under particular circumstances.
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/st> Major surgery is followed by pronounced sleep disturbances after traditional perioperative care potentially leading to prolonged recovery. The aim was to evaluate the rapid eye movement (REM) sleep duration and sleep architecture before and after fast-track hip and knee replacement with length of stay (LOS) <3 days. The primary endpoint was REM sleep duration on the first postoperative night compared with before operation. /st> Ten subjects (≥60 yr) receiving spinal anaesthesia and multimodal opioid-sparing postoperative analgesia for total hip or knee arthroplasty were included. Ambulatory polysomnography was performed one night before operation at home, continuously during hospitalization, and on the fourth postoperative night at home. Sleep staging was performed according to the American Academy of Sleep Medicine manual. Opioid use, pain, and inflammatory response (C-reactive protein) were also evaluated. /st> The mean LOS was 1.5 (1-2) days. The mean REM sleep time decreased from a mean of 18.2 (9.5-23.5)% of total sleep time to 1.2 (0-5.8)% on the first postoperative night (P=0.002); awake time increased from 19.1 (3.7-44.4)% to 44.3 (12.2-70.6)% (P=0.009); and sleep architecture on the first postoperative night was more disturbed than before operation. Sleep architecture normalized on the fourth postoperative night. There was no association between opioid use, pain scores, and inflammatory response with a disturbed sleep pattern. /st> Despite ultra-short LOS and provision of spinal anaesthesia with multimodal opioid-sparing analgesia, REM sleep was almost eliminated on the first postoperative night after fast-track orthopaedic surgery but returned to pre-admission levels when at home on the fourth postoperative night.
Article
The aim of this study was to compare the effects of total sleep deprivation (TSD), rapid eye movement (REM) sleep and slow wave sleep (SWS) interruption and sleep recovery on mechanical and thermal pain sensitivity in healthy adults. Nine healthy male volunteers (age 26–43 years) were randomly assigned in this double blind and crossover study to undergo either REM sleep or SWS interruption. Periods of 6 consecutive laboratory nights separated by at least 2 weeks were designed as follows: N1 Adaptation night; N2 Baseline night; N3 Total sleep deprivation (40 h); N4 and N5 SWS or REM sleep interruption; N6 Recovery. Sleep was recorded and scored using standard methods. Tolerance thresholds to mechanical and thermal pain were assessed using an electronic pressure dolorimeter and a thermode operating on a Peltier principle. Relative to baseline levels, TSD decreased significantly mechanical pain thresholds (−8%). Both REM sleep and SWS interruption tended to decrease mechanical pain thresholds. Recovery sleep, after SWS interruption produced a significant increase in mechanical pain thresholds (+ 15%). Recovery sleep after REM sleep interruption did not significantly increase mechanical pain thresholds. No significant differences in thermal pain thresholds were detected between and within periods. In conclusion this experimental study in healthy adult volunteers has demonstrated an hyperalgesic effect related to 40 h TSD and an analgesic effect related to SWS recovery. The analgesic effect of SWS recovery is apparently greater than the analgesia induced by level I (World Health Organization) analgesic compounds in mechanical pain experiments in healthy volunteers.
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Although it is well known that pain induces changes in autonomic parameters, the extent to which these changes correlate with the experience of pain is under debate. The aim of the present study was to compare a combination of multiple autonomic parameters and each parameter alone in their ability to differentiate among 4 categories of pain intensity. Tonic heat stimuli (1minute) were individually adjusted to induce no pain, low, medium, and high pain in 45 healthy volunteers. Electrocardiogram, photoplethysmogram, and galvanic skin response were recorded, and the following parameters were calculated: heart rate; heart rate variability-high frequency (0.15 to 0.4Hz) spectral power; skin conductance level; number of skin conduction fluctuations; and photoplethysmographic pulse wave amplitude. A combination of parameters was created by fitting an ordinal cumulative logit model to the data and using linear coefficients of the model. Friedman test with post-hoc Wilcoxon test were used to compare between pain intensity categories for every parameter alone and for their linear combination. All of the parameters successfully differentiated between no pain and all other pain categories. However, none of the parameters differentiated between all 3 pain categories (i.e., low and medium; medium and high; low and high). In contrast, the linear combination of parameters significantly differentiated not only between pain and no pain, but also between all pain categories (P<.001 to .02). These results suggest that multiparameter approaches should be further investigated to make progress toward reliable autonomic-based pain assessment.
Article
Sleep of good quantity and quality is considered a biologically important resource necessary to maintain homeostasis of pain-regulatory processes. To assess the role of chronic sleep disturbances in pain processing, we conducted laboratory pain testing in subjects with primary insomnia. Seventeen participants with primary insomnia (mean ± SEM 22.6 ± 0.9 yrs, 11 women) were individually matched with 17 healthy participants. All participants wore an actigraph device over a 2-week period and completed daily sleep and pain diaries. Laboratory pain testing was conducted in a controlled environment and included (1) warmth detection threshold testing, (2) pain sensitivity testing (threshold detection for heat and pressure pain), and (3) tests to access pain modulatory mechanisms (pain facilitation and inhibition). Primary insomnia subjects reported experiencing spontaneous pain on twice as many days as healthy controls during the at-home recording phase (p < 0.05). During laboratory testing, primary insomnia subjects had lower pain thresholds than healthy controls (p < 0.05 for heat pain detection threshold, p < 0.08 for pressure pain detection threshold). Unexpectedly, pain facilitation, as assessed with temporal summation of pain responses, was reduced in primary insomnia compared to healthy controls (p < 0.05). Pain inhibition, as assessed with the diffuse noxious inhibitory control paradigm (DNIC), was attenuated in insomnia subjects when compared to controls (p < 0.05). Based on these findings, we propose that pain-inhibitory circuits in patients with insomnia are in a state of constant activation to compensate for ongoing subclinical pain. This constant activation ultimately may result in a ceiling effect of pain-inhibitory efforts, as indicated by the inability of the system to adequately function during challenge.
Article
Sleep deprivation was found to exert complex effects on affective dimensions and modalities of pain perception both in healthy volunteers and patients with major depression. Considering multifaceted links between mood and pain regulation in patients with chronic somatoform pain, it is intriguing to study sleep deprivation effects for the first time in this group of patients. Twenty patients with a somatoform pain disorder according to ICD-10 diagnostic criteria were sleep-deprived for one night, followed by one recovery night. Clinical pain complaints (visual analog scale), detection- and pain thresholds (temperature and pressure) as well as mood states (Profile of Mood States) were assessed on the day prior to the experiment, on the day after sleep deprivation and on the day after recovery sleep. We found a discrepancy between significantly increased clinical pain complaints and unaltered experimental pain perception after sleep deprivation. Only the clinical pain complaints, but not the experimental pain thresholds were correlated with tiredness-associated symptoms. Total mood disturbances decreased and feelings of depression and anger improved significantly after sleep deprivation. However, these changes were not correlated with a change in clinical pain perception. We conclude that sleep deprivation may generally change the reagibility of the limbic system, but mood processing and pain processing may be affected in an opposite way reflecting neurobiological differences between emotional regulation and interoceptive pain processing.
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Sleep disturbance is one of the most common comorbid problems for chronic pain patients. The association between the two phenomena has long been recognized, but the nature of the relationship is not well-understood. Many agree that the relationship is likely bidirectional. In this review, we focus on one side of the relationship: whether and how disordered sleep adversely impacts pain. We discuss the available evidence from the epidemiologic, clinical, and human, as well as infrahuman laboratory studies. Generally, the literature supports the positive relationship between poor sleep and increased pain. Sleep deprivation also seems to attenuate analgesic effects of medications. Research delineating the causal or associative relationship between sleep and pain is still preliminary at this time. Continuing efforts in both experimental and clinical research are needed to develop a translationally meaningful understanding of how poor sleep impacts pain.
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Although postoperative pain remains incompletely controlled in some settings, increased understanding of its mechanisms and the development of several therapeutic approaches have substantially improved pain control in past years. Advances in our understanding of the process of nociception have led to insight into gene-based pain therapy, the development of acute opioid-induced hyperalgesia, and persistent postsurgical pain. Use of specific analgesic techniques such as regional analgesia could improve patient outcomes. We also examine the development of new analgesic agents and treatment modalities and regimens for acute postoperative pain.
Article
We investigated the effects of total and rapid eye movement (REM) sleep deprivation on the thermal nociceptive threshold and pain perception using the objective laser-evoked potential (LEP) and the subjective visual analogue scale (VAS). Twenty-eight male adult volunteers were assigned into Control (CTRL), Total (T-SD), and REM (REM-SD) Sleep Deprivation groups. The T-SD and REM-SD volunteers were totally or selectively deprived of sleep for 2 and 4 consecutive nights, respectively. Pain parameters were measured daily during the experimental period. Volunteers were stimulated on the back of the hand by blocks of 50 diode laser pulses. Intensities increased between successive blocks, ranging from nonnoxious to noxious levels, and the LEP threshold was identified based on the evoked-response onset. Both the LEP threshold and VAS ratings were significantly increased after the second night of T-SD. No significant variations were observed in the REM-SD group, suggesting a predominant role for slow wave sleep rather than selective REM-SD in pain perception. Also, for both sleep-deprived groups, the mean values of the LEP threshold and VAS ratings showed a gradual increase that was proportional to the SD deprivation time, followed by a decrease after 1 night of sleep restoration. These findings demonstrate a hyperalgesic modification to pain perception (as reflected by the augmented VAS) and a concomitant increase in the LEP threshold following T-SD, an apparently contradictory effect that can be explained by differences in the ways that attention affects these pain measurements.
Article
Paradoxical sleep deprivation (PSD) increases pain sensitivity and reduces morphine antinociception. Because dopaminergic neurons in the periaqueductal gray matter (PAG) participate in pain modulation and opioid-induced antinociception, we evaluated the effects of PSD on thermal pain sensitivity, morphine- and L-DOPA-induced antinociception and dopaminergic functionality in the PAG by assessing tyrosine hydroxylase (TH) immunoreactivity. Rats that were subjected to 96h of PSD received vehicle, morphine (2.5, 5 or 10mg/kg), L-DOPA (50 or 100mg/kg) or L-DOPA (50mg/kg)+morphine (2.5 and 5mg/kg) and were tested with a 46°C hot plate 1h after. The paw withdrawal latency responses to the hot plate were decreased in PSD rats and were modified by the highest dose of morphine, L-DOPA and L-DOPA+morphine. Analgesic effects were observed in control groups for all of the morphine doses as well as 100mg/kg of L-DOPA and L-DOPA (50mg/kg)+morphine (5mg/kg). The number of cell bodies that were immunopositive for TH in the PAG was reduced in PSD rats. In conclusion, increased thermal sensitivity was reversed by L-DOPA and could be caused by a reduction TH levels in the PAG. Our data also suggest a relationship between central dopaminergic networks and opiate-induced analgesia in rats.
Article
This descriptive, correlational study was conducted to determine orthopedic patients' night-time pain characteristics, their quality of sleep and the contributing factors to poor sleep experiences, and the relationship between pain and sleep. Data were collected by using the McGill Pain Questionnaire-SF (MPQ-SF) and Pittsburgh Sleep Quality Index (PSQI) on the second postoperative day. Data were analyzed using the SPSS version 10.0 for Windows. Mean age of the 75 patients was 49.55 ± 21.10 years and were hospitalized in the orthopedic wards for 10.56 ± 14.74 days. Of the sample, 65.3% were female and 36% had hip/knee arthroplasty surgery. Pain (45%) and noise (23%) were found to be the most cited factors affecting the sleep of patients in postoperative periods. They experienced "external" pain at the surgical site and verbalized their pain as "stabbing" and "tiring-exhausting." Patients' night-time pain was determined to be severe (6.59 ± 1.62); their quality of sleep was also poor (9.24 ± 3.53). A statistically significant correlation was found between patients' pain intensity and quality of sleep (p≤.05).
Article
In human pain experiments, as well as in clinical settings, subjects are often asked to assess pain using scales (eg, numeric rating scales). Although most subjects have little difficulty in using these tools, some lack the necessary basic cognitive or motor skills (eg, paralyzed patients). Thus, the identification of appropriate nonverbal measures of pain has significant clinical relevance. In this study, we assessed heart rate (HR), skin conductance (SC), and verbal ratings in 39 healthy male subjects during the application of twelve 6-s heat stimuli of different intensities on the subjects' left forearm. Both HR and SC increased with more intense painful stimulation. However, HR but not SC, significantly correlated with pain ratings at the group level, suggesting that HR may be a better predictor of between-subject differences in pain than is SC. Conversely, changes in SC better predicted variations in ratings within a given individual, suggesting that it is more sensitive to relative changes in perception. The differences in findings derived from between- and within-subject analyses may result from greater within-subject variability in HR. We conclude that at least for male subjects, HR provides a better predictor of pain perception than SC, but that data should be averaged over several stimulus presentations to achieve consistent results. Nevertheless, variability among studies, and the indication that gender of both the subject and experimenter could influence autonomic results, lead us to advise caution in using autonomic or any other surrogate measures to infer pain in individuals who cannot adequately report their perception. Skin conductance is more sensitive to detect within-subject perceptual changes, but heart rate appears to better predict pain ratings at the group level.
Article
As critical as waking brain function is to cognition, an extensive literature now indicates that sleep supports equally important, different, yet complementary operations. This review will consider recent and emerging findings implicating sleep, and specific sleep-stage physiologies, in the modulation, regulation and even preparation of cognitive and emotional brain processes. First, evidence for the role of sleep in memory processing will be discussed, principally focusing on declarative memory. Second, at a neural level, several mechanistic models of sleep-dependent plasticity underlying these effects will be reviewed, with a synthesis of these features offered that may explain the ordered structure of sleep, and the orderly evolution of memory stages. Third, accumulating evidence for the role of sleep in associative memory processing will be discussed, suggesting that the long-term goal of sleep may not be the strengthening of individually memory items, but, instead, their abstracted assimilation into a schema of generalized knowledge. Forth, the newly emerging benefit of sleep in regulating emotional brain reactivity will be considered. Finally, and building on this latter topic, a novel hypothesis and framework of sleep-dependent affective brain processing will be proposed, culminating in testable predictions and translational implications for mood disorders.
Article
The transition from wakefulness to sleep is characterized typically by a shift from sympathetic to parasympathetic regulation. Physiological functions, depending on the neurovegetative system, decrease overall. Previous studies have shown cardiovascular and electroencephalographic hyperactivity during wakefulness and sleep in insomniacs compared with normal sleepers, but there is very little evidence of this in the process of sleep onset. The purpose of this study was to compare cardiovascular and autonomic responses before and after falling asleep in eight insomniacs (who met DSM-IV criteria for primary insomnia) and eight normal sleepers. Non-invasive measures of heart rate (HR), stroke volume (SV), cardiac output (CO) and pre-ejection period (PEP) were collected by impedance cardiography during a night of polysomnographic recording. Frequency domain measures [low-frequency (LF), high-frequency (HF)] of heart rate variability (HRV) were also estimated. Decrements in HR and CO and increases in SV and HF normalized units (n.u.) were found in both groups after sleep onset compared with wakefulness. Conversely, PEP (related inversely to sympathetic β-adrenergic activity) showed increases after sleep onset in controls, but remained unchanged in insomniacs. PEP was also significantly lower in insomniacs than in normal sleepers in both conditions. These data suggest that, whereas normal sleepers follow the expected progressive autonomic drop, constant sympathetic hyperactivation is detected in insomniacs. These results support the aetiological hypothesis of physiological hyperarousal underlying primary insomnia.
Article
Objectives:Despite efforts to improve acute postoperative pain management, a substantial number of patients still experience moderate to severe pain during the immediate postoperative days. The purpose of the present study was to identify predictors of moderate to severe acute postoperative pain. Methods: A total of 1490 patients undergoing heterogeneous surgical procedures recorded their pain 3 times a day on a 100-mm visual analog scale from the day before the operation until 5 days postoperation. For each postoperative day, pain intensity was classified as moderate when the mean pain score was 41 to 74mm and as "severe when the mean pain score was 75 to 100 mm. Using logistic regression analyses, we examined the predictive value of a comprehensive set of preoperative and perioperative variables for moderate to severe pain. Results: The most important predictors seemed to be; preoperative pain, expected pain, surgical fear, and pain catastrophizing. Discussion: Several predictive factors of postoperative pain were identified in this study. These factors could be taken into account in postoperative pain management.
Article
Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was conducted to identify the independent predictive factors for postoperative pain and analgesic consumption. The authors identified 48 eligible studies with 23,037 patients included in the final analysis. Preoperative pain, anxiety, age, and type of surgery were four significant predictors for postoperative pain. Type of surgery, age, and psychological distress were the significant predictors for analgesic consumption. Gender was not found to be a consistent predictor as traditionally believed. Early identification of the predictors in patients at risk of postoperative pain will allow more effective intervention and better management. The coefficient of determination of the predictive models was less than 54%. More vigorous studies with robust statistics and validated designs are needed to investigate this field of interest.
Article
Insufficient duration of sleep is a highly prevalent behavioral pattern in society that has been shown to cause an increase in spontaneous pain and sensitivity to noxious stimuli. Prostaglandins (PGs), in particular PGE2, are key mediators of inflammation and pain, and we investigated whether PGE2 is a potential mediator in sleep-loss-induced changes in nociceptive processing. Twenty-four participants (7 females, age 35.1+/-7.1 years) stayed for 7 days in the Clinical Research Center. After two baseline days, participants were randomly assigned to either 3 days of 88 h of sleep deprivation (TSD, N=15) or 8h of sleep per night (N=9), followed by a night of recovery sleep. Participants rated the intensity of various pain-related symptoms every 2h across waking periods on computerized visual analog scales. PGE2 was measured in 24-h-urine collections during baseline and third sleep deprivation day. Spontaneous pain, including headache, muscle pain, stomach pain, generalized body pain, and physical discomfort significantly increased by 5-14 units on a 100-unit scale during TSD, compared to the sleep condition. Urinary PGE2 metabolite significantly increased by about 30% in TSD over sleep condition. TSD-induced increase in spontaneous pain, in particular headache and muscle pain, was significantly correlated with increase in PGE2 metabolite. Activation of the PGE2 system appears to be a potential mediator of increased spontaneous pain in response to insufficient sleep.