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Variability in the Relationship Between Sleep and Pain in Patients Undergoing Interdisciplinary Rehabilitation for Chronic Pain
Abstract
Objective
Chronic pain and sleep disturbance frequently coexist and often complicate the course of treatment. Despite the well-established comorbidity, there are no studies that have investigated concurrent changes in sleep and pain among patients participating in an interdisciplinary chronic pain rehabilitation program (ICPRP). The goal of this study was to investigate the daily changes in sleep and pain among patients participating in an ICPRP.Methods
Multilevel modeling techniques were used to evaluate the daily changes in total sleep time (TST) and pain among a sample of 50 patients with chronic noncancer pain participating in the ICPRP.ResultsIncreases in TST were predictive of less pain the following treatment day, although daily pain ratings were not predictive of that night's TST. Time in treatment was a significant predictor of both TST and pain reduction, even while controlling for age, gender, anxiety, and depression. Additional analyses revealed significant individual variability in the relationship between TST and next day pain. Individuals with stronger associations between previous night's TST and next day pain were found to experience the greatest treatment benefits overall, in terms of pain reduction and TST.Conclusions
Our results provide compelling support for individual variability of the pain–sleep relationship in patients with intractable pain conditions participating in an ICPRP. Importantly, these findings suggest that when pain and sleep are comorbid, both must be addressed to reap the maximum response to treatment programs such as an ICPRP.Perspective StatementThis study demonstrates the utility of treating sleep problems in patients participating in an interdisciplinary chronic pain rehabilitation program. Results highlight the benefits of accounting for individual variability in the pain-sleep relationship in a clinical setting and targeting sleep interventions for those individuals whose pain and sleep problems are comorbid.
... For example, sleep difficulties are common among chronic pain patients. When pain and sleep are comorbid, both must be addressed to attain the maximum response to pain rehabilitation programs [16]. A recent systematic review and meta-analysis revealed that multidisciplinary rehabilitation lessens pain intensity and disability compared to active physical interventions, and these effects appear to be sustained in the long term [17]. ...
... However, it was still high (around 6), which raises the question of whether it is time to reorganize the intervention and start to plan more follow-up with support, education, and assessment of mental conditions. Sleep deprivation is a risk factor for chronic pain [16]. Pain's interference with sleep was reduced in the current study. ...
... While sleep problems due to pain were slightly lower at one-year follow-up than they were pre-treatment, this difference was not significant. The results of Davin et al. [16] showed that a stronger association between the previous night's total sleep time and next-day pain contributed to the greatest overall treatment benefits in terms of pain reduction and total sleep time. This raises the question of whether enough is done in the intervention to deal with sleep problems in connection with pain. ...
Multidisciplinary long-term pain rehabilitation programs with a team of healthcare professionals are an integrated approach to treat patients with chronic non-malignant pain. In this longitudinal prospective cohort study, we investigated the long-term effects of multidisciplinary pain rehabilitation on the self-reported causes of pain, pain self-management strategies, sleep, pain severity, and pain’s interference with life, pre- and post-treatment. Eighty-one patients, aged 20–69 years, with chronic pain responded. The two most frequently reported perceived causes of pain were fibromyalgia and accidents. The difference in average self-reported pain severity decreased significantly at one-year follow-up (p < 0.001), as did pain’s interference with general activities, mood, walking ability, sleep, and enjoyment of life. At one-year follow-up, participants (21%) rated their health as good/very good and were more likely to state that it was better than a year before (20%). No change was found in the use of pain self-management strategies such as physical training at one-year follow-up. The intervention was effective for the participants, as reflected in the decreased pain severity and pain interference with life.
... 4 Although often conceptualized as a reciprocal relationship in which pain and sleep problems negatively impact one another, research indicates that the impact of poor sleep on subsequent pain is more clearly established than the impact of pain on subsequent sleep disturbance. 5 For example, results of one study suggested that better perceived sleep quality was predictive of lower pain intensity the next day, whereas a decrease in pain did not predict subsequent sleep. 6 In addition, studies have suggested that clinically significant insomnia symptoms (i.e., those that cause distress or impairment) may not improve from chronic pain treatment alone. ...
... 6 In addition, studies have suggested that clinically significant insomnia symptoms (i.e., those that cause distress or impairment) may not improve from chronic pain treatment alone. 5,7 These findings highlight the importance of addressing sleep problems for those with comorbid insomnia and chronic pain. ...
... Several studies indicate that patients with IPRP with greater levels of insomnia endorse worse pain, functional impairment, and emotional distress compared with those with lower levels of insomnia symptoms. 1,3,5,20 However, these may not present a barrier to meaningful clinical gains in pain-related outcomes. In one study, those with moderate and severe insomnia symptoms reported treatment benefit from the IPRP to a similar extent as those with no or mild insomnia symptoms. ...
Objectives
Insomnia is a highly prevalent problem among patients with chronic pain. Interdisciplinary pain rehabilitation programs (IPRPs) are a leading treatment option for chronic pain; however, research is limited and existing findings are mixed on the impact of insomnia symptoms on IPRP outcomes and the extent to which insomnia symptoms improve as a result of IPRP treatment.
Methods
In this study, insomnia and pain-related outcomes following a 10-week IPRP were examined from a relatively large sample (N = 393) of adult patients with varying chronic pain conditions who completed the Insomnia Severity Index (ISI) at program admission and discharge. Both group- and individual-level changes in insomnia severity were examined to evaluate statistically and clinically significant changes in insomnia symptoms, along with the impact of insomnia symptoms on measures of pain, emotional distress, and functioning. Participants were categorized as having no clinically significant insomnia symptoms (NCSI), mild, moderate, or severe insomnia based on ISI scores.
Results
Higher levels of insomnia severity were associated with worse pain, functioning, and emotional distress. Most patients reporting mild, moderate, or severe insomnia symptoms at program admission moved to a lower insomnia symptom category at the time of discharge (62%); however, only 33% of these patients reported a meaningful score reduction (i.e., ISI change ≥ 8 points). In addition, insomnia symptoms had a negative impact on treatment gains related to pain interference and physical health-related quality of life.
Discussion
These findings suggest that usual IPRP care confers overall treatment benefit for individuals with chronic pain and insomnia. However, insomnia symptoms may negatively impact pain treatment outcomes and usual care appears insufficient to address elevated insomnia patients for many patients. Additional insomnia-specific treatment may be warranted for patients with comorbid chronic pain.
... The relationship between pain and sleep is bidirectional, 50-80% of individuals with chronic pain have difficulty sleeping [5,6]. Studies such as [5,7,8] associate sleep deprivation with increasing pain sensitivity or even pain tolerance. ...
... The relationship between pain and sleep is bidirectional, 50-80% of individuals with chronic pain have difficulty sleeping [5,6]. Studies such as [5,7,8] associate sleep deprivation with increasing pain sensitivity or even pain tolerance. The risk of sleep disorders is 2 to 5 times higher in individuals with chronic pain [6]. ...
... Studies that explore the effect of non-pharmacological treatments on pain and sleep are limited [5]. Although the literature presents a shortage of studies in this specialty, TA may be an alternative, especially in the establishment of non-invasive treatments. ...
Statement of the Problem: Auriculotherapy (AT) is a TCM technique, which uses seeds instead of needles, based physiologically on the mechanical stimulation of the cranial nerves. In the context of understanding the new concept of health of the WHO, the AT is an integrative approach for achieving Global Health Care so as to achieve the global health care concerns. This study aimed to evaluate the effect of auriculotherapy on pain and sleep quality in patients with chronic pain. Methodology & Theoretical Orientation: This study was performed between February and March 2017 at the Faculdade Estácio de Sá de Vitória, Brazil. The pain evaluation was through VAS in 4 periods: maximum, minimum, average and at the time of evaluation; the evaluation of sleep quality was used the Pittsburgh Sleep Quality Index. Socio-demographic data included: gender, age, use of medication and BMI. All data are presented as mean (standard deviation), Teste Mann-Whitney and T-student with P-values < 0.05 were regarded as significant. Findings: Participated in this study Thirty-two individuals with age (M = 43.18, SD = 17.86), the time with pain in years (M = 3.67, SD = 3.68), 81.7% were female, 75% of the individuals used medication and BMI (M = 26.67; SD = 6.20). The pain presented improvement in the maximum level and the average of the pain and sleep quality before did not have statistically significant results. Conclusion & Significance: This study showed that TA is efficacy for reduction levels of pain. However, AT was not effective in improving sleep quality.
... In the context of an interdisciplinary chronic pain rehabilitation programme (ICPRP), it was also shown that previous night's total sleep time (TST) predicted next-day pain, but the strength of this association was not the same magnitude for each person; rather, its association varied across individuals [9]. That is, for some people a night of less sleep was very strongly associated with heightened next day pain, whereas others had weaker associations. ...
... This is of clinical importance when tailoring interventions for individuals with chronic pain and perhaps even more so for those with comorbid pain and sleep disturbance. A previous study from our centre [9] supported individual variability in the relationship between pain and sleep. Specifically the study demonstrated greater improvements in pain reduction and sleep across a 3 week interdisciplinary pain treatment programme for those individuals who had a strong association between previous night's total sleep time and next day pain. ...
Background and aim:
Pain catastrophizing is linked to heightened pain and poorer coping among individuals with chronic pain, yet little is known about how pain catastrophizing associates with sleep and pain over the course of treatment for chronic pain. Previous research employing a cross-sectional design suggests that sleep mediates the association between pain catstrophizing and pain, but there have been no longitudinal studies examining the directionality of these associations. Thus, the aim of this study was to test two competing theoretical models. The first model specified that pain catastrophizing leads to increased pain via poor sleep. The second model specified that poor sleep leads to increased pain catastrophizing via increased pain.
Methods:
This study examined the relations between pain catastrophizing, sleep, and pain among 50 consecutive patients (36 female, 14 male) ages 20-80 (M=45.96, SD=13.94) with chronic, non-malignant pain who were admitted to the Cleveland Clinic, Chronic Pain Rehabilitation Programme (CPRP). The CPRP, within the Neurological Centre for Restoration, Neurologic Institute at the Cleveland Clinic, is a comprehensive, interdisciplinary programme designed to treat patients with disabling chronic pain. As part of their daily, morning update with their case manager, patients completed self-report ratings of their previous night's sleep time (TST), and their current pain, anxiety, and depression. Pain catastrophizing was assessed at admission and discharge.
Results:
Over the course of treatment, daily TST increased from approximately 5h and 20min per night to nearly 6h and 30min per night, and average daily pain, daily depression, and daily anxiety decreased over the course of treatment. As the data in this study has a multilevel structure, with daily reports nested with in patients, we conducted multilevel path models to examine the longitudinal relations between pain catastrophizing, sleep, and pain. Multilevel path analysis permits the analysis of interdependent data without violating the assumptions of standard multiple regression. Models were conducted for pain catastrophizing and each of its subscales: rumination, magnification and helplessness. The findings were uniform across the composite pain catastrophizing scale and its subscales. There was an indirect path from sleep to pain catastrophizing (post-treatment) via pain, but not from pain catastrophizing (pre-treatment) to pain via sleep. There were also direct effects of sleep on pain and from pain to pain catastrophizing (post-treatment). Additionally, decreases in pain over the course of treatment were related to lower pain catastrophizing post-treatment.
Conclusion and implications:
These results call into question previous evidence that pain catastrophizing indirectly affects pain by way of its impact on sleep. Rather, our findings suggest that pain mediates the relationship between sleep and levels of pain catastrophizing. These results therefore underscore importance and value in collecting longitudinal data and potential influence on the conclusions gained with regards to sleep, pain and psychological variables. These findings may be of clinical importance when tailoring interventions for individuals with chronic pain and perhaps even more so for those with comorbid pain and sleep disturbance; prioritizing the treatment of sleep difficulties could result in improvements to pain-related outcomes.
... While we did not observe significant moderating effects of age group, sex, or chronic pain, with interventions in mind, further research should investigate other potential moderators of withinperson links. Results from an interdisciplinary intervention program for chronic pain showed that longer-term changes in sleep duration were only linked with longer-term changes in pain for people with stronger daily links between sleep duration and pain (49). It thus seems worthy to identify whose sleep is linked with their pain and self-rated health and for whom it could thus be helpful to simultaneously target sleep and pain in interventions. ...
Sleep is crucial for well-being, health, and cognitive functioning both from day-to-day and in the long-term. Because older adults experience declines in health and cognitive functioning as well as changes in sleep characteristics it is especially important to understand the interplay between sleep and daily well-being and functioning in this age group. The distinction between sleep quality and sleep duration should also be considered as their associations with daily functioning may differ. Using a broad theoretical approach to daily functioning, I thus examined daily associations of sleep quality and sleep duration with affective, health-related, and cognitive functioning in old and very old age. In this dissertation, I used data from two seven-day experience sampling studies with young-old and old-old adults. In addition to reporting on their sleep quality and sleep duration each morning, participants rated their current emotions and stress experiences, reported their momentary health and pain, and participated in two trials of a working memory task six times per day. Using these data, I first tested theoretical predictions that sleep is linked with affective stress reactivity rather than negative affect per se. Multilevel structural equation models (SEM) based on data from 325 older adults showed that after nights with lower sleep quality people reported more stressor-unrelated negative affect but not stronger stress reactivity the next day. However, when people experienced increased stress reactivity during the day, they reported lower sleep quality the following night. Sleep duration was not significantly linked with affective experiences. Second, I aimed to clarify the previously indeterminate temporal direction of associations between sleep and health perceptions. Partially confirming the predictions, results from dynamic SEM based on data from 170 older adults showed that when participants slept better than usual, they reported less pain and increased self-rated health the next day. Sleeping longer was not linked with either pain or self-rated health. Regarding the reversed direction, on days when people rated their health better, they slept better, but not longer, the next night. Third, I examined links of sleep with initial levels, learning improvements, and variability in working memory across a week and analyzed whether variations in sleep and working memory were linked from day to day. Results from multilevel location-scale models based on data from 160 older adults showed that people who slept longer and people who slept shorter than the sample average showed lower initial performance levels, but a stronger increase of working memory performance over time (i.e., larger learning effects), relative to people with average sleep duration. Sleep duration did not predict performance variability over one week. Sleeping shorter than usual was only linked with worse next-day working memory performance for people with short average sleep durations. Individual differences in sleep quality were not significantly associated with initial performance levels, learning effects, or variability of working memory in daily life. The associations between sleep and daily functioning did not systematically differ with participants’ age. Finally, I integrate the results for the different areas of daily functioning, consider the strengths and limitations of the current research, and give an outlook of avenues for future research, including suggestions for interventions. In summary, the results from my dissertation underline that sleep is highly relevant for daily functioning in old age, and that it is important to distinguish between sleep quality and sleep duration. The results suggest a critical role of sleep quality for affective well-being and health perceptions, whereas sleep duration may be more important for cognitive performance. Overall, sleep may be a promising target for interventions to improve older adults’ daily lives.
... While we did not observe significant moderating effects of age group, sex, or chronic pain, with interventions in mind, further research should investigate other potential moderators of withinperson links. Results from an interdisciplinary intervention program for chronic pain showed that longer-term changes in sleep duration were only linked with longer-term changes in pain for people with stronger daily links between sleep duration and pain (49). It thus seems worthy to identify whose sleep is linked with their pain and self-rated health and for whom it could thus be helpful to simultaneously target sleep and pain in interventions. ...
Background:
Sleep and health perceptions such as self-ratings of pain and health are closely linked. However, the temporal ordering of such associations is not well understood and it remains unclear whether sleep quality and sleep duration show similar or differential associations with health perceptions.
Methods:
We used ecological momentary assessment data from 123 young-old (66-69 years, 47% women) and 47 old-old adults (84-90 years, 60% women). Across seven consecutive days, participants reported their sleep quality and sleep duration each morning and rated their momentary pain and health six times per day. We applied dynamic structural equation models to examine bidirectional links of morning reports of sleep quality and duration with daily levels of self-rated pain and health.
Results:
In line with the hypotheses, results showed that when participants reported better sleep quality than what is typical for them, they reported less pain and better self-rated health on the day that followed. Longer sleep duration was not linked with subsequent pain or self-rated health. On days when people rated their health as better than usual, they reported better sleep quality but not longer sleep duration the following night. These associations were not moderated by age, gender, or chronic pain.
Conclusion:
Findings suggest that in old age sleep quality is more relevant for health perceptions than sleep duration. Associations between sleep quality and self-rated health seem to be bidirectional; daily pain was linked to prior but not subsequent sleep quality.
... • Sleep hygiene: sleep disorders are among the most common comorbidities for those experiencing chronic pain [60]. Sleep medications are commonly prescribed, and though these may be of benefit, it is appropriate for practitioners to emphasize sleep hygiene improvement for more effective and sustainable results. ...
Though there has been a 44.4% decrease in the number of prescriptions written for opioid analgesics between the years 2011–2020 in the United States, drug overdose rates continue to climb sharply, reaching nearly 107,000 for a prior 12-months period as of early 2022, driven primarily by the use of illicit opioids. It is estimated that 80–90% of individuals with a substance use disorder (SUD) receive no treatment, and for those with opioid use disorder (OUD) who do find their way to treatment, less than half are offered potentially life-saving medication. Contemporaneously, chronic pain is one of the most common and most disabling health conditions, and frequently involves complex decision-making between the patient and the health care team regarding the treatment approach. Though prescribing trends have ebbed in recent years, opioids continue to be the most prescribed class of drug in the United States despite well-publicized associated harms. It is more critical than ever that stakeholders urgently work to facilitate and destigmatize evidence-based substance use disorder treatment, and promote safe, effective, and holistic care pathways for patients suffering from chronic pain.
... IPRPs have also demonstrated significant improvements in insomnia symptoms (Craner et al., 2020). However, IPRP participation alone appears inadequate for treating clinical insomnia (Asih et al., 2014;Davin et al., 2014). Results of a recent study suggested that approximately 80% of IPRP participants endorsed at least mild insomnia; however, only 33% of those reported a meaningful reduction in symptoms at discharge (Craner & Flegge, 2021). ...
Background/Objective
Prior research indicates interdisciplinary pain rehabilitation program (IPRP) usual care (UC) does not sufficiently address sleep problems among individuals with comorbid chronic pain and clinical levels of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based insomnia intervention. The current study investigates the translation of CBT-I into an IPRP.
Method
In this single-site, prospective, randomized controlled pilot study, insomnia and pain-related outcomes were examined for adults participating in a 10-week IPRP (N = 79) who were allocated to a 4-session group-based CBT-I (IPRP+CBT-I) or usual care (IPRP-UC) condition.
Results
Patients in the IPRP+CBT-I group showed improvements in insomnia symptoms at the end compared to the beginning of the CBT-I group; however, there were no IPRP outcome differences relative to the IPRP-UC condition. Both groups reported statistically significant reductions in insomnia, pain severity, pain-related life interference, and depressed mood. Fewer than one-third of participants reported clinically meaningful reductions in insomnia symptoms following IPRP participation.
Conclusions
Further efforts are needed to address sleep problems in pain rehabilitation settings.
... Among individuals with rheumatic diseases, feeling rested after sleep and having a good sleep structure predict better HRQOL outcomes [18]. When pain and sleep are comorbid, both must be addressed to reap the maximum response to pain rehabilitation programs [19]. ...
Multidisciplinary pain-management programs have the potential to decrease pain intensity, improve health-related quality of life (HRQOL), and increase sleep quality. In this longitudinal prospective cohort study, the aim was to investigate the long-term effects of multidisciplinary pain rehabilitation interventions in Iceland. More precisely, we (a) explored and described how individuals with chronic pain evaluated their pain severity, sleep, and HRQOL at pre-treatment and at one-year follow-up and (b) examined what predicted the participants’ one-year follow-up HRQOL. Seventy-nine patients aged 20–68 years, most of whom were women (85%), responded. The participants scored their pain lower at one-year follow-up (p < 0.001). According to their response, most of them had disrupted sleep, mainly because of pain. One year after the treatment, more participants slept through the night (p = 0.004), and their HRQOL increased. Higher pre-treatment mental component summary (MCS) scores and having pursued higher education predicted higher MCS scores at one-year follow-up, and higher pre-treatment physical component summary (PCS) scores predicted higher PCS scores at one-year follow-up. Sleep problems, being a woman, and having children younger than 18 years of age predicted lower MCS scores at one-year follow-up. These findings are suggestive that patients should be examined with respect to their mental status, and it could be beneficial if they received some professional support after completing the intervention.
... We found that although sleep quality predicted pain the next morning, evening pain did not appear to influence sleep. Several previous diary studies have demonstrated bidirectional relationships between pain and sleep disturbance [25,26], but our results are consistent with a number of previous diary studies showing that whilst sleep predicted pain, pain did not predict sleep [27][28][29]. Overall the pain and sleep literature demonstrates a stronger and more consistent influence of sleep on pain than the influence of pain on sleep [10], with experimental and longitudinal studies also demonstrating the consistent influence of sleep on pain [3]. There are a number of mechanisms by which sleep can influence pain; for example sleep influences opioid systems and dopaminergic signalling, inflammatory processes, and mood, which can in turn influence pain [3,30]. ...
Objectives:
Insomnia is commonly comorbid with chronic pain, and typically leads to worse outcomes. Two factors that could contribute to a cycle of pain and sleeplessness are pre-sleep cognitive arousal (repetitive thought processes) and low mood. This study aimed to examine how pain, sleep disturbance, mood, and pre-sleep cognitive arousal inter-relate, to determine whether low mood or pre-sleep cognitive arousal contribute to a vicious cycle of pain and insomnia.
Methods:
Forty seven chronic pain patients completed twice daily diary measures and actigraphy for one week. Analyses investigated the temporal and directional relationships between pain intensity, sleep quality, time awake after sleep onset, anhedonic and dysphoric mood, and pre-sleep cognitive arousal. Fluctuations in predictor variables were used to predict outcome variables the following morning using mixed-effects modelling.
Results:
For people with chronic pain, an evening with greater pre-sleep cognitive arousal (relative to normal) led to a night of poorer sleep (measured objectively and subjectively), lower mood in the morning, and a greater misperception of sleep (underestimating sleep). A night of poorer sleep quality led to greater pain the following morning. Fluctuations in pain intensity and depression did not have a significant influence on subsequent sleep.
Conclusions:
For people with chronic pain, cognitive arousal may be a key variable exacerbating insomnia, which in turn heightens pain. Future studies could target cognitive arousal to assess effects on sleep and pain outcomes.
... Another method for assessing daily fluctuations is via the use of daily selfreport diaries. In a microlongitudinal study examining the bidirectional relationship between sleep and pain, better sleep predicted lower pain the following day; however, daily pain ratings did not predict subsequent night's sleep [59,74]. Finally, novel self-report measures, such as the Pain-Related Beliefs and Attitudes about Sleep (PBAS) may shed light onto the prevalence and role of dysfunctional sleep beliefs within the context of chronic pain [75]. ...
Purpose of Review
Good nighttime sleep is essential for maintenance of optimal daytime functioning. When nighttime sleep is disrupted, there are countless associated daytime consequences. One of the more prominent daytime consequences of disrupted sleep is pain. While the association between sleep and pain has received great empirical attention, there is still much unknown. This paper aims to summarize and evaluate the state-of-the-science of the interrelations among sleep, pain, and mood.
Recent Findings
Cumulative scientific evidence suggests that nighttime sleep is associated with both daytime pain and daytime mood disturbances. A growing body of research indicates that disruptions in mood may be one mechanism through which sleep disruptions are related to daytime pain. The study of common biological substrates may shed additional light on the interrelations among sleep, pain, and mood.
Summary
Mood represents an important link between sleep and pain. Future investigations would be well suited to appropriately sample a variety of indicators from the domains of sleep, pain, and mood. Studies that test triadic treatments that simultaneously address sleep, pain, and mood are needed.
... There are also longitudinal studies assessing the longterm changes in pain symptoms in patients with sleep disturbances. As evidence of the relationship between sleep disturbances and chronic pain continues to grow, studies call for treatment options that address both conditions concurrently [23][24][25]. ...
Objective:
The objective of this review is to answer three questions: 1) How are chronic pain severity and pain duration affected in patients with chronic pain and sleep disturbances that occur simultaneously? 2) What are common comorbidities and pain-related symptoms seen in patients with chronic pain and sleep disturbances? and 3) What are potentially effective pharmacological and nonpharmacological treatment options for both conditions?
Methods:
Ovid Medline and PubMed were searched. Search terms included sleep wake disorder, chronic pain, fibromyalgia, treatment outcome, psychotherapy, complementary therapies, and therapeutics. Studies that assessed outcomes between individuals with chronic pain and those with concurrent chronic pain and sleep disturbances were included. Randomized controlled clinical trials of treatments for both conditions were included.
Results:
Sixteen studies indicated that patients with both chronic pain and sleep disturbances have greater pain severity, longer duration of pain, greater disability, and are less physically active than those without sleep disturbances. Patients with both conditions are more likely to have concurrent depression, catastrophizing, anxiety, and suicidal ideation. Thirty-three randomized controlled trials assessed treatment for both chronic pain and sleep disturbances. Pregabalin was the most frequently studied medication, showing improvement in pain and sleep symptoms. Cognitive behavioral therapy for insomnia showed long-term improvement in sleep for patients with chronic pain.
Conclusions:
Individuals with chronic pain and sleep disturbances have greater symptom severity, longer duration of symptoms, more disability, and additional comorbidities. Pharmacological and nonpharmacological treatments may be useful in the treatment of concurrent chronic pain and sleep disturbances, but further study is needed.
... In fact, numerous studies have demonstrated that, among individuals with chronic pain, pain intensity levels vary substantially over time periods ranging from moments to hours to days. 13,28,47,60,66,72,84 One of the best ways to understand individuals' dynamical pain experience is to use an intensive and repeated assessment of pain-relevant variables in real-time and in the real-world settings. 77 A majority of the extant research on chronic pain, however, has relied on single retrospective assessments of average, worst, or least pain intensity levels. ...
Pain is a dynamic experience subject to substantial individual differences. Intensive longitudinal designs best capture the dynamical ebb and flow of the pain experience across time and settings. Thanks to the development of innovative and efficient data collection technologies, conducting an intensive longitudinal pain study has become increasingly feasible. However, the majority of longitudinal studies have tended to examine average level of pain as a predictor or as an outcome, while conceptualizing intra-individual pain variation as noise, error, or a nuisance factor. Such an approach may miss the opportunity to understand how fluctuations in pain over time are associated with pain processing, coping, other indices of adjustment, and treatment response. The present review introduces the four most frequently used intra-individual variability indices: the intra-individual standard deviation/variance, autocorrelation, the mean square of successive difference, and probability of acute change. In addition, we discuss recent development in dynamic structural equation modeling in a non-technical manner. We also consider some notable methodological issues, present a real-world example of intra-individual variability analysis, and offer suggestions for future research. Finally, we provide statistical software syntax for calculating the aforementioned intra-individual pain variability indices so that researchers can easily apply them in their research. We believe that investigating intra-individual variability of pain will provide a new perspective for understanding the complex mechanisms underlying pain coping and adjustment, as well as for enhancing efforts in precision pain medicine. Audio accompanying this abstract is available online as Supplemental Digital Content at http://links.lww.com/PAIN/A817.
... These findings are consistent with the body of research supporting the role that sleep quality has in influencing pain intensity, 19 including results from interdisciplinary pain treatment studies. 37 These results support the potential utility of the sleep-specific component of the treatment program examined here for reducing pain and improving function. The result also supports the investigation of the beneficial effects of 38 as potential pain treatments in and of themselves. ...
Background
Interdisciplinary chronic pain treatment is effective for reducing pain intensity and pain‐related disability, and improving psychological function. However, the mechanisms that underlie these treatment‐related benefits are not yet well‐understood. Sleep problems and fatigue are modifiable factors often comorbid with chronic pain. The goal of this study was to evaluate the role that changes in sleep quality and fatigue might have on the benefits of an interdisciplinary chronic pain treatment.
Methods
A total of 125 adults with chronic pain participated in a four‐week interdisciplinary pain management program. Measures of depression, sleep disturbance, fatigue, pain intensity, and physical function were administered at pre‐ and post‐treatment. Three regression analyses were conducted to evaluate the contribution of pre‐ to post‐treatment improvements in fatigue and sleep disturbance to the pre‐ to post‐treatment improvements in pain intensity, disability, and depression, while controlling for demographic characteristics (age and sex) and pain intensity.
Results
Changes in fatigue and sleep disturbance, made independent and significant contributions to the prediction of treatment‐related benefits in pain intensity; improvements in depressive symptoms were predicted by improvements in fatigue, and improvements in disability were only predicted by pre‐treatment and pre‐ to post‐treatment decreases in pain intensity (one of the control variables).
Conclusions
In addition to sleep, fatigue emerged as a key potential mechanism of multidisciplinary chronic pain treatment‐related improvements, suggesting that interventions including elements which effectively target sleep and fatigue may enhance the efficacy of interdisciplinary chronic pain programs. This possibility should be evaluated in future research.
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... Furthermore, this finding may have clinical as well as theoretical importance. In a clinical study assessing the efficacy of an interdisciplinary rehabilitation program for chronic pain, inter-individual variability in the strength of the relationship between sleep duration and next-day pain predicted treatment benefits [33]. ...
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Purpose Experimental studies on the associations between sleep and evoked pain in healthy individuals have generally demonstrated increased pain sensitivity following sleep deprivation, yet few have addressed the association between habitual sleep patterns and next-day pain sensitivity. This study aimed to assess relationships between habitual sleep quantity, quality, and timing based on objective measurement of sleep (actigraphy) and experimentally evoked cold-pain perception during the day in healthy young men.Methods Forty-eight healthy, young male participants without pain or sleep disturbance were examined via cold pressor test to obtain measures of cold-pain threshold, tolerance, and intensity in the morning, afternoon, and evening, in a randomized-order repeated-measures design. Sleep characteristics were assessed by actigraphy for 7days prior to testing. Correlations (Spearman) were computed between all sleep and pain measures. Sleep measures that significantly correlated with pain were entered as covariates in repeated-measures (RM) ANOVA.Results Longer sleep duration and later sleep timing were associated with increased sensitivity to evoked cold-pain tests at different times of the day (p < 0.05). After controlling for age, BMI, and weekday–weekend differences in sleep duration and bedtime, longer sleep duration, and later wake time were associated with lower pain threshold, and later bed- and wake times were associated with lower pain tolerance (p < 0.05). Sleep quality was not associated with any pain measures.Conclusions Objectively measured habitual sleep duration and timing are associated with cold-pain perception in healthy young men. Further investigation is needed to elucidate the mechanism underlying the detrimental effects of long sleep duration and late sleep timing on pain perception.
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The ASAM Handbook on Pain and Addiction provides clinical guidance to health care professionals who treat patients with co-occurring pain and addiction. Produced by the largest medical society dedicated to the improvement of addiction care, the handbook takes an evidence-based approach. Its advice is based on the current scientific literature and the advice of well-regarded organizations and government agencies, including NIDA, CDC, SAMHSA, PCSS-O, and ASAM itself. The ASAM Handbook is organized in five sections, which cover the core concepts of pain and addiction; diagnosis and treatment; treating pain in patients with, or at risk for, addiction; treating substance use disorders (SUD) and addiction in patients with co-occurring pain; and adapting treatment to the needs of specific populations. Each chapter concludes with suggestions for further reading on the topics discussed. The Handbook is ideal for primary care practitioners, mental health clinicians, addiction clinicians, and pain clinicians who wish to bridge the knowledge gap related to treating patients suffering from both pain and addiction.
Objectives:
Chronic pain, with or without an identified diagnosis or cause, is widespread and commonly associated with sleep disturbances. However, research has often used poor quality measures of sleep and focused on specific pain conditions, thereby limiting its reliability and applicability to the wider CP population. This study meta-analysed the findings from studies that used objective polysomnographic measures of sleep or examined diagnosed sleep disorders in people with CP.
Methods:
Three databases were searched (PubMed, PsychINFO, Embase; inception to June 2017) for case-controlled polysomnography studies and studies that reported the prevalence of diagnosed sleep disorders in adults with CP. Hedge's g effect sizes and prevalence rates were calculated using the data from 37 studies.
Results:
Polysomnographic measures of sleep onset latency and efficiency, time awake after sleep onset and awakenings were all significantly worse in those with CP when compared to healthy controls (large effects). Total sleep time, light sleep duration (NREM 1), number of stage-shifts, respiratory-related events and periodic limb-movements were also worse for those with CP, albeit to a lesser extent (small to medium effects). The pooled prevalence of sleep disorders in CP was 44%, with insomnia (72%), restless legs syndrome (32%) and obstructive sleep apnea (32%) being the most common diagnoses.
Conclusions:
Objective polysomnographic measures indicate that individuals with CP experience significant sleep disturbances, particularly with respect to sleep initiation and maintenance. Clinically diagnosed sleep disorders are also very prevalent. It is imperative that sleep disturbances and disorders be assessed and treated in conjunction with the CP.
Objective: Animal-assisted therapy is used in various ways to improve the quality of life of people with chronic pain. The aim of this work was to conduct a systematic review of the literature, and summarize what is known about this form of complementary therapy. Methods: A search was conducted in the following databases MEDLINE (via PubMed), CINAHL, PsycINFO, Web of Science Core Collection, Psychology and Behavioral Sciences Collection, since its inception until January 2016. Results: A total of 179 items were found, and 135 were reviewed for potential inclusion in this study. Finally, we have included 7 articles. The results of the studies reported in these articles show that, in general, people who have participated in animal-assisted therapy report lower pain intensity, improved mood and overall better quality of life. Published reports do not provide detailed information about the type of intervention being used, nor its specific components, thus offering little possibility of replication. Conclusions: Reviewed studies show positive results, however these are based on poor designs. Future research with greater rigor and control is warranted. Future publications need to provide better descriptions of the interventions that are used, this is critical to identify which variables are ultimately responsible for the beneficial effects that are being reported.
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.
To assess the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) in patients with non-malignant chronic pain.
Twenty-eight subjects with chronic neck and back pain were stratified according to gender, age, and ethnicity, then assigned to one of the two treatment groups: CBT-I or a contact control condition.
Eight weeks of CBT-I including sleep restriction, stimulus control, sleep hygiene, and one session of cognitive therapy devoted to catastrophic thoughts about the consequences of insomnia.
Outcomes included sleep diary assessments of sleep continuity, pre-post measures of insomnia severity (ISI), pain (Multidimensional Pain Inventory), and mood (BDI and POMS). Subjects receiving CBT-I (n=19), as compared to control subjects (n=9), exhibited significant decreases in sleep latency, wake after sleep onset, number of awakenings, and significant increase in sleep efficiency. The diary findings were paralleled by significant changes in the ISI (p=0.05). Significant improvement (p=0.03) was found on the Interference Scale of the Multidimensional Pain Inventory. The groups did not significantly differ on mood measures or measures of pain severity.
CBT-I was successfully applied to patients experiencing chronic pain. Significant improvements were found in sleep as well as in the extent to which pain interfered with daily functioning. The observed effect sizes for the sleep outcomes appear comparable to or better than meta-analytic norms for subjects with Primary Insomnia.
Osteoarthritis pain affects more than half of all older adults, many of whom experience co-morbid sleep disturbance. Pain initiates and exacerbates sleep disturbance, whereas disturbed sleep maintains and exacerbates pain, which implies that improving the sleep of patients with osteoarthritis may also reduce their pain. We examined this possibility in a secondary analysis of a previously published randomized controlled trial of cognitive behavioral therapy for insomnia (CBT-I) in patients with osteoarthritis and co-morbid insomnia.
Twenty-three patients (mean age 69.2 years) were randomly assigned to CBT-I and 28 patients (mean age 66.5 years) to an attention control. Neither directly addressed pain management. Twelve subjects crossed over to CBT-I after control treatment. Sleep and pain were assessed by self-report at baseline, after treatment, and (for CBT-I only) at 1-year follow-up.
CBT-I subjects reported significantly improved sleep and significantly reduced pain after treatment. Control subjects reported no significant improvements. One-year follow-up found maintenance of improved sleep and reduced pain for both the CBT-I group alone and among subjects who crossed over from control to CBT-I.
CBT-I but not an attention control, without directly addressing pain control, improved both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia. These results are unique in suggesting the long-term durability of CBT-I effects for co-morbid insomnia. They also indicate that improving sleep, per se, in patients with osteoarthritis may result in decreased pain. Techniques to improve sleep may be useful additions to pain management programs in osteoarthritis, and possibly other chronic pain conditions as well.
The Pain Disability Index (PDI) is a brief instrument that was developed to assess pain-related disability, providing information that complements assessment of physical impairment. This paper presents the results of two studies concerning the psychometric properties and the validity of the PDI. In study I, PDI scores of 108 patients appeared internally consistent (alpha = .86), although a factor analysis revealed two factors. The first factor (59.3% of variance) seemed to include more discretionary, less obligatory activities. The second factor (14.3% of variance) included activities more basic to daily living and survival. Study II found that the PDI scores of 37 former inpatients were significantly higher than 36 former outpatients who responded to a follow-up questionnaire. These findings support the validity of the PDI. Several methodologic issues are discussed, and suggestions are made for future uses of the instrument.
Sixty participants with insomnia secondary to chronic pain were assigned randomly to either a cognitive-behavioral therapy (CBT) or a self-monitoring/waiting-list control condition. The therapy consisted of a multicomponent 7-week group intervention aimed at promoting good sleep habits, teaching relaxation skills, and changing negative thoughts about sleep. Treated participants were significantly more improved than control participants on self-report measures of sleep onset latency, wake time after sleep onset, sleep efficiency, and sleep quality, and they showed less motor activity in ambulatory recordings of nocturnal movement. At a 3-month follow-up assessment, treated participants showed good maintenance of most therapeutic gains. These results provide the 1st evidence from a randomized controlled trial that CBT is an effective treatment for insomnia that is secondary to chronically painful medical conditions.
Most chronic pain results primarily from nervous system sensitization and therefore resists efforts to find and correct responsible peripheral pathology. Medications for acute pain often help minimally or transiently. Pain rehabilitation programs have arisen to treat this condition. Goals emphasize normalization of function and quality of life more than pain reduction. Programs utilize physical and psychological reconditioning and behavior modification to replace 'sick role behavior' with 'wellness behaviors.' Medication management emphasizes drugs that reduce nervous system sensitization. Published literature compellingly shows that pain rehabilitation programs produce long-term improvements in pain, mood, function, and health care utilization.
* The only advanced programming book on R
* Begins with simple interactive use and progresses by gradual stages
* Written by the award winning author of the S language from which R evolved
John Chambers has been the principal designer of the S language since its beginning, and in 1999 received the ACM System Software award for S, the only statistical software to receive this award. He is author or coauthor of the landmark books on S.
Now he turns to R, the enormously successful open-source system based on the S language. R's international support and the thousands of packages and other contributions have made it the standard for statistical computing in research and teaching.
This book guides the reader through programming with R, beginning with simple interactive use and progressing by gradual stages, starting with simple functions. More advanced programming techniques can be added as needed, allowing users to grow into software contributors, benefiting their careers and the community. R packages provide a powerful mechanism for contributions to be organized and communicated.
The techniques covered include such modern programming enhancements as classes and methods, namespaces, and interfaces to spreadsheets or data bases, as well as computations for data visualization, numerical methods, and the use of text data.
Chronic pain is difficult to treat and often precedes or exacerbates sleep disturbances such as insomnia. Insomnia, in turn, can amplify the pain experience. Both conditions are associated with inflammatory processes, which may be involved in the bi-directional relationship between pain and sleep. Cognitive behavioral therapy (CBT) for pain and CBT for insomnia are evidence based interventions for, respectively, chronic pain and insomnia. The study objectives were to determine the feasibility of combining CBT for pain and for insomnia and to assess the effects of the combined intervention and the stand alone interventions on pain, sleep, and mood outcomes compared to a control condition.
Twenty-one adults with co-occurring chronic pain and chronic insomnia were randomized to either CBT for pain, CBT for insomnia, combined CBT for pain and insomnia, or a wait-list control condition.
The combined CBT intervention was feasible to deliver and produced significant improvements in sleep, disability from pain, depression and fatigue compared to the control condition. Overall, the combined intervention appeared to have a strong advantage over CBT for pain on most outcomes, modest advantage over both CBT for insomnia in reducing insomnia severity in chronic pain patients.
CBT for pain and CBT for insomnia may be combined with good results for patients with co-occurring chronic pain and insomnia.
The psychometric properties of the Depression Anxiety Stress Scales (DASS) were evaluated in a normal sample of N = 717 who were also administered the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). The DASS was shown to possess satisfactory psychometric properties, and the factor structure was substantiated both by exploratory and confirmatory factor analysis. In comparison to the BDI and BAI, the DASS scales showed greater separation in factor loadings. The DASS Anxiety scale correlated 0.81 with the BAI, and the DASS Depression scale correlated 0.74 with the BDI. Factor analyses suggested that the BDI differs from the DASS Depression scale primarily in that the BDI includes items such as weight loss, insomnia, somatic preoccupation and irritability, which fail to discriminate between depression and other affective states. The factor structure of the combined BDI and BAI items was virtually identical to that reported by Beck for a sample of diagnosed depressed and anxious patients, supporting the view that these clinical states are more severe expressions of the same states that may be discerned in normals. Implications of the results for the conceptualisation of depression, anxiety and tension/stress are considered, and the utility of the DASS scales in discriminating between these constructs is discussed.
Fifty women with fibromyalgia syndrome (FS) recorded their sleep quality, pain intensity, and attention to pain for 30 days, using palm-top computers programmed as electronic interviewers. They described their previous night's sleep quality within one-half hour of awakening each day, and at randomly selected times in the morning, afternoon, and evening rated their present pain in 14 regions and attention to pain during the last 30 min. We analyzed the 30-day aggregates cross-sectionally at the across-persons level and the pooled data set of 1500 person-days at the within-persons level after adjusting for between-persons variation and autocorrelation. Poorer sleepers tended to report significantly more pain. A night of poorer sleep was followed by a significantly more painful day, and a more painful day was followed by a night of poorer sleep. Pain attention and sleep were unrelated at the across-persons level of analysis. But there was a significant bi-directional within-person association between pain attention and sleep quality that was not explained by changes in pain intensity.
The relationship between pain and sleep seems to be reciprocal: if pain may interrupt or disturb sleep, poor sleep can also influence pain perception. However the influence of sleep disturbances on pain sensitivity remain poorly investigated. The aim of this study was to assess the effect of REM sleep deprivation on the reaction of rats subjected to different noxious stimuli. In each experiment 16 Wistar male rats were randomly assigned to two groups: controls (n=8), and REM sleep deprived rats (n=8). REM sleep deprivation was elicited using the 'inverted flower pot' technique. Four different experiments were performed to assess the sensitivity to mechanical (vocalization threshold in paw pressure), thermal (tail withdrawal latency in hot water immersion), electrical (envelope of 2nd peep in tail shock test) and chemical (analgesic behavior in formalin test) noxious stimuli. All experiments were performed over a 5-day period with baseline (day 1, day 2) in a dry environment and REM sleep deprivation (day 3, day 4 and day 5) in a wet environment. Under wet conditions, vocalization threshold in the paw pressure test (-20%, P=0.005), and tail withdrawal latency in the hot water immersion test (-21%, P=0.006) were significantly lower, and the envelope of 2nd peep in the tail electrical shock was significantly greater (+78%, P=0.009), in REM sleep deprived rats compared to controls. However, under wet conditions the mean duration of nociceptive behaviors in the formalin test did not differ between the two groups. In conclusion, REM sleep deprivation induces a significant increase in the behavioral responses to noxious mechanical, thermal and electrical stimuli in rats.
Sleep disturbances are frequently reported in victims following burn injuries. This prospective study was designed to assess sleep quality and to examine its daily relationship to pain intensity within the first week of hospitalization. Twenty-eight non-ventilated patients were interviewed during 5 consecutive mornings (number of observations=140) to collect information about perceived quality of sleep (visual analogue scale, number of hours, number of awakenings, presence of nightmares). Pain intensity was assessed at rest (nighttime, morning, during the day) and following therapeutic procedures using a 0-10 numeric scale. Seventy-five percent of patients reported sleep disturbances at some point during the study although, in most patients, sleep quality was not consistently poor. Pooled cross-section regression analyses showed significant temporal relationships between quality of sleep and pain intensity such that a night of poor sleep was followed by a significantly more painful day. Pain during the day was not found to be a significant predictor of poor sleep on the following night. These results support previous findings that perceived quality of sleep following burn injury is poor. Moreover, they show a daily relationship between quality of sleep and acute burn pain in which poor sleep is linked to higher pain intensity during the day.
Patients completing a multidisciplinary pain treatment were contacted to obtain 13-year follow-up information on pain, mood, employment, and general health.
Study objectives were to determine if post-treatment improvements were maintained over a lengthy follow-up period and to compare patients' general health to norms of comparably aged persons.
Although many studies have demonstrated the short-term effectiveness of multidisciplinary pain treatment programs for chronic low back pain, few studies have documented that these treatment gains are maintained over time. Only two studies have reported patient outcomes on a long-term basis (10+ years). Those studies have documented that patient gains during treatment are generally maintained during follow-up.
An attempt was made to contact all patients completing an inpatient chronic back pain rehabilitation program at the University of Iowa's Spine Diagnostic and Treatment Center. Of the 45 participants, 28 were located and 26 agreed to participate in a telephone interview. Analyses of pretreatment and posttreatment data revealed these follow-up participants did not differ from the larger study sample.
Patients maintained their treatment gains in all areas (pain intensity and interference, negative mood). Additionally, patients showed levels of general health comparable to similarly aged peers with the exceptions of pain (more pain) and physical functioning (lower functioning, more pain interference). More than half the sample was employed; of those not employed, few reported this was due to pain.
The data lend support to the long-term effectiveness of multidisciplinary treatment programs for chronic low back pain.
The management of insomnia in patients experiencing chronic pain requires careful evaluation, good diagnostic skills, familiarity with cognitive-behavioural interventions and a sound knowledge of pharmacological treatments. Sleep disorders are characterised by a circular interrelationship with chronic pain such that pain leads to sleep disorders and sleep disorders increase the perception of pain. Sleep disorders in individuals with chronic pain remain under-reported, under-diagnosed and under-treated, which may lead--together with the individual's emotional, cognitive and behavioural maladaptive responses--to the frequent development of chronic sleep disorders. The moderately positive relationship between pain severity and sleep complaints, and the specificity of pain-related arousal and mediating variables such as depression, illustrate that insomnia in relation to chronic pain is multifaceted and poorly understood. This may explain the limited success of the available treatments. This article discusses the evaluation of patients with chronic pain and insomnia and the available pharmacological and nonpharmacological interventions to manage the sleep disorder. Non-pharmacological interventions should not be considered as single interventions, but in association with one another. Some non-pharmacological interventions especially the cognitive and behavioural approaches, can be easily implemented in general practice (e.g. stimulus control, sleep restriction, imagery training and progressive muscle relaxation). Hypnotics are routinely prescribed in the medically ill, regardless of their adverse effects; however, their long-term efficacy is not supported by robust evidence. Antidepressants provide an interesting alternative to hypnotics, since they can improve pain perception as well as sleep disorders in selected patients. Sedative antipsychotics can be considered for sleep disturbances in those patients exhibiting psychotic features, or for those with contraindications to benzodiazepines. Low doses of sedative antipsychotics may improve chronic insomnia in the elderly. However, no intervention is likely to be effective unless a good physician-patient relationship is developed.
Insomnia is a pervasive problem for many patients suffering from medical and psychiatric conditions. Even when the comorbid disorders are successfully treated, insomnia often fails to remit. In addition to compromising quality of life, untreated insomnia may also aggravate and complicate recovery from the comorbid disease. Cognitive behavior therapy for insomnia (CBT-I) has an established efficacy for primary insomnia, but less is known about its efficacy for insomnia occurring in the context of medical and psychiatric conditions. The purpose of this article is to present a rationale for using CBT-I in medical and psychiatric disorders, review the extant outcome literature, highlight considerations for adapting CBT-I procedures in specific populations, and suggest directions for future research. Outcome studies were identified for CBT-I in mixed medical and psychiatric conditions, cancer, chronic pain, HIV, depression, posttraumatic stress disorder, and alcoholism. Other disorders discussed include: bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder. The available data demonstrate moderate to large treatment effects (Cohen's d, range=0.35-2.2) and indicate that CBT-I is a promising treatment for individuals with medical and psychiatric comorbidity. Although the literature reviewed here is limited by a paucity of randomized, controlled studies, the available data suggest that by improving sleep, CBT-I might also indirectly improve medical and psychological endpoints. This review underscores the need for future research to test the efficacy of adaptations of CBT-I to disease specific conditions and symptoms.
Cross-sectional research in clinical samples, as well as experimental studies in healthy adults, suggests that the experiences of pain and sleep are bi-directionally connected. However, whether sleep and pain experiences are prospectively linked to one another on a day-to-day basis in the general population has not previously been reported. This study utilizes data from a naturalistic, micro-longitudinal, telephone study using a representative national sample of 971 adults. Participants underwent daily assessment of hours slept and the reported frequency of pain symptoms over the course of one week. Sleep duration on most nights (78.0%) was between 6 and 9h, and on average, daily pain was reported with mild frequency. Results suggested that hours of reported sleep on the previous night was a highly significant predictor of the current day's pain frequency (Z=-7.9, p<.0001, in the structural equation model); obtaining either less than 6 or more than 9h of sleep was associated with greater next-day pain. In addition, pain prospectively predicted sleep duration, though the magnitude of the association in this direction was somewhat less strong (Z=-3.1, p=.002, in the structural equation model). Collectively, these findings indicate that night-to-night changes in sleep affect pain report, illuminating the importance of considering sleep when assessing and treating pain.
Introduction to multilevel modeling concepts. Centre for Multileveling Modeling
- Steele F Module
Growth curve analysis using multilevel regression and structural equation modeling
- F G Stoel Rd Garre