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Abstract

Among people with chronic pain, insomnia is highly prevalent, closely related to the mechanism of central sensitization, characterized by low-grade neuroinflammation, and commonly associated with stress or anxiety; in addition, it often does not respond effectively to drug treatments. This review article applies the current understanding of insomnia to clinical practice, including assessment and conservative treatment of insomnia in people with chronic pain. Cognitive-behavioral therapy for insomnia can be efficacious for improvements in sleep initiation, sleep maintenance, perceived sleep quality, and pain interference with daily functioning in people with chronic pain. A recent systematic review concluded that with additional training, physical therapist-led cognitive-behavioral interventions are efficacious for low back pain, allowing their implementation within the field. Cognitive-behavioral therapy for insomnia, as provided to people with chronic pain, typically includes education, sleep restriction measures, stimulus control instructions, sleep hygiene, and cognitive therapy.

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... In addition, to date, there is no review that has been conducted on the association between sleep and chronic neck pain (CNP). However, due to the similar underlying physiological and psychological pain mechanisms [25], a similar link with sleep as seen in CLBP could be expected in patients reporting CNP. Therefore, the aim of the current systematic review is to provide an update of the existing review of Kelly et al. (2011) regarding the relationship between CLBP and sleep [16]. ...
... Both experimental and longitudinal studies have indicated that modifications in the facilitation and inhibition of pain processes may constitute overlapping mechanisms in the relationship between sleep and chronic pain. Accordingly, sleep disturbances affect the immune system, causing a shift towards a presumably glia-mediated pro-inflammatory state, resulting in hyperalgesia [25,63,64]. Psychological factors such as chronic stress, mood, and anxiety also contribute to the increased pain sensitivity via the mediating role of the hypothalamus-pituitary-adrenal (HPA) axis [25,63]. ...
... Accordingly, sleep disturbances affect the immune system, causing a shift towards a presumably glia-mediated pro-inflammatory state, resulting in hyperalgesia [25,63,64]. Psychological factors such as chronic stress, mood, and anxiety also contribute to the increased pain sensitivity via the mediating role of the hypothalamus-pituitary-adrenal (HPA) axis [25,63]. Additionally, dysfunctional monoaminergic pathways and changes in endogenous substances (orexin, vitamin D, nitric oxide) seem to be involved in the alterations in endogenous pain modulation due to sleep disturbances [25,63]. ...
Article
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Chronic spinal pain, including both neck and low back pain, is a common disabling disorder in which sleep problems are frequently reported as a comorbidity. The complex processes of both sleep and chronic pain seem to have overlapping mechanisms, which may explain their often established bidirectional relationship. This systematic review aims to investigate the assumed association between sleep and chronic spinal pain by providing an overview of the literature from the last decade. Eligible studies were obtained by searching four databases (PubMed, Embase, Web of Science, and PsycARTICLES). Articles were found relevant if they included a human adult population and investigated the possible association between sleep parameters and chronic spinal pain. Only studies published after January 2009 were included, as this review aimed to provide an update of a previous literature overview on this topic. The quality of the studies was assessed by risk of bias and level of evidence. A total of twenty-seven studies (6 cohort, 5 case-control, and 16 cross-sectional studies) were included in this systematic review. The methodological quality of these studies was low to moderate. The majority of studies reported weak to moderate evidence for an association between sleep parameters and chronic spinal pain, with more severe pain accompanied by more disturbed sleep. Addressing frequently reported sleep problems in chronic spinal pain patients therefore appears to be a necessary complement to pain management to achieve optimal treatment outcomes.
... This is due to the effect sleep has on motor learning, wound healing, recovery, chronic pain, and physical disability. 17,66,67 In community-dwelling older adults, poor sleep is significantly and independently associated with physical disability, even after controlling for other established risk factors. 24 Good-quality sleep has been shown to enhance motor learning, 68 and sleep deprivation may impair the acquisition of new skills. ...
... 65 Improving sleep quality may also help support chronic pain management by modulating central sensitization, inflammatory dysregulation, and pain perception. 17,66,67 Sleep quality is also important to consider in inpatient physical therapist practice. Sleep disturbance is common in critically ill patients, and the degree of the sleep disturbance increases with the severity of illness. ...
Article
There is a reciprocal relationship between common health conditions encountered in physical therapist practice, disability, and healthy living factors, such as physical inactivity, blood pressure, sleep quality, diet, and obesity. This relationship is apparent across all practice settings. Physical therapists are well positioned in the health care system to mitigate chronic disease by routinely screening and addressing healthy living factors to improve overall health and lower the risk for chronic disease (healthy living medicine). However, there are several challenges to the successful implementation of this framework in physical therapist practice. This Perspective will elucidate this relationship between HL behaviors and physical therapist practice, review the current state of practice regarding screening and intervention of 5 key healthy living behaviors, and outline future steps the profession can take toward implementing precision medicine using a healthy living medicine approach.
... Inadequate management of subacute or chronic pain may result in increased comorbidities and patient harm. Studies have linked untreated chronic pain with a myriad of medical issues such as memory loss, dementia, depression, functional deficits, anxiety, insomnia, suicidality, and early mortality [12][13][14][15][16][17][18]. 4. IPM acuity scale Whether or not a procedure is urgently or emergently indicated cannot be determined purely on the basis of whether or not the operation is 'elective' [19]. ...
... Neodgovarajući tretman subakutnog ili hroničnog bola može imati kao posledicu porast pridruženih oboljenja i može nauditi pacijentu. U različitim studijama utvrđena je povezanost između nelečenog hroničnog bola i niza medicinskih stanja, kao što su: gubitak pamćenja, demencija, depresija, funkcionalni deficiti, anksioznost, nesanica, suicidnost, i rana smrtnost [12][13][14][15][16][17][18]. 4. ITB skala za procenu statusa i potreba pacijenata Da li je neka intervencija indikovana kao "hitna" ili "urgentna" ne može se utvrditi samo na osnovu toga da li je operacija "neobavezna" [19]. ...
Article
Introduction: The COVID-19 pandemic has generated considerable turmoil in the interventional pain management (IPM) community. Due to IPM being classified as 'elective', numerous pain practices across the United States were forced to close during the pandemic, leaving chronic pain patients untreated for indefinite periods, and IPM physicians with increased stress and burnout. Results: In response to these detrimental effects, various re-opening tools and techniques have been created to facilitate a cautious resumption of in-person interventional pain practice. Due to their ability to minimize person-to-person contact, telehealth and pharmacotherapy played a more significant role in IPM during the pandemic, but their increased utilization has also led to the exacerbation of substance abuse and the opioid epidemic. The interplay between steroid use and its immunosuppressive effects, in relation to the COVID-19 infection and the COVID-19 vaccine, has also arisen as an issue of concern. Conclusion: As practices begin to safely re-open throughout the United States, the effects felt by chronic pain patients during the pandemic must be emphasized and not ignored. This review emphasizes the struggles pain patients have had to face during the pandemic and the need to update and redefine regulations regarding interventional and chronic pain management.
... This theory suggests that the interactions are bi-directional. Their conclusions concur with our results regarding trigger point needling, which deactivates nociceptors, deprograms the affected muscles, and allows mandibular movements free of muscle conditioning [63][64][65][66]. ...
... Clinically, in situations of chronic pain, a proper understanding by the patient of the mechanism behind the pain is considered crucial [63][64][65]. Secondly, understanding the role of trigger point needling, its interventions in nociceptors, their pathways, and the effects of the technique on pain relief are also important [66]. ...
Article
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Background and Objectives: The objective of our clinical trial was to determine the effectiveness of the deep dry needling technique (DDN) (neuromuscular deprogramming) as a first step in the treatment of temporomandibular disorders. Methods and Materials: The double-blind randomized clinical trial comprised 36 patients meeting the inclusion criteria who had signed the corresponding informed consent form. The participants were randomly distributed into two groups, the Experimental group (Group E) and the Control group (Group C). Group E received bilateral DDN on the masseter muscle, while Group C received a simulation of the technique (PN). All the participants were evaluated three times: pre-needling, 10 min post-needling, and through a follow-up evaluation after 15 days. These evaluations included, among other tests: pain evaluation using the Visual Analog Scale (VAS) and bilateral muscle palpation with a pressure algometer; evaluation of the opening pattern and range of the mouth, articular sounds and dental occlusion using T-scans; and electromyography, which was used to evaluate the muscle tone of the masseter muscles, in order to control changes in mandibular position. Results: Digital control of occlusion using Tec-Scan (digital occlusion analysis) showed a significant reduction both in the time of posterior disclusion and in the time needed to reach maximum force in an MI position after needling the muscle, which demonstrated that there were variations in the static position and the trajectory of the jaw. The symmetry of the arch while opening and closing the mouth was recovered in a centric relation, with an increase in the opening range of the mouth after the procedure. Conclusions: facial pain is significantly reduced and is accompanied by a notable reduction in muscle activity after needling its trigger points.
... Due to the negative impact that MSD represent, it is essential to identify factors that affect pain and represent a barrier in their treatment, especially those that are modifiable, such as a poor SQ [21,22]. This would guide therapeutic strategies, especially in individuals with chronic pain, where pharmacological treatment has achieved modest results, increasing the need to improve non-pharmacological approaches [22][23][24] and comprehensive management [24,25]. ...
... Due to the negative impact that MSD represent, it is essential to identify factors that affect pain and represent a barrier in their treatment, especially those that are modifiable, such as a poor SQ [21,22]. This would guide therapeutic strategies, especially in individuals with chronic pain, where pharmacological treatment has achieved modest results, increasing the need to improve non-pharmacological approaches [22][23][24] and comprehensive management [24,25]. ...
Article
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Poor sleep quality (SQ) negatively affects pain associated with musculoskeletal disorders (MSD). As the level of economic development of a country determines its sanitary conditions, these can influence the sleep-pain relationship; therefore, it is relevant to generate evidence in the population with MSD in developing countries. This cross-sectional study sought to determine the effect of poor SQ on pain in Chilean individuals with MSD, controlling for sex and duration of pain (in months). Method: A total of 228 individuals were included. SQ was measured with the Pittsburg Sleep Quality Index (PSQI), pain (intensity, interference and distress relative to pain) was measured with visual analog scales. Structural equation modeling (SEM) was performed to analyze the effect of SQ on pain. Results: A high frequency of poor SQ was present in the studied group, and was more prevalent in women. The SEM model evidenced that poor SQ predicts greater pain. Sex influences sleep quality and pain, but not pain duration. Conclusions: These findings indicate that poor SQ predicts higher pain in MSD and that women exhibit worse SQ and more significant pain than men. Our findings support that SQ should be considered in the comprehensive approach to pain in individuals with MSD.
... 15,16 Dysfunctional sleep and persistent musculoskeletal pain share an aberrant process with multiple neurophysiologic outputs. 17 Mechanisms include higher levels of the pro-inflammatory mediators that promote aberrant nociceptive signalling, 18 contributing to the physiological and phenotypic changes in glial cells. 19 Further, abnormal changes have been demonstrated in serotonergic and dopaminergic pathways associated with poor sleep and pain. ...
... 20 Given this interaction between persistent musculoskeletal pain and poor sleep, screening for sleep disturbances should be a primary consideration for clinicians. 17 Temporomandibular (TM) disorders, a subset of musculoskeletal pain, impact between 5% and 12% of the population in the United States. 21 An estimated 15% of patients experiencing a painful TM disorder will progress to having persistent musculoskeletal pain. ...
Article
Background Painful temporomandibular (TM) disorders result in 4.3 billion dollars spent annually in the United States. The complex interplay of physiological processes in persistent pain and dysfunctional sleep has been established. Recently, dysfunctional sleep has been identified as a potential pathway to the onset of painful TM disorder. Objectives The aims were to (1) identify self‐report outcome measures (SROMs) of sleep quality that are clinimetrically sound in patients with painful TM disorders and (2) determine whether sleep dysfunction has any diagnostic or prognostic value for this population. Methods A systematic search following PRISMA guidelines was run in six databases: CINAHL, Dental, PsychALL, PubMed, Scopus and Web of Science. Any study involving minors was excluded. Risks of biases were examined in all studies. Diagnostic pooled findings were reported. Results Of the identified articles (n = 681), 18 were included in this systematic review (n = 1 clinimetric studies, n = 11 diagnostic studies, n = 6 prognostic studies). Nine different assessment tools were used; only the Pittsburg Sleep Quality Index (PSQI) has been validated in patients with painful TM disorders. Overall, sleep dysfunction was diagnostic for painful TM disorders. The pooled relative risk of sleep dysfunction was 1.71 (95% CI 1.30. 2.26). When PSQI scores were greater than 5/21, the unadjusted hazard ratio for development of painful TM disorders was reported to be 2.1. Conclusion At present, the only SROM that has diagnostic and prognostic value in evaluating and managing patients with painful TM disorders is the PSQI.
... Overall, they illustra in FM, restoring one component of the abovementioned pain-insomnia-anxie could, through a sort of virtuous circle, allow improvement of the other compone One mechanism underlying the pathological vicious circle between pain, in and anxiety could be the hyperexcitability of the central nervous system that e chronic pain syndromes and to which highly contributes central sensitization, on main FM features [64]. Indeed, insomnia, anxiety, and chronic pain are each as with increased brain excitation [65,66], and could thus mutually reinforce each ot way. The implication of limbic structures (see above [55,58]) could explain the imp of the affective pain component in the loop. ...
... One mechanism underlying the pathological vicious circle between pain, insomnia, and anxiety could be the hyperexcitability of the central nervous system that exists in chronic pain syndromes and to which highly contributes central sensitization, one of the main FM features [64]. Indeed, insomnia, anxiety, and chronic pain are each associated with increased brain excitation [65,66], and could thus mutually reinforce each other this way. The implication of limbic structures (see above [55,58]) could explain the importance of the affective pain component in the loop. ...
Article
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Background: Fibromyalgia (FM) is a chronic pain disease characterized by multiple symptoms whose interactions and implications in the disease pathology are still unclear. This study aimed at investigating how pain, sleep, and mood disorders influence each other in FM, while discriminating between the sensory and affective pain dimensions. Methods: Sixteen female FM patients were evaluated regarding their pain, while they underwent-along with 11 healthy sex- and age-adjusted controls-assessment of mood and sleep disorders. Analysis of variance and correlations were performed in order to assess group differences and investigate the interactions between pain, mood, and sleep descriptors. Results: FM patients reported the typical widespread pain, with similar sensory and affective inputs. Contrary to controls, they displayed moderate anxiety, depression, and insomnia. Affective pain (but neither the sensory pain nor pain intensity) was the only pain indicator that tendentially correlated with anxiety and insomnia, which were mutually associated. An affective pain-insomnia-anxiety loop was thus completed. High ongoing pain strengthened this vicious circle, to which it included depression and sensory pain. Conclusions: Discriminating between the sensory and affective pain components in FM patients disclosed a pathological loop, with a key role of affective pain; high ongoing pain acted as an amplifier of symptoms interaction. This unraveled the interplay between three of most cardinal FM symptoms; these results contribute to better understand FM determinants and pathology and could help in orienting therapeutic strategies.
... This brings us to physical activity as a key lifestyle factor in patients with chronic pain, and the potential of exercise therapy and physical activity interventions to address this factor ( Figure 1). A systematic literature review included in this Special Issue discusses the available evidence (including short-and long-term effects) supporting specific versus general exercise therapy for patients with chronic neck and shoulder pain [10]. Sleep is another key lifestyle factor perpetuating the condition in many patients with chronic pain [10,11]. ...
... A systematic literature review included in this Special Issue discusses the available evidence (including short-and long-term effects) supporting specific versus general exercise therapy for patients with chronic neck and shoulder pain [10]. Sleep is another key lifestyle factor perpetuating the condition in many patients with chronic pain [10,11]. This factor was addressed by several papers included in the Special Issue. ...
Article
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Chronic pain has a massive personal and socioeconomic impact and remains a challenge for many clinicians around the world [...]
... Another pitfall for clinicians applying a pain phenotyping approach is that one might neglect the individual variability within one pain phenotype. Therefore, precision medicine for patients with chronic pain is more than accounting for CS, and it also implies addressing relevant comorbidities, such as insomnia [73] and obesity [74], and lifestyle factors that sustain CS, such as stress [75], physical inactivity [76] and unhealthy diet [77], depending on the individual patient characteristics. ...
Article
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Recently, the International Association for the Study of Pain (IASP) released clinical criteria and a grading system for nociplastic pain affecting the musculoskeletal system. These criteria replaced the 2014 clinical criteria for predominant central sensitization (CS) pain and accounted for clinicians' need to identify (early) and correctly classify patients having chronic pain according to the pain phenotype. Still, clinicians and researchers can become confused by the multitude of terms and the variety of clinical criteria available. Therefore, this paper aims at (1) providing an overview of what preceded the IASP criteria for nociplastic pain ('the past'); (2) explaining the new IASP criteria for nociplastic pain in comparison with the 2014 clinical criteria for predominant CS pain ('the present'); and (3) highlighting key areas for future implementation and research work in this area ('the future'). It is explained that the 2021 IASP clinical criteria for nociplastic pain are in line with the 2014 clinical criteria for predominant CS pain but are more robust, comprehensive, better developed and hold more potential. Therefore, the 2021 IASP clinical criteria for nociplastic pain are important steps towards precision pain medicine, yet studies examining the clinimetric and psychometric properties of the criteria are urgently needed.
... routine are available (Nijs , et al., 2018). An awareness of overlapping syndromes as illustrated in Table 1, is also key for clinicians to have a working knowledge of. ...
... Clinicians need to be better informed about sleep hygiene guidelines because sleep quality may affect individuals with lower back pain. A review article 80 in Table 3. Physical Therapy stated that "Stress and sleep are consistently interconnected, as evidenced in numerous studies reporting strong associations between anxiety levels and insomnia severity, such as in people with chronic low back pain." (p. ...
Article
This article highlights the role that lifestyle medicine plays in managing lower back pain as a cost-effective intervention strategy. It is suggested that lifestyle medicine strategies, such as incorporating whole foods and a plant-based diet, sustainable physical activity and mind-body exercises, restorative sleep, stress resiliency, awareness and mitigation of substance abuse and addiction, and establishing meaningful social networks and self-care strategies, be a part of managing chronic lower back pain.
... We should acknowledge, however, that researchers have still a limited understanding of the complex relationship between SSD and sleep. Beside mediation by neurotransmitters (dopamine, serotonin, or endogenous opioids), alternative theories include the proximity of the pain, sleep, and negative affect and expectation neural pathways or the role played by hyper-arousal states and altered central nervous system information processing [73,74]. ...
Article
Full-text available
This study aimed to investigate the relationship between somatic symptom disorder (SSD) and sleep disorders, following three research questions: (1) How are these disorders correlated? (2) What are the comorbidities reported in these patients? and (3) What are the most effective pharmacological and non-pharmacological treatments for both conditions? PubMed, Scopus, OVID, Medline, and ProQuest databases were searched for relevant articles published between 1957-2020. Search terms included "somatic symptoms disorder", "sleep disorders", "insomnia", "somatoform", "somatization", "therapeutic", "psychotherapy", and alternative, formerly used terms for SSD. Forty papers were finally included in the study. Prevalence of insomnia in SSD patients ranged between 20.4%-48%, with this being strongly correlated to somatic symptoms and psychosocial disability. The most relevant comorbidities were generalized anxiety disorder, depression, fatigue, negative mood, substance use, orthorexia, alexithymia, anorexia, weight loss, poor eating habits, and acute stress disorder. Patients receiving antidepressant therapy reported significant improvements in insomnia and somatic symptoms. In terms of non-pharmacological interventions, cognitive-behavioral therapy (CBT) showed improvements in sleep outcomes, while the Specialized Treatment for Severe Bodily Distress Syndromes (STreSS) may represent an additional promising option. Future research could include other medical and psychosocial variables to complete the picture of the relationship between sleep disorders and somatic symptoms.
... We should acknowledge, however, that researchers have still a limited understanding of the complex relationship between SSD and sleep. Beside mediation by neurotransmitters (dopamine, serotonin, or endogenous opioids), alternative theories include the proximity of the pain, sleep, and negative affect and expectation neural pathways or the role played by hyper-arousal states and altered central nervous system information processing [73,74]. ...
Article
Full-text available
This study aimed to investigate the relationship between somatic symptom disorder (SSD) and sleep disorders, following three research questions: (1) How are these disorders correlated? (2) What are the comorbidities reported in these patients? and (3) What are the most effective pharmacological and non-pharmacological treatments for both conditions? PubMed, Scopus, OVID, Medline, and ProQuest databases were searched for relevant articles published between 1957–2020. Search terms included “somatic symptoms disorder”, “sleep disorders”, “insomnia”, “somatoform”, “somatization”, “therapeutic”, “psychotherapy”, and alternative, formerly used terms for SSD. Forty papers were finally included in the study. Prevalence of insomnia in SSD patients ranged between 20.4%–48%, with this being strongly correlated to somatic symptoms and psychosocial disability. The most relevant comorbidities were generalized anxiety disorder, depression, fatigue, negative mood, substance use, orthorexia, alexithymia, anorexia, weight loss, poor eating habits, and acute stress disorder. Patients receiving antidepressant therapy reported significant improvements in insomnia and somatic symptoms. In terms of non-pharmacological interventions, cognitive-behavioral therapy (CBT) showed improvements in sleep outcomes, while the Specialized Treatment for Severe Bodily Distress Syndromes (STreSS) may represent an additional promising option. Future research could include other medical and psychosocial variables to complete the picture of the relationship between sleep disorders and somatic symptoms.
... Our finding of a high prevalence of insomnia in people with severe chronic pain is in line with previous studies [9,32], as is our finding of a high prevalence after the IPRP [33], albeit decreased. In our study, most of the pre-treatment demographic and pain-related variables were statistically significantly associated with pre-treatment clinical insomnia, with the exception of gender, where no statistically significant association was seen. ...
Article
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Insomnia and chronic pain are prevalent health complaints. Previous research has shown that they are closely associated, but their interaction and causality are not completely understood. Further research is needed to uncover the extent to which a treatment strategy focusing on one of the conditions affects the other. This study aimed to map the prevalence of insomnia symptoms among patients in interdisciplinary pain rehabilitation program (IPRP) and investigate associations between the degree of insomnia at baseline and the treatment outcome regarding pain intensity, physical function, social function, mental well-being, anxiety, and depression. Of the 8515 patients with chronic pain, aged 15–81 who were registered in the Swedish Quality Registry for Pain Rehabilitation during 2016–2019 and participated in IPRP, 7261 had follow-up data after treatment. Logistic regression analysis was used to investigate associations. The prevalence of clinical insomnia, according to Insomnia Severity Index (ISI), among chronic pain patients in IPRP was 66%, and insomnia symptoms were associated with both country of birth and educational level. After IPRP, the prevalence of clinical insomnia decreased to 47%. There were statistically significant associations between the degree of insomnia symptoms before IPRP and physical function (p < 0.001), social function (p = 0.004) and mental well-being (p < 0.001). A higher degree of insomnia symptoms at baseline was associated with improvement after IPRP. In conclusion, IPRP seem to have beneficial effects on insomnia symptoms in chronic pain patients. Nevertheless, almost half of the patients still suffer from clinical insomnia after IPRP. The possible effect of systematic screening and treatment of insomnia for improving the effect of IPRP on pain is an important area for future research.
... Subjects with higher levels of stress and anxiety also have sleep disturbances [72,73]. General workers with moderate to severe sleep problems were associated with a risk of 1.16-1.89 ...
Article
Objectives: Office workers with chronic neck pain demonstrates signs of widespread hyperalgesia, less efficient descending pain modulation, which could indicate sensitization of central pain pathways. No studies have assessed a wide variety of office workers with different chronic neck pain disorders and assessed the impact of pain intensity on assessments of central pain pathways. This study aimed to assessed pressure pain thresholds (PPTs), temporal summation of pain (TSP) and conditioned pain modulation (CPM) and to associate these with pain intensity and disability in subgroups of office workers. Methods: One hundred-and-seventy-one office workers were distributed into groups of asymptomatic and chronic neck pain subjects. Chronic neck pain was categorized as chronic trapezius myalgia and chronic non-specific neck pain and as 'mild-pain' (Visual Analog Scale [VAS]≤3) and 'moderate-pain' (VAS>3) groups. PPTs, TSP, CPM, and Copenhagen Psychosocial Questionnaire II were assessed in all subjects. Neck Disability Index and Pain Catastrophizing Scale were assessed in all the symptomatic office workers. Results: PPTs were lower in moderate pain (n=49) and chronic trapezius myalgia (n=56) compared with asymptomatic subjects (n=62, p<0.05). TSP was facilitated in moderate pain group compared with mild pain (n=60, p<0.0001) group and asymptomatic subjects (p<0.0001). No differences were found in CPM comparing the different groups (p<0.05). Multiple regression analysis identified Neck Disability Index and TSP as independent factors for prediction of pain intensity in chronic trapezius myalgia (R2=0.319) and chronic non-specific neck pain (R2=0.208). Somatic stress, stress and sleep as independent factors in chronic non-specific neck pain (R2=0.525), and stress in moderate pain group (R2=0.494) for the prediction of disability. Conclusions: Office workers with chronic trapezius myalgia and moderate pain intensity showed significant signs of widespread pressure hyperalgesia. Moreover, the moderate pain group demonstrated facilitated TSP indicating sensitization of central pain pathways. Neck Disability Index and TSP were independent predictors for pain intensity in pain groups. Sleep and stress were independent predictors for disability.
... To address this limitation, our future work includes a large-scale study in which we administer the validated SHI-AR to a larger and more representative sample of the Lebanese population, during the confinement period. In addition to its use for assessing sleep hygiene in general Arabic-speaking populations, the SHI-AR can also be used to assess sleep hygiene in specific Arabic-speaking populations where sleep is critical to overall health, or in populations prone to poor sleep hygiene such as athletes [16], college students [2], adolescents [17], elderly people [18], pregnant women [19] or people with chronic pain [20]. Therefore, using the SHI-AR, future research can aim to address the current knowledge gaps regarding sleep hygiene in specific Arabic-speaking populations. ...
Article
Aim this study aims to assess the reliability and validity of an Arabic version of the Sleep Hygiene Index (SHI) Methods A methodological study was carried out in four stages: initial translation by 2 professional translators, evaluation and synthesis of the initial translation by project managers, back-translation and validation. The Arabic (SHI-AR) and English (SHI-ENG) versions of the SHI were administered across Lebanon as an anonymous online survey in April 2020. Internal consistency of the SHI-AR and inter-rater reliability were assessed by calculating Cronbach alpha (α) and Intraclass Correlation Coefficient (ICC) respectively. Inter-rater agreement for each item of the SHI was measured using Cohen’s Kappa coefficient. Construct validity was investigated by exploratory factor analysis (EFA). Results 363 participants were enrolled in the study (129 men, 234 women, mean age 30 +/- 11 years). There was no statistically significant difference between mean overall scores on the 2 versions of the SHI with mean scores of 19.16 +/- 7.4 and 19.25 +/- 7.6 on SHI-AR and SHI-ENG respectively (p = 0.265). Internal consistency was satisfactory (α = 0.749), and the inter-rater agreement for the total scores of the 2 versions of the SHI was excellent (ICC = 0.980). All items of the SHI showed substantial to high level of agreement between the 2 versions. EFA established four factors underlying the questionnaire. Conclusion The Arabic version of the SHI is a valid tool to assess sleep hygiene in Arabic speaking populations.
... Evidence strongly suggests a bidirectional relationship, with pain and sleep co-existing and impacting each other [54,55]. Insomnia and pain seem to share similar pathways, such as mesolimbic dopaminergic pathways and serotoninergic pathways [16,56]. Generally, pain is associated with an increased stress-response and elevated levels of arousal [57], which can negatively affect sleep [58]. ...
Article
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Insomnia is a major problem in the chronic spinal pain (CSP) population and has a negative impact on health and well-being. While insomnia is commonly reported, underlying mechanisms explaining the relation between sleep and pain are still not fully understood. Additionally, no reviews regarding the prevention of insomnia and/or associated factors in people with CSP are currently available. To gain a better understanding of the occurrence of insomnia and associated factors in this population, we conducted a systematic review of the literature exploring associates for insomnia in people with CSP in PubMed, Web of Science and Embase. Three independent reviewers extracted the data and performed the quality assessment. A meta-analysis was conducted for every potential associate presented in at least two studies. A total of 13 studies were found eligible, which together identified 25 different potential associates of insomnia in 24,817 people with CSP. Twelve studies had a cross-sectional design. Moderate-quality evidence showed a significantly higher rate for insomnia when one of the following factors was present: high pain intensity, anxiety and depression. Low-quality evidence showed increased odds for insomnia when one of the following factors was present: female sex, performing no professional activities and physical/musculoskeletal comorbidities. Higher healthcare use was also significantly related to the presence of insomnia. One study showed a strong association between high levels of pain catastrophizing and insomnia in people with chronic neck pain. Last, reduced odds for insomnia were found in physically active people with chronic low back pain compared to inactive people with chronic low back pain. This review provides an overview of the available literature regarding potential associates of insomnia in people with CSP. Several significant associates of insomnia were identified. These findings can be helpful to gain a better understanding of the characteristics and potential origin of insomnia in people witch CSP, to identify people with CSP who are (less) likely to have insomnia and to determine directions of future research in this area.
... Положительное влияние на сон могла оказать и проводимая в наблюдаемой группе пациентов кинезитерапия в комбинации с психологическими методами контроля боли, что рассматривается как основа ведения пациентов с хронической болью [22]. Лечебные упражнения и пешие прогулки уменьшают тревогу, депрессию, чувство страха, катастрофизацию, что в свою очередь оказывает положительное влияние на сон [23,24]. Формирование персонального комплекса упражнений рассматривалось нами не только как способ улучшить физическую активность, повысить приверженность лечению, мотивацию на выздоровление, но и как вспомогательный метод коррекции инсомнии. ...
Article
Patients with chronic non-specific low back pain (CNSLBP) often have sleep disturbances (insomnia), which negatively affects pain severity, mental state, activities of everyday living, and the overall quality of life. The prevalence of insomnia in patients with CNSLBP and the effectiveness of its therapy require further investigation. Objective : to identify the prevalence of insomnia and the effectiveness of its treatment in CNSLBP. Patients and methods . The study included 71 patients aged 18–75 years (mean age 55.09±13.0 years) with CNSLBP. A single sleep hygiene educational session was run in the standard treatment group (n=34; mean age – 51±14 years). Intervention in the extended therapy group (n=37; mean age – 59±12 years) included an educational program dedicated to sleep, which was an individual face-to-face course of 4–5 sessions over two weeks and a telephone survey after three months. We used the Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) to assess sleep disturbances, a numerical rating scale (NRS) to assess pain, the International Physical Activity Questionnaire (IPAQ-SF), and the 12-item short form health survey (SF-12) to assess physical activity and quality of life. The survey was carried out three times (at the admission, after 7–10 and 80–90 days). Results and discussion . In both groups of patients with CNSLBP, PSQI scores improved in a week and after 3 months compared with baseline (p<0.05). Sleep quality between 7 th and 90 th days significantly improved only in the extended therapy group (p=0.025). ISI scores significantly improved during inpatient treatment in both groups (p<0.05), but between 7 th and 90 th days significantly improved only in the extended therapy group (р=0.048). Back pain intensity according to NRS significantly decreased in a week and after 3 months, compared to baseline (р<0.0001). Significant increase in physical activity (p≤0.001), physical and mental components of quality of life (p<0.05) were found only in the extended therapy group. Conclusion . Most patients with CNSLBP have insomnia, the treatment of which can improve sleep and help reduce pain.
... Despite the published guidelines for reporting core outcomes in chronic pain research, 12 most of included studies did not reported all of them, in particular avoiding sleep disturbance assessment which was accounted as an important factor in chronic pain field. 36 Further studies should take into account core outcomes and larger follow-up period with more rigorous methodological assessment to clarify the results of the present systematic review. ...
Article
Exercise therapy and education are recommended from several guidelines for managing symptoms in chronic nonspecific spinal pain (CNSP) patients. However, no systematic reviews have previously analyzed the effectiveness of pain science education (PSE) plus exercise therapy for managing CNSP related symptoms. Systematic searches were conducted on 10 databases looking for randomized control trials (RCTs) aimed to evaluate the effectiveness on pain, disability, kinesiophobia, and catastrophizing. Data were analyzed using random-effects meta-analyses and studies were appraised using the Cochrane ROB tool and GRADE. A total of eight RCTs (n=622) were included in the qualitative-analysis and five were selected for meta-analysis. PSE plus exercise therapy showed improvements in pain (5RCTs: short-term: SMD: -0.53 [-0.86,-0.2]; 4RCTs: intermediate-term: SMD: -0.57 [-1.01,-0.14]; low quality), disability (4RCTs: short-term: SMD: -0.24 [-0.53,0.05]; 4RCTs: intermediate-term: SMD: -0.93 [-1.08,-0.03]; low-to-very-low quality), kinesiophobia (3RCTs: short-term: SMD: -0.7 [-1.51,0.11]; 4RCTs: intermediate-term: SMD: -0.93 [-1.57,-0.30]; moderate-to-very-low quality), and catastrophizing (2RCTs: short-term: MD: -3.26 points [-6.15,-0.37]; 3RCTs: intermediate-term: MD: -4.94 points [-8.08,-1.81]; low-to-very-low quality) compared to exercise alone. A qualitative-analysis showed improvements in the experimental group compared to multimodal physiotherapy (1RCT; low-to-very-low quality), whereas no clear benefits were reported compared to PSE alone (1RCT; very-low quality) or no intervention (1RCT; very-low quality). There is low to very-low certainty of the evidence suggesting that PSE plus exercise therapy reduces CNSP related-symptoms. PERSPECTIVE: Based on low-quality data from small samples, PSE plus exercise therapy reduces CNSP related symptoms. The evidence requires further investigation due to the limited number of studies with short follow-up periods (CRD42020168968).
... 12,15,114,148 Hybrid CBT programs include general sleep and pain education, sleep restriction therapy, stimulus control for sleep and pain, sleep hygiene instructions, cognitive therapy specific to sleep and pain thinking, relaxation or stress management, and cognition-targeted exercise therapy. 103,129 Thus, hybrid CBT can help individuals with insomnia and coexisting chronic pain, especially when mood disturbances and hyperarousal mechanisms are present, by improving cognitive (eg, catastrophizing and anticipation), affective, perceptive, and coping skills associated with both sleep disturbances and chronic pain 16,22,39,49,91 (Fig. 1). ...
... An inverse relationship with the quality of sleep and pain intensity was also shown (44). Insomnia is prevalent in patients with chronic pain and is associated with a lack of response to treatments (45). ...
Article
Background: Control of chronic pain and mainly the partial or complete loss of response to analgesics is a major unmet need. Multiple mechanisms underline the development of tolerance to analgesics in general and specifically to opioids. The autonomic nervous system (ANS) plays a role in the development of analgesic tolerance and chronobiology. Objectives: To review the mechanisms associated with the development of nonresponsiveness to analgesics. Study design: Literature review. Setting: The review is followed by a description of a new method for overcoming resistance and improving the response to analgesics. Methods: Conducted a detailed review of the relevant studies describing the mechanisms that underlie tolerance to pain medications, and the potential roles of the ANS and chronobiology in the development of drug resistance. Results: The autonomic balance is reflected by heart rate variability, an example of a fundamental variability that characterizes biological systems. Chronotherapy, which is based on the circadian rhythm, can improve the efficacy and reduce the toxicity of chronic medications. In this article, we present the establishment of an individualized variability- and chronobiology-based therapy for overcoming the compensatory mechanisms associated with a loss of response to analgesics. We describe the premise of implementing personalized signatures associated with the ANS, and chronobiology, as well as with the pathophysiology of pain for establishing an adaptive model that could improve the efficacy of opioids, in a highly dynamic system. Limitations: The studies presented were selected based on their relevance to the subject. Conclusions: The described variability-based system may ensure prolonged effects of analgesics while reducing the toxicity associated with increasing dosages.
... 18,19 The duration of pain is also known to influence the relationship, with this effect especially being prominent in chronic pain patients. 20 Previous studies report sleep problems in 40-88% of patients depending on the specific chronic pain condition. 21 As much as 90% of patients with TMD report poor sleep quality. ...
Article
Background: While evidence is accumulating to propose a specific contribution of sleep disorders and low quality sleep in the pathogenesis of temporomandibular disorders (TMD), management of primary sleep disorders in the process of preventing and treating TMD still remains scientifically unsupported. Objective: To investigate the association of primary sleep disorders with TMD risk in South Korea. Patients and methods: This study was based on the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) of South Korea with 468,882 participants. After excluding participants diagnosed in 2002, those with a diagnosis of a primary sleep disorder in 2003-2005 were recruited. All participants diagnosed with TMD between January 1, 2006 and December 31, 2013 received follow-up. Cox proportional hazards regression was performed to determine the adjusted hazard ratios (aHR) and 95% confidence interval (CI) for TMD according to the presence or absence of a primary sleep disorder diagnosis. Results: After adjusting for all covariates, primary sleep disorder patients had a 44% higher risk for TMD compared with non-sleep disorder participants (aHR 1.44, 95% CI 1.02-2.04). The incidence rate of TMD was nearly twice as high in participants with sleep disorders compared with those without (6.08 vs 3.27, per 104 person-years). In subgroup analysis, an association was observed with those over 60 years old or who frequently exercised physically. Conclusion: Primary sleep disorders could be an important independent risk factor for the initiation and maintenance of TMD. Patients with sleep disorders should be monitored for possible co-occurrence of TMD-related symptoms that could aggravate sleep disorders in turn.
... Within the chronic pain field, there is cumulating evidence that unhealthy lifestyle factors such as physical inactivity, increased psychological distress, poor sleep, unhealthy diet, and smoking are associated with chronic pain severity and sustainment [30][31][32]. A proposed mechanism underlying the association between lifestyle and pain in this regard is related to inflammatory mediators. ...
Article
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During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.
... Similar distributions of the patients in 3 groups were found for the walking, standing, lying down and social life, and in 2 groups for sleeping, sexual life, travelling, and pain intensity. We know that a cause of insomnia is chronic pain, and we observed an improvement of the quality in sleep as we managed to decrees the pain felt in LBP syndrome (17,18), and it should be monitored on a longer period of time to verify if it is a consistent improvement. We should take into consideration the specific socio-economical factors of the Romanian nationality patients when analyzing some aspects of the everyday life such as sexual life (19) which has shown a clear improvement, but still with a notable dissatisfaction (from social viewpoint, as there is certain stigma about this essential aspect of life) and travelling (from the economical perspective, is quite prohibitive), which also showed a statistically relevant improvement (20). ...
Article
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Introduction. Low back pain has a direct and proportional impact on function and a general one on the quality of life. The present study aims to evaluate the functional impact of low back pain using specific self-assessment tools as indexes of appreciation and epidemiological correlations of potential risk factors involved. The conceptual model of our research is based on the importance of correlating symptoms with clinical assessment, using scales of pain, disability, quality of life, and determination of epidemiological correlations of these areas and the determined factors of the pathology. Material and method. The study group is made up of 106 cases with clinical diagnostic of low back pain, admitted from 28 September 2020 to 28 March 2021, at Balneal and Rehabilitation Sanatorium of Techirghiol. After performing anamnesis, general clinical examination, specific neuro-musculo-skeletal examination, the patients filled the surveys highlighting the impact of their low back pain on functionality and disability deriving from it. The survey included the Oswestry Disability Index, the Functional Independence Measure (FIM) instrument and the Visual analog scale (VAS) score evaluated at the moment of hospitalization and at discharge. Statistical analysis of data was carried out and correlations between variables resulting from study were highlighted. The study was conducted according to the norms of deontology and medical ethics. The authors declare no conflict of interest. Results and discussions. Lumbar pathology is common in patients who are hospitalized for a complex balneary-physical-kinetic treatment at Balneal and Rehabilitation Sanatorium of Techirghiol. About 80% of patients who have addressed to our unit in which the study was conducted, have presented low back pain. The majority of patients were females, representing 57,55% of the total number. Regarding the patients’ age, 58,5% of them were in the 50-70 years interval. The study reveals a major positive impact of our treatment on spinal symptomatology, an effect pointed out by the relevant statistical differences between the admittance and discharge VAS scores(p<0.001). Reporting the investigated disability with the Oswestry questionnaire of painful lumbar syndrome, and functional evaluation scale (FIM) demonstrates the impact of this pathology on the patient's social life, once again emphasizing the special attention to be paid to axial pathology, both as curative treatment and the importance of prophylactic treatment. Statistical analysis of identified risk factors, reveals the importance of prophylaxis and patient’s education in this area. A strong and important statistical correlation was found between the Oswestry total score and the walking and standing items, and a moderate, but strong correlation with the other items. Regarding the sex life item, the correlation is existent, but at a modest level. Conclusions. The study reveals the importance of correlation of the data obtained from anamnesis, the general clinical examination and the specific examination neuromioarthrokinetic with assessment tools that determine the level of functional independence, the functional impact on social life in high-frequency pathologies treated in medical facilities that provide healthcare in the field of medical recovery. It is necessary to quantify the therapeutic results obtained, in order to assess the level of improvement in quality of life. Keywords: low back pain, balneal, functional indicators, quality of life
... Sleep quality affects the likelihood of the resolution of chronic widespread pain [30]. In chronic pain patients, sleep and pain can turn into a vicious cycle; sleep deprivation causes increased pain which in turn causes sleep deprivation [31]. Physical activity has previously been shown to be an important health factor in numerous chronic diseases [32]. ...
Article
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Background Chronic pain is a common condition which causes patients much suffering and is very costly to society. Factors known to be associated with chronic pain include female gender, acute pain, depression, and anxiety. This study investigated whether stress, sleep disturbance, and physical inactivity were risk factors for developing chronic pain among young adults, and whether there were any interactions between these. Methods This retrospective longitudinal study was based on an existing database from a cohort study on IT use and health, called Health 24 Years. A questionnaire was sent to students aged 19–24 in Sweden for five consecutive years, containing questions on pain, stress, sleep, physical activity, technology use, health, and more. In logistic regressions, stress, sleep, and physical activity at baseline were potential predictors of chronic pain one and four years later. In addition, a new variable including all possible interactions between potential predictors was created to test for effect modification between risk factors. Results At the one-year follow-up, stress, non-restorative sleep, and physical inactivity showed odds ratios of 1.6 (95% CI: 1.0–2.4), 1.5 (95% CI: 1.0–2.3), and 1.8 (95% CI: 1.1–3.0) respectively after adjusting for confounders, the reference being non-stressed, having restorative sleep and being active. At the four-year follow-up, stress showed an adjusted odds ratio of 1.9 (95% CI: 1.3–2.9), while non-restorative sleep and physical inactivity were statistically insignificant. At the one-year follow-up, the interaction between risk factors were significant. The most clear example of this effect modification was to be inactive and not have -restorative sleep, compared to individuals who were active and had restorative sleep, showing an adjusted odds ratio of 6.9 (95% CI: 2.5–19.2) for developing chronic pain one year after baseline. This in comparison of odds ratios for only inactive respectively only non-restorative sleep being 1.7 (95% CI: 0.6–5.3) respectively 1.6 (95% CI: 0.7–3.5). Conclusions Stress, non-restorative sleep, and physical inactivity were risk factors for developing chronic pain one year after baseline, and stress were also a risk factor four years after baseline. These findings suggest that non-restorative sleep and inactivity are risk factors in the short term while stress is a risk factor in both the short and the long term. In addition to the independent effects of non-restorative sleep and inactivity, their combination seems to further increase the odds of chronic pain.
... A relationship has been found between sleep disorder and age, gender, education duration, QoL, and depression [27]. Insomnia is widespread in people with chronic pain and is closely related to the central sensitization mechanism [28]. Sleep disorder plays a role in the etiology of FMS, which can also be observed among patients with spondyloarthritis [7,29]. ...
Article
Background: Central sensitization (CS) has been held responsible in previous studies for persistent pain and persistently high disease activity in axial spondyloarthritis (axSpA). Sleep disturbance is also regarded as an important problem for patients with axSpA. Aims: This study determines the CS levels of patients with axSpA compared to healthy controls (HC) and investigates its relationship with disease activity, quality of life (QoL), and sleep quality. Methods: Eighty-two patients with axSpA (group 1: mean age 38.83 ± 10.11 (76.8%male)) and 40 healthy volunteers (group2: mean age 38.58 ± 7.48 (77.5%male)) were included in this cross-sectional observational study. Evaluation parameters were visual analog scale (VAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Short Form-36 (SF-36), Central Sensitization Inventory (CSI), and Pittsburgh Sleep Quality Index (PSQI). Also, participants were divided into subgroups as CSI < 40 and CSI ≥ 40. Groups were compared to themselves. A correlation between the patients' CSI scores and other evaluation parameters was examined. Results: CS rates were 45.1% and 7.5% for axSpA and HC, respectively (p < 0,001). The frequency of severe forms of CS was higher in patients with axSpA than in the healthy controls (p < 0.05). AxSpA patients with CS exhibited significantly higher pain, MASES, BASDAI, ASDAS-CRP, and PSQI scores than axSpA patients without CS (p < 0.05). A close relationship between CS severity and the female gender, pain, disease activity, sleep quality, and QoL was found among axSpA patients. Conclusions: Clinical CS is common among axSpA patients. CS adversely affects disease activity, pain, sleep quality, and QoL of axSpA patients. CS should be considered when planning axSpA treatment.
... It has been reported that this pharmacological effect could be limited in cases of secondary sleep disturbance induced by pain [13]. Indiscriminate use of these drugs can cause a number of side effects, such as sedation, daytime sleepiness, dizziness, and cognitive and motor impairments [14,15]. ...
Article
Full-text available
Chronic pain and sleep have a bidirectional relationship that promotes a vicious circle making chronic pain more difficult to treat. Therefore, pain and sleep should be treated simultaneously. In our previous study, we suggested that hyperactivation of ascending serotonergic neurons could cause secondary sleep disturbance in chronic pain. This study aimed to demonstrate the effects of a tricyclic antidepressant (amitriptyline) and a selective 5-hydroxy-tryptamine 2A (5-HT 2A ) antagonist (MDL 100907) that adjust serotonergic transmission, on secondary sleep disturbance induced in a preclinical chronic pain model. We produced a chronic neuropathic pain model by partial sciatic nerve ligation in mice, analyzed their electroencephalogram (EEG) and electromyogram (EMG) using the SleepSign software, and evaluated the sleep condition of the pain model mice after administration of amitriptyline or MDL 100907. Amitriptyline improved thermal hyperalgesia and the amount of sleep, especially non-REM sleep. Time change of normalized power density of δ wave in the nerve ligation group with amitriptyline administration showed a normal pattern that was similar to sham mice. In addition, MDL 100907 normalized sleep condition similar to amitriptyline, without improvement in pain threshold. In conclusion, amitriptyline could improve sleep quantity and quality impaired by chronic pain. 5-HT 2A receptor antagonism could partially contribute to this sleep improvement, but is not associated with pain relief.
... Regarding the sleep-pain cluster, the results of this metasynthesis suggest that the interaction of these two symptoms is perceived as bidirectional. In this regard, there is an increasing amount of scientific evidence showing that there is a bidirectional relationship between pain and sleep [28,57,[62][63][64][65][66]. The proposed underlying physiological mechanisms of the sleep-chronic pain relationship involve multiple brain structures and systems such as the monoaminergic system [65,67], opioid and endocannabinoid systems, the orexinergic system, the immune system, the hypothalamus-pituitary-adrenal axis, and the pineal melatonin system, among others [65]. ...
Article
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Poor sleep quality is a major concern and a highly prevalent symptom in fibromyalgia. We aimed to develop a metasynthesis of qualitative studies to assess how people diagnosed with fibromyalgia experience and manage poor sleep quality following the concepts of the Symptom Management Theory. The principles of metasynthesis established by Sandelowski and Barroso were utilized. A pre-planned comprehensive search was implemented in PubMed, Scopus, ISI WebofScience, and Cinahl Plus databases. The methodological quality was assessed following the CASP Qualitative Checklist. The findings of the studies were subjected to a metasummary and a metasynthesis. Seventeen studies were included in the metasynthesis. Two overarching themes were pre-established: (1) experience of poor sleep quality in Fibromyalgia and (2) poor sleep quality management strategies in Fibromyalgia. Four sub-themes emerged from the results: (1) evaluation of poor sleep quality, (2) response to poor sleep quality, (3) management strategies to favor sleep, and (4) managing the consequences of a sleepless night. Poor sleep quality is a severe and disabling symptom that negatively impacts the general health status of people diagnosed with FM. Prescribed treatments are commonly seen as ineffective and self-management strategies are a last resort and do not show beneficial effects.
... Ideally, tools like PCS, PSEQ, or TSK-17 should be re-assessed serially throughout treatment and at discharge to assess the change in central pain processing post-treatment. However, we analyzed the PGQ items that could suggest changes within the nervous system: sleep (Nijs et al., 2019(Nijs et al., , 2018 and doing things more slowly due to muscle dyscoordination (Stefanik et al., 2020) and guarded movement patterns (Laird, Gilbert, Kent, and Keating, 2014). ...
Article
Background Persistent pregnancy-related pelvic girdle pain (PGP) and the resulting consequences may considerably influence a woman’s quality of life. The complexity of this condition requires a whole-person centered approach. In response to COVID-19 outbreak, telerehabilitation has emerged as a promising alternative to traditional in-person visits. Purpose The aim of this report was to present the potential of telerehabilitation for persistent postpartum PGP within the biopsychosocial framework. Case Description A 26-year-old female presented with persistent pregnancy-related PGP of 8 months duration after her first vaginal delivery. The video-consults were performed using telerehabilitation platform. The patient received six telerehabilitation consults of 45 min duration over five weeks. Assessment of physical and psychosocial factors, cognitively focused strategies including pain neurophysiology education, sensory-motor remapping exercises, and graded increase of activity were administered. Rehabilitation was divided into the following phases: assessment, desensitization, graded exposure, and supported independence. Outcomes The Pelvic Girdle Questionnaire (PGQ) score was significantly reduced from 72.2 during the assessment to 15.3 at discharge. This change was significantly more substantial than the minimal clinically important change estimated for the PGQ. Conclusion Physiotherapists can utilize telerehabilitation to assist them with enacting appropriate care measures for persistent PGP within a biopsychosocial framework.
... 8 The routine care and management of chronic pain conditions seldom screens or targets sleep problems, despite the high prevalence of reported sleep problems in this population. 9,10 In addition, research examining sleep architecture among individuals with chronic pain indicates deviations from healthy controls in the form of less rapid eye movement (REM) sleep, fewer sleep cycles, and a possible decrease in slow-wave-sleep (N3). [11][12][13] Woo and Ratnayake 10 concluded that the healthcare community recognised the detrimental impacts sleep problems have on health and wellbeing outcomes for individuals with chronic pain. ...
Article
Full-text available
Background Chronic pain conditions affect up to one third of the adult population in the United Kingdom. Sleep problems are prevalent and negatively impact quality of life. Lack of standardised tools for routine screening and assessment of sleep changes have been a barrier for sleep management. Novel sleep wearables offer an exciting and accessible way to measure sleep but have not been tested outside of the consumer-led landscape and are not commonly used in research and clinical settings. Aims The study aimed to explore the feasibility and acceptability of a sleep monitoring headband (Dreem 2) utilising EEG technology and accompanying smartphone application among a cohort of adults with chronic pain. Results Twenty-one adults (81% women) completed a one-week home sleep study using a sleep headband and accompanying app. Ninety per cent of participants met the pre-defined requirement of two-night's sleep recording. All participants recorded one night of sleep data via the sleep headband. The majority (76%) of participants were satisfied with the sleep study, and 86% of participants were willing to wear the headband longer than the 2-night minimum requirement. Finally, 76% reported the headband as ‘somewhat’ or ‘extremely’ comfortable whist awake; 57% rated the headband as comfortable during sleep. Conclusion The Dreem 2 headband appears to be a feasible and acceptable means of collecting sleep measurements among individuals with chronic pain, despite common sleep disturbances. These devices may have utility for screening, assessment and monitoring in research and practice. Further research is needed to provide guidelines and training for integration.
... Our path model found that distress directly affected sleep quality in women with FMS. Accordingly, treatment strategies targeting sleep in women with FMS should be applied, as indicated for many other chronic pain disorders [39][40][41]. Sensitization (i.e., self-reported variables of sensitization and neuropathic symptoms) had an indirect effect on explaining the relationship between distress and severity in the current path model. This indirect mediating effect agrees with a recent meta-analysis reporting that psychological/emotional factors are associated with somatosensory function in people with musculoskeletal pain [42]. ...
Article
Full-text available
We aimed to explore a path model identified using a structural equation model (SEM) which best explains the multivariate contributions of sensitization, sensitivity, and emotional variables to clinical severity in women with FMS. Pain features, the Central Sensitization Inventory (CSI), painDETECT, S-LANSS, the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI), the Pain Catastrophizing Scale (PCS), the Pain Vigilance and Awareness Questionnaire (PVAQ), the 11-item Tampa Scale for Kinesiophobia (TSK-11), and pressure pain thresholds (PPTs) were collected from 113 women with FMS. Four latent variables were created: severity (clinical pain features), sensitivity (PPTs), sensitization (S-LANSS, CSI, painDETECT), and distress (HADS-A, HADS-D, PCS, PVAQ, TSK-11). Data fit for the measurement model were considered excellent (RMSEA = 0.043, CFI = 0.966, SRMR = 0.067, and NNFI = 0.960). Distress had a significant relationship with the mediators of sleep (β = 0.452, p = 0.031) and sensitization (β = 0.618, p = 0.001). The only mediator with a significant effect (β = 1.113, p < 0.001) on severity was sensitization. A significant indirect effect of sensitization (β = 0.687, p = 0.001) that explained the relationship between distress and severity was also identified. The proposed model suggests that distress and sensitization, together with poor sleep, have a complex mediating effect on severity in women with FMS. The identified path model can be leveraged in clinical trials investigating treatment approaches for FMS.
... As detailed above, these conditions have, in turn, been associated with increased ADRD risk [3,20,23,[46][47][48][49][50][51][52]. In addition, chronic stress [109], depression [15,[126][127][128], anxiety [15,126,128], and sleep impairment [129,130] can both result from and exacerbate chronic pain. These factors have also been significantly associated with cognitive decline [33,35,131,132] and incident dementia [35,42,94,[132][133][134][135], and may in part mediate the observed relationships between chronic pain and the subsequent accelerated deterioration in cognitive function and development of ADRD [83,94]. ...
Article
Background: Growing evidence suggests that chronic pain and certain chronic pain conditions may increase risk for cognitive decline and dementia. Objective: In this systematic review, we critically evaluate available evidence regarding the association of chronic pain and specific common chronic pain conditions to subsequent decline in cognitive function, new onset cognitive impairment (CI), and incident Alzheimer's disease and related dementias (ADRD); outline major gaps in the literature; and provide a preliminary conceptual model illustrating potential pathways linking pain to cognitive change. Methods: To identify qualifying studies, we searched seven scientific databases and scanned bibliographies of identified articles and relevant review papers. Sixteen studies met our inclusion criteria (2 matched case-control, 10 retrospective cohort, 2 prospective cohort), including 11 regarding the association of osteoarthritis (N = 4), fibromyalgia (N = 1), or headache/migraine (N = 6) to incident ADRD (N = 10) and/or its subtypes (N = 6), and 5 investigating the relation of chronic pain symptoms to subsequent cognitive decline (N = 2), CI (N = 1), and/or ADRD (N = 3). Results: Studies yielded consistent evidence for a positive association of osteoarthritis and migraines/headaches to incident ADRD; however, findings regarding dementia subtypes were mixed. Emerging evidence also suggests chronic pain symptoms may accelerate cognitive decline and increase risk for memory impairment and ADRD, although findings and measures varied considerably across studies. Conclusion: While existing studies support a link between chronic pain and ADRD risk, conclusions are limited by substantial study heterogeneity, limited investigation of certain pain conditions, and methodological and other concerns characterizing most investigations to date. Additional rigorous, long-term prospective studies are needed to elucidate the effects of chronic pain and specific chronic pain conditions on cognitive decline and conversion to ADRD, and to clarify the influence of potential confounding and mediating factors.
... In this paper, a cursory review of potential movement and dietary interventions for those with CS has been offered, but there are many other factors that can, and ideally should, be addressed; from sleep habits (Nijs et al., 2018), to emotional processing (O'Sullivan 2018), and from pain neuroscience education (Nijs et al., 2019) to assessing both conscious and unconscious belief patterns (O'Sullivan 2018; Wallden and Chek 2018). ...
Article
Several randomized controlled trials have implemented cognitive behavioral therapy for insomnia (CBT-I) for patients with comorbid insomnia and chronic pain. This systematic review and meta-analysis investigated the effectiveness of CBT-I on patient-reported sleep, pain, and other health outcomes (depressive symptoms, anxiety symptoms, and fatigue) in patients with comorbid insomnia and chronic non-cancer pain. A systematic literature search was conducted using eight electronic databases. Upon duplicate removal, 6,374 records were screened against the inclusion criteria. Fourteen randomized controlled trials were selected for the review, with twelve (N=762 participants) included in the meta-analysis. At post-treatment, significant treatment effects were found on global measures of sleep (standardized mean difference=0.89), pain (0.20), and depressive symptoms (0.44). At follow-up (up to 12 months), CBT-I significantly improved sleep (0.56). Using global measures of sleep, we found a probability of 81% and 71% for having better sleep after CBT-I at post-treatment and final follow-up, respectively. The probability of having less pain after CBT-I at post-treatment and final follow-up was 58% and 57%, respectively. There were no statistically significant effects on anxiety symptoms and fatigue at either assessment point. Future trials with sufficient power, longer follow-up periods, and inclusion of CBT for pain components are warranted.
Chapter
While some people are considered “good sleepers”, others struggle to go to sleep or stay asleep during the night. It may be difficult to know when someone needs attention from a sleep specialist. There are myriad of tools or applications that can be available to help make that assessment. To decide if help is needed, it is important to keep in mind the following: (1) How does the individual feel upon waking up? If one feels refreshed and ready for the day without feeling tired, sleepy, moody, suffering from constant headache, or having trouble focusing or concentrating, then medical attention may not be immediately necessary. (2) Is this person's sleep or sleep behavior affecting others during sleep? Has there been excessive snoring that bothers others? Has there been harm or injury to this person or bed partners? Is the restless sleep keeping others from resting? If the answer is yes to any of the above, then consider talking to a medical provider. This chapter will review conditions that a sleep medicine practitioner can help diagnose and treat.
Article
Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.
Article
Sleep plays a vital role in older adults’ health. The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) trial, conducted in Maryland between 2012 and 2016, is a 5-month biobehavioral environmental intervention study to reduce functional disabilities in 300 low-income older adults. Individual and environmental factors impacting sleep were addressed in CAPABLE. This secondary data analysis was to test the preliminary effect of CAPABLE on actigraph-measured sleep, compared with a social engagement control in 73 CAPABLE participants with pretest-posttest actigraph data. Participants in this analysis were aged 75.8±7.5 years; 86.3% of them were females and 84.9% were Black/African Americans. Both CAPABLE intervention and social engagement control improved sleep efficiency and reduced sleep onset latency. The effect of CAPABLE on sleep was comparable to social engagement. These findings underline the importance of promoting physical function and maintaining social activity for sleep in low-income older adults with disabilities.
Article
Background: Physiotherapists assess lifestyle factors, including sleep health, that contribute to poor health outcomes. Recommendations of sleep screening assessments have been provided; however, physical therapists’ ability to successfully identify which patients would benefit from additional consultation has not been established. Objective: To determine if physiotherapists can accurately apply an evidence-based sleep decision tree to four hypothetical standardized patient cases. Methods: Participants applied the sleep decision tree to the four standardized cases via an online platform. Likert scales were used to assess perception of ease of use, likelihood of use, and how helpful they thought the sleep decision tree would be. Descriptive analyses and multiple linear regression models were conducted. Results: Eighty-eight individuals participated in the study. Most participants correctly answered the cases with 1 and 3 decision points (92% and 84%, respectively). In contrast, few participants correctly answered the cases with 4 and 5 decision points (7% and 14%, respectively). Seventy-four (84%) respondents indicated the sleep decision tree was easy to use; 57 (65%) answered they were likely to use the sleep decision tree in clinical practice; and 66 (75%) said the sleep decision tree would be helpful to their clients. Conclusions: Physiotherapists were able to accurately apply a sleep decision tree to simpler patient cases but were frequently unable to apply it to more complex patient cases. This may be due to lack of education, perceived ease of using, and relevance of the sleep decision tree to their clinical practice. The sleep decision tree may aid physiotherapists in assessing sleep health, screening for sleep disturbances, and referring for further assessment.
Article
Background: Patients with gastrointestinal cancers experience moderate to high levels of sleep disturbance during chemotherapy that decreases their functional status and quality of life (QOL). Objective: The objectives of this study were to identify subgroups of patients with gastrointestinal cancers with distinct sleep disturbance profiles and evaluate for differences among these subgroups in demographic, clinical, and sleep characteristics, as well as co-occurring symptoms and QOL outcomes. Methods: Patients (n = 405) completed questionnaires 6 times over 2 cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct sleep disturbance profiles. Results: Three distinct sleep disturbance profiles (ie, low, high, very high) were identified. Compared with the low class, patients in the other 2 classes were significantly younger and less likely to be married and to exercise on a regular basis and received a higher number of previous treatments. Compared with the low class, patients in the other 2 classes reported higher levels of anxiety, depressive symptoms, morning and evening fatigue, and pain and lower levels of attentional function and QOL scores at enrollment. Conclusions: This study is the first to use latent profile analysis to identify subgroups of patients with gastrointestinal cancers with distinct sleep disturbance profiles. Findings provide new insights on the associations between sleep disturbance and multiple co-occurring symptoms in these patients. Implications for practice: Clinicians can identify patients who are at the highest risk for sleep disturbance and recommend a variety of sleep hygiene interventions (eg, establishment of a bedtime routine), as well as initiate interventions for other co-occurring symptoms.
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Bakgrunn: Opioider for behandling av langvarige smerter kan forskrives på blå resept, men bør ikke brukes samtidig med andre vanedannende legemidler. Hensikt: Å undersøke bruk av opioider på blå resept i perioden 2009-2019, samt å studere bruk av andre vanedannende legemidler (benzodiazepiner og z-hypnotika) blant dem som fikk opioider på blå resept i 2019. Metode: Data ble hentet fra Reseptregisteret. En prevalent opioidbruker i 2019 ble definert som en person med minst én utlevering av et smertestillende opioid på blå resept for langvarige smerter også i 2018. Bruk av andre vanedannende legemidler ble definert som minst én utlevering av et annet vanedannende legemiddel i løpet av samme år. Resultater: Totalt 18 443 personer (67% kvinner) fikk utlevert opioider på blå resept i 2019, en økning fra 5 568 i 2009 via 10 693 i 2016 og 16 133 i 2017. Av de 18 443 var 14 202 (77%) prevalente opioidbrukere. Blant de prevalente brukerne fikk 88% utlevert 100 mg orale morfinekvivalenter (OMEQ) eller mindre per dag. Totalt fikk 54% av de prevalente opioidbrukerne utlevert minst ett annet vanedannende legemiddel i 2019. Z-hypnotika var oftest forekommende blant de som brukte 100 mg OMEQ eller mindre per dag, mens benzodiazepiner alene eller i kombinasjon med z-hypnotika dominerte blant opioidbrukerne som fikk utlevert mer enn 100 mg OMEQ per dag. Mengden utlevert av andre vanedannende legemidler økte med mengden opioider brukt per dag. En større andel kvinner enn menn fikk utlevert andre vanedannende legemidler i 2019. Konklusjon: Studien indikerer at bruk av andre vanedannende legemidler forekommer hos en stor andel av dem som får forskrevet opioider på blå resept. Dette er tegn på et uheldig forskrivningsmønster som bør studeres nærmere.
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Amongst adults with chronic pain, overweight and obesity are highly prevalent. The association between chronic pain and overweight is driven by several explanations, including increased biomechanical load, changes in the gut microbiome, and low-grade (neuro)inflammation. Moreover, the link between overweight, obesity and chronic pain can best be considered from a lifestyle perspective. Since conservative treatment for chronic pain is often limited to short-term and small effects, addressing important comorbidities within a lifestyle approach could be the next step towards precision medicine for these patients. Indeed, evidence shows that combining weight reduction with conservative pain management is more effective to reduce pain and disability, compared to either intervention alone. This perspective article aims to update the reader with the current understanding of the possible explanatory mechanisms behind the interaction between overweight/obesity and chronic pain in an adult population. Second, this paper applies this knowledge to clinical practice, including assessment and conservative treatment of overweight/obesity in adults with chronic pain. Henceforth, clinical recommendations and guidelines are provided based on available scientific evidence and the authors’ clinical expertise. Impact This paper will guide clinicians in the implementation of weight reduction programs within pain management.
Article
Introduction: Prognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR. There is a need to identify modifiable psychosocial and sleep-related variables, and to find out whether changes in central pain processing influence prognosis after RCR. This will improve our knowledge on how to optimise recovery, using a holistic rehabilitation approach. Methods and analysis: This longitudinal study will analyse 141 participants undergoing usual care for first time RCR. Data will be collected 1-21 days preoperatively (T1), then 11-14 weeks (T2) and 12-14 months (T3) postoperatively. We will use mixed-effects linear regression to assess relationships between potential prognostic factors and our primary and secondary outcome measures-the Western Ontario Rotator Cuff Index; the Constant-Murley Score; the Subjective Shoulder Value; Maximal Pain (Numeric Rating Scale); and Quality of Life (European Quality of Life, 5 dimensions, 5 levels). Potential prognostic factors include: four psychosocial variables; pain catastrophising, perceived stress, injury perceptions and patients' expectations for RCR; sleep; and four factors related to central pain processing (central sensitisation inventory, temporal summation, cold hyperalgesia and pressure pain threshold). Intercorrelations will be assessed to determine the strength of relationships between all potential prognostic indicators.Our aim is to explore whether modifiable psychosocial factors, sleep-related variables and altered central pain processing are associated with outcomes pre-RCR and post-RCR and to identify them as potential prognostic factors. Ethics and dissemination: The results of the study will be disseminated at conferences such as the European Pain Congress. One or more manuscripts will be published in a peer-reviewed SCI-ranked journal. Findings will be reported in accordance with the STROBE statement and PROGRESS framework. Ethical approval is granted by the Ethical commission of Canton of Zurich, Switzerland, No: ID_2018-02089 TRIAL REGISTRATION NUMBER: NCT04946149.
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Objective In a sample of patients with gynecologic cancer receiving chemotherapy, we sought to identify subgroups of patients with distinct sleep disturbance profiles and assess for differences in patient characteristics and the severity of co-occurring symptoms among these subgroups. Methods Adults with gynecologic cancer (n = 232) completed questionnaires six times over two chemotherapy cycles. Sleep disturbance was assessed using the General Sleep Disturbance Scale (GSDS). Clinically meaningful sleep disturbance was defined as a GSDS total score of ≥43. Subgroups of patients with distinct sleep disturbance profiles were identified using latent profile analysis. Differences in patient characteristics and co-occurring symptoms were assessed using Chi-square, Kruskal Wallis, and one-way analysis of variance. Results Four distinct sleep disturbance profiles were identified: Low (18.5%), Moderate (43.6%), High (29.3%), and Very High (8.6%). Compared to the Low class, patients in the other three classes had lower functional status scores and higher levels of depressive symptoms, trait anxiety, and morning and evening fatigue. Compared to the Low class, patients in the Very High class were younger, had a higher body mass index, and were more likely to report a diagnosis of depression or back pain. Conclusions Over 80% of the patients with gynecologic cancer reported sleep disturbance that persisted over two cycles of chemotherapy. Patients in the Very High class experienced problems with both sleep initiation and maintenance. Clinicians should routinely assess sleep disturbance alongside depression, anxiety, and fatigue. Interventions that target the underlying mechanisms of these co-occurring symptoms are warranted.
The high prevalence and societal burden of chronic pain, its undertreatment, and disparities in its management have contributed to the acknowledgment of chronic pain as a serious public-health concern. The concurrent opioid epidemic, and increasing concern about overreliance on opioid therapy despite evidence of limited benefit and serious harms, has heightened attention to this problem. The biopsychosocial model has emerged as the primary conceptual framework for understanding the complex experience of chronic pain and for informing models of care. The prominence of psychological processes as risk and resilience factors in this model has prompted extensive study of psychological treatments designed to alter processes that underlie or significantly contribute to pain, distress, or disability among adults with chronic pain. Cognitive-behavioral therapy is acknowledged to have strong evidence of effectiveness; other psychological approaches, including acceptance and commitment therapy, mindfulness, biofeedback, hypnosis, and emotional-awareness and expression therapy, have also garnered varying degrees of evidence across multiple pain conditions. Mechanistic studies have identified multiple pathways by which these treatments may reduce the intensity and impact of pain. Despite the growing evidence for and appreciation of these approaches, several barriers limit their uptake at the level of organizations, providers, and patients. Innovative methods for delivering psychological interventions and other research, practice, and policy initiatives hold promise for overcoming these barriers. Additional scientific knowledge and practice gaps remain to be addressed to optimize the reach and effectiveness of these interventions, including tailoring to address individual differences, concurrently addressing co-occurring disorders, and incorporating other optimization strategies.
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This chapter describes the interactions between pain and sleep and how pain is processed during sleep. It overviews the most frequent sleep disorders in chronic pain and provides advice for clinicians to guide patients in the management of sleep in the absence or in the presence of sleep disorders. Sleep quality can be easily estimated in pain and sleep clinics through patients' self‐reports, via semistructures interviews, which include use of visual analogue scales and screening questionnaires. Polysomnography at home or in a sleep laboratory supervised by a physician are both important tools to assess sleep quality and the presence of sleep disorders. Psychotherapy can help to modify sleep habits, painand/or sleep expectations and catastrophizing behaviors. Acupuncture seems to help some individuals with insomnia, sleep apnea and pain. Magnetic or direct current non‐invasive brain stimulation are emerging therapies for persistent pain among non‐responders to usual pain or sleep treatment.
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The review shows the relationship between tension-type headache (THT) and insomnia. The pathophysiological and psychological mechanisms of their mutual influence on each other are considered. Evidence is provided that the combination of these pathologies often leads to the development of maladaptive coping strategies that aggravate the patient's condition. The features and difficulties of therapy of patients suffering from TTH and insomnia are considered in detail. It has been shown that the treatment of such patients should include approaches aimed at stopping TTH, sleep disorders and associated emotional disorders using drug and non-drug methods of treatment.
Article
Objectives To examine the possible bidirectional association between insomnia and comorbid chronic low back pain (LBP) and lower limb pain and to explore whether high-sensitivity C-reactive protein (hsCRP) amplifies these associations. Methods We calculated adjusted risk ratios (RR) with 95% confidence intervals (CI) for the development of insomnia and mild-to-severe chronic LBP and lower limb pain at 11 years follow-up in participants aged ≥32 years and with hsCRP ≤10 mg/L at baseline in 2007–2008: 3,714 without chronic LBP or lower limb pain (sample 1) and 7,892 without insomnia (sample 2). Results Compared to participants without chronic pain, participants with comorbid chronic LBP and lower limb pain had a RR of insomnia of 1.37 (95% CI 1.12–1.66). Compared with participants without insomnia, participants with insomnia did not have an increased risk of comorbid chronic LBP and lower limb pain (RR: 1.06, 95% CI 0.76–1.46); however, participants with insomnia had a RR of chronic LBP of 1.20 (95% CI 1.02–1.42). There was no strong amplifying effect of elevated hsCRP (3.00–10.0 mg/L) on these associations. Conclusions These findings suggest that elevated hsCRP does not amplify the associations between insomnia and mild-to-severe chronic LBP and lower limb pain. Further research using data on the temporal relation between insomnia, chronic pain, and inflammatory responses are required to fully understand the causal pathways.
Article
Fibromyalgia (FM) often occurs under the mask of non-specific low back pain (NLBP). Objective: to compare the combined disorders and treatment efficacy in FM and chronic NLBP (chNLBP). Patients and methods. We examined 33 patients with chNLBP (27 women and 6 men, mean age 51.5±16.7 years) and 53 patients with FM (47 women and 6 men, mean age 46.8±14.6 years). Pain intensity was assessed using a numerical rating scale (NRS), using the Hospital Anxiety and Depression Scale (HADS), the Screening for Somatoform Symptoms-2 (SOMS-2), the Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), updated Fibromyalgia Impact Questionnaire (FIQR; disability in patients with FM), Oswestry Index (IO; disability in patients with chNLBP). Comprehensive treatment of patients included educational conversations, cognitive behavioral therapy, kinesitherapy, among drugs antidepressants, and in patients with FM anticonvulsants. Results and discussion. Previously, the diagnosis of FM was established only in 15% of patients, the diagnosis of chNLBP – in 82% of patients. The intensity of pain in FM was 7.1±1.9 points according to the NRS and was higher than in chNLBP (5.6±2.4 points; p=0.002). In the group of patients with FM compared to patients with chNLBP, significantly higher values of anxiety according to HADS (10.9±4.5 and 6.9±4.0 points; p<0.001), sleepiness according to ESS (8.2±4.6 and 6.2±4.6 points; p=0.014), somatization according to SOMS-2 (28.0 and 20.0 points; p<0.001) were detected. Possible anatomical causes of pain have been identified in all patients with chNLBP and only in 13% of patients with FM. 6 months after thestart of treatment in the FM group, pain intensity significantly (p<0.001) decreased to 3.7±2.6 points according to the NRS, anxiety to 6.7±3.5 points according to HADS, depression to 4.7±2 .6 points according to HADS, disability from 54.9±18.4 to 34.0±20.2 points according to FIQR; in chNLBP group pain intensity significantly (p<0.05) decreased to 2.6±2.1 points according to the NRS, anxiety decreased to 4.2±2.5 points according to HADS, depression to 6.5±3.3 points according to HADS, disability from 37.8±17.4 to 14.5±14.2 points according to IO. Conclusion. FM is less frequently diagnosed in comparison with chNLBP, accompanied by a higher pain intensity, anxiety, sleepiness and somatization. Complex therapy leads to a stable positive effect both in chNLBP and in FM.
Article
Aims and objectives This study's purpose was to identify the correlates of sleep quality in older adults with chronic disease. Background Sleep quality is a common problem in older adults that may be affected by physical and mental status. Design A cross-sectional correlational design was employed. Methods The study was conducted between July 2019 and April 2020 in a teaching hospital of southern Taiwan. The Geriatric Depression Scale, Pittsburgh Sleep Quality Index and Numerical Rating Scale were used to assess depression, sleep quality and physical pain respectively. Results Of the 120 older adults (age >65 years) with chronic disease, the average Pittsburgh Sleep Quality Index score was 5.67. A total of 45.8% subjects had sleep disturbance. Older adults who were living with a partner and those who urinated at night were significantly more likely to report sleep disturbance. The presence of sleep disturbance was associated with greater levels of depression and higher levels of physical pain. Conclusion Living with a partner, nocturia, physical pain and depression were associated with the presence of sleep disturbance in older adults with chronic disease. Relevance to clinical practice The results of this study can help healthcare providers understand the factors associated with sleep disturbance in older adults with chronic disease, thereby facilitating the early resolution of sleep disturbance issues in this population.
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This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of non-pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform disorders unspecified, somatoform autonomic dysfunction, pain disorder and alternative somatoform diagnoses proposed in literature) and MUPS in adults in comparison with treatment as usual, waiting list controls, attention placebo, psychological placebo and other psychological or physical therapies.
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Aim: The aim of this study was to investigate the neuroendocrine, autonomic, and metabolic system responses to suvorexant in psychiatric subjects with insomnia. Design: This prospective study was conducted in Kusatsu Hospital in Hiroshima, Japan and included 40 psychiatric inpatients treated with suvorexant from December 2014 to April 2016. Methods: Questionnaire of Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) scores were checked at baseline, Week 2, and Week 4, and fasting serum levels of prolactin, insulin, cortisol, noradrenaline, white blood cell count, and average pulse rate were measured at baseline and Week 4 and Week 8 after suvorexant initiation. Sequential change of the values were compared against baseline respectively. Results: Subjective sleep quality scores were significantly decreased at Weeks 2 and 4, and sleep duration, habitual sleep efficacy, and global scores were significantly decreased at Week 4 from baseline. Total scores on the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9 significantly decreased at Week 4 from baseline. The levels of cortisol and white blood cell count were decreased, significantly at Week 8, and the levels of pulse rate were significantly decreased at Week 4 from baseline. The levels of noradrenaline decreased, although not significantly. The prolactin levels remained unchanged, and no trend was found in the insulin levels. Conclusion: Suvorexant treatment resulted in overall improvement in the quality of sleep and the severity of anxiety and depression. This dual orexin antagonist may be related to autonomic functions and neuroendocrine systems, especially in the hypothalamus-pituitary-adrenal axis in psychiatric subjects.
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We aimed to evaluate gender differences in the relationships between headache features, sleep quality, anxiety, depressive symptoms and burden of headache in 193 patients (73% women) with chronic tension type headache (CTTH). Sleep quality was assessed with the Pittsburgh Sleep Quality Index. Headache features were collected with a four-week diary. The Hospital Anxiety and Depression Scale was used to assess anxiety/depressive symptoms. Headache Disability Inventory was used to evaluate the burden of headache. In men with CTTH, sleep quality was positive correlated with headache frequency (r = 0.310; P = 0.018), emotional (r = 0.518; P < 0.001) and physical (r = 0.468; P < 0.001) burden of headache, and depressive symptoms (r = 0.564; P < 0.001). In women, positive correlations were observed between sleep quality and headache intensity (r = 0.282; P < 0.001), headache frequency (r = 0.195; P = 0.021), emotional burden (r = 0.249; P = 0.004) and depressive symptoms (r = 0.382; P < 0.001). The results of stepwise regression analyses revealed that depressive symptoms and emotional burden of headache explained 37.2% of the variance in sleep quality in men (P < 0.001), whereas depressive symptoms and headache intensity explained 17.4% of the variance in sleep quality in women (P < 0.001) with CTTH. Gender differences associated with poor sleep should be considered for proper management of individuals with CTTH.
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BACKGROUND: Fibromyalgia is a clinically well-defined chronic condition with a biopsychosocial aetiology. Fibromyalgia is characterized by chronic widespread musculoskeletal pain, sleep problems, cognitive dysfunction, and fatigue. Patients often report high disability levels and poor quality of life. Since there is no specific treatment that alters the pathogenesis of fibromyalgia, drug therapy focuses on pain reduction and improvement of other aversive symptoms. OBJECTIVES: To assess the benefits and harms of selective serotonin reuptake inhibitors (SSRIs) in the treatment of fibromyalgia. METHODS: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 5), MEDLINE (1966 to June 2014), EMBASE (1946 to June 2014), and the reference lists of reviewed articles. Selection criteria: We selected all randomized, double-blind trials of SSRIs used for the treatment of fibromyalgia symptoms in adult participants. We considered the following SSRIs in this review: citalopram, fluoxetine, escitalopram, fluvoxamine, paroxetine, and sertraline. Data collection and analysis: Three authors extracted the data of all included studies and assessed the risks of bias of the studies. We resolved discrepancies by discussion. MAIN RESULTS: The quality of evidence was very low for each outcome. We downgraded the quality of evidence to very low due to concerns about risk of bias and studies with few participants. We included seven placebo-controlled studies, two with citalopram, three with fluoxetine and two with paroxetine, with a median study duration of eight weeks (4 to 16 weeks) and 383 participants, who were pooled together. All studies had one or more sources of potential major bias. There was a small (10%) difference in patients who reported a 30% pain reduction between SSRIs (56/172 (32.6%)) and placebo (39/171 (22.8%)) risk difference (RD) 0.10, 95% confidence interval (CI) 0.01 to 0.20; number needed to treat for an additional beneficial outcome (NNTB) 10, 95% CI 5 to 100; and in global improvement (proportion of patients who reported to be much or very much improved: 50/168 (29.8%) of patients with SSRIs and 26/162 (16.0%) of patients with placebo) RD 0.14, 95% CI 0.06 to 0.23; NNTB 7, 95% CI 4 to 17. SSRIs did not statistically, or clinically, significantly reduce fatigue: standard mean difference (SMD) -0.26, 95% CI -0.55 to 0.03; 7.0% absolute improvement on a 0 to 10 scale, 95% CI 14.6% relative improvement to 0.8% relative deterioration; nor sleep problems: SMD 0.03, 95 % CI -0.26 to 0.31; 0.8 % absolute deterioration on a 0 to 100 scale, 95% CI 8.3% relative deterioration to 6.9% relative improvement. SSRIs were superior to placebo in the reduction of depression: SMD -0.39, 95% CI -0.65 to -0.14; 7.6% absolute improvement on a 0 to 10 scale, 95% CI 2.7% to 13.8% relative improvement; NNTB 13, 95% CI 7 to 37. The dropout rate due to adverse events was not higher with SSRI use than with placebo use (23/146 (15.8%) of patients with SSRIs and 14/138 (10.1%) of patients with placebo) RD 0.04, 95% CI -0.06 to 0.14. There was no statistically or clinically significant difference in serious adverse events with SSRI use and placebo use (3/84 (3.6%) in patients with SSRIs and 4/84 (4.8%) and patients with placebo) RD -0.01, 95% CI -0.07 to 0.05. AUTHORS' CONCLUSIONS: There is no unbiased evidence that SSRIs are superior to placebo in treating the key symptoms of fibromyalgia, namely pain, fatigue and sleep problems. SSRIs might be considered for treating depression in people with fibromyalgia. The black box warning for increased suicidal tendency in young adults aged 18 to 24, with major depressive disorder, who have taken SSRIs, should be considered when appropriate.
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Aims: Cognitive and behavioral treatments (CBT) for sleep problems and chronic pain have shown good results, although these results could improve. More recent developments based on the psychological flexibility model, the model underlying Acceptance and Commitment Therapy (ACT) may offer a useful addition to traditional CBT. The aim of this study was to examine whether an ACT-based treatment for chronic pain is associated with improved sleep. Secondly, we examined the associations between changes on measures of psychological flexibility and sleep-related outcomes. Methods: The study used an observational cohort methodology. Participants were 252 patients (73.8% female) attending a 4-week, interdisciplinary, pain management program in London, United Kingdom. Participants completed standard self-report measures of pain and functioning, sleep outcomes, and processes of psychological flexibility. Pre- to post-treatment, and pre-treatment to follow-up measures were examined for statistically significant differences using paired samples t-tests. Secondarily, hierarchical multiple regression analyses were conducted to examine change in process measures in relation to change in treatment outcome. Results: Participants showed statistically significant improvements (all p < 0.001) at post-treatment on measures of insomnia severity (d = 0.45), sleep interference (d = 0.61), and sleep efficiency (d = 0.32). Significant improvements in insomnia severity and sleep interference were also observed at 9-month follow up. Small to medium effect sizes were observed across the sleep outcomes. Statistically significant changes were also observed on measures of psychological flexibility, and these improvements were significantly associated with improvements on sleep-related outcomes, independently contributing up to 19% of unique variance. Conclusion: This study supports the potential usefulness of ACT-based treatments for chronic pain for addressing co-occurring sleep difficulties. Further research is needed to determine how to improve the impact of this treatment for co-morbid pain and sleep difficulties, possibly using a randomized-controlled trial design.
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Background: This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well-defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co-exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health-related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives: To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria: We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis: Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention-to-treat analysis without imputation for drop-outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results: We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias.The primary outcomes in our review were participant-reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross-over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant-based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions: We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia.
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Background: Analgesic medication is the most frequently prescribed treatment for low back pain (LBP), of which paracetamol (acetaminophen) is recommended as the first choice medication. However, there is uncertainty about the efficacy of paracetamol for LBP. Objectives: To investigate the efficacy and safety of paracetamol for non-specific LBP. Search methods: We conducted searches on the Cochrane Central Register of Controlled Trials (CENTRAL, which includes the Back and Neck Review Group trials register), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, LILACS, and IPA from their inception to 7 August 2015. We also searched the reference lists of eligible papers and trial registry websites (WHO ICTRP and ClinicalTrials.gov). Selection criteria: We only considered randomised trials comparing the efficacy of paracetamol with placebo for non-specific LBP. The primary outcomes were pain and disability. We also investigated quality of life, function, adverse effects, global impression of recovery, sleep quality, patient adherence, and use of rescue medication as secondary outcomes. Data collection and analysis: Two review authors independently performed the data extraction and assessed risk of bias in the included studies. We also evaluated the quality of evidence using the GRADE approach. We converted scales for pain intensity to a common 0 to 100 scale. We quantified treatment effects using mean difference for continuous outcomes and risk ratios for dichotomous outcomes. We used effect sizes and 95% confidence intervals as a measure of treatment effect for the primary outcomes. When the treatment effects were smaller than 9 points on a 0 to 100 scale, we considered the effect as small and not clinically important. Main results: Our searches retrieved 4449 records, of which three trials were included in the review (n = 1825 participants), and two trials were included in the meta-analysis. For acute LBP, there is high-quality evidence for no difference between paracetamol (4 g per day) and placebo at 1 week (immediate term), 2 weeks, 4 weeks, and 12 weeks (short term) for the primary outcomes. There is high-quality evidence that paracetamol has no effect on quality of life, function, global impression of recovery, and sleep quality for all included time periods. There were also no significant differences between paracetamol and placebo for adverse events, patient adherence, or use of rescue medication. For chronic LBP, there is very low-quality evidence (based on a trial that has been retracted) for no effect of paracetamol (1 g single intravenous dose) on immediate pain reduction. Finally, no trials were identified evaluating patients with subacute LBP. Authors' conclusions: We found that paracetamol does not produce better outcomes than placebo for people with acute LBP, and it is uncertain if it has any effect on chronic LBP.
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Background: Insomnia is of major public health importance. While cognitive behavioral therapy is beneficial, in-person treatment is often unavailable. We assessed the effectiveness of internet-delivered cognitive behavioral therapy for insomnia. Objectives: The primary objectives were to determine whether online cognitive behavioral therapy for insomnia could improve sleep efficiency and reduce the severity of insomnia in adults. Secondary outcomes included sleep quality, total sleep time, time in bed, sleep onset latency, wake time after sleep onset, and number of nocturnal awakenings. Data sources: We searched PubMed/MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Library, Embase, and the Web of Science for randomized trials. Methods: Studies were eligible if they were randomized controlled trials in adults that reported application of cognitive behavioral therapy for insomnia via internet delivery. Mean differences in improvement in sleep measures were calculated using the Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis. Results: We found 15 trials, all utilizing a pretest-posttest randomized control group design. Sleep efficiency was 72% at baseline and improved by 7.2% (95% CI: 5.1%, 9.3%; p<0.001) with internet-delivered cognitive behavioral therapy versus control. Internet-delivered cognitive behavioral therapy resulted in a decrease in the insomnia severity index by 4.3 points (95% CI: -7.1, -1.5; p = 0.017) compared to control. Total sleep time averaged 5.7 hours at baseline and increased by 20 minutes with internet-delivered therapy versus control (95% CI: 9, 31; p = 0.004). The severity of depression decreased by 2.3 points (95% CI: -2.9, -1.7; p = 0.013) in individuals who received internet-delivered cognitive behavioral therapy compared to control. Improvements in sleep efficiency, the insomnia severity index and depression scores with internet-delivered cognitive behavioral therapy were maintained from 4 to 48 weeks after post-treatment assessment. There were no statistically significant differences between sleep efficiency, total sleep time, and insomnia severity index for internet-delivered versus in-person therapy with a trained therapist. Conclusion: In conclusion, internet-delivered cognitive behavioral therapy is effective in improving sleep in adults with insomnia. Efforts should be made to educate the public and expand access to this therapy. Registration Number, Prospero: CRD42015017622.
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Introduction: Central sensitization (CS) is present in a variety of chronic pain disorders, including whiplash, temporomandibular disorders, low back pain, osteoarthritis, fibromyalgia, headache, lateral epicondylalgia among others. In spite of our increased understanding of the mechanisms involved in CS pain, its treatment remains a challenging issue. Areas covered: An overview of the treatment options we have for desensitising the CNS in patients with CS pain is provided. These include strategies for eliminating peripheral sources of nociception, as well as pharmacotherapy and conservative interventions that primarily address top-down (i.e., brain-orchestrated) mechanisms. Expert opinion: A combination of different strategies, each targeting a different 'desensitizing' mechanism, might prove superior over monotherapies. Such combined therapy may include both bottom-up and top-down (e.g., opioids, combined μ-opioid receptor agonist and noradrenaline reuptake inhibitor drugs) strategies. Topically applied analgesic therapies have strong potential for (temporally) decreasing peripheral nociceptive input (bottom-up approach). Targeting metabolic (e.g., ketogenic diets) and neurotrophic factors (e.g., decreasing brain-derived neurotrophic factor) are promising new avenues for diminishing hyperexcitability of the CNS in central sensitization pain patients. Addressing conservative treatments, pain neuroscience education, cognitive behavioural therapy and exercise therapy are promising treatments for CS pain.
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Objectives: To investigate associated dimensions of fatigue regarding cognitive impairment, psychomotor performances, muscular effort power and circulating cytokine levels and their relations to symptom intensity in a sample of pure chronic fatigue syndrome (CFS) patients without overlapping objective sleepiness or sleep disorders. Methods: 16 CFS patients were compared to 14 matched controls. We assessed structured symptom-scales, polysomnography, multiple sleep latency tests, attention (Zazzo-Cancellation ZCT, digit-symbol-substitution DSST), psychomotor vigilance and speed (PVT, finger tapping test, FTT), dynamometer handgrip force (tonic and phasic trials) and circulating cytokines (IFN-γ, IL-1b, IL-6, IL-8, IL-10, TNF-α). Results: In addition to fatigue, CFS patients presented with higher affective symptom intensity and worse perceived sleep quality. Polysomnography showed more slow-wave sleep and microarousals in CFS but similar sleep time, efficiency and light-sleep durations than controls. Patients presented with impaired attention (DSST, ZCT), slower reaction times (PVT) but not with lower hit rates (FTT). Notwithstanding lower grip strength during tonic and phasic trials, CFS also presented with higher fatigability during phasic trials. Cytokine levels were increased for IL-1b, IL-8, IL-10 and TNF-α and fatigue intensity was correlated to grip strength and IL-8. Conclusions: In contrast to sleepiness, chronic fatigue is a more complex phenomenon that cannot be reduced to one single measured dimension (i.e., sleep propensity). Showing its relations to different measurements, our study reflects this multidimensionality, in a psychosomatic disorder such as CFS. To obtain objective information, routine assessments of fatigue should rule out sleepiness, combine aspects of mental and physical fatigue and focus on fatigability.
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Promoting physical activity is key to the management of chronic pain, but little is understood about the factors facilitating an individual's engagement in physical activity on a day-to-day basis. This study examined the within-person effect of sleep on next day physical activity in patients with chronic pain and insomnia. 119 chronic pain patients monitored their sleep and physical activity for a week in their usual sleeping and living environment. Physical activity was measured using actigraphy to provide a mean activity score each hour. Sleep was estimated with actigraphy and an electronic diary, providing an objective and subjective index of sleep efficiency (A-SE, SE) and a sleep quality rating (SQ). The individual and relative roles of these sleep parameters, as well as morning ratings of pain and mood, in predicting subsequent physical activity were examined in multilevel models that took into account variations in relationships at the 'Day' and 'Participant' levels. Of the 5 plausible predictors SQ was the only significant within-person predictor of subsequent physical activity, such that nights of higher sleep quality were followed by days of more physical activity, from noon to 11pm. The temporal association was not explained by potential confounders such as morning pain, mood or effects of the circadian rhythm. In the absence of interventions, chronic pain patients spontaneously engaged in more physical activity following a better night of sleep. Improving nighttime sleep may well be a novel avenue for promoting daytime physical activity in patients with chronic pain.
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The present study aims at studying interactions between cognitive performance and conditioned pain modulation in patients with chronic whiplash-associated disorders (WAD) and healthy controls. In addition, the relation between cortisol concentrations and cognitive performance will be studied in patients with chronic WAD. Thirty-one subjects, 16 healthy subjects and 15 patients with chronic WAD, were enrolled and subjected to several self-report and physiological measures. Self-report measures encompassed pain rating during a procedure evaluating conditioned pain modulation. Afterward, they were subjected to physiological measures, which are cognitive tests (Stroop task, psychomotor vigilance task, and operation span task) preceded and followed by salivary cortisol concentration measurements. Chronic WAD patients performed worse in recall at the operation span task and presented longer reaction times at the psychomotor vigilance task and at the Stroop task when sleep-related words were shown (p < .05). Conditioned pain modulation and cortisol concentrations were not significantly different between patients and controls (p > .05). Only in the healthy subjects, conditioned pain modulation and baseline cortisol concentrations were correlated to cognitive performance (p < .05). This is the first study addressing the relation between pain inhibition and cognitive performance in chronic WAD. We did not reveal impaired pain inhibition but did reveal cognitive dysfunctions in patients with chronic WAD. In healthy subjects, pain inhibition was related to cognitive performance but not in the patient group.
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Ample evidence suggests that sleep and pain are related. However, many questions remain about the direction of causality in their association, as well as mechanisms that may account for their association. The prevailing view has generally been that they are reciprocally related. The present review critically examines the recent prospective and experimental literature (2005-present) in an attempt to update the field on emergent themes pertaining to the directionality and mechanisms of the association of sleep and pain. A key trend emerging from population-based longitudinal studies is that sleep impairments reliably predict new incidents and exacerbations of chronic pain. Microlongitudinal studies employing deep subjective and objective assessments of pain and sleep support the notion that sleep impairments are a stronger, more reliable predictor of pain than pain is of sleep impairments. Recent experimental studies suggest that sleep disturbance may impair key processes that contribute to the development and maintenance of chronic pain, including endogenous pain inhibition and joint pain. Several biopsychosocial targets for future mechanistic research on sleep and pain are discussed, including dopamine and opioid systems, positive and negative affect, and sociodemographic factors. This critical review examines the recent prospective and experimental research (2005-present) on the association of sleep and pain in an attempt to identify trends suggestive of directionality and potential mechanisms. An update on this literature is needed to guide future clinical efforts to develop and augment treatments for chronic sleep disturbance and chronic pain.
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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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Morphine is the most efficacious and widely prescribed treatment for pain. However, it decreases the total amount of deep sleep and rapid eye movement sleep in humans. Acute morphine administration at low doses causes wakefulness in animal models. To clarify the mechanism by which morphine affects sleep-wake behavior, we investigated the effects of morphine on the sleep-promoting neurons of the ventrolateral preoptic area (VLPO), a putative sleep-active nucleus, using in vitro brain slices by the patch-clamp technique. We also examined the effects of morphine on sleep-wake profiles after administration of opioid receptor antagonist to the VLPO using EEG and electromyogram recordings in freely moving rats. The results showed that morphine inhibited the firing rate of sleep-promoting neurons and hyperpolarized their membrane potentials without affecting interneurons in the VLPO. Morphine-induced hyperpolarization of membrane potentials could be reversed by, D-Phe-Cys-Thr-D-Trp-Orn-Thr-Pen-Thr-NH2 (CTOP), a mu receptor antagonist, in the presence of tetrodotoxin. However, after the mu receptors were blocked by CTOP, morphine still suppressed the firing of the sleep-promoting neurons. This effect was antagonized by nor-BIN, a kappa receptor antagonist. Activation of kappa receptor by U50488H inhibited the firing of the sleep-promoting neurons. These results indicate that morphine could inhibit the activity of sleep-promoting neurons in the VLPO through mu and kappa receptors. EEG recordings revealed that morphine injected subcutaneously induced arousal in a dose-dependent manner. CTOP microinjected into VLPO antagonized the arousal effects of morphine, but nor-BIN did not. However, CTOP alone was not associated with any changes in the physiological sleep-wake cycle. Taken together, these findings clearly indicate that morphine inhibits sleep-promoting neurons in the VLPO by affecting mu receptors and so induces wakefulness in rats.
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Pain influences sleep and vice versa. We performed an umbrella review of meta-analyses on treatments for diverse conditions in order to examine whether diverse medical treatments for different conditions have similar or divergent effects on pain and sleep. We searched published systematic reviews with meta-analyses in the Cochrane Database of Systematic Reviews until October 20, 2011. We identified randomized trials (or meta-analyses thereof, when >1 trial was available) where both pain and sleep outcomes were examined. Pain outcomes were categorized as headache, musculoskeletal, abdominal, pelvic, generic or other pain. Sleep outcomes included insomnia, sleep disruption, and sleep disturbance. We estimated odds ratios for all outcomes and evaluated the concordance in the direction of effects between sleep and various types of pain and the correlation of treatment effects between sleep and pain outcomes. 151 comparisons with 385 different trials met our eligibility criteria. 96 comparisons had concordant direction of effects between each pain outcome and sleep, while in 55 the effect estimates were in opposite directions (P<0.0001). In the 20 comparisons with largest amount of evidence, the experimental drug always had worse sleep outcomes and tended to have worse pain outcomes in 17/20 cases. For headache and musculoskeletal pain, 69 comparisons showed concordant direction of effects with sleep outcomes and 36 showed discordant direction (P<0.0001). For the other 4 pain types there were overall 27 vs. 19 pairs with concordant vs. discordant direction of effects (P = 0.095). There was a weak correlation of the treatment effect sizes for sleep vs. headache/musculoskeletal pain (r = 0.17, P = 0.092). Medical interventions tend to have effects in the same direction for pain and sleep outcomes, but exceptions occur. Concordance is primarily seen for sleep and headache or musculoskeletal pain where many drugs may both disturb sleep and cause pain.
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Computerised cognitive behavioural therapy (CCBT) is an innovative mode of delivering services to patients with psychological disorders. The present paper uses a meta-analysis to systematically review and evaluate the effectiveness of CCBT for insomnia (CCBT-I). A comprehensive search was conducted on 7 databases including MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Library, Social Sciences Citation Index and PubMed (up to March 2011). Search terms covered 3 concepts: (1) [internet, web, online, computer-aided, computer-assisted, computer-guided, computerized OR computerised] AND (2) [CBT, cognitive therapy, behavio(u)ral therapy OR behavio(u)r therapy] AND (3) [insomnia, sleep disorders OR sleeping problem]. 533 potentially relevant papers were identified, and 6 randomised controlled trials (RCTs) that met the selection criteria were included in the review and analysis. Two RCTs were done by the same group of investigators (Ritterband and colleagues) using the same internet programmes. Post-treatment mean differences between groups showed that the effects of CCBT-I on sleep quality, sleep efficiency, the number of awakenings, sleep onset latency and the Insomnia Severity Index were significant, ranging from small to large effect sizes. However, effects on wake time after sleep onset, total sleep time and time in bed were non-significant. On average, the number needed to treat was 3.59. The treatment adherence rate for CCBT-I was high (78%). The results lend support to CCBT as a mildly to moderately effective self-help therapy in the short run for insomnia. CCBT-I can be an acceptable form of low-intensity treatment in the stepped care model for insomnia.
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No randomised, controlled trials have been conducted to date on the efficacy of psychological and pharmacological treatments of pain catastrophising (PC) in patients with fibromyalgia. Our aim in this study was to assess the effectiveness of cognitive-behaviour therapy (CBT) and the recommended pharmacological treatment (RPT) compared with treatment as usual (TAU) at the primary care level for the treatment of PC in fibromyalgia patients. We conducted a six-month, multicenter, randomized, blinded, parallel group, controlled trial in which patients were randomly assigned to one of three study arms: CBT (n = 57), RPT (n = 56) and TAU at the primary care level (n = 56). The major outcome of this study was PC in patients with fibromyalgia. The secondary variables were pain acceptance, depression, anxiety, pain, global function and quality of life. CBT significantly decreased global PC at the six-month follow-up examination with effect sizes of Cohen's d = 0.73 and 1.01 compared with RPT and TAU, respectively. CBT was also more effective than RPT and TAU at increasing pain acceptance at the six-month follow-up examination (effect sizes of Cohen's d = 0.77 and 0.80, respectively). Compared with RPT and TAU, CBT was more effective at improving global function based on the Fibromyalgia Impact Questionnaire (six-month effect sizes Cohen's d = 0.44 and 0.53, respectively) and quality of life based on the European Quality of Life Scale (six-month effect sizes Cohen's d = 0.11 and 0.40, respectively). There were no differences among the three treatments with regard to pain and depression. CBT shows higher efficacy than RPT and TAU not only in key outcomes in FM, such as function and quality of life, but also in relevant mediators of treatment effects, such as pain catastrophising and pain acceptance. ISRCTN: ISRCTN10804772.
Article
Objective. To compare sleep dimensions in patients suffering from chronic pain of different origins, and with a group of pain-free subjects. To analyze the relationship between depression and/or anxiety and sleep disorders in musculoskeletal, neuropathic and fibromyalgia patients. Methods. This cross-sectional study included patients diagnosed with neuropathic pain (NP) (N = 104), musculoskeletal pain (MSK) (N = 99) or fibromyalgia (FM) (N = 51), and pain free subjects (N = 72). Information about sleep dimensions (MOS-sleep), duration and intensity of pain (Visual Analogue Scale), and anxiety and depression (Hospital Anxiety and Depression scale) was collected. Results. Of the 254 patients with chronic pain (PCP) studied, the mean pain intensity was 6.6 (SD = 1.9) with an average duration of 9 years. The scores in all sleep dimensions of the MOS-sleep were higher in CPP (more disturbances) compared to pain free patients, and differences were observed among the 3 groups of PCP, with FM most severely affected. Anxiety (ß=1.3), depression (ß=1.1), intensity (ß=1.7) and duration of pain (ß=0.04), were associated with more sleep problems in MSK patients. By contrast, anxiety (ß=2.5) and duration of pain (ß=0.05) were negatively related to sleep in the NP patients, and only depression (ß=1.3) affected FM patients. Conclusions. The sleep pattern differs among groups of PCP in the presence or absence of mood disorders. Understanding these disorders in each specific group of PCP is fundamental, and it can contribute to improve the clinical situation of the patients and better orientating therapeutic strategies.
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Introduction: The mechanism of sensitization of the central nervous system partly explains the chronic pain experience in many patients, but the etiological mechanisms of this central nervous system dysfunction are poorly understood. Recently, an increasing number of studies suggest that aberrant glial activation takes part in the establishment and/or maintenance of central sensitization. Areas covered: This review focused on preclinical work and mostly on the neurobiochemistry studied in animals, with limited human studies available. Glial overactivation results in a low-grade neuroinflammatory state, characterized by high levels of BDNF, IL-1β, TNF-α, which in turn increases the excitability of the central nervous system neurons through mechanisms like long-term potentiation and increased synaptic efficiency. Aberrant glial activity in chronic pain might have been triggered by severe stress exposure, and/or sleeping disturbances, each of which are established initiating factors for chronic pain development. Expert opinion: Potential treatment avenues include several pharmacological options for diminishing glial activity, as well as conservative interventions like sleep management, stress management and exercise therapy. Pharmacological options include propentofylline, minocycline, β -adrenergic receptor antagonists, and cannabidiol. Before translating these findings from basic science to clinical settings, more human studies exploring the outlined mechanisms in chronic pain patients are needed.
Article
Study Objectives: Sleep quality is associated with different aspects of psychopathology, but relatively little research has examined links between sleep quality and externalizing behaviors or callous-unemotional traits. We examined: (1) whether an association exists between sleep quality and externalizing behaviors; (2) whether anxiety mediates this association; (3) whether callous-unemotional traits are associated with sleep quality. Methods: Data from two studies were used. Study 1 involved 1556 participants of the G1219 study aged 18–27 years (62% female). Questionnaire measures assessed sleep quality, anxiety, externalizing behaviors, and callous-unemotional traits. Study 2 involved 338 participants aged 18–66 years (65% female). Questionnaires measured sleep quality, externalizing behaviors, and callous-unemotional traits. In order to assess objective sleep quality, actigraphic data were also recorded for a week from a subsample of study 2 participants (n = 43). Results: In study 1, poorer sleep quality was associated with greater externalizing behaviors. This association was partially mediated by anxiety and moderated by levels of callous-unemotional traits. There was no significant relationship between sleep quality and callous-unemotional traits. In study 2, poorer sleep quality, as assessed via self-reported but not objective measures, was associated with higher levels of externalizing behaviors. Furthermore, in study 2, better sleep quality (indicated in both questionnaires and actigraphy measures: lower mean activity, and greater sleep efficiency) was associated with higher levels of callous-unemotional traits. Conclusions: Self-reports of poorer sleep quality are associated with externalizing behaviors, and this association is partially mediated by anxiety. Callous-unemotional traits are not associated with poor sleep and may even be related to better sleep quality. This is an exceptional finding given that poor sleep quality appears to be a characteristic of most psychopathology.