CLINICAL REVIEWHow do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature
Introduction
Chronic pain and insomnia are major health problems worldwide. Each are independently linked to significant reductions in quality of life,1., 2., 3. psychiatric morbidity,4., 5. medical morbidity,6 disability,7., 8. and are separately estimated to cost the US economy well over $70 billion per annum in direct and indirect costs.9., 10., 11. Both conditions have increased incidence in late life and thus can be expected to increase in prevalence in the next decade as the US population ages. While chronic pain and chronic insomnia exact profound negative consequences individually, when they occur together, their combined impact in terms of personal suffering and lost productivity is likely magnified.12
Studies show that at least 50% of patients with diverse chronic pain conditions complain of significant sleep disturbance, with some investigations finding sleep disturbance as high as 70–88%.13., 14., 15., 16. In the United States alone, this conservatively translates into 28 million Americans who have sleep complaints in the context of chronically painful conditions.
The purpose of this article is to review the evidence linking sleep disturbance and pain and to examine the impact of cognitive-behavioral interventions for pain on sleep and cognitive-behavioral interventions for insomnia on pain. Our approach assumes that it is possible to make some global generalizations about the experience of chronic pain across different types of pain conditions. In so doing, however, we recognize that: 1) there are pain conditions in which sleep disturbance is more common and 2) there are aspects of the pain and sleep disturbance relationship, which may be specific to distinct pain conditions. With regard to frequency, for example, a 1996 National Sleep Foundation commissioned Gallup Poll, reported that back pain, headaches, and muscle aches, respectively, were the most frequent type of pain experienced at night by a representative sample of 2000 US adults.17 With respect to unique pain-sleep relationships that vary by pain condition, cluster headaches, for example, frequently occur during REM Sleep and/or may be provoked by the transition from REM to NREM sleep.18., 19. Tension headaches, however, have not been associated with REM sleep, but are more consistently linked with sleep continuity disturbance and reductions in slow wave sleep (SWS).19., 20. For a review of sleep disturbance described by type of pain condition, we refer readers to recent articles by Menefee and colleagues21 and Cohen and colleagues.22
Section snippets
Experimental studies
As early as 1934, Copperman and colleagues noted the possibility that sleep disruption might have direct effects on nociceptive processes.23 After 60 h of total sleep deprivation, reduced cutaneous thresholds for touch and pain were observed in response to von Frey hairs applied to multiple sites. The greater the amount of sleep deprivation, the lower the pain threshold. Nearly 30 years ago, Moldofsky and colleagues selectively disrupted stage 4 sleep and observed next day dolorometric measures
Experimental studies
Experimental studies on the effects of painful stimuli on sleep have consistently shown pain to cause microarousal as measured by increased high frequency EEG activity in the alpha and beta ranges at the expense of slow frequency EEG activity.54., 55., 56. For example, painful stimuli delivered to muscle and joint reduces delta frequency activity and enhances high frequency activity in the alpha, beta, and sigma ranges.55 These authors concluded that pain lightens sleep and diminishes the
Treating sleep disturbance in patients with chronic pain
Clinical trials that report whether the treatment of pain is associated with improvements in sleep and vice versa, might provide a complementary level of evidence in evaluating the hypothesis that the relationship between clinical pain and sleep is reciprocal. The question of how to treat sleep disturbance secondary to pain, however, has seldom been systematically explored. In clinical practice, patients with chronic pain are often prescribed opioid analgesics at night or sedative pain
Clinical trials
Basler et al. (1991) conducted a waiting list controlled trial of CBT for pain in 45 subjects with chronic pain associated with ankylosing spondylitis.80 Endpoints measured at 12 weeks and six months were self-report measures of pain intensity, sleep, physical functioning, and psychological distress. CBT produced significant improvements on all outcome measures, which were maintained at follow-up. Notably CBT improved ‘pain-related’ sleep problems with an effect size of .41 at post treatment
Clinical trials
It is also important to consider whether CBT for primary insomnia may be successfully applied to chronic pain conditions and to determine whether improvement in sleep is associated with decreased pain intensity and negative mood states. While the assessment and treatment of sleep in clinical trials of chronic pain is just beginning to receive systematic attention, ten years ago, Morin and colleagues published two cases studies of CBT for insomnia secondary to pain.81., 82. These reports
Practice points
Our review underscores the need for continued research to develop appropriate practice guidelines to assess and treat sleep disturbance in chronic pain. The review identifies a need for clinicians to more thoroughly assess sleep disturbance in their patients and suggests that treating sleep disturbance is likely to require focused intervention, beyond simply treating pain. Cognitive behavioral therapy for insomnia represents a promising possibility for patients, particularly when they manifest
Research agenda
The current review suggests a number of fruitful avenues for future research, both with respect to fully elaborating the complex interrelationships between pain, insomnia, and negative mood and identifying the best treatment strategies. Both basic and clinical research studies are needed that incorporate systematic and thorough measures of sleep and pain using longitudinal designs. First, sleep researchers can bring their expertise and methodologies to the study of sleep disturbances associated
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