How does sleep interfere with chronic spinal pain? Unraveling the vicious cycle of sleeping problems and pain

Research output: ThesisPhD Thesis

Abstract

Chronic spinal pain consists of chronic low back and / or chronic neck pain persisting for at least three months. This condition is ubiquitous and occurs in all age groups and in every socioeconomic class. Its prevalence has risen drastically in recent decades, putting chronic spinal pain at the top of the ranking of most disabling conditions worldwide. Tremendous personal and societal burden therefore arise from the diverse costs.
The current dissertation addresses nonspecific chronic spinal pain, implying that
no source of tissue damage can be identified or that the extent of tissue damage is insufficient to explain the origin of the pain experienced. Therefore, the current best evidence treatment approach for nonspecific chronic spinal pain consists of pain neuroscience education followed by cognition-targeted exercise therapy. However, the present therapy approach is not yet optimal in alleviating pain and related disability.
Therefore, the treatment of nonspecific chronic spinal pain must extend beyond mere pain and thus should be approached from a broader perspective, involving lifestyle factors such as sleep.

More than half of patients with nonspecific chronic spinal pain report suffering
from insomnia (i.e., commonly reported sleep disturbances with negative daytime
consequences such as fatigue). Moreover, a growing body of evidence indicates
an interaction between sleep and pain, possibly involving overlapping underlying
mechanisms. Consequently, a vicious cycle can develop in which increased severity of pain exacerbate sleep problems, and vice versa. However, sleep disturbances are increasingly put forward as driving factor in this interaction as they not only perpetuate and deteriorate pain, but also predict the onset of pain.

The rising awareness of the impact of sleep disturbances on chronic pain raises further research questions regarding this complex relationship. Therefore, the principal objective of this thesis is to unravel the association between insomnia on pain in patients with nonspecific chronic spinal pain in order to optimize therapy and to improve the outcomes. This way, the vicious cycle between sleeping problems and pain could be broken.

To elaborate on this overarching objective, this dissertation was structured into three main sections, each with a distinct purpose for which corresponding studies were conducted.

The aim of the first section was to provide an update of the evidence regarding the association between sleep and chronic spinal pain. Therefore, chapter 1 consists ofa systematic review investigating this complex interaction. The results of this study confirm the presence of an association between sleep parameters and pain in patients with (nonspecific) chronic spinal pain. As such, weak to moderate evidence was found that higher poorer sleep was related to higher pain intensity levels in patients with chronic spinal pain. In addition, the review highlighted the role of sleep problems as a predictor for (nonspecific) chronic spinal pain as well as for nonrecovery from chronic low back pain, but not vice versa. From the findings of this review, it seems appropriate to address the commonly reported sleep problems in patients with (nonspecific) chronic spinal pain. Sleep management may thus be a necessary extension to pain treatment to
achieve optimal therapy outcomes.

The second section then further explored the association between sleep and chronic spinal pain. By conducting a mediation analysis in chapter 2, the role of both fatigue and sleepiness in the interaction between sleep and nonspecific chronic spinal pain was investigated. Data for this cross-sectional study were derived from the baseline assessments of a randomized controlled trial including patients with nonspecific chronic spinal pain and comorbid insomnia. A significant mediating role of physical but not of mental fatigue was found in a first analysis of the association between insomnia severity and pain. However, no association was found between objective and subjective sleep duration, sleepiness and pain in a second mediation analysis.
Therefore, providing more focus on reducing physical fatigue as a specific treatment goal within a cognitive-behavioral approach may potentially lead to more robust treatment outcomes.
Finally, the third section aimed at investigating the added value of the implementation of cognitive-behavioral therapy for insomnia within physical therapy. Chapter 3 therefore consists of an elaborated guide of an integrated approach (i.e., cognitive behavioral therapy for insomnia and pain). Points of attention regarding certain dysfunctional thoughts and coping strategies of patients with nonspecific chronic spinal pain and comorbid insomnia were highlighted within the outlined therapy.
Subsequently, the objective of chapter 4 was to provide the preliminary results of a large-scale randomized controlled trial in which the additional benefits of integrating cognitive-behavioral therapy for insomnia into the current best therapy approach for nonspecific chronic spinal pain were explored. Adding cognitive-behavioral therapy for insomnia to the current physical therapy approach did not result in a significant short-term reduction in pain severity compared to the control therapy (receiving the current physical therapy approach) in patients with chronic spinal pain and comorbid insomnia. However, integrating cognitive-behavioral therapy for insomnia into the current best evidence treatment appears to add short-term incremental effects in terms of improvement in insomnia-related symptoms and self-reported signs of
central sensitization. Potentially, improvements in sleep may have a delayed positive effect on long-term pain severity, but this requires a longer follow-up period.

In conclusion, the current dissertation yields a better understanding of the interaction between insomnia and nonspecific chronic spinal pain. Furthermore, these findings were translated to a therapeutic approach where the implementation of cognitive behavioral therapy for insomnia seems promising in optimizing therapy outcomes.
Future studies should continue to elucidate the relationship between sleep and pain, taking into account other lifestyle factors
Original languageEnglish
QualificationDoctor in Rehabilitation Sciences and Physiotherapy
Awarding Institution
  • Ghent University
  • Vrije Universiteit Brussel
Supervisors/Advisors
  • Cagnie, Barbara, Supervisor, External person
  • Meeus, Mira, Supervisor, External person
  • Ickmans, Kelly, Supervisor
  • Mairesse, Olivier, Supervisor
Award date20 Oct 2022
Publication statusPublished - 2022

Keywords

  • chronic spinal pain
  • sleep interfere

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