Pain management around the clock: the significance of sleep   February 12th, 2024

Our work and lifestyle choices are contributing to the normalization of poor sleep1,2. This is in contrast with the extensive research linking good quality sleep with positive mood, learning, memory consolidation, and physical recovery. Conversely, poor sleep leads to important consequences for our health1. For individuals with musculoskeletal conditions and chronic pain, the impact of poor sleep is even more profound. 

Previous longitudinal studies showed that poor sleep quality reduces pain thresholds, perpetuates pain, and impacts the transition from localized to generalized pain2,3. Sleep disorders can develop following an acute, painful injury4,5. However, recent studies indicate a bidirectional relationship between sleep and pain, with some suggesting that sleep disturbances are better predictors of future pain than vice versa1,2.

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia4, as it is proven to be highly effective to improve sleep quality8,9. Furthermore, it leads to moderate positive effects on depression and anxiety, rumination and stress6. CBT-I can be provided in group therapy or individually, with the possibility of following the therapy online. It covers  psychoeducation, behavioral changes such as sleep hygiene, stimulus control, and time-in-bed restriction, and cognitive therapy in seven weeks7. Although CBT-I is highly effective for sleep consolidation, it has no or only small effects on pain when applied in clinical pain populations4,8,9. This might be due to the ‘time-in-bed restriction’ behavioral component of CBT-I. While the application of time-in-bed restriction is very effective in quickly consolidating sleep, it is known to have negative effects on pain. Indeed, the provision of ‘time-in-bed restriction’ in CBT-I leads to a decreased total sleep time, which in turn is associated with increased nociceptive sensitivity and pain intensity4,10,11. In this context, pain and discomfort are also reported side effects of CBT-I in primary insomnia patients11. Additionally, insomnia is not the only sleep disorder that could impact chronic pain patients. Restless leg syndrome, obstructive sleep apnea, and excessive daytime sleepiness are other sleep disorders that chronic pain patients may experience12,13.

In conclusion, the relationship between sleep and pain is a complex puzzle that demands further exploration. Furthermore, there is a clear need for more effective, tailored interventions addressing this complex relationship to provide relief and improved well-being for individuals who suffer from both chronic pain and sleep disturbances.

Zosia Goossens

2024 Pain in Motion

References and further reading:

1. Whale, K. & Gooberman-Hill, R. The Importance of Sleep for People With Chronic Pain: Current Insights and Evidence. JBMR Plus vol. 6 Preprint at (2022).

2. Campanini, M. Z. et al. Bidirectional associations between chronic low back pain and sleep quality: A cohort study with schoolteachers. Physiol Behav 254, (2022).

3. Van Looveren, E. et al. The association between sleep and chronic spinal pain: A systematic review from the last decade. Journal of Clinical Medicine vol. 10 Preprint at (2021).

4. Selvanathan, J. et al. Cognitive behavioral therapy for insomnia in patients with chronic pain – A systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews vol. 60 Preprint at (2021).

5. Koffel, E. et al. The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial. Health Psychology 35, 41–49 (2016).

6. Cheng, P., Kalmbach, D. A., Castelan, A. C., Murugan, N. & Drake, C. L. Depression prevention in digital cognitive behavioral therapy for insomnia: Is rumination a mediator? J Affect Disord 273, 434–441 (2020).

7. Malfliet, A. et al. The added value of cognitive behavioral therapy for insomnia to current best evidence physical therapy for chronic spinal pain: protocol of a randomized controlled clinical trial. Braz J Phys Ther 23, 62–70 (2019).

8. Enomoto, K. et al. Comparison of the effectiveness of cognitive behavioral therapy for insomnia, cognitive behavioral therapy for pain, and hybrid cognitive behavioral therapy for insomnia and pain in individuals with comorbid insomnia and chronic pain: A systematic review and network meta-analysis. Sleep Med Rev 66, 101693 (2022).

9. Vitiello, M. v, Rybarczyk, B., von Korff, M., Stepanski, E. J. & Korff, V. M. Cognitive Behavioral Therapy for Insomnia Improves Sleep and Decreases Pain in Older Adults with Co-Morbid Insomnia and Osteoarthritis. Journal of Clinical Sleep Medicine vol. 5 (2009).

10. Cheng, S. K. & Dizon, J. Computerised Cognitive Behavioural Therapy for Insomnia. and Psychosomatics 81, 206–216 (2012).

11. Kyle, S. D., Morgan, K., Spiegelhalder, K. & Espie, C. A. No pain, no gain: An exploratory within-subjects mixed-methods evaluation of the patient experience of sleep restriction therapy (SRT) for insomnia. Sleep Med 12, 735–747 (2011).

12. Duo, L. et al. Sleep disorders in chronic pain and its neurochemical mechanisms: a narrative review. Frontiers in Psychiatry vol. 14 Preprint at (2023).

13. Roizenblatt, M., Rosa Neto, N. S., Tufik, S. & Roizenblatt, S. Pain-related diseases and sleep disorders. Brazilian Journal of Medical and Biological Research vol. 45 792–798 Preprint at (2012).