Sleep and Pain: Interaction of Two Vital Functions

ABSTRACT

Disturbed sleep is a key complaint of people experiencing acute and chronic pain. These two vital functions, sleep and pain, interact in complex ways that ultimately impact the biological and behavioral capacity of the individual. Polysomnographic studies of patients experiencing acute pain during postoperative recovery show shortened and fragmented sleep with reduced amounts of slow wave and rapid eye movement (REM) sleep, and the recovery is accompanied by normalization of sleep. Objective assessments of sleep in patients with various chronic pain conditions have been less definitive with some studies showing fragmented and shortened sleep and others showing normal sleep. Although daytime fatigue is a frequent complaint associated with complaints of pain-related disturbed sleep, objective assessments of daytime sleepiness reveal minimally elevated levels of sleepiness and emphasize the importance of distinguishing sleepiness and fatigue. The pain-sleep nexus has been modeled in healthy pain-free subjects and the studies have demonstrated the bidirectionality of the sleep-pain relation. Given this bidirectionality, treatment must focus on alleviation of both the pain and sleep disturbance. Few of the treatment studies have done such, and as a result no clear consensus on treatment approaches, much less on differential etiology-based treatment strategies, has emerged.

KEYWORDS

Sleep disturbance - fatigue - sleepiness - pain

REFERENCES

• 1 Chapman C R, Gavrin J. Suffering: the contributions of persistent pain.  Lancet. 1999;  353 2233-2237
• 2 Pilowsky I, Crettenden I, Townley M. Sleep disturbances in clinic patients.  Pain. 1985;  23 27-33
• 3 Gislason T, Almquist M. Somatic diseases and sleep complaints. An epidemiological study of 3201 Swedish men.  Acta Med Scand. 1987;  221 475-481
• 4 Moffitt P F, Kalucy E C, Kalucy R S, Baum F E, Cooke R D. Sleep difficulties, pain and other correlates.  J Intern Med. 1991;  230 245-249
• 5 Ellis B W, Dudley H AF. Some aspects of sleep research in surgical stress.  J Psychosom Res. 1976;  20 303-308
• 6 Kavey N B, Altshuler K Z. Sleep in herniorrhaphy patients.  Am J Surg. 1979;  138 683-687
• 7 Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care.  BMJ. 1985;  290 1029-1032
• 8 Lehmkuhl P, Prass D, Pichlmayr I. General anaesthesia and postnarcotic sleep disorders.  Neuropsychobiology. 1987;  18 37-42
• 9 Knill R L, Moote C A, Skinner M I, Rose E A. Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week.  Anesthesiology. 1990;  73 52-61
• 10 Rosenberg J, Wildschiodtz G, Pedersen M H, von Jessen F, Kehlet H. Late postoperative nocturnal episodic hypoxaemis and associated sleep pattern.  Br J Anaesth. 1994;  72 145-150
• 11 Rosenberg-Adamsen S, Kehlet H, Dodds C, Rosenberg J. Postoperative sleep disturbances: Mechanisms and clinical implications.  Br J Anaesth. 1996;  76 552-559
• 12 Lamberg L. Chronic pain linked with poor sleep; exploration of causes and treatment.  JAMA. 1999;  281 691-692
• 13 Jennum P, Jensen R. Sleep and headache.  Sleep Med Rev. 2002;  6 471-479
• 14 Drake M E, Pakalnis M S, Andrews J M, Bogner J E. Nocturnal sleep recording with cassette EEG in chronic headaches.  Headache. 1990;  30 600-603
• 15 Chervin R D, Zallek S N, Lin X, Hall J M, Sharma N, Hedger K M. Sleep disordered breathing in patients with cluster headache.  Neurology. 2000;  54 2302-2306
• 16 Paiva T, Farinha A, Martins A, Batista A, Guilleminault C. Chronic headaches and sleep disorders.  Arch Intern Med. 1997;  157 1701-1705
• 17 Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus-Miller L. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial.  JAMA. 1998;  280 1837-1842
• 18 Rowbotham M C, Twilling L, Davies P S, Reisner L, Taylor K, Mohr D. Oral opioid therapy for chronic peripheral and central neuropathic pain.  N Engl J Med. 2003;  348 1223-1232
• 19 Sang-Ho A, Hea-Woon P, Bum-Suk L et al.. Gabapentin effect on neuropathic pain compared among patients with spinal cord injury and different durations of symptoms.  Spine. 2003;  28 341-347
• 20 Mundel T, Martin S, LaMoreaux L, Hotary L, Roth T. Polysomnographic evaluation of sleep disturbance in neuropathic pain.  Sleep. 2003;  265 A354
• 21 Mahowald M L, Mahowald M W. Nighttime sleep and daytime functioning (sleepiness and fatigue) in well-defined chronic rheumatic diseases.  Sleep Med. 2000;  1 179-193
• 22 Mahowald M L, Mahowald M W. Nighttime sleep and daytime functioning (sleepiness and fatigue) in less well-defined chronic rheumatic diseases with particular reference to the “alpha-delta NREM sleep anomaly.”  Sleep Med. 2000;  1 195-207
• 23 Drewes A M, Svendsen L, Bjerregard K, Taagholt S J. Sleep in rheumatoid arthritis: a comparison with healthy subjects and studies of sleep/wake interactions.  Br J Rheumatol. 1998;  37 71-81
• 24 Drewes A M, Bjerregard K, Taagholt S J, Svendsen L. Zopiclone as night medication in rheumatoid arthritis.  Scand J Rheumatol. 1998;  27 180-187
• 25 Walsh J K, Muehlbach M J, Lauter S A, Hilliker A, Schweitzer P K. Effects of triazolam on sleep, daytime sleepiness, and morning stiffness in patients with rheumatoid arthritis.  J Rheumatol. 1996;  23 245-252
• 26 Lavie P, Hahir M, Lorder M, Scharf Y. Nonsteroidal antiinflammatory drug therapy in rheumatoid arthritis. Lack of association between clinical improvement and effects on sleep.  Arthritis Rheum. 1991;  34 655-659
• 27 Lavie P, Epstein R, Tzischinsky O, Gilad D. Actigraphic measurements of sleep in rheumatoid arthritis: comparison of patients with low back pain and controls.  J Rheumatol. 1992;  19 362-365
• 28 Hirsch M, Carlander B, Verge M, Tafte M. Objective and subjective sleep disturbances in patients with rheumatoid arthritis. A reappraisal.  Arthritis Rheum. 1994;  37 41-49
• 29 Roehrs T, Carskadon M, Dement W, Roth T. Daytime sleepiness and alertness. In: Kryger MH, Roth T, Dement WC Principles and Practice of Sleep Medicine. 3rd Ed New York; WB Saunders Company 2000: 43-52
• 30 Mahowald M W, Mahowald M L, Bundlie S R, Ytterberg S R. Sleep fragmentation in rheumatoid arthritis.  Arthritis Rheum. 1989;  32 974-983
• 31 Moldofsky H, Scarisbrick P, England R, Smythe H. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects.  Psychosom Med. 1975;  37 341-351
• 32 Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation.  Psychosom Med. 1976;  38 35-44
• 33 Moldofsky H, Lue F A. The relationship of alpha delta EEG frequencies to pain and mood in “fibrositis” patients with chlorpromazine and L-tryptophan.  Electroencephalogr Clin Neurophysiol. 1980;  50 71-80
• 34 Shapiro C M, Devins G M, Hussain M RG. Sleep problems in patients with medical illness.  BMJ. 1993;  306 1532-1535
• 35 Hauri P, Hawkins D. Alpha-delta sleep.  Electroencephalogr Clin Neurophysiol. 1973;  34 233-237
• 36 Moldofsky H, Saskin P, Lue F A. Sleep and symptoms in fibrositis syndrome after a febrile illness.  J Rheumatol. 1988;  15 1701-1704
• 37 Moldofsky H, Lue F A, Smythe H. Alpha EEG sleep and morning symptoms of rheumatoid arthritis.  J Rheumatol. 1983;  10 373-379
• 38 Schaefer K M. Sleep disturbances and fatigue in women with fibromyalgia and chronic fatigue syndrome.  J Obstet Gynecol Neonatal Nurs. 1995;  24 229-233
• 39 Whelton C L, Salit I, Moldofsky H. Sleep, Epstein-Barr virus infection, musculoskeletal pain, and depressive symptoms in chronic fatigue syndrome.  J Rheumatol. 1992;  19 939-943
• 40 Buchwald D S, Pascualy R, Bombardier C. Sleep disorders in patients with chronic fatigue.  Clin Infect Dis. 1994;  18 S68-S72
• 41 Pascualy R, Buchwald D. Chronic fatigue syndrome and fibromyalgia. In: Kryger MH, Roth T, Dement WC Principles and Practice of Sleep Medicine. 3rd Ed Philadelphia; WB Saunders Company 2000: 1040-1049
• 42 American Sleep Disorders Association Atlas Task Force . EEG arousals: scoring rules and examples.  Sleep. 1992;  15 173-184
• 43 Affleck G, Urrows S, Tennen H, Higgins P, Abeles M. Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia.  Pain. 1996;  68 363-368
• 44 Drewes A M, Nielsen K D, Arendt-Nielsen L, Birket-Smith L, Hansen L M. The effect of cutaneous and deep pain on the electroencephalogram during sleep: an experimental study.  Sleep. 1997;  20 632-640
• 45 Lavigne G, Zucconi M, Castronovo C, Manzini C, Marchettine P, Smirne S. Sleep arousal response to experimental thermal stimulation during sleep in human subjects free of pain and sleep problems.  Pain. 2000;  84 283-290
• 46 Lavigne G, Zucconi M, Castronovo C et al.. Heart rate changes during sleep in response to experimental thermal (nociceptive) stimulations in healthy subjects.  Clin Neurophysiol. 2001;  112 532-535
• 47 Bentley A J, Newton S. Zio CD. Sensitivity of sleep stages to painful thermal stimuli.  J Sleep Res. 2003;  12 143-147
• 48 Roehrs T, Merlotti L, Petrucelli N, Stepanski E, Roth T. Experimental sleep fragmentation.  Sleep. 1994;  17 438-443
• 49 Breus M J, O'Conner P J, Ragan S T. Muscle induced by novel eccentric exercise does not disturb the sleep of normal young men.  J Pain. 2000;  1 67-76
• 50 Kleitman N. Sleep and Wakefulness. Chicago; The University of Chicago Press 1939
• 51 Moldofsky H, Scarsbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation.  Psychosom Med. 1976;  38 35-44
• 52 Older S A, Battafarano D F, Danning C L et al.. The effects of delta wave sleep interruption on pain thresholds and fibromyalgia-like symptoms in healthy subjects; correlation with insulin-like growth factor I.  J Rheumatol. 1998;  25 1180-1186
• 53 Lentz M J, Landis C A, Rothermel J, Shaver J LF. Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women.  J Rheumatol. 1999;  26 1586-1592
• 54 Onen S H, Alloui A, Gross A, Eschallier A, Dubray C. The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects.  J Sleep Res. 2001;  10 35-42
• 55 Rosenthal L, Roehrs T A, Rosen A, Roth T. Level of sleepiness and total sleep time following various time in bed conditions.  Sleep. 1993;  16 226-232
• 56 Drake C, Roehrs T, Burduvali E, Bonahoom A, Rosekind M, Roth T. Effects of rapid versus slow accumulation of sleep loss.  Psychophysiology. 2001;  38 979-987
• 57 Roehrs T, Shore E, Papineau K, Rosenthal L, Roth T. A two-week sleep extension in sleepy normals.  Sleep. 1996;  19 576-582
• 58 Roehrs T, Blaisdell B, Greenwald M K, Roth T. Pain threshold and sleep loss.  Sleep. 2003;  265 A196
• 59 Burduvali E, Roehrs T A, Blaisdell B, Fortier J, Roth T. Codeine, pain threshold, and midday sleepiness.  Sleep. 2004;  265 A118
• 60 Monk T. Shift work. In: Kryger MH, Roth T, Dement WC Principles and Practice of Sleep Medicine. 3rd Ed. New York; WB Saunders Company 2000: 600-605
• 61 Basbaum A I, Jessell T M. The perception of pain. In: Kandel ER, Schwartz JH, Jessell TM Principles of Neuroscience. 4th Ed. New York; McGraw-Hill 2000: 472-491
• 62 Melzack R, Wall P D. Pain mechanisms: a new theory.  Science. 1965;  150 971-979
• 63 Saper C B, Chou T C, Scammell T E. The sleep switch: hypothalamic control of sleep and wakefulness.  Trends Neurosci. 2001;  24 726-731
• 64 Benington J H, Kodali S K, Heller H C. Stimulation of A1 adenosine receptors mimics the electroencephalographic effects of sleep deprivation.  Brain Res. 1995;  692 79-85
• 65 Ribeiro J A, Sebastiao A M, deMendonca A. Adenosine receptors in the nervous system: pathophysiological implications.  Prog Neurobiol. 2002;  68 377-392
• 66 Abram S E, O'Connor T C. Characteristics of the analgesic effects and drug interactions of intrathecal carbachol in rats.  Anesthesiology. 1995;  83 844-849
• 67 Klampt J G, Prado W A. Antinociception and behavioral changes induced by carbachol microinjected into identified sites of the rat brain.  Brain Res. 1991;  549 9-18
• 68 Hartvig P, Gillberg P G, Grodh T, Post C. Cholinergic mechanisms in pain and analgesia.  Trends Pharmacol Sci. 1989;  (suppl) S75-S79
• 69 Collins J G. Spinally administered neostigmine: something to celebrate.  Anesthesiology. 1995;  82 327-328
• 70 Sitaram N, Gillin J C. Acetylcholine: possible involvement in sleep and analgesia. In: Davis KL, Berger PA Brain Acetylcholine and Neuropsychiatric Disease. New York; Plenum 1979: 311-343
• 71 Moreton J E, Roehrs T, Khazan N. Drug self-administration and sleep-wake activity in rats dependent on morphine, methadone or 1-alpha-cetyl-methadol.  Psychopharmacology (Berl). 1976;  47 237-241
• 72 Lewis S A, Oswald I, Evans J I, Akindele M O, Tompsett S L. Heroin and human sleep.  Electroencephalogr Clin Neurophysiol. 1970;  28 374-381
• 73 Kay D C. Human sleep during chronic morphine intoxication.  Psychopharmacologia. 1975;  44 117-124
• 74 Kay D C, Pickworth W B, Neidert G L, Falcone D, Fishman P M, Othmer E. Opioid effects on computer derived sleep and EEG parameter in nondependent human addicts.  Sleep. 1979;  2 175-191
• 75 Kakigi R, Watanabe S, Yamasaki H. Pain-related somatosensory evoked potentials.  J Clin Neurophysiol. 2000;  17 295-308
• 76 Qiu Y, Inui K, Wang X, Tran T D, Kakigi R. Effects of attention, distraction and sleep on CO2 laser evoked potentials related to C-fibers in humans.  Clin Neurophysiol. 2002;  113 1579-1585
• 77 Kakigi R, Naka D, Okusa T et al.. Sensory perception during sleep in humans: a magnetoencephalographic study.  Sleep Med. 2003;  4 493-507
• 78 Blackburn-Munro G, Blackburn-Munro R E. Chronic pain, chronic stress and depression: coincidence or consequence?.  J Neuroendocrinol. 2001;  13 1009-1023
• 79 Tsigos C, Chrousos G P. Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress.  J Psychosom Res. 2002;  53 865-871
• 80 Bonnet M, Arand D. Twenty-four hour metabolic rate in insomniacs and matched normal sleepers.  Sleep. 1995;  18 581-588
• 81 Vgontzas A N, Tsigos C, Bixler E O. Chronic insomnia and activity of the stress system: a preliminary study.  J Psychosom Res. 1998;  45 21-31
• 82 Lushington K, Dawson D, Lack L. Core body temperature is elevated during constant wakefulness in elderly poor sleepers.  Sleep. 2000;  23 504-510
• 83 Lichstein K L, Wilson N M, Noe S L, Aguillard R N, Bellur S N. Daytime sleepiness in insomnia: behavioral, biological and subjective indices.  Sleep. 1994;  17 693-702
• 84 Lichstein K L, Johnson R S. Pupillometric discrimination in insomniacs.  Behav Res Ther. 1994;  32 123-129
• 85 Arnold L M, Keck P E, Welge J A. Antidepressant treatment of fibromyalgia.  Psychosomatics. 2000;  41 104-113
• 86 Menefee L A, Cohen M JM, Anderson W R, Doghramji K, Frank E D, Lee H. Sleep disturbance and nonmalignant chronic pain: a comprehensive review of the literature.  Pain Med. 2000;  1 156-172
• 87 Moldofsky H, Lue F, Mously C, Roth-Schecter B, Reynolds W. The effects of zolpidem in patients with fibromyalgia: a dose ranging, double-blind, placebo controlled modified crossover study.  J Rheumatol. 1996;  23 529-533
• 88 Backonja M, Beydoun A, Edwards K R et al.. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus.  JAMA. 1998;  280 1831-1836
• 89 Rice A S, Maton S. Gabapentin in postherpetic neuralgia: a randomized, double-blind, placebo controlled study.  Pain. 2001;  94 215-224