Lack of Sleep Co-Morbidity for Low Back Pain?

Does sleeplessness exacerbate low back pain?

A team of multinational researchers asked that question and looked specifically at the role problematic sleep plays in back pain related healthcare utilization and disability.

Their work, “Does Disordered Sleep Moderate the Relationship Between Pain, Disability and Downstream Health Care Utilization in Patients With Low Back Pain? A Longitudinal Cohort From the US Military Health System,” appears in the November 1, 2019 edition of Spine. 

Co-author Daniel Rhon, D.Sc., director of the Primary Care Musculoskeletal Research Center, explained the genesis of this work to OTW, “A frequent complaint we began to notice was a report of poor or very little sleep by service members when taking their history during consultation for musculoskeletal pain of various types. It seemed especially prevalent in patients with spinal pain.”

“Taking into account the nature of work in this setting (night shifts, austere training environments, deployments across multiple time zones and locations, and even a culture that likely tends to minimize the importance of sleep), it’s not surprising that sleep is poor, but it’s secondary effects on musculoskeletal pain are not always considered.”

Furthermore, said Dr. Rhon, “It is well documented that pain is a subjective experience, especially chronic pain. Sleep has been shown to influence the pain experience (how the brain interprets and ‘experiences’ pain—via modulation or sensitization), and specifically in patients with spinal pain. Because of this, disordered sleep could be contributing to the problem.”

While the role of opioids wasn’t explored in this study, Dr. Rhon did say, “We know that opioids can disrupt sleep, and our prior work has shown a relationship between opioids and sleep disorders. So, you can imagine it starts getting complicated when we have patients taking opioids for pain, and not sleeping well for several reasons (could be opioids, and could be pain limiting sleep, or could be disordered sleep regardless, or combination of all), and we may not be doing our best to consider this interaction.”

Along with co-author, Vincent Mysliwiec, M.D., a former sleep consultant to the Army surgeon general and author of several papers on the problem of sleep in soldiers in general, Rhon and the research team collected data for 757 consecutive participants. One hundred ninety five (26.8%) were diagnosed with a subsequent sleep disorder.

According to the authors, “Sleepiness was not a significant predictor of healthcare utilization.” However, the research team did find that disability, pain intensity, and presence of a sleep disorder were present and that higher disability, pain intensity, and presence of a sleep disorder was clearly associated with higher predicted visits and costs for lower back pain.

Dr. Rhon summarized the team’s findings to OTW, “I think the salient findings from this study were that patients with low back pain [LBP] AND comorbid sleep disorder diagnoses (primarily insomnia and sleep apnea), had much greater back pain related medical utilization (visits and costs).”

“My recommendations:

1. Consider screening for sleep issues both before and after surgery (common tools like the Insomnia Severity Index, the Pittsburg Sleep Quality Index or evening the sleep disturbance measures in PROMIS are all a good start.
2. Evaluate what sleep quality looks like before surgery and also assess after surgery.
3. Come up with plans for managing any potential sleep issues (provide education and self-management tools to patients, consider referrals for the appropriate patients, continuous monitoring and step-up/step-down criteria, etc.). The details of much of this will be site- and setting-specific.”

“Don’t minimize the potential influence of sleep on the pain experience in some of your patients. Increased awareness of sleep problems, and appropriate treatments/referrals, may actually improve the pain-related outcomes for some of your patients. Consider sleep quality both before (pre-op), and regularly after surgical procedures.”