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- Issue 65
- Effects of non-pharmacological interventions on sleep…
Effects of non-pharmacological interventions on sleep in chronic low back pain: a systematic review and meta-analysis of randomised controlled trials
Key Points
- Decreased sleep and increased pain is a common clinical presentation.
- Interventions addressing pain do not necessarily improve sleep.
BACKGROUND & OBJECTIVE
Low back pain is the leading cause of disability worldwide and will impact as much as 80% of the worldwide population. People with chronic low back pain (CLBP) frequently experience sleep impairments, such as poor sleep quality, difficulties falling asleep, and reduced sleep satisfaction.
This systematic review aimed to consolidate the evidence on the effects of different types of non-pharmacological interventions on sleep, specifically in adults with CLBP, and the concurrent impact on pain intensity and back-related disability.
It is important to understand that pain and sleep are related and that if a person is not sleeping well, interventions for pain may seem less effective.
METHODS
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This review included peer-reviewed journal articles published in English only.
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The search consisted of six electronic databases, using search terms such as “back pain,” “sleep” and “systematic review.”
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Articles that included subjects >18 years old with CLBP, defined as pain between the lower ribs and buttock creases, were eligible for inclusion. Any non-pharmacologic intervention, such as exercise, cognitive behavioral therapy, or massage to improve sleep could be included compared to other interventions, such as placebo treatment, no treatment (true control), waitlist control (delayed treatment), attention control, or usual care. Studies needed to include primary outcomes of sleep, in addition to secondary outcomes of pain intensity and back-related disability to be included. Finally, only parallel and crossover RCTs were included in the systematic review.
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Ultimately 19 studies were included in the systematic review, and 13 studies were included in the meta-analysis.
RESULTS
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The non-pharmacological pain interventions had a small effect on improving sleep and reducing sleep disturbance (however, this wasn’t clinically meaningful), which was associated with a medium effect on reducing pain intensity.
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The interventions included acupuncture, education, electrophysical therapy, exercise training, external lumbar support, massage, and psychological interventions. The variability of the interventions may have resulted in inconsistencies in the effects across studies.
LIMITATIONS
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The low to very low quality of evidence of the included studies due to risk of bias, imprecision and inconsistency in results limits the confidence of these results.
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The outcome measures used, especially for sleep quality, lacked specificity and validity.
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There were no eligible studies investigating interventions other than those designed to treat low back pain primarily.
CLINICAL IMPLICATIONS
Pain and sleep are intertwined, with people experiencing chronic pain often reporting sleep disturbance of some sort. While clinically, this presentation is not unusual, the direction of its relationship and the mechanisms underlying it are not yet completely understood (1).
For example, both pain and lack of quality sleep can have a negative effect on mood, cognitive abilities and motivation (1).
Even without knowing the directionality of the pain-sleep relationship, it may be possible to predict some improvement in pain following a cognitive behavioral intervention directed at addressing insomnia (2). While there was an improvement in both pain and sleep following the intervention, it is still not possible to draw a causal conclusion that improved sleep will improve pain. Another recent study found that participants who reported better sleep also reported lower pain the following day (3). While this sounds promising, there is still no strong causal relationship between improved sleep and less pain.
It is important to understand that pain and sleep are related and that if a person is not sleeping well, interventions for pain may seem less effective. As future research will demystify the relationship between pain and sleep, it is reasonable at this time to make sure both issues are adequately addressed to maximize outcomes.
+STUDY REFERENCE
SUPPORTING REFERENCE
- Herrero Babiloni, A, De Koninck, BP, Beetz, G, De Beaumont, L, Martel, MO & Lavigne, GJ 2019, ‘Sleep and pain: recent insights, mechanisms, and future directions in the investigation of this relationship’, Journal of Neural Transmission, vol. 127, no. 4, pp. 647–660.
- Smith, MT, Finan, PH, Buenaver, LF, Robinson, M, Haque, U, Quain, A, McInrue, E, Han, D, Leoutsakis, J & Haythornthwaite, JA 2015, ‘Cognitive-Behavioral Therapy for Insomnia in Knee Osteoarthritis: A Randomized, Double-Blind, Active Placebo-Controlled Clinical Trial’, Arthritis & Rheumatology, vol. 67, no. 5, pp. 1221–1233.
- O’Hagan, ET, Cashin, AG, Hübscher, M, Mohammad alsaadi, S, Gustin, S & McAuley, JH 2023, ‘Does poor sleep quality lead to increased low back pain the following day?’, Scandinavian Journal of Pain, vol. 0, no. 0.
- Staffe, AT, Bech, MW, Clemmensen, SLK, Nielsen, HT, Larsen, DB & Petersen, KK 2019, ‘Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants’, in G Biagini (ed.), PLOS ONE, vol. 14, no. 12, p. e0225849.