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Sleep and Pain Polly Ashworth

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Presentation on theme: "Sleep and Pain Polly Ashworth"— Presentation transcript:

1 Sleep and Pain Polly Ashworth
Gloucestershire and Herefordshire Pain Management Service Gloucestershire Hospitals NHS Foundation Trust

2 Circadian rhythms in sleepiness

3 Circadian rhythms in sleepiness
Postprandial dip Conference dinner

4 Overview “Normal” sleep and insomnia Sleep and pain
Non-pharmacological treatments for insomnia in pain Other sleep disorders Implications

5 “Am I normal?” Total sleep time Sleep onset latency – 30 mins
Number/length of awakenings Sleep efficiency – 85%

6 Sleep and ageing Adult 7-7½ hours Older adult 6-6½ hours

7 Misperceptions of sleep
Poor sleepers underestimate their sleep Retrospective estimates skewed by salience of “bad nights”

8 Definition of Insomnia
More than 30 minutes awake at night 3+ nights a week 6+ months duration Distress or daytime impairment Non complaining short sleeper

9 Consequences of Insomnia
Concentration and memory Risk of depression, anxiety, substance misuse Risk of accidents Health care use Work absenteeism Roth & Ancoli-Israel 1999 Ancoli-Israel & Roth 1999 Ohayon 1997

10 Links between sleep and pain
Insomnia common in pain patients - 50%+ Daily interaction – more pain in day means less sleep that night Sleep deprivation – reduces pain thresholds – induces pain in healthy Tang et al 07 Affleck et al 96 Moldofsky et al 76 Lautenbacher et al 06

11 Links between sleep and pain
Good sleep reduces impact of pain variations on mood Sleep parameters predict severity / persistence of chronic pain Other sleep disorders more prevalent in pain populations Hamilton et al 07 Smith et al 08, Davies et al 08 Watson et al 08, Walker et al 07, Webster et al 08

12 Patients’ perspective

13 How important is sleep to our patients?
Walking or moving about Pain relief Disturbed sleep Lack of fitness and energy Managing mood Unhelpful pacing Understanding pain Balance or falls Other Medication side effects Work issues Relationships Sex life Financial Current legal claim Concerns about your partner Health Needs Assessment – Frances Cole

14 Pain Sleep disturbance Patients’ experience of sleep and pain
“I just can’t get comfortable” Patients’ experience of sleep and pain “It’s my pain that wakes me up” Pain Sleep disturbance “Unless my pain improves I’ll never get a decent night’s sleep”

15 Sleep in pain patients

16 Sleep amongst pain patients.
Survey data Sleep efficiency 68% Total sleep time 6 hours Total time in bed 9 hours Objective measures Longer sleep onset latency Shorter total sleep time More, and longer, awakenings Naughton, Ashworth, Davidson 07

17 Comparing good and poor sleepers amongst pain patients
n.s. Ashworth, Davidson, Espie (in press)

18 Factors linked with poor sleep in chronic pain patients
β t R2 Adjusted R2 F Pain at night .42 5.22*** .51 .49 20.89*** Beliefs about sleep .27 3.73*** Depression .23 2.69** Disability .04 0.56 Daytime pain .03 0.38 Age .02 0.35 Pain related anxiety -.01 -0.16 Ashworth, Davidson, Espie (in press)

19 Pain and Sleep Pain Sleep disturbance

20 CBT Model of Insomnia Sleep disturbance Bad sleep habits
Emotional and Physiological Arousal Unhelpful beliefs and thinking Bad sleep habits Consequences

21

22 How can we help?

23 Common approaches to sleep problems in pain
Nothing Sleep hygiene advice Sedating anti-depressants (eg Amitriptyline) Anti-convulsant therapies (eg Gabapentin) Hypnotics - sleeping tablets (e.g. Temazepam) Anxiolytics – (e.g. Diazepam)

24 CBT for insomnia – what is it? – does it work if you have pain?

25 CBT for insomnia (CBT-I)
Education Relaxation Sleep hygiene Sleep scheduling – strengthening bed/sleep connection – restricting time in bed Thought challenging

26 Education What is “normal” sleep? How much sleep do you need?
Will insomnia harm you? How do you know how well you are sleeping?

27 Sleep hygiene Coffee Cigarettes Alcohol Eating Exercise
Bedroom Noise/ Temperature/Light Alarm clock Mobile Phone

28 Sleep scheduling 1 Strengthen the bed/sleep connection
Don’t spend time in bed watching TV, eating etc Wind down routine (90 minutes) Go to bed at night only when you are sleepy If you are not asleep after 20 minutes get up Get up at the same time each morning Avoid naps if you can

29 Sleep scheduling 2 Restricting time in bed
Find out average sleep time from sleep diary Agree a sleep “window” of this average length (but not less than 6-7 hours) Anchor sleep around regular get up time Threshold time set for going to bed When sleep efficiency reaches 90% sleep window increased by 15 mins

30 Sleep scheduling example
Average sleep time = 7 hours …but time in bed = 10.5 hours Set sleep window = 7 hours Anchor get up time at 7am Threshold for going to bed = midnight

31 Cognitive therapy Challenging dysfunctional beliefs and thoughts about sleep Techniques for “racing mind” Imagery relaxation Putting the day to rest Give up trying

32 3 key messages Reduce time in bed If you can’t sleep, get up
Don’t lose sleep over losing sleep

33 Does CBT improve sleep even if you have pain?

34 Pain interferes with sleep
Do PMP’s improve sleep? Pain Depression Anxiety Sleep Pigeon Seville & Flood 2003 (n=65) Pain interferes with sleep Restless sleep Ashworth Burke & McCracken 2008 (n=42) Sleep quality ✓(?) Sleep beliefs ………….probably not

35 Does CBT-I work for insomnia if you have pain?
Currie et al (2000) N=60 Benign pain of musculoskeletal origin, but not fibromyalgia, and insomnia Already treated in pain service 7 x 2½ hour group sessions CBT-I Baseline sleep efficiency 70%, TST 6h

36 Currie et al (2000) * PSQI

37 Currie et al (2000) MPI-Pain Severity

38 Does CBT-I work for insomnia if you have pain?
Edinger et al (2005) n=47 Fibromyalgia and insomnia Recruited by newspaper advert Randomised to CBT, Sleep Hygiene, WLC 6 sessions delivered 1:1 Baseline sleep efficiency 80%, TST 7h

39 Edinger et al (2005) * * Insomnia Symptom Questionnaire

40 Edinger et al (2005) McGill Pain Q’re

41 …but we can’t do that….

42 Glasgow Sleep Clinic Model
5 x 50min weekly sessions Group of 6 Nurse trained in 2 days Manualised programme Effectiveness demonstrated in primary insomnia Espie et al 07 cancer and insomnia Espie et al 08

43 Espie et al (2007) – Primary Insomnia
* PSQI

44 Other sleep disorders

45 Sleep apnoea Features Excessive daytime sleepiness
Impaired concentration Snoring (but not always) Links: FMS? Opiate use (75% vs 3% gen pop)

46 Sleep Apnoea Sleep on your side Avoid alcohol Lose weight
Medication review Continuous Positive Airway Pressure Machine (CPAP)

47 Restless legs Worse with rest
Uncomfortable sensation and urge to move legs Worse with rest Immediate and complete relief on movement Worse in evening/early night More common in people with pain (33% FMS vs 3%, Watson et al 08) May be exacerbated by pain, poor sleep, some medications, or low iron

48 Restless Legs Check iron levels Review medication
General sleep hygiene, exercise, hot bath Pharmacological therapies

49 Conclusions

50 Conclusions Sleep disturbance is important
It’s not just caused by the pain Cognitive therapy for insomnia works, even if you have pain too Watch out for other sleep disorders

51 Implications

52 What can you do next week?
Don’t give up on asking about sleep Add to your sleep hygiene advice Recommend CBT-I to people with insomnia and pain Look for other sleep disorders as well as insomnia

53 Useful materials Measures: Pittsburgh Sleep Quality Index
Insomnia Symptom Questionnaire Dysfunctional Beliefs About Sleep Scale Epworth Sleepiness Scale Guidelines and patient information leaflets: American Academy of Sleep Medicine

54 Useful materials Ree & Harvey (2004) Insomnia
in Bennett-Levy et al Oxford Guide to Behavioural Experiments in CT Colin Espie (2006) Overcoming insomnia and sleep problems Morin & Espie (2003) Insomnia A Clinicians Guide to Assessment and Treatment Perlis et al (2006) CBT of Insomnia

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57 Don’t we do this on PMP already?
CBT-I CBT pain Education Focus on sleep Focus on pain Relaxation Sleep hygiene Bed/sleep connection Restricting time in bed Thought challenge Time spent on sleep All A bit


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