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

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Presentation on theme: "Sleep and Pain Polly Ashworth Gloucestershire and Herefordshire Pain Management Service Gloucestershire Hospitals NHS Foundation Trust"— 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 Conference dinner Postprandial dip

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

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

6 Sleep and ageing Older adult 6-6 ½ hours Adult 7-7½ 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 More than 30 minutes awake at night 3+ nights a week 3+ nights a week 6+ months duration 6+ months duration Distress or daytime impairment Distress or daytime impairment Non complaining short sleeper

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

10 Links between sleep and pain Insomnia common in pain patients - 50%+ Insomnia common in pain patients - 50%+ Daily interaction – more pain in day means less sleep that night Daily interaction – more pain in day means less sleep that night Sleep deprivation – reduces pain thresholds – induces pain in healthy 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 Good sleep reduces impact of pain variations on mood Good sleep reduces impact of pain variations on mood Sleep parameters predict severity / persistence of chronic pain Sleep parameters predict severity / persistence of chronic pain Other sleep disorders more prevalent in pain populations 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 Links between sleep and pain

12 Patients’ perspective

13 How important is sleep to our patients? 1. Walking or moving about 2. Pain relief 3. Disturbed sleep 4. Lack of fitness and energy 5. Managing mood 6. Unhelpful pacing 7. Understanding pain 8. Balance or falls 9. Other 10. Medication side effects 11. Work issues 12. Relationships 13. Sex life 14. Financial 15. Current legal claim 16. Concerns about your partner Health Needs Assessment – Frances Cole

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

15 Sleep in pain patients

16 Sleep amongst pain patients. Survey data Sleep efficiency68% Total sleep time6 hours Total time in bed9 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 βtR2R2 Adjusted R 2 F Pain at night *** *** Beliefs about sleep *** Depression ** Disability Daytime pain Age Pain related anxiety Ashworth, Davidson, Espie (in press)

19 Pain Sleep disturbance Pain and Sleep

20 CBT Model of Insomnia Sleep disturbance 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 Nothing Sleep hygiene advice Sleep hygiene advice Sedating anti-depressants (eg Amitriptyline) Sedating anti-depressants (eg Amitriptyline) Anti-convulsant therapies (eg Gabapentin) Anti-convulsant therapies (eg Gabapentin) Hypnotics - sleeping tablets (e.g. Temazepam) Hypnotics - sleeping tablets (e.g. Temazepam) Anxiolytics – (e.g. Diazepam) Anxiolytics – (e.g. Diazepam)

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

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

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

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

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

29 Sleep scheduling 2 Restricting time in bed Find out average sleep time from sleep diary Find out average sleep time from sleep diary Agree a sleep “window” of this average length (but not less than 6-7 hours) Agree a sleep “window” of this average length (but not less than 6-7 hours) Anchor sleep around regular get up time Anchor sleep around regular get up time Threshold time set for going to bed Threshold time set for going to bed When sleep efficiency reaches 90% sleep window increased by 15 mins 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 Challenging dysfunctional beliefs and thoughts about sleep Techniques for “racing mind” Techniques for “racing mind” Imagery relaxation Imagery relaxation Putting the day to rest Putting the day to rest Give up trying Give up trying

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

33 Does CBT improve sleep even if you have pain?

34 Do PMP’s improve sleep? PainDepressionAnxietySleep 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 N=60 Benign pain of musculoskeletal origin, but not fibromyalgia, and insomnia Already treated in pain service Already treated in pain service 7 x 2½ hour group sessions CBT-I 7 x 2½ hour group sessions CBT-I Baseline sleep efficiency 70%, TST 6h 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 n=47 Fibromyalgia and insomnia Recruited by newspaper advert Recruited by newspaper advert Randomised to CBT, Sleep Hygiene, WLC Randomised to CBT, Sleep Hygiene, WLC 6 sessions delivered 1:1 6 sessions delivered 1:1 Baseline sleep efficiency 80%, TST 7h 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 5 x 50min weekly sessions Group of 6 Group of 6 Nurse trained in 2 days Nurse trained in 2 days Manualised programme Manualised programme Effectiveness demonstrated in primary insomnia Espie et al 07 primary insomnia Espie et al 07 cancer and insomnia Espie et al 08 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 Excessive daytime sleepiness Impaired concentration Impaired concentration Snoring (but not always) Snoring (but not always) Links: FMS? Opiate use Opiate use (75% vs 3% gen pop) (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 Uncomfortable sensation and urge to move legs Uncomfortable sensation and urge to move legs Worse with rest Worse with rest Immediate and complete relief on movement Immediate and complete relief on movement Worse in evening/early night Worse in evening/early night More common in people with pain 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 May be exacerbated by pain, poor sleep, some medications, or low iron

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

49 Conclusions

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

51 Implications

52 What can you do next week? 1. Don’t give up on asking about sleep 2. Add to your sleep hygiene advice 3. Recommend CBT-I to people with insomnia and pain 4. 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

55

56

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


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