Transcript How do you “learn to live with” chronic pain?

Sleep and Pain
Polly Ashworth
Gloucestershire and Herefordshire Pain Management Service
Gloucestershire Hospitals NHS Foundation Trust
[email protected]
Circadian rhythms in sleepiness
12pm
12noon
4pm
8pm
Circadian rhythms in sleepiness
Postprandial
dip
Conference
dinner
12pm
12noon
4pm
8pm
Overview
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“Normal” sleep and insomnia
Sleep and pain
Non-pharmacological treatments for
insomnia in pain
Other sleep disorders
Implications
“Am I normal?”
Total sleep time
Sleep onset latency – 30 mins
Number/length of awakenings
Sleep efficiency – 85%
Sleep and ageing
Adult
7-7½ hours
Older adult
6-6½ hours
Misperceptions of sleep
Poor sleepers
underestimate their sleep
Retrospective estimates
skewed by salience of
“bad nights”
Definition of Insomnia
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More than 30 minutes awake at night
3+ nights a week
6+ months duration
Distress or daytime impairment
Non complaining short sleeper
Consequences of Insomnia
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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
Links between sleep and pain
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Insomnia common in pain patients - 50%+
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Daily interaction
– more pain in day means less sleep that night
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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
Links between sleep and
pain
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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
Patients’ perspective
How important is sleep to
our patients?
1.
Walking or moving about
9.
Other
2.
Pain relief
10. Medication
3.
Disturbed sleep
11. Work
4.
Lack of fitness and energy
12. Relationships
5.
Managing mood
13. Sex
6.
Unhelpful pacing
14. Financial
7.
Understanding pain
15. Current
8.
Balance or falls
16. Concerns
side effects
issues
life
legal claim
about your partner
Health Needs Assessment – Frances Cole
Patients’ experience of
sleep and pain
“It’s my pain that
wakes me up”
“I just can’t get
comfortable”
Pain
“Unless my pain
improves
I’ll never get a
decent night’s sleep”
Sleep disturbance
Sleep in pain patients
Sleep amongst pain patients.
Survey data
Sleep efficiency
68%
Total sleep time
6 hours
Total time in bed
9 hours
Objective measures
Naughton, Ashworth, Davidson 07
Longer sleep onset latency
Shorter total sleep time
More, and longer, awakenings
Comparing good and poor
sleepers amongst pain patients
70
60
n.s.
**
**
**
50
**
**
40
30
20
10
0
Daytime pain Pain at night
Depression
Good Sleepers
Anxiety
Disability
Poor Sleepers
Beliefs about
sleep
** p<0.001
Ashworth, Davidson, Espie (in press)
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)
Pain and Sleep
Pain
Sleep disturbance
CBT Model of Insomnia
Bad sleep
habits
Emotional and
Physiological
Arousal
Sleep
disturbance
Consequences
Unhelpful beliefs
and thinking
How can we help?
Common approaches to
sleep problems in pain
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Nothing
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Sleep hygiene advice
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Sedating anti-depressants (eg Amitriptyline)
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Anti-convulsant therapies (eg Gabapentin)
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Hypnotics - sleeping tablets (e.g. Temazepam)
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Anxiolytics – (e.g. Diazepam)
CBT for insomnia
– what is it?
– does it work if you have pain?
CBT for insomnia (CBT-I)
Education
Relaxation
Sleep hygiene
Sleep scheduling
– strengthening bed/sleep connection
– restricting time in bed
Thought challenging
Education
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What is “normal” sleep?
How much sleep do you need?
Will insomnia harm you?
How do you know how well you are
sleeping?
Sleep hygiene
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Coffee
Cigarettes
Alcohol
Eating
Exercise
Bedroom Noise/
Temperature/Light
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Alarm clock
Mobile Phone
Sleep scheduling 1
Strengthen the bed/sleep connection
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Don’t spend time in bed watching TV, eating etc
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Wind down routine (90 minutes)
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Go to bed at night only when you are sleepy
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If you are not asleep after 20 minutes get up
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Get up at the same time each morning
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Avoid naps if you can
Sleep scheduling 2
Restricting time in bed
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Find out average sleep time from sleep diary
Agree a sleep “window” of this average length (but
not less than 6-7 hours)
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Anchor sleep around regular get up time
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Threshold time set for going to bed
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When sleep efficiency reaches 90%
sleep window increased by 15 mins
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
Cognitive therapy
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Challenging dysfunctional beliefs and
thoughts about sleep
Techniques for “racing mind”
Imagery relaxation
Putting the day to rest
Give up trying
3 key messages
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Reduce time in bed
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If you can’t sleep, get up
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Don’t lose sleep over losing sleep
Does CBT improve sleep even if
you have pain?
Do PMP’s improve sleep?
Pain Depression
Pigeon
Seville &
Flood
2003
(n=65)
Ashworth
Burke &
McCracken
2008
(n=42)
✓
✓
✓
✓
Anxiety
Sleep
✓
Pain interferes
with sleep
✗
Restless sleep
✗
✓
Sleep quality
✓(?)
Sleep beliefs
✗
………….probably not
Does CBT-I work for insomnia if
you have pain?
Currie et al (2000)
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N=60 Benign pain of musculoskeletal origin, but
not fibromyalgia, and insomnia
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Already treated in pain service
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7 x 2½ hour group sessions CBT-I
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Baseline sleep efficiency 70%, TST 6h
Currie et al (2000)
Sleep Quality
16
12
PSQI
*
8
4
0
WLC
CBT
Baseline
post treatment
3m follow up
Currie et al (2000)
Pain
10
7.5
MPI-Pain
Severity
5
2.5
0
CBT
Baseline
WLC
Post treatment
3m Follow up
Does CBT-I work for insomnia if
you have pain?
Edinger et al (2005)
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n=47 Fibromyalgia and insomnia
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Recruited by newspaper advert
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Randomised to CBT, Sleep Hygiene, WLC
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6 sessions delivered 1:1
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Baseline sleep efficiency 80%, TST 7h
Edinger et al (2005)
Insomnia Symptoms
60
*
*
CBT
SH
Insomnia 40
Symptom
Questionnaire
20
0
Baseline
Post treatment
WLC
6m follow up
Edinger et al (2005)
Pain
40
30
McGill
20
Pain Q’re
10
0
CBT
Baseline
SH
Post treatment
WLC
6m Follow up
…but we can’t do that….
Glasgow Sleep Clinic Model
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5 x 50min weekly sessions
Group of 6
Nurse trained in 2 days
Manualised programme
Effectiveness demonstrated in
 primary insomnia
 cancer and insomnia
Espie et al 07
Espie et al 08
Espie et al (2007) – Primary Insomnia
Sleep Quality
16
12
PSQI
*
8
4
0
CBT
Baseline
TAU
Post treatment
6m Follow up
Other sleep disorders
Sleep apnoea
Features
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Excessive daytime
sleepiness
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Impaired concentration
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Snoring (but not always)
Links: FMS?
Opiate use
(75% vs 3% gen pop)
Sleep Apnoea
•
Sleep on your side
•
Avoid alcohol
•
Lose weight
•
Medication review
•
Continuous Positive Airway Pressure
Machine (CPAP)
Restless legs
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Uncomfortable sensation and urge to move legs
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Worse with rest
Immediate and complete relief on movement
Worse in evening/early night
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More common in people with pain
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(33% FMS vs 3%, Watson et al 08)
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May be exacerbated by pain, poor sleep, some
medications, or low iron
Restless Legs
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Check iron levels
Review medication
General sleep hygiene, exercise, hot
bath
Pharmacological therapies
Conclusions
Conclusions
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Sleep disturbance is important
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It’s not just caused by the pain
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Cognitive therapy for insomnia works,
even if you have pain too
Watch out for other sleep disorders
Implications
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
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
www.aasm.org
Useful materials
Colin Espie
(2006)
Ree & Harvey (2004)
Insomnia
Overcoming
insomnia and
sleep problems
in Bennett-Levy et al
Morin & Espie
(2003)
Perlis et al
(2006)
Insomnia
A Clinicians Guide
to Assessment and
Treatment
Oxford Guide to
Behavioural
Experiments in CT
CBT of
Insomnia
[email protected]
Don’t we do this on PMP already?
CBT-I
CBT pain
Education
Relaxation
Sleep hygiene
Bed/sleep connection
Restricting time in bed
Focus on sleep
Focus on pain
✓
✓
✓
✓
✓
✓
✓
✗
Thought challenge
Focus on sleep
Focus on pain
All
A bit
Time spent on sleep