Background Waking feeling unrefreshed is associated with poor health outcomes including an increased risk of cardiovascular death. Pain is a robust predictor of waking feeling unrefreshed. Pain is a complex disorder and it is not clear whether the pain itself, or associated somatic symptoms, mental health conditions and lifestyle factors, predicts waking unrefreshed.
Objectives To investigate whether reporting pain was an independent predictor of waking unrefreshed among people with musculoskeletal pain.
Methods Participants in a population study completed the Estimation of Sleep Problems Scale (ESPS), which indicates the number of days in the past month participants have experienced unrefreshing sleep, problems with sleep onset, maintenance and night awakenings. Pain assessments (body map and duration >3 months) were used to classify participants as having no pain, acute pain, chronic pain and CWP (ACR criteria: pain lasting ≥3 months in the axial skeleton and contralateral body quadrants). Participants also reported demographics (date of birth, sex, English Index of Multiple Deprivation); somatic symptoms (Chalder Fatigue Scale (CFQ 11) and Inflammatory Bowel Syndrome (IBS)); mental health (Hospital Anxiety and Depression (HAD) scale); disability (Stanford Health Assessment Questionnaire (HAQ)) and lifestyle factors (average number of alcoholic drinks per week, smoking status and Rapid Assessment of Physical Activity (RAPA)). Univariable ordinal logistic regression tested the relationship between pain and waking unrefreshed. The model was then cumulatively adjusted for sleep, somatic symptoms, mental health, disability and lifestyle domains. All models were age, sex and deprivation adjusted. The results of a complete case analysis were comparable to those which used multiple imputation for missing data and the results of the complete case analyses are shown. Results were expressed as odds ratios (OR) with 95% confidence intervals (CI).
Results Of 1913 people who had complete data, 1376 (72%) woke unrefreshed on at least one day in the past month (41% 1–7 days; 31% ≥8 days). Compared to those with no pain, people with acute pain and chronic pain were two (OR 2.0, 95% CI (1.5–2.6) and 2.2 (1.9–2.7), respectively) times more likely to wake unrefreshed; those with CWP were five (5.0 (4.0–6.3)), times more likely to wake unrefreshed. Following adjustment for all other variables, the relationship between reporting chronic pain (1.5 (1.2–1.8)) or CWP (1.9 (1.4–1.5)) and waking unrefreshed was attenuated, but remained statistically significant. The reporting of acute pain was not an independent predictor of waking unrefreshed (1.4 (0.98–1.9)). Problems with sleep onset (≥8 days vs 0: 2.9 (2.0–4.1)) and maintenance (≥8 days vs 0: 5.9 (4.1–8.4)), night awakenings (≥8 days vs 0: 2.5 (1.7–3.7)), IBS (2.2 (1.2–4.0)), currently smoking (vs never: 1.5 (1.02–2.1)) and engagement in activities such as stretching and yoga (vs none: 0.8 (0.6–0.97)), physical (1.3 (1.2–1.3)) but not mental (0.99 (0.9–1.1)) fatigue, and anxiety (definite vs no: 2.4 (1.8–3.1)), but not depression (definite vs no: 1.5 (0.8–2.6)), were associated with waking unrefreshed.
Conclusions This study suggests that among people with chronic pain, the risk of waking feeling unrefreshed may be reduced through interventions that target factors such as smoking cessation, IBS management, physical fatigue and anxiety.
Acknowledgements J. Anderson, M. Mulvey, A. Rashid
Disclosure of Interest None declared