Background & Aims
Over half of individuals with shoulder and other upper extremity conditions requiring surgery experience insufficient and poor sleep. While the bidirectional nature of sleep and pain is well-known, sleep characteristics may serve as better predictors of pain outcomes than pain intensity is of sleep outcomes, specifically after surgery. Research shows the utility of pain trajectories for predicting the development of chronic post-surgical pain, yet there is a dearth of research examining how changes in postoperative sleep to post-surgical pain outcomes. One pathway through which poor sleep may contribute to chronic pain is increased systemic inflammation. Shortened sleep and increased sleep disturbances induce an outsized inflammatory reaction. This study aimed to discern the association between postoperative sleep presentations and inflammation on longitudinal postoperative pain outcomes following orthopedic surgery.
Methods
This prospective study recruited 42 patients undergoing upper extremity arthroplasty or arthroscopic procedures from a large medical center in the Southeastern US. Adult patients without a history of sleep apnea, insomnia, not taking opioid or steroidal medications in the past 30-days, with no history of widespread chronic pain or inflammatory disease, and not undergoing a revision procedure were eligible. Participants completed surveys, including past 24-hour average pain intensity on the pain Numeric Rating Scale and both PROMIS Sleep Disturbance and Pain Interference, and provided blood samples 2-weeks before surgery and at 2-, 6-, 12-, and 24-weeks after. Linear mixed effects models estimated postoperative pain outcomes based on changes in PROMIS Sleep Disturbance scores and change in cytokine levels. No differences in demographic or clinical characteristics were noted between participants based on surgery type nor surgical site.
Results
The sample was mostly female (73%) and 62 years old on average (±11). Most participants identified as white (71%) or Black/African American (27%). Half of participants underwent arthroplasty (52%) or arthroscopic procedures (48%) for their shoulder (79%) or elbow (21%). Changes in PROMIS Sleep Disturbance t-score predicted changes in postoperative average pain when accounting for surgery type, changes in cytokines and related receptors, specifically IL-6 and TNF, and preoperative sleep and pain scores. A clinically meaningful increase in PROMIS Sleep Disturbance (10-point) was linked to a 1-point increase in postoperative average pain (?=0.10;95% Confidence Interval:0.06-0.15;p<.01). Increases in plasma levels of cytokine receptors for IL-6 (?=0.001;p=0.021) and TNF (?=0.001;p=0.021) predicted increased postoperative average pain. Similar trends were observed in models predicting PROMIS Pain Interference with the same covariates. The sleep-pain relationship did not vary over time.
Conclusions
Postoperative pain intensity and pain interference were predicted by changes in postoperative sleep disturbances, independent of changes in inflammatory makers, out to 6-months following orthopedic surgery in this sample. These hypothesis generating results underscore the utility of implementing interventions capable of optimizing postoperative sleep to reduce pain intensity and interference following orthopedic surgery for upper extremities. This study’s longitudinal nature, use of repeated measures, and ability to account for potential mechanistic pathways that may drive the relationship between sleep disruption and pain (inflammatory markers), builds upon previous research limited to cross-sectional designs and patient-reported outcomes alone. Given their frequent co-occurrence, future longitudinal research with larger diverse samples undergoing orthopedic surgery is warranted to examine the mechanistic pathways between poor sleep and the development of chronic postoperative pain.
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Presenting Author
Nicholas A. Giordano
Poster Authors
Nicholas Giordano
PhD, RN, FAAN
Emory University
Lead Author
Katherine Yeager
PhD
Emory University
Lead Author
Eric Wagner
MD
Emory University
Lead Author
Michael B. Gottschalk
MD
Emory University
Lead Author
Donald Bliwise
PhD
Emory University
Lead Author
Sudeshna Paul
Phd
Emory University
Lead Author
Kim Dupree Jones
Emory University
Lead Author
Andrew H. Miller
MD
Emory University
Lead Author
Topics
- Models: Transition to Chronic Pain