Pain & Insomnia or Insomnia & Pain - treating which gives the best bang for our buck?

Does this sounds a bit like the chicken and egg story with a medical twist? 


A growing hot topic in the past 20 years is the association between sleep and pain; one way, bi-directional, one-way dominant? While some researchers have suggested a reciprocal relationship, others have proposed that pain could be worsened by sleep disturbance [1,2]. Recently, growing evidence has suggested that sleep disturbance predicts the onset or aggravation of pain [1,3], even in healthy individuals, regardless of age (teenager, young adult and adult). Researchers conducting a 2021 systematic review found that self-reported poor sleep quality on the prior night predicted increased lumbar pain intensity, whereas changes in spinal pain intensity on the previous day were not significantly related to the sleep quality on the subsequent night [3,4]. Findings from cohort studies note that baseline self-reported sleep disturbances predicted the onset of chronic pain in healthy individuals or pain aggravation in patients with chronic pain at follow-ups [5-7]. These findings highlight the importance of improving sleep to prevent or alleviate pain [8].

 Abstract 1

The differential effects of sleep deprivation on pain perception in individuals with or without chronic pain: A systematic review and meta-analysis

This systematic review (up to June 2022) examines and updates our knowledge from a 2014 paper, and examines the effects of different types of sleep deprivation (i.e., total, partial, selective and fragmented) on the experience of pain for people with and without chronic pain.

Cut to the Chase Summary

Clinically we are seeing clients with different forms of insomnia (i.e., sleep onset, sleep maintenance, early waking, fragmented) which is mimicked in research protocols as the various forms of sleep deprivation (SD) noted above. Due to the wide range of types of sleep deprivation protocols used in research, the conclusions were mixed; very limited to moderate evidence supporting the significant effects of total/partial SD or sleep fragmentation on increasing spontaneous pain intensity, peripheral sensitisation, or central sensitisation in healthy individuals and very limited evidence that total/partial SD significantly increased spontaneous pain intensity in people with chronic pain.

The researchers had two home messages;

  1. Sleep loss leads to increased pain perception in people with and without chronic pain. As sleep is a modifiable factor, improving sleep has potential clinical implications for pain management in individuals with concurrent sleep disturbance and chronic pain.
  2. Combined treatments for sleep and pain may be used to address the potential negative effects of sleep loss on both ascending and descending pain pathways.

Abstract 2 

Comparison of the effectiveness of cognitive behavioural therapy for insomnia, cognitive behavioural therapy for pain, and hybrid cognitive behavioural therapy for insomnia and pain in individuals with comorbid insomnia and chronic pain: A systematic review and network meta-analysis

This 2022 systematic review and analysis goes to the heart of our chicken and egg story. What first-line approach is most beneficial for clients with chronic pain; addressing their pain or addressing their insomnia?

Cut to the Chase Summary

Those treated with CBT-Insomnia were significantly improved compared with the control group for pain, disability, and depression at post-treatment at follow-up (3-12 months). However, there were no significant differences in effectiveness between CBT-Pain and the control for any outcomes. Thus, CBT-Insomnia might be the most effective treatment option for individuals with co-morbid insomnia and chronic pain. Note however, given the small sample sizes and high risk of bias of the included studies, these results must be interpreted with caution.

Take Home Clinical Consideration

Like all research we need larger numbers, with more target interventions over long periods of time, however, it would seem that there is now a solid trend when managing those clients with short or fragmented sleep patterns when you are treating or preventing pain. It is now fundamental to ask clients about their sleep patterns as part of your screening questions and to address any primary or secondary causes of insomnia, because the weight of current research evidence now indicates that it will influence your treatment outcomes.


[1] Andersen M, Araujo P, Frange C, Tufik S. Sleep disturbance and pain: A Tale of two common problems. Chest 2018;154(5):1249e59.

[2] Pinto SM, Cheung JP, Samartzis D, Karppinen J, Zheng Y-p, Pang MY, et al. Are morphometric and biomechanical characteristics of lumbar Multifidus related to pain intensity or disability in people with chronic low back pain after considering psychological factors or insomnia? Front Psychiatr 2022:in press.

[3] Van Looveren E, Bilterys T, Munneke W, Cagnie B, Ickmans K, Mairesse O, et al. The association between sleep and chronic spinal pain: A systematic review from the last decade. J Clin Med 2021;10(17):3836.

[4] Gerhart J, Burns J, Post K, Smith D, Porter L, Burgess H, et al. Relationships between sleep quality and pain-related factors for people with chronic low back pain: Tests of reciprocal and time of day effects. Ann Behav Med 2017;51(3):365e75.

[5] Tang NK, Goodchild CE, Sanborn AN, Howard J, Salkovskis PM. Deciphering the temporal link between pain and sleep in a heterogeneous chronic pain patient sample: a multilevel daily process study. Sleep 2012;35(5):675e87.

[6] Skarpsno E, Nilsen T, Mork P. The effect of long-term poor sleep quality on risk of back-related disability and the modifying role of physical activity. Sci Rep 2021;11(1):1e8. 15386.

[7] Skarpsno ES, Mork PJ, Nilsen TIL, Nordstoga AL. Influence of sleep problems and co-occurring musculoskeletal pain on long-term prognosis of chronic low back pain: The HUNT Study. J Epidemiol Community Health 2020;74(3): 283e9.

[8] Chang JR, Wang X, Lin G, Samartzis D, Pinto SM, Wong AY. Are changes in sleep quality/quantity or baseline sleep parameters related to changes in clinical outcomes in patients with nonspecific chronic low back pain?: A systematic review. Clin J Pain 2022;38(4):292e307.