Elsevier

Sleep Medicine

Volume 16, Issue 11, November 2015, Pages 1313-1320
Sleep Medicine

Original Article
The effect of sleep deprivation on pain perception in healthy subjects: a meta-analysis

https://doi.org/10.1016/j.sleep.2015.07.022Get rights and content

Highlights

  • Sleep deprivation has a medium effect (SMD = 0.62) on pain perception.

  • The calculated effect size is comparable with effect sizes achieved through pain treatment.

  • Sleep deprivation affects self-reported pain as well as pain threshold.

Abstract

Background

There is strong evidence indicating an interaction between sleep and pain. However, the size of this effect, as well as the clinical relevance, is unclear. Therefore, this meta-analysis was conducted to quantify the effect of sleep deprivation on pain perception.

Methods

A systematic literature search was conducted using the electronic databases PubMed, Cochrane, Psyndex, Psycinfo, and Scopus. By conducting a random-effect model, the pooled standardized mean differences (SMDs) of sleep deprivation on pain perception was calculated. Studies that investigated any kind of sleep deprivation in conjunction with a pain measurement were included. In cases of several pain measurements within a study, the average effect size of all measures was calculated.

Results

Five eligible studies (N = 190) for the between-group analysis and ten studies (N = 266) for the within-group analysis were identified. Sleep deprivation showed a medium effect in the between-group analysis (SMD = 0.62; CI95: 0.12, 1.12; z = 2.43; p = 0.015) and a large effect in the within-group analysis (SMD = 1.49; CI95: 0.82, 2.17; z = 4.35; p <0.0001). The test for heterogeneity was not significant in the between-group analysis (Q = 5.29; df = 4; p = 0.2584), but it was significant in the within-group analysis (Q = 53.49; df = 9; p <0.0001).

Conclusion

This meta-analysis confirms a medium effect (SMD = 0.62) of sleep deprivation on pain perception. As this meta-analysis is based on experimental studies in healthy subjects, the clinical relevance should be clarified.

Introduction

Chronic pain and sleep disorders are common in the general population. The prevalence of chronic pain ranges from 10% to 40% [1], which is comparable with the prevalence of sleep disorders (10–36% [2], [3], [4], [5], [6], [7], [8], [9]).

Increasingly more studies indicate a reciprocal relationship between sleep and pain [2], [3], [4], [5], [6], [10]. This hypothesis is based on epidemiological, pharmaceutical, clinical, and experimental studies. For example, 50–88% of patients with chronic pain also suffer from sleep disorders [11], [12], [13]. Alternatively, > 40% of patients with insomnia also report chronic pain [6]. Several pharmaceutical studies, including studies on eszopiclone [14], triazolam [15], or pregabalin [16], showed a simultaneous improvement of both sleep and pain. In addition, clinical trials highlight a bidirectional relationship between sleep and pain. Patients with a range of sleep disorders, such as obstructive sleep apnea syndrome (OSAS) [17] and restless legs syndrome (RLS) [18], seem to be hyperalgesic. The pain sensitivity improves with effective treatment of the respective sleep disorder. This improvement has been demonstrated in both pharmacological interventions, such as levodopa (L-DOPA) therapy for RLS [18], as well as non-pharmacological interventions, such as continuous positive airway pressure (CPAP) treatment for OSAS [17]. The latter study is of particular interest, as the improvement disappears immediately upon the discontinuation of CPAP therapy [17].

The first experimental study that showed an effect of sleep deprivation on pain perception was published in 1975 [19]. Since then, several studies have confirmed these results [7], [20], [21]. A review from 2006 showed a clear effect of sleep deprivation on pain perception in animals, whereas human data were inconclusive [22]. The same study group extended the systematic review in 2014 and found evidence of the hyperalgesic effect of sleep deprivation, both in animals and humans [23]. By focusing solely on controlled trials, a review indicated conclusive evidence of an increase of bodily complaints, or a decrease of pain thresholds, following sleep deprivation [24].

Varying explanations exist for the reciprocity between sleep and pain. For example, sleep and pain could share similar neurotransmitter systems, such as the dopaminergic system [25] and the serotonin system [26], or influence the endogenous opioid system [27]. In addition, substance P, which is involved in pain processes, interferes with sleep by reducing sleep efficiency or increasing awakenings [28]. However, the pathway of this interaction is not sufficiently clarified by the present research.

In summary, there is a large body of evidence for the interaction between sleep and pain. However, the size of this effect is unclear and the clinical relevance uncertain. Therefore, this meta-analysis was conducted to quantify the effect of sleep deprivation on pain perception.

Section snippets

Search strategy

Five electronic scientific databases, namely PubMed, Cochrane, Psyndex, Psycinfo, and Scopus, were used. The search was conducted on December 5, 2014, with no limitations on the publication date. All terms that were appropriate in former reviews were used [22], [23], [24], [29].

Sleep AND pain AND (“sleep restriction” OR “sleep deprivation” OR “sleep loss” OR “sleep interruption” OR “hyperalgesia” OR “total sleep deprivation” OR “partial sleep deprivation” OR “sleep fragmentation”)

One author

Study selection

Fig. 1 shows the study selection process. A total of 456 records were found in the searching procedure after removing duplicates. By screening the titles and abstracts, 34 potential eligible studies were identified. After full-text analyses, 21 studies were excluded for the following reasons: no primary research [40], [41], [42], no experimental design [43], no sleep deprivation [44], [45], [46], [47], [48], [49], no primary pain outcome [50], [51], only non-healthy participants [52], and no

Discussion

This meta-analysis confirms the effect of sleep deprivation on pain perception. A medium effect (SMD = 0.62) was found for the between-group analysis and a large effect (SMD = 1.49) was found for the within-group analysis. Sleep deprivation increases self-reported pain and affects evoked pain responses obtained through somatosensory testing protocols (eg, heat pain thresholds, pressure pain thresholds, or laser-evoked pain).

Patients with chronic pain exhibit several changes in sleep, such as

Conflict of interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2015.07.022.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

Acknowledgment

The authors thank Friederike Hurtig (F.H.) for screening abstracts and titles during the search procedure, Anna Glechner for her support in answering methodological questions, and Robert Jank for his support revising the manuscript.

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