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13 Articles in Volume 18, Issue #3
Anger Expression & Chronic Pain
Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Chronic Pain in Children
Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
Dousing the Physician Burnout Epidemic: An AMA Perspective
Harnessing the Power of Words
Inside ASRA with David Provenzano, MD
Management of Intrathecal Therapies by Interprofessional Teams
Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention
Physician Burnout: An Oldtimer’s View
Reporting Metrics, Media Coverage...Letters from the Minds of Peers and Patients
The Case for Slow-Release Anesthetics
The Impact of Pain Practice

Chronic Pain in Children

The link between post-traumatic stress & sleep, with Patrick Finan, PhD, and Melanie Noel, PhD

When children are exposed to traumatic events, their youth and naiveté may result in difficulties reacting to and managing post-traumatic stress symptoms (PTSS). The symptoms may be further complicated in youth living with chronic pain conditions, as the relationship between PTSS and chronic pain in this population has been linked to poor sleep, anxiety, and an overall unhealthy life that follows into adulthood.

Researchers have demonstrated that nearly 25% of youth experience at least one traumatic event by the age of 16,1 and that more than 60% experience a traumatic event during adolescence, with prevalence higher among female youth.2

While the types of distressing and traumatic events among youth do not differ among those with or without chronic pain, youth with chronic pain have been found to have higher rates of clinically elevated PTSS (32%), compared to those without chronic pain (8%). Among youth with chronic pain, those who reported more PTSS also reported worse pain outcomes and quality of life.3 Sleep disturbances have been considered an underlying factor in the co-occurrence of chronic pain and PTSS.

Evidence has further suggested that sleep is not simply a secondary symptom of post-traumatic stress disorder (PTSD), but rather a risk factor for worsening symptoms of the condition,4 making early intervention and treatment among this population crucial.

Sleep as a Mediator

“Chronic pain and sleep are intimately related, with strong evidence for a reciprocal association,” said Patrick Finan, PhD, assistant professor in the department of psychiatry and behavioral sciences at John Hopkins University School of Medicine in Baltimore, Maryland. “There is keen interest in using nonpharmacological sleep interventions as an indirect route to reducing clinical pain symptoms in individuals with comorbid chronic pain and insomnia.”

This type of intervention may be especially pertinent, as research by Cunningham et al, has shown that youth with chronic pain who have elevated internal mental health symptoms, such as anxiety, often do not respond well to conventional pain treatments.5

A recent study by Noel et al, examined the mediating role of sleep in the relationship between PTSS and pain in youth (ages 10 to 17).6 “Based on recent conceptual models of mutual maintenance, we hypothesized that poorer sleep quality would mediate the associations between higher PTSS and greater pain intensity and interference in youth with chronic pain,” wrote lead researcher Melanie Noel, PhD, assistant professor at the department of psychology at the University of Calgary and Alberta Children’s Hospital Research Institute, in the study’s abstract.

In the study, approximately 97 participants completed surveys on PTSS, pain, anxiety symptoms, and sleep quality, in addition to demographic characteristics. Higher levels of PTSS were linked to higher levels of pain intensity and pain interference, with the relationships partially explained by poor sleep quality. Results from the study revealed that, beyond the influence of demographics and anxiety symptoms, sleep quality partially mediated the relationships between PTSS and pain intensity and interference.

Hyperarousal, in which heightened anxiety leads to difficulty falling or staying asleep, is one of a few key areas of study that has been of interest in this relationship. Hyperarousal falls under one of the symptom clusters of PTSD,7 and has been linked to increased pain sensitivity, pain-related anxiety, and pain-avoidant behaviors.8 Future research should further examine relevant disturbances such as hyperarousal and their role between PTSS and chronic pain, according to Dr. Noel.

“While evidence from other sleep intervention studies suggests that sleep can be significantly improved by these interventions in comorbid pain and insomnia patients, the jury is still out with respect to their ability to reliably and effectively improve chronic pain outcomes,” Dr. Finan said. “This study shows that sleep quality accounts for part of the relationship between PTSS and pain in youth. It is a nice cross-sectional demonstration of these relationships and serves as a solid introductory study in this area of research. Clearly, there are a number of next steps that should emerge from this early demonstration of associations, including longitudinal work, and biobehavioral mechanistic work, as described by the authors of the study.”

Specific Interventions Needed

When chronic pain and PTSS co-occur in youth, sleep interventions may offer an important therapeutic target for subduing pain and mental health problems that could otherwise persist into adulthood.6 Unfortunately, not much research has been done in this area among this population, explained Dr. Noel. “Relatively brief psychological interventions (eg relaxation training, stimulus control therapy, cognitive restructuring) targeting sleep disturbances have been shown to lead to improvements in PTSS and chronic pain symptoms in adult samples,” she explained. In addition, cognitive behavioral therapy as a sleep intervention among adults has reduced insomnia severity and pain interference.9,10 “Similar work in youth with co-occurring pain and PTSS, in addition to examinations of other mechanisms underlying this co-occurrence, are needed.”

“In recent years, sleep has emerged as a key predictor of health across a variety of physiological, cognitive, and behavioral domains,” added Dr. Finan. “It is an empirical question whether primary treatment in this population should focus on remediation of PTSD symptoms, or instead target the proposed intermediate factor—sleep. To the extent that sleep can be effectively treated in youth with persistent PTSS, this could be a strategy to minimize downstream health consequences, such as pain.”

Dr. Finan further noted that, in the absence of improved PTSS, it may be difficult to treat sleep effectively, and that an effective sleep intervention among youth may take the shape of working on cognitive and behavioral factors that maintain PTSS and sleep problems simultaneously to ensure that the expected outcome includes reduced PTSS and reduced sleep disturbances.

On the pharmacological side, medications meant to aid sleep disturbances and disorders often impair function once patients awaken. Lemborexant, from Eisai Co (Tokyo) and Purdue Pharma, LLC (Stamford, Connecticut), may soon offer a solution. The investigational agent for sleep and wake regulation is being studied for the treatment of multiple sleep disorders.11 By acting on the orexin neurotransmitter system, the medication may dampen wakefulness without impeding the ability to awaken to external stimuli.11


Due to the relative success of sleep intervention therapies among adults with chronic pain and PTSD, similar interventions should be pursued for the pediatric population, especially due to the risks associated with untreated PTSS in this vulnerable demographic. Further research into sleep disturbances, their relation to chronic pain, and the use of interventional cognitive and pharmacological therapies as potential treatment is needed moving forward.

Last updated on: April 12, 2019
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Children’s Chronic Pain Trajectories May Predict Their Response to Intensive Rehab
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