The effects of recovery sleep on pain perception: A systematic review
Introduction
Reciprocal associations between sleep and pain have been proven since chronic pain conditions are often accompanied by sleep disturbances (Finan et al., 2013; McBeth et al., 2015; Sivertsen et al., 2015; Smith & Haythornthwaite, 2004; Tang et al., 2012) and since non-restorative sleep itself is predictive for the development of pain and the exacerbation of existing pain (Gupta et al., 2007; Mork & Nilsen, 2012). Additionally, experimental sleep deprivation (SD) studies have been conducted to assess effects of sleep alterations on pain in well-controlled laboratory settings, consistently showing hyperalgesic changes following SD (e.g. lower pain thresholds, enhanced pain complaints) (Karmann et al., 2014; Kundermann et al., 2004a; Lautenbacher et al., 2006). On the other hand, several findings may lead to believe that undisturbed (restorative) sleep might in turn help normalizing the pain system overnight. In accord, studies improving sleep quality/quantity in sleep-deprived healthy subjects tended to show reduced pain sensitivity thereafter (Roehrs et al., 2012). Further, improvements in sleep after cognitive behavioral therapy in patients with chronic pain (osteoarthritis) were associated with reduced pain (Smith et al., 2015; Vitiello et al., 2014).
During the past decades a major focus in sleep and pain research was on examining the deleterious effects of sleep deprivation on pain, which are meanwhile well known and repeatedly reviewed. But in line with the recent shift towards perspectives of resilience in pain research, an emphasis on positive outcomes and possible mechanisms of resilience, as these can be directly targeted in interventions (Goubert & Trompetter, 2017), begins to emerge. Therefore, the question whether recovery sleep is able to reset the deleterious effects of SD on pain has gained special interest. However, a systematic evaluation of effects of recovery sleep (RS) on pain is still missing, leaving unanswered whether undisturbed sleep following SD helps to reset occurring pain changes.
Also, mechanisms linking sleep and pain are not conclusively clarified, and thus, how restorative sleep might contribute to a pain normalization. For instance, slow wave sleep (SWS) rebound during RS was emphasized to be involved in a normalization of pain processing (Azevedo et al., 2011; Onen et al., 2001; Smith et al., 2007). Further, since pain is modulated by sleep-dependent (e.g. by homeostatic sleep drive) and circadian processes, chronobiological contributions seem likely (Hagenauer et al., 2017). Other perspectives focus on the opioidergic system (Ukponmwan et al., 1984), central serotonergic transmission (Foo & Mason, 2003), stress (Alexander et al., 2009; Araujo et al., 2011; McEwen & Karatsoreos, 2015) as well as central (Krause et al., 2019) and autonomic nervous system activity (Meerlo et al., 2008) since these factors are related to both pain perception and sleep modulation.
Taking these considerations into account, the main objectives of this review are (1) to systematically summarize effects of RS on pain by retrieving all relevant publications using predefined criteria and (2) to elaborate possible mechanisms of action. For this purpose, empirical animal and human studies conducting experimental SD and subsequent RS were reviewed. Pain had to be measured as the dependent variable and compared between the RS treatment and either an untreated control group or a baseline-condition.
Additionally, we aimed at identifying variables possibly moderating associations between RS and pain, therefore accounting for divergent results. Age and sex of subjects were considered as moderating variables, since both are associated with sleep (Luca et al., 2015) and pain (Lautenbacher et al., 2005; Mogil, 2012; Vendruscolo et al., 2004). In animal (rodent) studies, strains of rodents were considered (Mogil, 2009). Due to enhanced statistical power in larger samples, we included sample size as moderating variable. To reveal if results differ according to methods of pain induction or measures of pain perception, these variables were included as well, as done by previous reviews on SD-effects on pain (Karmann et al., 2014; Kundermann et al., 2004a; Lautenbacher et al., 2006). Since design and duration of sleep manipulations are of important influence, SD design and length (Karmann et al., 2014; Kundermann et al., 2004a; Lautenbacher et al., 2006) as well as length of RS (Jay et al., 2007; Lamond et al., 2007) were considered. The described moderators could be chosen since publications retrieved for this review allowed for their consideration.
Based on our theoretical assumptions, we hypothesized that RS (subsequently to SD) normalizes the pain system overnight. To our knowledge, this is the first review to systematically examine effects of RS on pain, therefore adding to and extending previous findings in this field of research.
Section snippets
Methods
The present review was prepared in compliance with the PRISMA guidelines for systematic reviews and meta-analyses (Moher et al., 2015). The PRISMA flow diagram was used to organize the selection process of suitable publications. Publication retrieval was done in three steps: First, electronic databases were searched for fitting publications using a predefined algorithm (see: 2.1 Database Search), afterwards duplicates were removed. Second, titles and abstracts were screened, and publications
Results
In the following paragraphs, the k = 29 studies will be described by detailing the study characteristics, the methods of pain induction and the measures of pain as well as sleep deprivation and recovery sleep; then, the main effects regarding the influence of recovery sleep on pain will be systematically summarized. Results are reported for animal and human subjects separately. A detailed overview can be found in Table 3 (animal studies) and 4 (human studies).
Discussion
The aim of this systematic review was to provide an overview about experimental research on the effects of recovery sleep on pain. Of overall 41 results showing hyperalgesic pain changes following SD (retrieved from 26 studies1
Declaration of Competing Interest
None.
Acknowledgements
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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