Theoretical review
Postoperative sleep disruptions: A potential catalyst of acute pain?

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Summary

Despite the substantial advances in the understanding of pain mechanisms and management, postoperative pain relief remains an important health care issue. Surgical patients also frequently report postoperative sleep complaints. Major sleep alterations in the postoperative period include sleep fragmentation, reduced total sleep time, and loss of time spent in slow wave and rapid eye movement sleep. Clinical and experimental studies show that sleep disturbances may exacerbate pain, whereas pain and opioid treatments disturb sleep. Surgical stress appears to be a major contributor to both sleep disruptions and altered pain perception. However, pain and the use of opioid analgesics could worsen sleep alterations, whereas sleep disruptions may contribute to intensify pain. Nevertheless, little is known about the relationship between postoperative sleep and pain. Although the sleep–pain interaction has been addressed from both ends, this review focuses on the impact of sleep disruptions on pain perception. A better understanding of the effect of postoperative sleep disruptions on pain perception would help in selecting patients at risk for more severe pain and may facilitate the development of more effective and safer pain management programs.

Introduction

Despite significant advances in the understanding of pain mechanisms and innovative developments of analgesic and anesthetic agents, acute postoperative pain control remains a challenge in about one-third of surgical patients [1]. In a large Dutch cohort of 1490 surgical patients who received postoperative pain treatment, patients still experienced moderate to severe pain on the day of the surgery, which continued in 15% at four days after surgery [2], [3]. Acute postoperative pain was also followed by chronic pain, which was severe in about 2–10% of postoperative patients [4]. In an attempt to improve postsurgical pain management, studies have identified several potential predictors of postoperative pain as well as several preoperative and psychological factors such as pain experience, age, duration, surgery, and previous chronic sleep problems (Fig. 1) [3], [5], [6], *[7], [8]. Mamie et al. [7] found that, of several factors known to affect postoperative pain, chronic sleep complaints before surgery constituted the strongest determinant of pain at rest postoperatively. Moreover, patients frequently report postoperative sleep disturbances in response to surgical stress, and some electroencephalographic studies have demonstrated decreased total sleep time in both slow wave sleep (SWS) and rapid eye movement (REM) sleep duration as well as increased sleep arousals [9]. Furthermore, clinical observations largely indicate that sleep and pain interact bidirectionally. Thus, clinical and experimental studies have demonstrated that sleep disturbances exacerbated pain perception in healthy subjects [9], [10], [11], [12], *[13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], *[24] and in several pain conditions [25], [26], whereas pain [27], [28], [29], [30] and pain management with opioids [31], [32] may disturb sleep. Surgical stress appears to be a major contributor to both sleep disruptions and altered pain perception, whereas sleep disturbances may alter pain perception and intensify pain postoperatively, and pain and the use of opioid analgesics may increase alterations in the quality and quantity of sleep. Although this bidirectional relationship between postsurgical sleep and pain has been addressed in this review, we focus on updating the state of the knowledge on the potential role of sleep disturbances in postsurgical pain exacerbation in the aim of helping in selecting patients at risk for more severe pain and facilitating the development of more effective and safer pain management programs.

This review is based on a documentary search of Medline and the Cochrane Library up to May 2013. Keywords used to research sleep disruptions after surgery were “sleep” associated with “surgery” or “postoperative.” All studies conducted in humans were selected. Keywords used to research the sleep–pain interaction were “sleep,” “sleep deprivation,”, “sleep fragmentation,” or “sleep disruption” associated with “pain” or “analgesia.” Studies in both animals and humans were considered. Keywords for sleep disruptions and pain in the postoperative period were “sleep,” “sleep deprivation,” “sleep fragmentation,” or “sleep disruption” associated with “pain” or “analgesia” and “surgery” or “postoperative.” Additional inclusion criteria were appropriate statistical and methodological descriptions (e.g., sample size, sleep deprivation protocol, pain measurement).

Section snippets

Sleep disruptions after anesthesia and surgery

Postoperative sleep disturbances are frequently reported: 42% of patients complained of unsatisfactory sleep after orthopedic, vascular, and general surgery (vs. 28% the night before surgery), and their sleep remained unsatisfactory after four days in 23% of cases [33], [34]. Notably, these patients reported the shortest total sleep time compared to before surgery. Fifteen days after surgery, one-quarter of patients again reported abnormal sleep, and 24% underwent hypnotic treatment [33]. Data

Putative factors in sleep disruption

Several factors may contribute to disturbed sleep patterns and sleep complaints after surgery (summarized in Fig. 1), including the environment, surgical stress, anesthesia, psychological factors, and pain [9]. The environment is often proposed as a disruptive factor [33], [46]: hospital-related environmental factors, especially in intensive care units (ICUs), such as noise, light, postoperative inconveniences, and the activities of the health care staff, can contribute to disturbed

The sleep–pain interaction

The relationship between pain and sleep involves multiple unidirectional or bidirectional interactions in which acute and chronic pain are associated with sleep disruptions and disturbed or shortened sleep can in turn alter pain perception [25], [26], [54], [55], [56], [57], [58]. It is important to clarify that the bidirectional model of the impact of pain on sleep and of sleep on pain is not absolute. Some subjects could be more vulnerable to these effects, and in some situations, sleep

Sleep disruptions and pain in the postoperative period

In a postsurgical study, Knill and colleagues [41] conducted polysomnographic recordings after cholecystectomy to investigate the relationship between pain and sleep. They found higher pain intensity (assessed each evening on a visual analog scale (VAS)) and higher opioid dosage (at night) when sleep was most severely disturbed, with SWS duration decrease, REM sleep abolition, and sleep fragmentation. They also found that REM recovery after surgery corresponded to gradual pain dissipation. In a

Conclusion

Clinical, experimental, and epidemiological data support that sleep disruption contribute to exacerbate pain perception and interfere with pain management. Although surgical procedures produce secondary effects such as postoperative pain, and inflammatory responses, sleep disruption probably contributes to the intensity of postoperative pain. Sleep is largely altered in postoperative surgery, especially in certain vulnerable patients, according to genetic and psychological factors. Pain and

Conflict of interest

None declared.

Acknowledgments

GJL holds a Canada Research Chair on Pain, Sleep and Traumatic Injuries. SK holds an F. Banting and C. Best Studentship from the Canadian Institutes of Health Research (CIHR). FC received a grant from the Network for Oral and Bone Health Research (Québec, Canada) and from the Rhône-Alpes Region (France). The authors would like to thank Margaret McKyes for text editing.

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