Risk Factors Associated with Clinical Insomnia in Chronic Low Back Pain: A Retrospective Analysis in a University Hospital in Korea

  • Kim, Shin Hyung (Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine) ;
  • Sun, Jong Min (Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine) ;
  • Yoon, Kyung Bong (Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine) ;
  • Moon, Joo Hwa (Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine) ;
  • An, Jong Rin (Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine) ;
  • Yoon, Duck Mi (Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine)
  • Received : 2014.10.16
  • Accepted : 2014.12.23
  • Published : 2015.04.01


Background: Insomnia is becoming increasingly recognized as a clinically important symptom in patients with chronic low back pain (CLBP). In this retrospective study, we have determined risk factors associated with clinical insomnia in CLBP patients in a university hospital in Korea. Methods: Data from four-hundred and eighty one CLBP patients was analyzed in this study. The Insomnia Severity Index (ISI) was used to determine the presence of clinical insomnia (ISI score ${\geq}15$). Patients' demographics and pain-related factors were evaluated by logistic regression analysis to identify risk factors of clinical insomnia in CLBP. Results: It was found that 43% of patients reported mild to severe insomnia after the development of back pain. In addition, 20% of patients met the criteria for clinically significant insomnia (ISI score ${\geq}15$). In a stepwise multivariate analysis, high pain intensity, the presence of comorbid musculoskeletal pain and neuropathic pain components, and high level of depression were strongly associated with clinical insomnia in CLBP. Among these factors, the presence of comorbid musculoskeletal pain other than back pain was the strongest determinant, with the highest odds ratio of 8.074 (95% CI 4.250 to 15.339) for predicting clinical insomnia. Conclusions: Insomnia should be addressed as an integral part of pain management in CLBP patients with these risk factors, especially in patients suffering from CLBP with comorbid musculoskeletal pain.


  1. Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine (Phila Pa 1976) 2012; 37: E668-77.
  2. Kelly GA, Blake C, Power CK, O'Keeffe D, Fullen BM. The association between chronic low back pain and sleep: a systematic review. Clin J Pain 2011; 27: 169-81.
  3. Bahouq H, Allali F, Rkain H, Hmamouchi I, Hajjaj-Hassouni N. Prevalence and severity of insomnia in chronic low back pain patients. Rheumatol Int 2013; 33: 1277-81.
  4. Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep Res 2007; 16: 85-95.
  5. Marin R, Cyhan T, Miklos W. Sleep disturbance in patients with chronic low back pain. Am J Phys Med Rehabil 2006; 85: 430-5.
  6. Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med 2007; 3: S7-10.
  7. van de Water AT, Eadie J, Hurley DA. Investigation of sleep disturbance in chronic low back pain: an age- and gender-matched case-control study over a 7-night period. Man Ther 2011; 16: 550-6.
  8. Park EJ, Lee SJ, Koh DY, Han YM. Repetitive transcranial magnetic stimulation to treat depression and insomnia with chronic low back pain. Korean J Pain 2014; 27: 285-9.
  9. Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2001; 2: 297-307.
  10. Cho YW, Song ML, Morin CM. Validation of a Korean version of the insomnia severity index. J Clin Neurol 2014; 10: 210-5.
  11. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res 2002; 52: 69-77.
  12. Nomura K, Yamaoka K, Nakao M, Yano E. Impact of insomnia on individual health dissatisfaction in Japan, South Korea, and Taiwan. Sleep 2005; 28: 1328-32.
  13. Lobbezoo F, Visscher CM, Naeije M. Impaired health status, sleep disorders, and pain in the craniomandibular and cervical spinal regions. Eur J Pain 2004; 8: 23-30.
  14. Cho CH, Jung SW, Park JY, Song KS, Yu KI. Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance? J Shoulder Elbow Surg 2013; 22: 222-8.
  15. Murphy SL, Lyden AK, Phillips K, Clauw DJ, Williams DA. Association between pain, radiographic severity, and centrally-mediated symptoms in women with knee osteoarthritis. Arthritis Care Res (Hoboken) 2011; 63: 1543-9.
  16. Bjornsdottir SV, Jonsson SH, Valdimarsdottir UA. Mental health indicators and quality of life among individuals with musculoskeletal chronic pain: a nationwide study in Iceland. Scand J Rheumatol 2014; 43: 419-23.
  17. Haukka E, Kaila-Kangas L, Ojajarvi A, Miranda H, Karppinen J, Viikari-Juntura E, et al. Pain in multiple sites and sickness absence trajectories: a prospective study among Finns. Pain 2013; 154: 306-12.
  18. Rohrbeck J, Jordan K, Croft P. The frequency and characteristics of chronic widespread pain in general practice: a case-control study. Br J Gen Pract 2007; 57: 109-15.
  19. O'Brien EM, Waxenberg LB, Atchison JW, Gremillion HA, Staud RM, McCrae CS, et al. Intraindividual variability in daily sleep and pain ratings among chronic pain patients: bidirectional association and the role of negative mood. Clin J Pain 2011; 27: 425-33.
  20. Narita M, Niikura K, Nanjo-Niikura K, Narita M, Furuya M, Yamashita A, et al. Sleep disturbances in a neuropathic pain-like condition in the mouse are associated with altered GABAergic transmission in the cingulate cortex. Pain 2011; 152: 1358-72.
  21. Yamashita A, Hamada A, Suhara Y, Kawabe R, Yanase M, Kuzumaki N, et al. Astrocytic activation in the anterior cingulate cortex is critical for sleep disorder under neuropathic pain. Synapse 2014; 68: 235-47.
  22. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA 1989; 262: 1479-84.
  23. Artner J, Lattig F, Cakir B, Gündel H, Reichel H, Spiekermann JA. Prevalence of mental disorders in multimodal therapy of chronic back pain. Orthopade 2012; 41: 950-7.
  24. Chiu YH, Silman AJ, Macfarlane GJ, Ray D, Gupta A, Dickens C, et al. Poor sleep and depression are independently associated with a reduced pain threshold. Results of a population based study. Pain 2005; 115: 316-21.
  25. O'Donoghue GM, Fox N, Heneghan C, Hurley DA. Objective and subjective assessment of sleep in chronic low back pain patients compared with healthy age and gender matched controls: a pilot study. BMC Musculoskelet Disord 2009; 10: 122.

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