The Association of Sleep Disturbances with Lower Back Pain

September 19, 2019

Sleep is a complex and necessary physiological and behavioral process which the body undergoes in a rhythmic fashion. During sleep, important processes such as growth, healing, physical recovery, memory processing, information retention and emotional regulation occur. Sleep disturbance (SD) affects approximately 30-45% of the western population. These disturbances can be characterized by sleep initiation difficulty, sleep maintenance difficulty, poor quality sleep and decreased sleep. SD confers dysregulation to the above processes and manifests as impairments in cognition, decision making, psychomotor function, occupational efficiency, quality of life amongst many others. In addition, poor sleep has been associated as a risk for cardiovascular disease, immune suppression, dementia, metabolic syndrome, depression and chronic pain. This article will discuss the association between sleep disturbance and low back pain.

Several studies have documented the association between SD and chronic pain. Many patients who report chronic pain show sleep associated disorders such as insomnia, restless leg syndrome, and obstructive sleep apnea. There are several proposed mechanisms which conceptualize a vicious cycle whereby significant pain impairs sleep and poor sleep exacerbates pain. Previous studies have thought that both mechanisms exist in concert; however recent studies have shown a stronger impact from poor sleep exacerbating chronic pain in adult populations – i.e. studies show sleep deprivation can induce hyperalgesic pain responses in participants compared to healthy controls. These hyperalgesic responses can be reversed by sleep restoration.

The exact mechanism for pain exacerbation and SD is not clearly understood. A proposed mechanism looks at the biochemical and neurophysiological level with poor sleep directly increasing production of pro-inflammatory cytokines with inhibition of endogenous opioid production. Central pain modulation systems that are associated with chronic pain include wind up of wide-dynamic range neurons conferring decreased threshold to pain response from external stimuli. Sleep deprivation is proposed to aid in the wind up phenomenon of these wide dynamic range neurons which leads to development and maintenance of chronic pain states.

Klyne et al and Paul-Savoie et al both documented the association specifically with subjective sleep quality and low back pain through conditioned pain modulation through diminished descending pain inhibition. It is suggested that the dysregulation of endogenous biochemical and physiological mechanisms described in the paragraph above are responsible for this; however no study has specifically identified endogenous pathway dysregulation as the cause and further research is needed.

In summary, the association between SD and chronic pain has been previously described. There is a strong association between subjective low back pain complaints and sleep quality. The proposed mechanism for this is felt to be primarily due to SD causing dysregulation of endogenous biochemical and neurophysiological modulation pathways; however this has not been confirmed in current literature. Treatment of chronic pain often involves a multi-disciplinary approach and the article stresses the importance of addressing SD in management of chronic pain complaints.


  1. Siegel JM (2011) REM sleep: a biological and psychological paradox. Sleep Med Rev 15(3):139–142
  2. Hillman DR, Lack LC (2013) Public health implications of sleep loss: the community burden. Med J Aust 199(8):S7–10
  3. Adams RJ, Appleton SL, Taylor AW et al (2017) Sleep health of Australian adults in 2016: results of the 2016 Sleep Health Foundation national survey. Sleep Health 3(1):35–42
  4. Zhai L, Zhang H, Zhang D (2015) Sleep duration and depression among adults: a meta-analysis of prospective studies. Depress Anxiety 32(9):664–670
  5. Zhang JM, An J (2007) Cytokines, inflammation, and pain. Int Anesthesiol Clin 45(2):27–37
  6. Yin J, Jin X, Shan Z et al (2017) Relationship of sleep duration with all-cause mortality and cardiovascular events: a systematic review and dose–response meta-analysis of prospective cohort studies. J Am Heart Assoc 6(9):e005947
  7. Mathias JL, Cant ML, Burke ALJ (2018) Sleep disturbances and sleep disorders in adults living with chronic pain: a meta-analysis. Sleep Med 52:198–210
  8. Klyne DM, Moseley GL, Sterling M, Barbe MF, Hodges PW (2018) Individual variation in pain sensitivity and conditioned pain modulation in acute low back pain: effect of stimulus type, sleep, and psychological and lifestyle factors. J Pain 19(8):942 e941–942 e918
  9. Andersen ML, Araujo P, Frange C, Tufik S (2018) Sleep disturbance and pain: a tale of two common problems. Chest 154(5):1249–1259
  10. Schuh-Hofer S, Baumgartner U, Treede RD (2015) Effect of sleep deprivation on the electrophysiological signature of habituation to noxious laser stimuli. Eur J Pain 19(8):1197–1209
  11. Faraut B, Leger D, Medkour T et al (2015) Napping reverses increased pain sensitivity due to sleep restriction. PLoS One [Electron Resour] 10(2):e0117425
  12. Klyne DM, Moseley GL, Sterling M, Barbe MF, Hodges PW (2018) Individual variation in pain sensitivity and conditioned pain modulation in acute low back pain: effect of stimulus type, sleep, and psychological and lifestyle factors. J Pain 19(8):942 e941–942 e918
  13. Paul-Savoie E, Marchand S, Morin M et al (2012) Is the deficit in pain inhibition in fibromyalgia influenced by sleep impairments? Open Rheumatol J 6:296–302
  14. Herrero babiloni A, De koninck BP, Beetz G, De beaumont L, Martel MO, Lavigne GJ. Sleep and pain: recent insights, mechanisms, and future directions in the investigation of this relationship. J Neural Transm (Vienna). 2019.