Original Report| Volume 13, ISSUE 4, P350-358, April 2012

Predictors of Clinical Pain in Fibromyalgia: Examining the Role of Sleep


      Understanding individual differences in the variability of fibromyalgia pain can help elucidate etiological mechanisms and treatment targets. Past research has shown that spatial extent of pain, negative mood, and aftersensation (pain ratings taken after experimental induction of pain) accounts for 40 to 50% of the variance in clinical pain. Poor sleep is hypothesized to have a reciprocal relationship with pain, and over 75% of individuals with fibromyalgia report disturbed sleep. We hypothesized that measures of sleep would increase the predictive ability of the clinical pain model. Measures of usual pain, spatial extent of pain, negative mood, and pain aftersensation were taken from 74 adults with fibromyalgia. Objective (actigraph) and subjective (diary) measures of sleep duration and nightly wake time were also obtained from the participants over 14 days. Hierarchical regression indicated that greater spatial extent (R2 = .26), higher aftersensation ratings (R2 = .06), and higher negative mood (R2 = .04) accounted for 36% of the variance in clinical pain (average of 14 daily pain ratings). None of the sleep variables were significant predictors of clinical pain. Results replicate previous research and suggest that spatial extent of pain, pain aftersensation, and negative mood play important roles in clinical pain, but sleep disturbance did not aid in its prediction.


      This study suggests that measures of sleep duration and nightly wake time do not predict fibromyalgia pain at the group level. Fibromyalgia patients may benefit from a 3-pronged approach to pain management: reducing pain’s spatial extent, normalization of central nervous system hypersensitivity, and psychobehavioral therapies for negative mood.

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        • Affleck G.
        • Urrows S.
        • Tennen H.
        • Higgins P.
        • Abeles M.
        Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia.
        Pain. 1996; 68: 363-368
        • Ancoli-Israel S.
        • Cole R.
        • Alessi C.
        • Chambers M.
        • Moorcroft W.
        • Pollak C.P.
        The role of actigraphy in the study of sleep and circadian rhythms.
        Sleep. 2003; 26: 342-392
        • Arnold L.M.
        • Rosen A.
        • Pritchett Y.L.
        • D’Souza D.N.
        • Goldstein D.J.
        • Iyengar S.
        • Wernicke J.F.
        A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder.
        Pain. 2005; 119: 5-15
        • Bair M.J.
        • Robinson R.L.
        • Katon W.
        • Kroenke K.
        Depression and pain comorbidity: A literature review.
        Arch Intern Med. 2003; 163: 2433-2445
        • Beck A.T.
        • Steer R.A.
        • Brown G.K.
        Manual for the Beck Depression Inventory-II.
        Psychological Corporation, San Antonio, TX1996
        • Bigatti S.M.
        • Hernandez A.M.
        • Cronan T.A.
        • Rand K.L.
        Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression.
        Arthritis Rheum. 2008; 59: 961-967
        • Branco J.
        • Atalaia A.
        • Paiva T.
        Sleep cycles and alpha-delta sleep in fibromyalgia syndrome.
        J Rheumatol. 1994; 21: 1113-1117
        • Coghill R.C.
        • Mayer D.J.
        • Price D.D.
        The roles of spatial recruitment and discharge frequency in spinal cord coding of pain: A combined electrophysiological and imaging investigation.
        Pain. 1993; 53: 295-309
        • Crofford L.J.
        • Rowbotham M.C.
        • Mease P.J.
        • Russell I.J.
        • Dworkin R.H.
        • Corbin A.E.
        • Young Jr., J.P.
        • LaMoreaux L.K.
        • Martin S.A.
        • Sharma U.
        Pregabalin for the treatment of fibromyalgia syndrome: Results of a randomized, double-blind, placebo-controlled trial.
        Arthritis Rheum. 2005; 52: 1264-1273
        • Dickenson A.H.
        • Sullivan A.F.
        NMDA receptors and central hyperalgesic states.
        Pain. 1991; 46: 344-346
        • Douglass D.K.
        • Carstens E.
        • Watkins L.R.
        Spatial summation in human thermal pain perception: Comparison within and between dermatomes.
        Pain. 1992; 50: 197-202
        • Dzierzewski J.M.
        • Williams J.M.
        • Roditi D.
        • Marsiske M.
        • McCoy K.
        • McNamara J.
        • Dautovich N.
        • Robinson M.E.
        • McCrae C.S.
        Daily variations in objective nighttime sleep and subjective morning pain in older adults with insomnia: Evidence of covariation over time.
        J Am Geriatr Soc. 2010; 58: 925-930
        • Edwards R.R.
        • Almeida D.M.
        • Klick B.
        • Haythornthwaite J.A.
        • Smith M.T.
        Duration of sleep contributes to next-day pain report in the general population.
        Pain. 2008; 137: 202-207
        • Edwards R.R.
        • Grace E.
        • Peterson S.
        • Klick B.
        • Haythornthwaite J.A.
        • Smith M.T.
        Sleep continuity and architecture: Associations with pain-inhibitory processes in patients with temporomandibular joint disorder.
        Eur J Pain. 2009; 13: 1043-1047
        • Engel C.C.
        • von Korff M.
        • Katon W.J.
        Back pain in primary care: Predictors of high health-care costs.
        Pain. 1996; 65: 197-204
        • Eriksen H.R.
        • Ursin H.
        Subjective health complaints, sensitization, and sustained cognitive activation (stress).
        J Psychosom Res. 2004; 56: 445-448
        • Fontaine K.R.
        • Conn L.
        • Clauw D.J.
        Effects of lifestyle physical activity on perceived symptoms and physical function in adults with fibromyalgia: Results of a randomized trial.
        Arthritis Res Ther. 2010; 12: R55
        • Gowans S.E.
        • deHueck A.
        • Voss S.
        • Silaj A.
        • Abbey S.E.
        • Reynolds W.J.
        Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia.
        Arthritis Rheum. 2001; 45: 519-529
        • Gureje O.
        Comorbidity of pain and anxiety disorders.
        Curr Psychiatry Rep. 2008; 10: 318-322
        • Hirsh A.T.
        • Waxenberg L.B.
        • Atchison J.W.
        • Gremillion H.A.
        • Robinson M.E.
        Evidence for sex differences in the relationships of pain, mood, and disability.
        J Pain. 2006; 7: 592-601
        • Horne J.A.
        • Shackell B.S.
        Alpha-like EEG activity in non-REM sleep and the fibromyalgia (fibrositis) syndrome.
        Electroencephalogr Clin Neurophysiol. 1991; 79: 271-276
        • Kundermann B.
        • Spernal J.
        • Huber M.T.
        • Krieg J.C.
        • Lautenbacher S.
        Sleep deprivation affects thermal pain thresholds but not somatosensory thresholds in healthy volunteers.
        Psychosom Med. 2004; 66: 932-937
        • Lemstra M.
        • Olszynski W.P.
        The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: A randomized controlled trial.
        Clin J Pain. 2005; 21: 166-174
      1. Lichstein KL, Riedel BW, Means MK: Psychological treatment of late-life insomnia, in Schultz R, Maddox G, Lawton MP (eds): Annual Review of Gerontology and Geriatrics: Vol. 19 Focus on Interventions Research With Older Adults. New York, NY, Springer, 1999, pp 74-110

        • Lichstein K.L.
        • Stone K.C.
        • Donaldson J.
        • Nau S.D.
        • Soeffing J.P.
        • Murray D.
        • Lester K.W.
        • Aguillard R.N.
        Actigraphy validation with insomnia.
        Sleep. 2006; 29: 232-239
        • Mannerkorpi K.
        • Nordeman L.
        • Cider A.
        • Jonsson G.
        Does moderate-to-high intensity Nordic walking improve functional capacity and pain in fibromyalgia? A prospective randomized controlled trial.
        Arthritis Res Ther. 2010; 12: R189
        • McCrae C.S.
        • Rowe M.A.
        • Tierney C.G.
        • Dautovich N.D.
        • Definis A.L.
        • McNamara J.P.
        Sleep complaints, subjective and objective sleep patterns, health, psychological adjustment, and daytime functioning in community-dwelling older adults.
        J Gerontol B Psychol Sci Soc Sci. 2005; 60: P182-P189
        • Meeus M.
        • Nijs J.
        Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome.
        Clin Rheumatol. 2007; 26: 465-473
        • Moldofsky H.
        The significance, assessment, and management of nonrestorative sleep in fibromyalgia syndrome.
        CNS Spectr. 2008; 13: 22-26
        • Moldofsky H.
        • Scarisbrick P.
        Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation.
        Psychosom Med. 1976; 38: 35-44
        • Moldofsky H.
        • Scarisbrick P.
        • England R.
        • Smythe H.
        Musculosketal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects.
        Psychosom Med. 1975; 37: 341-351
        • Nicassio P.M.
        • Moxham E.G.
        • Schuman C.E.
        • Gevirtz R.N.
        The contribution of pain, reported sleep quality, and depressive symptoms to fatigue in fibromyalgia.
        Pain. 2002; 100: 271-279
        • O’Brien E.M.
        • Waxenberg L.B.
        • Atchison J.W.
        • Gremillion H.A.
        • Staud R.M.
        • McCrae C.S.
        • Robinson M.E.
        Negative mood mediates the effect of poor sleep on pain among chronic pain patients.
        Clin J Pain. 2010; 26: 310-319
        • Oakley N.R.
        Validation with polysomnography of the Sleepwatch sleep/wake scoring algorithm used by the Actiwatch activity monitoring system.
        Mini Mitter Co., Inc., Bend, OR1997
        • Onen S.H.
        • Alloui A.
        • Gross A.
        • Eschallier A.
        • Dubray C.
        The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects.
        J Sleep Res. 2001; 10: 35-42
        • Price D.D.
        • Hu J.W.
        • Dubner R.
        • Gracely R.H.
        Peripheral suppression of first pain and central summation of second pain evoked by noxious heat pulses.
        Pain. 1977; 3: 57-68
        • Price D.D.
        • McHaffie J.G.
        • Larson M.A.
        Spatial summation of heat-induced pain: Influence of stimulus area and spatial separation of stimuli on perceived pain sensation intensity and unpleasantness.
        J Neurophysiol. 1989; 62: 1270-1279
        • Price D.D.
        • Staud R.
        • Robinson M.E.
        • Mauderli A.P.
        • Cannon R.
        • Vierck C.J.
        Enhanced temporal summation of second pain and its central modulation in fibromyalgia patients.
        Pain. 2002; 99: 49-59
        • Raymond I.
        • Ancoli-Israel S.
        • Choiniere M.
        Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries.
        Sleep Med. 2004; 5: 551-559
        • Raymond I.
        • Nielsen T.A.
        • Lavigne G.
        • Manzini C.
        • Choiniere M.
        Quality of sleep and its daily relationship to pain intensity in hospitalized adult burn patients.
        Pain. 2001; 92: 381-388
        • Roizenblatt S.
        • Moldofsky H.
        • Benedito-Silva A.A.
        • Tufik S.
        Alpha sleep characteristics in fibromyalgia.
        Arthritis Rheum. 2001; 44: 222-230
        • Spielberger C.D.
        • Gorsuch R.L.
        • Lushene R.E.
        Manual for the State-Trait Anxiety Inventory (“Self-Evaluation Questionnaire”).
        Consulting Psychologists Press, Palo Alto, CA1970
        • Staud R.
        • Cannon R.C.
        • Mauderli A.P.
        • Robinson M.E.
        • Price D.D.
        • Vierck Jr., C.J.
        Temporal summation of pain from mechanical stimulation of muscle tissue in normal controls and subjects with fibromyalgia syndrome.
        Pain. 2003; 102: 87-95
        • Staud R.
        • Price D.D.
        • Robinson M.E.
        • Vierck Jr., C.J.
        Body pain area and pain-related negative affect predict clinical pain intensity in patients with fibromyalgia.
        J Pain. 2004; 5: 338-343
        • Staud R.
        • Robinson M.E.
        • Vierck Jr., C.J.
        • Cannon R.C.
        • Mauderli A.P.
        • Price D.D.
        Ratings of experimental pain and pain-related negative affect predict clinical pain in patients with fibromyalgia syndrome.
        Pain. 2003; 105: 215-222
        • Staud R.
        • Vierck C.J.
        • Cannon R.L.
        • Mauderli A.P.
        • Price D.D.
        Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome.
        Pain. 2001; 91: 165-175
        • Turk D.C.
        • Okifuji A.
        • Sinclair J.D.
        • Starz T.W.
        Interdisciplinary treatment for fibromyalgia syndrome: Clinical and statistical significance.
        Arthritis Care Res. 1998; 11: 186-195
        • Wells K.B.
        • Golding J.M.
        • Burnam M.A.
        Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions.
        Gen Hosp Psychiatry. 1989; 11: 320-327
        • Wilson K.G.
        • Watson S.T.
        • Currie S.R.
        Daily diary and ambulatory activity monitoring of sleep in patients with insomnia associated with chronic musculoskeletal pain.
        Pain. 1998; 75: 75-84
        • Wolfe F.
        • Ross K.
        • Anderson J.
        • Russell I.J.
        • Hebert L.
        The prevalence and characteristics of fibromyalgia in the general population.
        Arthritis Rheum. 1995; 38: 19-28
        • Wolfe F.
        • Smythe H.A.
        • Yunus M.B.
        • Bennett R.M.
        • Bombardier C.
        • Goldenberg D.L.
        • Tugwell P.
        • Campbell S.M.
        • Abeles M.
        • Clark P.
        • Fam A.G.
        • Farber S.J.
        • Fiechtner J.J.
        • Franklin C.M.
        • Gattner R.A.
        • Hamaty D.
        • Lessard J.
        • Lichtbroun A.S.
        • Masi A.T.
        • McCain G.A.
        • Reynolds W.J.
        • Romano T.J.
        • Russell I.J.
        • Sheon R.P.
        The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee.
        Arthritis Rheum. 1990; 33: 160-172
        • Yunus M.B.
        Role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain.
        Best Pract Res Clin Rheumatol. 2007; 21: 481-497