Pain Linked With Poor Sleep Quality, Comorbidities in RA, PsA

Pain symptoms were associated with poor sleep, fibromyalgia, depression, and sleep apnea in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), according to a study published in Joint Bone Spine.¹

Issues with initiating and maintaining sleep are common among the general population and occur even more frequently among patients with inflammatory arthritides (IAs) such as RA and PsA.^2,3 Disease symptoms such as back pain or joint pain may disrupt sleep.¹

“In general, studies concerning RA indicate that measures of disease activity are quite weakly associated with various components of sleeping difficulties,” the study authors noted. “However, similar findings haven’t been found in cross-sectional studies regarding PsA, where joint counts, number of enthesitides, and the levels of CRP [C-reactive protein] and ESR [erythrocyte sedimentation rate] correlated significantly with sleeping difficulties.”

While active disease can factor into sleep disturbances, the authors noted that patients with RA reporting sleep difficulties also tend to report increased pain, tender joints, increased tenderness in general, and lower mood vs those who do not experience sleep disturbances.

Struggling to sleep | Image credit: terovesalainen - stock.adobe.com

“Sleep disturbances mainly stem from pain in patients with IAs, which, in turn might stem from active disease. However, several studies have indicated that the correlation between pain and objective inflammatory findings is low, whereas depression and pain catastrophizing are important contributors to pain in patients with RA,” the authors wrote.

Because cross-sectional studies of sleep disturbances have been limited, the researchers used a nationwide quality register database including clinical practice data to assess patients’ reported sleep difficulties and the association between sleep, comorbidities, and disease activity based on patient-reported outcomes (PROs) for pain, fatigue, and patient global assessment measures. Data were gathered from the Finnish Rheumatology Quality Register in Finland.

A total of 13,512 patients with RA and 3636 patients with PsA who had a visit between January 2023 and September 2022 were identified in the database. Of these patients, 6052 with RA had sleep status data available, whereas 1861 patients with PsA had sleep data available and were included in the analysis. There were no major demographic differences between patients who had sleep information available and those who did not.

Overall, 5072 (84%) patients with RA reported having good sleep, defined as little to no difficulties, while 980 (16%) reported poor sleep, defined as great difficulty or can’t sleep. Among patients with PsA, 1460 (78%) reported good sleep and 401 (22%) reported poor sleep. Female and older patients were more likely to report good sleep. The median values for objective disease activity measures were similar and low regardless of sleep status in both RA and PsA. Median PRO values among patients with no swollen joints in either disease were about 3 times higher in those with poor sleep compared with good sleep (P < .001).

Poor sleep was independently associated with more intense pain symptoms in both RA and PsA, with associations also seen between poor sleep and comorbid fibromyalgia. Poor sleep was also linked with depression in RA and sleep apnea in PsA. Patients who reported poor sleep showed significantly higher prevalences of all diagnoses, and they reported worse Stanford Health Assessment Questionnaire and pain catastrophizing scores.

“Our main observation was that sleep disturbances and comorbidities were independently associated with pain,” the authors explained.

While one study strength was its size and inclusion of a nationwide patient population, one limitation was that the measurement tool for sleep was not a large research questionnaire and was instead a simple question. However, such simplicity is feasible in day-to-day practice, the authors noted.

“In conclusion, this study highlights the importance of the evaluation of sleep and comorbidities such as fibromyalgia, sleep apnea, depression and anxiety in patients with RA and PsA who present intense symptoms, especially in patients with no objective signs of an active disease,” the authors wrote.

References

1. Weman L, Salo H, Kuusalo L, et al. Intense symptoms of pain are associated with poor sleep, fibromyalgia, depression and sleep apnea in patients with rheumatoid arthritis and psoriatic arthritis: a register based study. Joint Bone Spine. Published online May 23, 2024. doi:10.1016/j.jbspin.2024.105744

2. Nicassio PM, Ormseth SR, Kay M, et al. The contribution of pain and depression to self-reported sleep disturbance in patients with rheumatoid arthritis. Pain. 2012;153(1):107-112. doi:10.1016/j.pain.2011.09.024

3. Skougaard M, Stisen ZR, Jørgensen TS, et al. Increased prevalence of sleep disturbance in psoriatic arthritis is associated with inflammatory and non-inflammatory measures. Scand J Rheumatol. 2023;52(3):259-267. doi:10.1080/03009742.2022.2044116