Journal of Pediatric Psychology Advance Access published online on December 3, 2007
Journal of Pediatric Psychology, doi:10.1093/jpepsy/jsm117
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Brief Report: Actigraphic Sleep and Daytime Naps in Adolescent Girls with Chronic Musculoskeletal Pain
1Family & Child Nursing, 2Department of Pediatrics, and 3Biobehavioral Nursing & Health Systems, University of Washington
All correspondence concerning this article should be addressed to Carol A. Landis, DNSc, RN, FAAN, Department of Biobehavioral Nursing & Health Systems, University of Washington, Box 357266, Seattle, WA 98195-7266, USA. E-mail: calandis{at}u.washington.edu
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Abstract |
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Objectives A descriptive pilot study to examine sleep and daytime naps in adolescent girls with chronic musculoskeletal (MSK) pain. Methods Seventeen girls (14.9 ± 2.0 years) completed questionnaires on anxiety and depressive symptoms during their clinic visit, and maintained a sleep diary and wore an actigraph for 7 days. Parents completed a daily diary of their teen's medications and approaches used to ease pain. Results Average nighttime sleep was 7.2 hr by actigraphy. All participants had mean sleep efficiency <90%. In diaries, 76.5% of the girls reported daytime naps; five girls reported more than three days with naps and more naps were associated with lower sleep efficiency and total nighttime sleep. Conclusions Adolescent girls with chronic MSK pain may sleep fewer hours at night than is recommended and nap in the daytime to compensate for insufficient nighttime sleep.
Key words: adolescents; actigraphy; anxiety; depression; naps; pain; sleep.
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Introduction |
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Adequate sleep in childhood is essential for health, physical and intellectual growth, and normal development. Recent findings suggest that youth with chronic musculoskeletal (MSK) pain syndromes, including those with juvenile fibromyalgia (JF) (Roizenblatt et al., 1997
; Siegel, Janeway, & Baum, 1998; Tayag-Kier et al., 2000), juvenile rheumatoid arthritis (JRA) (Amos, Curry, Drutz, Frost, & Warren, 1997; Bloom et al., 2002; Labyak, Stein, Bloom, Owens, & Lunsford, 2001; Passarelli et al., 2006; Zamir, Press, Tal, & Tarasiuk, 1998), and complex regional pain syndrome (Meltzer, Logan, & Mindell, 2005), have sleep disturbances with prolonged sleep latency, reduced sleep duration and sleep efficiency, more nocturnal arousals and awakenings, decreased rapid-eye-movement (REM) sleep, and frequent leg movements. Prior studies of sleep in youth with chronic MSK pain have relied on self-report or lab-based polysomnography (PSG). Although actigraphy has been used to assess sleep in youth with migraine and abdominal pain (Bruni, Russo, Violani, & Guidetti, 2004; Haim et al., 2004), it has not been used in youth with chronic MSK pain. Actigraphy is less expensive compared to PSG and allows prolonged objective sleep monitoring in a youth's home environment. The purpose of this pilot study was to describe actigraphic sleep and daytime naps in adolescent girls with chronic MSK pain. Since depression and anxiety symptoms are likely to occur in youth with chronic pain syndromes (Eccleston, Crombez, Scotford, Clinch, & Connell, 2004), symptoms of depression and anxiety were also included in this study. |
Methods |
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Sample
Nineteen girls were recruited from a children's hospital-based clinic specializing in the treatment of chronic MSK pain. The sample was limited to adolescent girls because chronic MSK pain problems disproportionately affect females around the age of menarche (Sherry, 2000
). The inclusion criterion was pain in more than one body area for a minimum of 3 months. This criterion is consistent with an established definition of chronic pain by the International Association for the Study of Pain (1986) and observations that chronic MSK pain rarely affects a single body site (Carnes et al., 2007). Girls were excluded if they had: (a) a chronic condition such as cancer, diabetes, or asthma; (b) a diagnosed sleep disorder; or (c) a family history of narcolepsy in a first-degree relative.
Procedures for Data Collection
An information packet was given to teens and their parents who met eligibility criteria during a clinic visit. If the teen and parent expressed interest, a research team member obtained parental consent and teen assent. The teen completed questionnaires, wore an actigraph and completed a diary for each of the next 7 days. Parents completed a daily summary of the teen's medications and approaches used to ease pain. Upon completion of the study, parents returned the diary and actigraph to the investigators in a pre-addressed envelope.
Measures
Wrist Actigraphy
An Actiwatch 64 (MiniMitter-Respironics, Inc., Bend, OR, USA) actigraph was worn on the nondominant wrist for 7 days. An actigraph provides continuous motion data using an accelerometer to monitor the speed and degree of arm movements. The motion data were scored as sleep or wake into 1-min epochs using Actiware-Sleep 3.4 analysis software (MiniMitter-Respironics, Inc., Bend, OR, USA). The actigraphy sleep variables included: (a) sleep onset (first 10 min segment with no more than one epoch of any recorded activity); (b) sleep offset (last 10 min segment with no more than one epoch of any recorded activity); (c) sleep latency (time from the teen's reported bedtime till actigraphic sleep onset); (d) total sleep time (TST, time between sleep onset and sleep offset scored as sleep); (e) wake after sleep onset (WASO, time between sleep onset and sleep offset scored as wake); (f) sleep efficiency (TST/time in bed multiplied by 100); and (g) fragmentation index (number of wake bouts between sleep onset and sleep offset expressed per hour).
Diary
A booklet containing a sleep and pain diary was used to collect daily reports of (a) bedtimes, rise times, and number of daytime naps; and (b) pain intensity and location each evening at bedtime and each morning when they woke up. Information on daily bedtime and rise time was used in the processing and analysis of actigraphy data. Pain intensity was assessed using a "0–10" numerical rating scale with 0 = "does not hurt at all" to 10 = "hurts as much as you can imagine". Pain location was assessed on a drawing of "Mr. Bones," and the percent of body area marked as "hurting" was estimated by applying the "Rule of Nines" as in burn patients (Wallace, 1951). We categorized pain location to the head, neck, trunk, or limb if they marked any part of those body locations for more than 6 out of 14 possible occasions.
Children's Depression Inventory (CDI)
The CDI (Kovacs, 1992) is a 27-item self-report instrument to assess depressed mood during the previous 2 weeks. The CDI has good validity and internal consistency with children and adolescents (Kovacs, 1992) and in our sample the Cronbach's 
was.81.
Revised Children's Manifest Anxiety Scale (RCMAS)
The RCMAS (Reynolds & Richmond, 1985) is a 37-item instrument designed to assess anxiety levels in children from 6 to 19 years of age. The RCMAS has adequate reliability (Reynolds & Richmond, 1997), and the KR20 for the total scale in our sample was.91.
Parental Daily Summary of Youth's Treatment of Symptoms
Parents completed a daily diary on medications and any intervention that the teen received to ease pain.
Data Analysis
Pain variables and actigraphy-derived sleep variables were averaged over 7 days. Pearson product-moment correlation was used to assess relations between number of daytime naps during the 7-day period and the actigraphy variables.
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Results |
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Sample Characteristics
Of the 19 girls enrolled in the study, one was hospitalized and another girl had difficulty wearing the actigraph (stating "it is too painful") resulting in a final sample size of 17 girls. The demographic and clinical characteristics of the girls are shown in Table I. Mean pain intensity scores in the evening and morning were similar. Mean percentage of body area marked as painful was slightly less in the morning compared to the evening. Twelve girls (70.5%) reported pain in the limb, 11 (64.7%) in the trunk, 3 (17.6%) in the neck, and 3 (17.6%) in the head. Three girls were above the clinical cut-off score for depression, and seven had clinically significant anxiety scores. Two of the three participants with clinically significant depression also had clinically significant levels of anxiety. Study participants took multiple medications during the study period, including analgesics or NSAIDS (n = 6 girls), antihistamines (n = 5), SSRI antidepressants (n = 6), SNRI antidepressants (n = 1), sleeping medication (n = 1), steroids (n = 1), muscle relaxants (n = 2), anticonvulsants (n = 1), antipsychotics (n = 1), and migraine medication (n = 1). Eight girls took more than one type of medication, and two girls did not take any medications during the 7-day study. Parents reported in the diary that girls used a variety of nonmedication approaches for pain including back rubs, deep-breathing, warm baths, naps, rest, massage, exercise, and yoga.
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Actigraphic Sleep
Actigraphy showed that only four girls had total nighttime sleep of at least 8 hr, six slept 7 and 8 hr, and seven slept <7 hr (Table II). Mean sleep efficiency was below 90% with three girls having a mean sleep efficiency <75%.
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Relations Between Actigraphic Sleep and Daytime Naps
In the daily diaries, 76.5% of the girls reported naps; five girls reported >3 days with naps during the week. Of the five girls who napped >3 days, two were above the cut-off score for clinical anxiety. Table II shows the correlations between actigraphy sleep and number of daytime naps during the 7-day period. More naps were associated with lower sleep efficiency and total nighttime sleep.
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Discussion |
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Most participants experienced disturbed sleep with reduced nighttime sleep, increased nighttime wakefulness, and decreased sleep efficiency. The increased amount of nighttime wakefulness and number of awakenings are consistent with previous studies of youth with chronic MSK pain syndromes (Meltzer et al., 2005
; Tayag-Kier et al., 2000). Participants also experienced symptoms of depression and anxiety that are similar to previous research of self-reported sleep disturbances in youth with chronic pain (Bloom et al., 2002; Palermo & Kiska, 2005). Although pain is often considered to disrupt sleep, girls’ reports of evening and morning pain were consistent, suggesting that sleep was not disturbed enough to increase pain, or it was not restorative enough to decrease pain the next morning. Because of the cross-sectional nature of this study, we could not determine if pain, depression, or anxiety triggered sleep disturbances, or if emotional symptoms were increased by disturbed sleep. One hypothesis generated from our results is that youth with chronic MSK pain who have more severe sleep disturbances would have more emotional symptoms and be at greater risk for clinically significant anxiety or depression.
Previous research using PSG in healthy youth suggest that they require 
9 1/4 hr of nighttime sleep to maintain optimal alertness during the day (Carskadon et al., 1980). No participant in our study achieved 9 1/4 hr of nighttime sleep. Although no standard actigraphic criteria are available for defining poor sleep in adolescents, sleep efficiency of participants in this study was lower than that of healthy adolescents (Carskadon, Wolfson, Acebo, Tzischinsky, & Seifer, 1998). In addition, napping was common in our sample, and girls taking more daytime naps had lower sleep efficiency and less total nighttime sleep. A second hypothesis generated from this study is that youth with chronic MSK pain who do not obtain sufficient nighttime sleep may nap during the day as one way to achieve the recommended 9 1/4 hr over a 24-hr day or alternatively, to help manage their pain.
Several limitations of this study should be considered when interpreting our results. First, our study did not include self-reported measures of sleep quality, and only focused on nighttime actigraphic sleep. Second, participants were on many medications that affect sleep. Third, we did not obtain specific medical diagnoses on our participants. Although it has been suggested that several types of chronic MSK pain conditions fall within a similar spectrum (Sherry, 2000), youth with distinct chronic pain conditions may experience different levels of pain and functional disability (Kashikar-Zuck, Goldschneider, Powers, Vaught, & Hershey, 2001; Palermo & Kiska, 2005). Despite these limitations, based on objective sleep data, our findings suggest that adolescent females with chronic MSK pain experience sleep disturbances. Future research should include both objective and self-report measures of sleep and daytime napping in larger samples of adolescents with and without chronic pain so that we can increase understanding of the impact of napping on sleep and pain in youth with chronic MSK pain.
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Acknowledgments |
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This study was supported by NINR funded Center for Women's Health Research NR04011 (S.E.L.), and NR08136 (C.A.L.).
Conflicts of interest: None declared.
Received April 29, 2007; revision received November 3, 2007; accepted November 5, 2007
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