Association between chronic neck pain and sleep duration in US adults: A cross-sectional study

doi:10.21203/rs.3.rs-3217908/v1

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Association between chronic neck pain and sleep duration in US adults: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-3217908/v1

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The relationship between sleep duration and chronic neck pain is poorly understood. Therefore, we explore this association by compiling data from the National Health and Nutrition Examination Survey (NHANES) ranging from 2009 to 2010, including 3036 adults (age ≥ 20 years). We selected sex, gender, education level, race, marital status, alcohol status, smoking status, hypertension, hyperlipidemia, PIR(poverty-income ratio), and BMI༈Body mass index༉ as covariates. WTMEC2YR as weights for multivariate logistic regression models analysis. In the total population, the second, third, and fourth quartiles had an OR of 0.56 (95%CI: 0.38, 0.84); 0.40 (95%CI: 0.24,0.66); 0.77(95%CI: 0.32,1.83) compared with the lowest reference group of sleep duration for chronic neck pain (P_trend=0.03). When sleep duration is less than 7.45 hours, sleep duration has a negative relationship with the incidence of chronic neck pain (P < 0.05). And the optimal sleep hours show the difference among the gender; the optimal sleep time in the female group is 6.27 hours (P < 0.001), and in the male group is 7.75 hours (P < 0.001).

Health sciences/Diseases

Health sciences/Health care

Health sciences/Medical research

Neck pain ranks fourth among causes of disability (1). The prevalence of neck pain is more prevalent in women than men (2). The cause of neck pain is influenced by various factors, such as sitting or doing tasks with a non-physiologic neck position for a long time without adequate leisure. Chronic Neck Pain is characterized as lasting more than three months and needs a long recovery time (3). Relative factors associated with chronic neck pain include a sedentary lifestyle, headache, psychopathology, poor work physical environment, and low work satisfaction (4). Besides, the potential pathophysiology of chronic neck pain establishes a link with the central nervous system (5).

Sleep doesn’t play a single function in the human body, but many complex physiologic functions, such as development, immune system, cognition, disease, and behavior (6, 7). Therefore, sleep deprivation will cause dysfunction in body systems, including higher cortical function and endocrine, metabolic, and neuromodulation disorders (8–10).

Sleep disturbances, which weaken the physiological homeostasis and restoration regulated by a reasonable sleep time (11), broadly exist in the chronic spinal pain population (12). Furthermore, the nerve system alteration in the chronic pain population shows similar mechanisms to the sleep disorder population (13, 14). Pain increase and sleep disturbance negatively affect each other, forming a vicious cycle (15). However, little research has been done to explore the direct association between sleep duration and the incidence of chronic neck pain. Hence, it is necessary to elucidate the relationship to reduce the risk of developing chronic neck pain to some extent. Conclusively, we collect data from the National Health and Nutrition Examination Survey (NHANES) database in 2009 ~ 2010 to study the association of chronic neck pain with sleep duration.

1. Study population

All data were obtained from NHANES, a program to evaluate US citizens' health and nutritional status and has been authorized by The National Center for Health Statistics ethical review. And all subjects signed the informed consent before enrolment in this program. The research screened adults (age 20 and above) who participated in NHANES from 2009 to 2010 for this study.

Initially, there were a total of 10425 participants enrolled by NHANES. All subjects (aged ≥ 20 years) were enquired whether they had a history of back/neck/hip pain for more than six weeks. Participants with incomplete information of chronic neck pain lasting more than three months(n = 6471), sleep duration(n = 6), and covariates(n = 912). Finally, 3036 participants were included. (Fig. 1)

2. Exposure variable

The computer-Assisted Personal Interviewing (CAPI) system was applied to generate sleep duration information from participants who answered: “How much sleep do you usually get at night on weekdays or workdays?”

3. Outcome variable

In this study, the participants were asked: “Have you ever had pain, aching, or stiffness in the Back/Neck/Hip almost every day for at least 6 weeks?” And then, the participants will be divided into 2 groups: have pain last for 6 weeks and no. For the population that experienced pain last 6 weeks, the next question is: “Was there one time when you had pain, aching, or stiffness in your Neck almost every day for 3 or more months in a row?” Participants who answered yes were considered the chronic neck pain population. And Participants who answered no were excluded from this study.

4. Covariates

The covariates selected in this study that may impact the relationship between sleep duration and chronic neck pain include age, gender, race, education level, marital status, PIR, BMI, Hypertension, hyperlipidemia, smoking, and alcohol status. Some of them were categorized including education level (< high school, completed high school, >high school), race (Black, White, Mexican, Others), marital status (married/living with a partner or widowed/divorced/separated/never married) and Poverty-income ratio (poverty threshold is setting as PIR is 1). Body mass index (BMI) (< 18.5 kg/m2 indicating underweight, 18.5 to < 25.0 kg/m2 indicating normal, 25.0 to < 30.0 kg/m2 indicating overweight, ≥ 30.0 kg/m2 indicating obese).(16, 17) Hypertension diagnosis according to medication history, systolic and diastolic blood pressure. Hyperlipoidemia diagnosis is based on the value of Triglyceride (TG), Low-density lipoprotein (LDL), and High-density lipoprotein (HDL). Smoking status (never smoking, < 100 cigarettes in a lifetime; former smoker, ≥ 100 cigarettes and not currently smoking; current smoker, ≥ 100 cigarettes and currently smoking.) Alcohol status (never, <lifetime; former, ≥ 12 drinks in a year/lifetime and didn’t drink last year; current, ≥ 12 drinks and currently drink.)

5. Statistical analysis

In this study, the continuous variables are described as mean ± standard error or median(interquartile). Depending on the normality of the distribution, the χ2 test and Wilcoxon are applied to compare variables among groups. And categorical variables are described as percentages. WTMEC2YR was used as the weight of the logistic regression to elucidate the relationship between factors and the incidence of chronic neck pain. The continuous variable of Sleep durations was categorized into quartiles applied to the Multivariable logistic regression model. Model 1 was not adjusted model; Model 2 was adjusted for age and gender; Model 3 was adjusted for age, gender, race, PIR, BMI, education levels, hypertension, hyperlipidemia, marital status, smoking, and alcohol status. Besides, a weighted restricted cubic spline (RCS) model was constructed to show the association between sleep duration and the incidence of chronic neck pain. Furthermore, the RCS model was further categorized by gender to elucidate this relationship.

All data were analyzed using R (The R Foundation, Vienna, Austria) and Empower (X&Y Solutions, Boston, MA, USA). P < 0.05 indicates statistical significance.

1. The characteristics of participants

This study totally collects 3036 subjects’ basic information. As shown in Table 1, around 9.75% (296/3036) of the study population experienced chronic neck pain last more than 3 months. Compared with the non-chronic neck pain group, participants with chronic neck pain were more inclined to be older (45.99± 0.77 years), white, poorer, have hypertension and hyperlipidemia, with more smoking, and less sleep duration.

Table 1. Basic characteristics of the study participants.

Variable	Total (n=3036)	No pain (n=2740)	Pain (n=296)	P
Age, mean (SE)	42.72(0.37)	42.37(0.36)	45.99(0.77)	< 0.0001
Gender (%)				0.1
Female	1516(49.93)	1340(49.06)	176(56.02)
Male	1520(50.07)	1400(50.94)	120(43.98)
Race n (%)				0.01
White	1352(44.53)	1192(66.26)	160(76.04)
Black	591(19.47)	540(12.04)	51(9.97)
Mexican	595(19.60)	549(8.99)	46(6.39)
Others	498(16.40)	459(12.70)	39(7.60)
Marital status n (%)				0.93
Married/living with partner	1851(60.97)	1673(63.99)	178(64.24)
Widowed/divorced/separated/never married	1185(39.03)	1067(36.01)	118(35.76)
PIR n (%)				0.04
< 1.00	669(22.04)	580(13.45)	89(19.72)
>= 1.00	2367(77.96)	2160(86.55)	207(80.28)
BMI n (%)				0.17
< 18.5 kg/m2	41(1.35)	40(1.99)	1(0.14)
18.5 to < 25.0 kg/m2	837(27.57)	768(30.24)	69(26.44)
25.0 to < 30.0 kg/m2	1010(33.27)	906(32.72)	104(36.31)
≥ 30.0 kg/m2	1148(37.81)	1026(35.05)	122(37.10)
Educational level n (%)				0.18
< High school	772(25.43)	693(16.15)	79(18.45)
Completed high school	680(22.40)	606(21.37)	74(25.79)
> High school	1584(52.17)	1441(62.49)	143(55.76)
Hypertension n (%)				0.002
No	2065(68.02)	1902(73.00)	163(61.27)
Yes	971(31.98)	838(27.00)	133(38.71)
Hyperlipidemia n (%)				< 0.0001
No	947(31.19)	882(33.32)	65(19.92)
Yes	2089(68.81)	1858(66.68)	231(80.08)
Smoking status n (%)				< 0.001
Never	1736(57.18)	1620(59.70)	116(42.22)
Former	615(20.26)	539(20.91)	76(24.96)
Current	685(22.56)	581(19.39)	104(32.82)
Alcohol status n (%)				0.35
No	811(26.71)	727(22.48)	84(24.81)
Yes	2225(73.2)	2013(77.5)	212(75.19)
Sleep duration(h), mean (SE)	6.9(0.03)	6.95(0.02)	6.4(0.15)	0.002

Abbreviations: SE, standard error; PIR, family income to poverty ratio; BMI, body mass index.

Continuous variables were described as mean (standard error), and categorical variables were described as numbers(percentage).

P-values were calculated by weight χ2 test and Wilcoxon.

2. The association between sleep duration and chronic neck pain.

The relationship between sleep duration and chronic neck pain of multivariate logistic regression shows in Table 2. Sleep duration has been divided into quarters according to the distribution. Mid-range sleep (6~7 hours, 7~8 hours) has different odds ratios (95% confidence intervals) in different models. The group of sleep duration between 6 to 7 hours has OR of 0.56(95%CI:0.37,0.83); 0.54(95%CI:0.36,0.82); 0.56(95%0.38,0.84) in the three models respectively(P=0.01). The group of sleep duration between 7 to 8 hours has OR of 0.41(95%CI:0.25,0.67); 0.002(95%CI:0.24,0.67); 0.002(95%0.24,0.66) in the three models respectively(P=0.001). Therefore, the results show that proper sleep duration (6~8 hours) will reduce the incidence of chronic neck pain. However, there is not statistically significant for long sleep durations (8~12 hours) associated with reduced risk of chronic neck pain. (P=0.53)

Table 2. Associations of sleep duration with chronic neck pain.

Variable	Model I （OR,95%CI）	P	Model II (OR,95%CI)	P	Model III (OR,95%CI)	P
Duration of sleep (h)
[2,6]	Ref		Ref		Ref
(6,7)	0.56(0.37,0.83)	0.01	0.54(0.36,0.82)	0.01	0.56(0.38, 0.84)	0.01
(7,8)	0.41(0.25,0.67)	0.002	0.40(0.24,0.67)	0.002	0.40(0.24, 0.66)	0.001
(8,12)	0.80(0.34,1.89)	0.59	0.79(0.32,1.94)	0.58	0.77(0.32,1.83)	0.53
P_trend		0.03		0.04		0.03

OR odds ratio, CI confidence interval.

Model I, not adjusted.

Model II, adjustment variables were added to Model I: age and gender.

Model III, adjustment variables were added to Model II: education level, race, marital. status, alcohol status, smoking status, hypertension, hyperlipidemia, PIR, BMI.

A weighted restricted cubic spline (RCS) model has been established to explore further the association between sleep duration and chronic neck pain. (Fig2) In the total population, 7.48 hours as an optimal sleep duration minimizes chronic neck pain risk (Fig 2a) (P<0.05). Next, we divided the population by gender, Fig 2b illustrates that there is a different optimal sleep duration among females and males, 6.27 hours of sleep for females and 7.75 hours of sleep for males. However, Fig 2b also describes that when sleep duration is more than 6.27 hours in the females’ group and 7.75 hours in the males’ group, sleep duration extension will not further reduce the incidence of chronic neck pain.

The results from logistic regression analysis and the weighted RCS model illustrate that sleep duration was an independent factor in the occurrence of chronic neck pain. The optimal sleep duration is different among females and males: for females is 6.27 hours/day, and for males is 7.75 hours/day. Sleep duration extension (>7.48 hours/day) would not reduce the chronic neck pain risk.

The etiology of chronic pain plays a critical role in the relationship between sleep and pain involving the neurobiological field. As such, whatever the type of pain, including inflammatory, central, peripheral, or structural, will influence the association with sleep (18, 19). The change in pain processes constitutes overlapping mechanisms of sleep and chronic pain. Accordingly, sleep disorders will influence the immune system to a certain extent, shifting to a pro-inflammatory state mediated by glial cells with the occurrence of hyperalgesia (20-22). Psychological factors, including anxiety, chronic stress, and mood through the hypothalamus-pituitary-adrenal (HPA) axis, will also increase pain sensitivity (20, 21). A bidirectional relationship between pain and sleep impacts each other (23, 24). A similar pathway between insomnia and pain seems to include serotoninergic and mesolimbic dopaminergic pathways (20, 21). A study found there exists a negative relationship between sleepiness and the duration of pain, which means patients in the early phase of chronic pain are more likely to have sleep problems than patients suffering for a long time (25). Negative behavioral and cognitions will arise, forming a vicious cycle between sleep and chronic pain because of sleep disorder (26). People who experienced a long time of chronic pain are prone to worry about their health status, which will further harm sleep quality (27-30). And research has found that people who suffer pain and sleep problems simultaneously are more likely to develop anxiety, depression, and suicidal ideation (31). Moreover, the previous study showed no clear causal ordering between sleep, pain, and depression (23, 31).

The situation of sleep disorders is different among the gender. A study found that women are inclined to be 1.5 times more than men to develop insomnia. This phenomenon might arise from mental factors, such as anxiety and depression, or genetic factors (32). Owing to the sleep of woman and man is different(33), the optimal sleep duration also exist difference among gender, which is meaningful in our study.

There are still some limitations in this study. Firstly, we could not find a causal relationship between sleep duration and chronic neck pain because of a cross-sectional study. Secondly, the participants' sleep duration and chronic neck pain information from the questionnaire. Therefore, significant recall bias will disturb the results. Thirdly, the uncontrolled confounding we don’t know will influence the results. Lastly, we only can obtain 2 years of data from NHANES about neck pain. The size of the sample may not be large enough to be representative.

In this study, we find sleep duration as an independent factor influencing the incidence of chronic neck pain. And the optimal sleep duration is different among gender. 6.27 hours/day is the optimal sleep duration for the female group, and 7.75 hours/day is the optimal sleep duration for the male group. Sleep duration extension (>7.48 hours/day) will not reduce the chronic neck pain risk.

Data availability

All the original data were accessed from https://www.cdc.gov/nchs/nhanes/about_nhanes.

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No competing interests reported.

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Association between chronic neck pain and sleep duration in US adults: A cross-sectional study

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