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Does Disordered Sleep Moderate the Relationship Between Pain, Disability and Downstream Health Care Utilization in Patients With Low Back Pain?

A Longitudinal Cohort From the US Military Health System

Rhon, Daniel I. DSc∗,†,‡; O’Hagan, Edel MSc§,¶; Mysliwiec, Vincent MD; Lentz, Trevor A. PhD

doi: 10.1097/BRS.0000000000003114

Study Design. Prospective cohort.

Objective. The purpose of this study was to evaluate the influence of disordered sleep on the relationship between pain and health care utilization (HCU) and pain-related disability and HCU in individuals with low back pain (LBP).

Summary of Background Data. Disordered sleep and pain influence LBP outcomes, but their relationship with health care seeking after an episode of LBP has not been investigated and could help identify who is at risk for long-term medical care.

Methods. This study included patients with LBP participating in a self-management class at a large US military hospital between March 1, 2010 and December 4, 2012. Pain intensity, disability (Oswestry Disability Index), and sleepiness (Epworth Sleepiness Scale) were captured at baseline. Medical visits for a sleep disorder in the 12 months before the class and LBP-related healthcare utilization for the 12 months following the class were abstracted from the Military Health System Data Repository. Separate multivariate analyses evaluating pain intensity and disability as predictors of HCU were developed, with sleepiness and the presence of a sleep disorder as potential moderators. Analyses were adjusted for age, sex, history of back pain, and mental health comorbidities.

Results. A total of 757 consecutive participants were included, with 195 (26.8%) diagnosed with a subsequent sleep disorder. Sleepiness was not a significant predictor of HCU. The main effects of disability, pain intensity, and presence of a sleep disorder were significant across all analyses, with higher disability, pain intensity, and presence of a sleep disorder associated with higher predicted visits and costs for LBP. The presence of a sleep disorder was not a significant moderator in any model.

Conclusion. Higher pain intensity and disability predicted higher pain-related HCU in the year following a LBP self-management class. The presence of a sleep disorder diagnosis, as recorded in medical records, had a significant independent effect on LBP-related health care visits and costs beyond the influences of pain intensity, disability, and other key demographic and health-related characteristics, but did not moderate these relationships.

Level of Evidence: 3

Consecutive patients seen for back pain were also assessed for presence of disordered sleep. Patients with a sleep disorder had greater downstream healthcare utilization than those without a sleep disorder. Higher pain intensity and disability scores, and presence of a sleep disorder were all associated with greater downstream low back-related visits and medical costs.

Brooke Army Medical Center, San Antonio, TX

Physical Performance Service Line, Army Office of the Surgeon General, Falls Church, VA

Duke Clinical Research Institute, Duke University, Durham, NC

§Neuroscience Research Australia, Sydney, NSW Australia

Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.

Address correspondence and reprint requests to Daniel I. Rhon, DSc, Center for the Intrepid, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234; E-mail:

Received 17 December, 2018

Revised 15 March, 2019

Accepted 8 May, 2019

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense, or the U.S. Government.

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