The association between proportion of night shifts and musculoskeletal pain and headaches in nurses: a cross-sectional study.

BACKGROUND AND PURPOSE: Shift work is associated with musculoskeletal pain and headaches, but little is known about how the intensity of shift work exposure is related to musculoskeletal pain and headaches. This study aimed to investigate whether a higher proportion of night shifts is associated with a higher occurrence of musculoskeletal pain and headaches. Furthermore, to investigate whether sleep duration can mediate this potential association. METHOD: The study included 684 nurses in rotating shift work who responded to a daily questionnaire about working hours, sleep, and pain for 28 consecutive days. The data were treated cross-sectionally. RESULTS: A negative binomial regression analysis adjusted for age and BMI revealed that working a higher proportion of night shifts is not associated with a higher occurrence of musculoskeletal pain and headaches. On the contrary, those working ≥ 50% night shifts had a significantly lower occurrence of pain in the lower extremities than those who worked < 25% night shifts (IRR 0.69 95% CI 0.51, 0.94). There was no indication of a mediation effect with total sleep time (TST). CONCLUSION: The results of this study indicate that working a higher proportion of night shifts is not associated with a higher occurrence of musculoskeletal pain and headaches.

Which combined nerve conduction study scores are best suited for polyneuropathy in diabetic patients?

INTRODUCTION/AIMS: Nerve conduction studies (NCS) are widely used in diagnosing diabetic polyneuropathy. Combining the Z scores of several measures (Z-compounds) may improve diagnostics by grading abnormality. We aimed to determine which combination of nerves and measures is best suited for studies of diabetic polyneuropathy. METHODS: Sixty-eight patients with type 1 diabetes and 35 controls were included in this study. NCS measurements were taken from commonly investigated nerves in one arm and both legs. Different Z-compounds were calculated and compared with reference material to assess abnormality. A sensitivity proxy, the accuracy index (AI), and Cohen's d were calculated. RESULTS: Z-compounds with the highest AI consisted of the tibial and peroneal motor, and the sural, superficial peroneal, and tibial medial plantar sensory nerves in one or two legs. All Z-compounds were able to discriminate between diabetic subjects and nondiabetic controls (mean Cohen's d = 1.42 [range, 1.03-1.63]). The association between AI and number of measures was best explained logarithmically (R2  = 0.401), with diminishing returns above approximately 14 or 15 measures. F-wave inclusion may increase the AI of the Z compounds. Although often clinically useful among the non-elderly, the additional inclusion of medial plantar NCS into Z-compounds in general did not improve AI. DISCUSSION: Performing unilateral NCS in several motor and sensory lower extremity nerves is suited for the evaluation of polyneuropathy in diabetic patients. The use of Z-compounds may improve diagnostic accuracy in diabetic polyneuropathy and may be particularly useful for follow-up research studies as single summary measures of NCS abnormality development over time.

Sleep patterns and insomnia in a large population-based study of middle-aged and older adults: The Tromsø study 2015-2016.

Epidemiological studies assessing adult sleep duration have yielded inconsistent findings and there are still large variations in estimation of insomnia prevalence according to the most recent diagnostic criteria. Our objective was to describe sleep patterns in a large population of middle-aged and older adults, by employing accurate measures of both sleep duration and insomnia. Data stem from the Tromsø Study (2015-2016), an ongoing population-based study in northern Norway comprising citizens aged 40 years and older (n = 21,083, attendance = 64.7%). Sleep parameters were reported separately for weekdays and weekends and included bedtime, rise time, sleep latency and total sleep time. Insomnia was defined according to recent diagnostic criteria (International Classification of Sleep Disorders; ICSD-3). The results show that 20% (95% confidence interval,19.4-20.6) fulfilled the inclusion criteria for insomnia. The prevalence was especially high among women (25%), for whom the prevalence also increased with age. For men, the prevalence was around 15% across all age groups. In all, 42% of the women reported sleeping <7 hr (mean sleep duration of 7:07 hr), whereas the corresponding proportion among males was 52% (mean sleep duration of 6:55 hr). We conclude that the proportion of middle-aged and older adults not getting the recommended amount of sleep is worryingly high, as is also the observed prevalence of insomnia. This warrants attention as a public health problem in this population.

Shift work, low-grade inflammation, and chronic pain: a 7-year prospective study.

OBJECTIVES: We investigated prospective associations of shift work with chronic pain and C-reactive protein (CRP), an indicator of inflammation. Furthermore, we elucidated CRP as a possible mediator and/or moderator of effects of shift work on pain. METHODS: Data from a 7 years follow-up study were analyzed (N = 2323). Shift work and chronic pain of "neck/shoulder", "arm/hand", "upper back", "low back", "hip/leg/feet", and "other regions" were measured by questionnaires. "Chronic widespread pain", "number of chronic pain sites", and "any chronic pain" were computed. CRP was measured in serum samples. Logistic and Poisson regressions were conducted. Mediation was assessed by casual mediation analyses and moderation by the Relative Excess Risk due to Interaction (RERI). RESULTS: Shift work was not associated with any chronic pain variable and no mediation was detected. CRP was associated with low back pain, hip/leg pain, and "number of pain sites", and also with the combination of shift work and CRP of 1-2.99 mg/L (compared to: no shiftwork and CRP < 1). Additionally, shiftwork and CRP 1-2.99 mg/L was associated with risk of "any chronic pain" (OR: 1.76, 95% CI: 1.12, 2.85), which was not associated with CRP alone. Moderation analyses suggested the risks for "any chronic pain" and "number of pain regions" increased when individuals with elevated CRP worked shifts-beyond what the separate effects of CRP and shift would suggest. CONCLUSIONS: We found no evidence of shift work in general affecting CRP or chronic pain. However, shift work and elevated CRP combined may influence chronic pain.

Brain monitoring in hospitals needs to be strengthened. / Hjerneovervåking i sykehusene må styrkes.

Careful brain monitoring saves lives and is beneficial to patients' health. Nevertheless, Norway lacks guidelines for brain monitoring in hospitals.

Pain complaints are associated with quick returns and insomnia among Norwegian nurses, but do not differ between shift workers and day only workers.

PURPOSE: To determine whether common work schedule characteristics among Norwegian nurses were associated with subjective pain complaints. METHODS: A cross-sectional study in a sample of 1585 nurses, part of the longitudinal questionnaire-based cohort project 'Survey of Shift work, Sleep and Health' (SUSSH). Pain from six regions were assessed: 'headache', 'neck/shoulder/upper back', 'upper extremities', 'lower back', 'lower extremities', and 'abdomen'. Logistic and negative binomial regression (adjusted for age, sex, percentage of full-time equivalent, marital status and children living at home) were conducted where work schedule, number of night shifts last year, number of quick returns (QR) last year (< 11 h between shifts) and insomnia were predictors of localized pain, widespread pain and number of pain sites. RESULTS: Localized pain, widespread pain and number of pain sites were associated with insomnia (OR 2.06, 95% CI 1.66-2.55, OR 2.14, 95% CI 1.47-3.09, IRR 1.70, 95% CI 1.51-1.91, respectively). Work schedule and number of night shifts worked last year were not associated with any of the three pain measures. Number of QRs worked last year tended to be associated with number of pain sites. CONCLUSION: The study did not support the hypothesis that non-daytime work schedules are associated with pain complaints. Neither was there support for the hypothesis linking number of night shifts, or the number of QRs, to pain complaints. Future studies should aim to determine the association between QRs and pain in more detail. Pain complaints were associated with insomnia.

Does insomnia modify the association between C-reactive protein and migraine? The Tromsø Study 2015-2016.

BACKGROUND: The relationship between high sensitivity C-reactive protein and migraine is unclear. The aim of this cross-sectional population-based study was to investigate the association between high sensitivity C-reactive protein and types of headache, and to evaluate the impact of insomnia on this association. METHODS: A total of 20,486 (63%) out of 32,591 invited, aged ≥40 years or older, participated in the seventh wave of the Tromsø study conducted in 2015-2016 and had valid information on headache, insomnia and high sensitivity C-reactive protein. The influence of insomnia on the association between questionnaire-based diagnoses of headache and elevated high sensitivity C-reactive protein defined as >3.0 mg/L was assessed using multiple logistic regression, estimating prevalence odds ratio with 95% confidence intervals. RESULTS: A total of 6290 participants (30.7%) suffered from headache during the last year. Among these, 1736 (8.5%) fulfilled the criteria of migraine, 991 (4.8%) had migraine with aura, 746 (3.6%) migraine without aura (3.8%), and 4554 (22.2%) had non-migrainous headache. In the final multi-adjusted analysis, elevated high sensitivity C-reactive protein was associated with headache (odds ratio 1.10, 95% confidence interval 1.01-1.20), migraine (odds ratio 1.17, 95% confidence interval 1.01-1.35), and migraine with aura (odds ratio 1.23, 95% confidence interval 1.01-1.53). No association was found between elevated high sensitivity C-reactive protein and migraine without aura or non-migrainous headache. The association between high sensitivity C-reactive protein and migraine was strongly dependent on insomnia status. Among individuals with insomnia, elevated high sensitivity C-reactive protein was associated with migraine (odds ratio 1.49, 95% confidence interval 1.02-2.17), and migraine with aura (odds ratio 1.59, 95% confidence interval 1.03-2.45), whereas no such relationship was found among those without insomnia. CONCLUSIONS: In this cross-sectional study, participants with migraine, in particular migraine with aura, were more likely to have elevated high sensitivity C-reactive protein, evident only among those with insomnia.

The impact of C-reactive protein levels on headache frequency in the HUNT study 2006-2008.

BACKGROUND: Increased high sensitivity C- reactive protein (hs-CRP) levels have been found in many earlier studies on migraine, and recently also in persons with migraine and insomnia. The aim of this study was to see whether these findings could be reproduced in a large-scale population-based study. METHODS: A total of 50,807 (54%) out of 94,194 invited aged ≥20 years or older participated in the third wave of the Nord-Trøndelag Health Study study performed in 2006-2008. Among these, 38,807 (41%) had valid measures of hs-CRP and answered questions on headache and insomnia. Elevated hs-CRP was defined as > 3.0 mg/L. The cross-sectional association with headache was estimated by multivariate analyses using multiple logistic regression. The precision of the odds ratio (OR) was assessed with 95% confidence interval (CI). RESULTS: In the fully adjusted model, elevated hs-CRP was associated with migraine (OR 1.14, 95% CI 1.04-1.25) and migraine with aura (OR 1.15, 95% CI 1.03-1.29). The association was strongest among individuals with headache ≥15 days/month for any headache (OR 1.26, 95% CI 1.08-1.48), migraine (OR 1.62, 95% CI 1.21-2.17), and migraine with aura (OR 1.84, 95% CI 1.27-2.67). No clear relationship was found between elevated hs-CRP and headache less than 7 days/month or with insomnia. CONCLUSIONS: Cross-sectional data from this large-scale population-based study showed that elevated hs-CRP was associated with headache ≥7 days/month, especially evident for migraine with aura.

Sleep duration mediates abdominal and lower-extremity pain after night work in nurses.

OBJECTIVES: The aim of this study was to investigate the association between different working shifts (i.e. morning, evening, night shifts) and headache, musculoskeletal and abdominal pain, and the extent to which reduced sleep duration could account for these associations. METHODS: Nurses (N = 679, 649 female, aged 22-53 years) were followed up for a period of 28 consecutive days, responding to a diary about sleep, shift type and pain complaints (measured on a Likert-type scale ranging from 0 to 3). Generalised structural equation modelling mediation analysis (GSEM) was performed to test whether shift type was associated with higher incidence or higher intensity of pain (headache, pain in neck/shoulders/upper back, upper extremity, low back, lower extremity and abdominal pain), and if this effect was mediated by sleep duration (continuous variable), after controlling for age, work and lifestyle factors. RESULTS: Pain scores in lower extremities were decreased following night shifts in general. However, when night shifts were followed by short sleep duration, the risk of pain in the lower extremities and abdominal pain were increased. Headache and pain in the upper extremity were increased after night shifts, but were not associated with sleep duration. Pain in the neck/shoulder/upper back and lower back was not related to shift work. CONCLUSIONS: Among nurses in a three-shift rotating schedule, night shifts increased the risk of pain in several regions, but only pain in the lower extremities and abdomen was related to reduced sleep duration.

Does pain sensitivity change by migraine phase? A blinded longitudinal study.

Objective Studies suggest that pain thresholds may be altered before and during migraine headaches, but it is still debated if a central or peripheral dysfunction is responsible for the onset of pain in migraine. The present blinded longitudinal study explores alterations in thermal pain thresholds and suprathreshold heat pain scores before, during, and after headache. Methods We measured pain thresholds to cold and heat, and pain scores to 30 seconds of suprathreshold heat four times in 49 migraineurs and once in 31 controls. Sessions in migraineurs were categorized by migraine diaries as interictal, preictal (≤one day before attack), ictal or postictal (≤one day after attack). Results Trigeminal cold pain thresholds were decreased ( p = 0.014) and pain scores increased ( p = 0.031) in the ictal compared to the interictal phase. Initial pain scores were decreased ( p < 0.029), and the temporal profile showed less adaptation ( p < 0.020) in the preictal compared to the interictal phase. Hand cold pain thresholds were decreased in interictal migraineurs compared to controls ( p < 0.019). Conclusion Preictal heat hypoalgesia and reduced adaptation was followed by ictal trigeminal cold suballodynia and heat hyperalgesia. Our results support that cyclic alterations of pain perception occur late in the prodromal phase before headache. Further longitudinal investigation of how pain physiology changes within the migraine cycle is important to gain a more complete understanding of the pathogenic mechanisms behind the migraine attack.

Prevalence of insomnia in a general adult population cohort using different diagnostic criteria: The seventh survey of the Tromsø study 2015-2016.

Insomnia disorder is a subjective complaint of sleep dissatisfaction including both night-time and daytime symptoms. Currently there are three commonly used diagnostic manuals each with their own set of criteria, which is often credited for the wide range in insomnia prevalence reported by population-based studies, especially those with self-reported insomnia. However, there are limited studies directly comparing different criteria and little is known about associations with health outcomes. Thus, the aim of this study was to compare the most commonly used diagnostic criteria for insomnia from the literature and to explore the associations with a range of physical and mental health outcomes. We used data from 21,083 women and men from the seventh survey of the population-based Tromsø Study which included adults aged 40-99 years. A revised version of the Bergen Insomnia Scale was used to define insomnia based on the 4th (revised) and 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR and DSM5), the 10th edition of the International Classification of Diseases (ICD-10), and the 3rd edition of the International Classification of Sleep Disorders (ICSD-3). We found the following prevalence of insomnia: DSM-IV-TR 23.6 %, DSM5 8.5 %, ICD-10 9.9 % and ICSD-3 20.0 %. When looking at each symptom, we found over half the participants classified as having insomnia using the DSM-IV-TR and ICSD-3 criteria did not report having impaired daytime functioning at least three days per week. Overall, participants with DSM5 and ICD-10 insomnia appeared to have worse health profiles, based on a higher percentage meeting the cut-off for possible anxiety or depression, reporting a psychological problem or chronic pain, and using antidepressants, painkillers or sleeping pills. However logistic regression models showed largely the same health factors had the same association with the odds for being classified as having insomnia disorder from each set of criteria. Overall, this study suggests that insomnia prevalence may be overestimated if daytime symptoms are not adequately included in accordance with current guidelines.

Night work, season and alertness as occupational safety hazards in the Arctic: protocol for the Noralert observational crossover study among Norwegian process operators.

INTRODUCTION: The objective of this study is to determine the effects of night work, Arctic seasonal factors and cold working environments on human functions relevant to safety. The study aims to quantify the contribution of (1) several consecutive night shifts, (2) seasonal variation on sleepiness, alertness and circadian rhythm and (3) whether a computational model of sleep, circadian rhythms and cognitive performance can accurately predict the observed sleepiness and alertness. METHODS AND ANALYSIS: In an observational crossover study of outdoor and indoor workers (n=120) on a three-shift schedule from an industrial plant in Norway (70 °N), measurements will be conducted during the summer and winter. Sleep duration and quality will be measured daily by smartphone questionnaire, aided by actigraphy and heart rate measurements. Sleepiness and alertness will be assessed at regular intervals by the Karolinska Sleepiness Scale and the psychomotor vigilance test, respectively. Saliva samples will assess melatonin levels, and a blood sample will measure circadian time. Thermal exposures and responses will be measured by sensors and by thermography. ETHICS AND DISSEMINATION: All participants will give written informed consent to participate in the study, which will be conducted in accordance with the Declaration of Helsinki. The Norwegian Regional Committee for Medical Research Ethics South-East D waivered the need for ethics approval (reference 495816). Dissemination plans include academic and lay publications, and partnerships with national and regional policymakers.

Polyneuropathy in Adolescent Childhood Cancer Survivors: The PACCS Study.

BACKGROUND: Childhood cancer survivors (CCS) are at risk of polyneuropathy due to chemotherapy, but studies in young survivors are scarce and diagnosis is challenging. We aimed to study the presence of polyneuropathy and the possible effect of cumulative doses of chemotherapeutic agents in a representative group of adolescent survivors. METHODS: CCS aged nine to 18 years and age- and sex-matched controls were recruited from the cross-sectional Physical Activity and Fitness among Childhood Cancer Survivors (PACCS) study. CCS with various cancer diagnoses who had ended cancer treatment one year or more before study were included. Polyneuropathy was evaluated clinically and with nerve conduction studies (NCSs) in three motor and five sensory nerves. We used mixed-effects linear regression models to compare CCS and controls, and investigate possible associations between cumulative chemotherapy doses and NCS amplitudes. RESULTS: A total of 127 CCS and 87 controls were included, with 14% CCS having probable or confirmed polyneuropathy. NCS amplitudes were lower in survivors compared with controls in all nerves. The largest mean difference was 3.47 µV (95% confidence interval [CI], 2.18 to 4.75) in the tibial plantar medial sensory and 1.91 mV (95% CI, 0.78 to 3.04) in the tibial motor nerve. The cumulative dose of platinum derivatives was associated with lower tibial motor nerve amplitude (-0.20; 95% CI, -0.35 to -0.04 mV for 100 mg/m2 dose increase) but not in other nerves. We found no significant associations between vinca alkaloids cumulative dose and amplitudes. CONCLUSIONS: CCS without clinical signs or symptoms of polyneuropathy may have subtle nerve affection. The clinical long-term impact of this novel observation should be evaluated in larger, longitudinal studies.

Accuracy of neuropathic pain measurements in patients with symptoms of polyneuropathy: validation of painDETECT, Self-Completed Leeds Assessment of Neuropathic Symptoms and Signs, and Douleur Neuropathique 4.

ABSTRACT: Pain is a common symptom in patients referred to polyneuropathy assessment. Diagnostic evaluation and choice of treatment may depend on whether the pain is likely to be neuropathic or not. This study aimed to investigate the diagnostic accuracy of 3 tools commonly used to differentiate between neuropathic and nonneuropathic pain. To accomplish this, we included patients with bilateral distal lower extremity pain, referred to neurological outpatient clinics at 5 Norwegian University hospitals for polyneuropathy assessment. The patients filled in Norwegian versions of painDETECT, the Self-Completed Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), and the clinician-rated Douleur Neuropathique 4 (DN4). All patients underwent a clinical examination and nerve conduction measurements and were classified according to the NeuPSIG neuropathic pain criteria (reference standard). In total, 729 patients were included, of which 63% had neuropathic pain by the reference standard. Only DN4 demonstrated high sensitivity (0.87), whereas all 3 tools had low specificity (≤0.65). Importantly, the tools' predictive ability was unsatisfactory; The probability of getting a correct test result was 3 quarters at best, and at worst, no better than two fifths. Consequently, we show that neither DN4, painDETECT, nor S-LANSS can be confidently used to assess neuropathic pain in a neurological outpatient population with symptoms of polyneuropathy.

Diagnostic accuracy of the 5.07 monofilament test for diabetes polyneuropathy: influence of age, sex, neuropathic pain and neuropathy severity.

INTRODUCTION: There is a need for simple and cheap diagnostic tools for diabetic polyneuropathy (DPN). We aimed to assess the diagnostic accuracy of the 5.07/10 g monofilament test in patients referred to polyneuropathy assessments, as well as to examine how disease severity, age, sex and neuropathic pain (NP) impact diagnostic accuracy. RESEARCH DESIGN AND METHODS: Five Norwegian university hospitals recruited patients with diabetes aged 18-70 referred to neurological outpatient clinics for polyneuropathy assessments. The 5.07/10 g Semmes-Weinstein monofilament examination (SWME) was validated against the Toronto consensus for diagnosing diabetic neuropathies; the results were stratified by age, sex and NP. Disease severity was graded by a combined nerve conduction study (NCS) Z-score, and logistic regression was applied to assess whether disease severity was a predictor of diagnostic accuracy. RESULTS: In total, 506 patients were included in the study. Global sensitivity was 0.60 (95% CI 0.55, 0.66), specificity 0.82 (95% CI 0.75, 0.87), positive and negative predictive values were 0.86 (95% CI 0.81, 0.90) and 0.52 (95% CI 0.46, 0.58), respectively, positive and negative likelihood ratios were 3.28 (95% CI 2.37, 4.53) and 0.49 (95% CI 0.42, 0.57), respectively. The SWME was less sensitive in females (0.43), had lower specificity in patients with NP (0.56), and performed worse in patients ≥50 years. NCS-based disease severity did not affect diagnostic accuracy (OR 1.15, 95% CI 0.95, 1.40). CONCLUSIONS: This multicenter study demonstrates poor diagnostic performance for the 5.07/10 g SWME in patients with diabetes referred to polyneuropathy assessments; it is particularly unsuited for female patients and those with NP. The diagnostic accuracy of the SWME was not influenced by NCS-based disease severity, demonstrating that it does not perform better in patients with later stages of DPN. We do not recommend the use of the 5.07/10 g monofilament in the evaluation of patients with diabetes referred to polyneuropathy assessments.

Review of techniques useful for the assessment of sensory small fiber neuropathies: Report from an IFCN expert group.

Nerve conduction studies (NCS) are an essential aspect of the assessment of patients with peripheral neuropathies. However, conventional NCS do not reflect activation of small afferent fibers, including Aδ and C fibers. A definitive gold standard for laboratory evaluation of these fibers is still needed and therefore, clinical evaluation remains fundamental in patients with small fiber neuropathies (SFN). Several clinical and research techniques have been developed for the assessment of small fiber function, such as (i) microneurography, (ii) laser evoked potentials, (iii) contact heat evoked potentials, (iv) pain-related electrically evoked potentials, (v) quantitative thermal sensory testing, (vi) skin biopsy-intraepidermal nerve fiber density and (vii) corneal confocal microscopy. The first five are physiological techniques, while the last two are morphological. They all have advantages and limitations, but the combined use of an appropriate selection of each of them would lead to gathering invaluable information for the diagnosis of SFN. In this review, we present an update on techniques available for the study of small afferent fibers and their clinical applicability. A summary of the anatomy and important physiological aspects of these pathways, and the clinical manifestations of their dysfunction is also included, in order to have a minimal common background.