The association between pain and sleep in fibromyalgia

Buse Keskindag, Meryem Karaaziz


Objective: To clarify the association between pain and sleep in fibromyalgia. 


Methods: Electronic databases, including PsycINFO, the Cochrane database for systematic reviews, PubMed, EMBASE, and Ovid were searched to identify eligible articles. Databases independently screened and  the quality of evidence using a reliable and valid quality assessment tool was assessed. 


Results: In total, 16 quantitative studies fulfilled the inclusion criteria. According to the results, increased pain in fibromyalgia was associated with reduced sleep quality, efficiency, and duration and increased sleep disturbance and onset latency and total wake time. Remarkably, depressive symptoms were also related to both pain and sleep in patients with fibromyalgia.  


Conclusion: Management strategies should be  developed to decrease pain while increasing sleep quality in patients with fibromyalgia. Future studies should also consider mood disorders and emotional dysfunction, as comorbid conditions could occur with both pain and sleep disorder in fibromyalgia. 


Saudi Med J 2017; Vol. 38 (5): 465-475
doi: 10.15537/smj.2017.5.17864

How to cite this article:

Keskindag B, Karaaziz M. The association between pain and sleep in fibromyalgia. Saudi Med J. 2017 May;38(5):465-475. doi: 10.15537/smj.2017.5.17864.


Pain; sleep ; fibromyalgia ; systematic review

Full Text:



Bergman S. A general practice approach to management of chronic widespread musculoskeletal pain and fibromyalgia (Revised). In: Adebajo OA, Dickson J, editors. Collected Reports on the Rheumatic Diseases. Series 4 (Revised). Halmstad (SW): Arthritis Research Campaign; 2005. p. 129-139.

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33: 160-172.

Wolfe F. New American College of Rheumatology Criteria for Fibromyalgia: A Twenty-Year Journey. Arthritis Care Res 2010; 62: 583-584.

Cote KA, Moldofsky H. Sleep, daytime symptoms, and cognitive performance in patients with fibromyalgia. J Rheumatol 1997; 24: 2014-2023.

Shaver JL, Lentz M, Landis CA, Heitkemper MM, Buchwald DS, Woods NF. Sleep, psychological distress, and stress arousal in women with fibromyalgia. Res Nurs Health 1997; 20: 247-257.

Lashley FR. A review of sleep in selected immune and autoimmune disorders. Holist Nurs Pract 2003; 17: 65-80.

Mease P, Arnold LM, Choy EH, Clauw DJ, Crofford LJ, Glass JM, et. al. Fibromyalgia syndrome module at OMERACT 9: domain construct. J Rheumatol 2009; 36: 2318-2329.

Consoli G, Marazziti D, Ciapparelli A, Bazzichi L, Massimetti G, Giacomelli C, et al. The impact of mood, anxiety, and sleep disorders on fibromyalgia. Compr Psychiatry 2012; 53: 962-967.

Affleck G, Tennen H, Urrows S, Higgins P, Abeles M, Hall C, et. al. Fibromyalgia and women’s pursuit of personal goals: a daily process analysis. Health Psychol 1998; 17: 40-47.

Arnold LM, Crofford LJ, Mease PJ, Burgess SM, Palmer SC, Abetz L, et. al. Patient perspectives on the impact of fibromyalgia. Patient Educ Couns 2008; 73: 114-120.

Kelly GA, Blake C, Power CK, O’Keeffe D, Fullen BM. The association between chronic low back pain and sleep: a systematic review. Clin J Pain 2011; 27: 169-181.

Chiu YH, Silmana AJ, Macfarlane GJ, Ray D, Gupta A, Dickens C, et. al. Poor sleep and depression are independently associated with a reduced pain threshold. Results of a population based study. Pain 2005; 115: 316-321.

Kundermann B, Spernal J, Huber MT, Krieg JC, Lautenbacher S. Sleep deprivation affects thermal pain thresholds but not somatosensory thresholds in healthy volunteers. Psychosom Med 2004; 66: 932-937.

Nicassio PM, Wallston KA. Longitudinal relationships among pain, sleep problems, and depression in rheumatoid arthritis. J Abnorm Psychol 1992; 101: 514-520.

Arnold LM, Hudson JI, Keck PE, Auchenbach MB, Javaras KN, Hess EV. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry 2006; 67: 1219-1225.

Liberati M, Tetzlaff AJ, Altman DG. The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement. PLoS Med 2009; 6: e1000097.

Khan KS, Kunz R, Kleijnen J, Antes G. Five steps to conducting a systematic review. J R Soc Med 2003; 96: 118-121.

Effective Public Health Practice Projec. Quality Assessment Tool for Quantitative Studies. [cited 2009]. Available from

Deeks JJ, Dinnes J, D’Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7: 1-173.

Affleck G, Urrows S, Tennen H, Higgins P, Abeles M. Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia. Pain 1996; 68: 363-368.

Nicassio PM, Moxham EG, Schuman CE, Gevirtz RN. The contribution of pain, reported sleep quality, and depressive symptoms to fatigue in fibromyalgia. Pain 2002; 100: 271-279.

Hamilton N, Catley D, Karlson C. Sleep and the affective response to stress and pain. Health Psychol 2007; 26: 288-295.

Bigatti SM, Hernandez AM, Cronan TA, Rand KL. Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression. Arthritis Care Res 2008; 59: 961-967.

O’Brien EM, Waxenberg LB, Atchison JW, Gremillion HA, Staud RM, McCrae CS, et al. Negative mood mediates the effect of poor sleep on pain among chronic pain patients. Clin J Pain 2010; 26: 310-319.

Schaefer C, Chandran A, Hufstader M, Baik R, McNett M, Goldenberg D et al. The comparative burden of mild, moderate and severe fibromyalgia: results from a cross-sectional survey in the United States. Health Qual Life Outcomes 2011; 9: 71.

Wagner JS, DiBonaventura MD, Chandran AB, Cappelleri JC. The association of sleep difficulties with health-related quality of life among patients with fibromyalgia. BMC Musculoskelet Disord 2012; 13: 199.

Hamilton NA, Pressman M, Lillis T, Atchley R, Karlson C, Stevens N. Evaluating evidence for the role of sleep in fibromyalgia: A test of the sleep and pain diathesis model. Cognit Ther Res 2012; 36: 806-814.

Anderson RJ, McCrae CS, Staud R, Berry RB, Robinson ME. Predictors of clinical pain in fibromyalgia: Examining the role of sleep. J Pain 2012; 13: 350-358.

Kothari DJ, Davis MC, Yeung EW, Tennen HA. Positive affect and pain : mediators of the within-day relation linking sleep quality to activity interference in fibromyalgia. Pain 2015; 156: 540-546.

Miro E, Martinez MP, Sanchez AI, Prados G, Medina A. When is pain related to emotional distress and daily functioning in fibromyalgia syndrome? The mediating roles of self-efficacy and sleep quality. Br J Health Psychol 2011; 16: 799-814.

Diaz-Piedra C, Catena A, Miro E, Martinez MP, Sanchez AI, Buela-Casal G. The impact of pain on anxiety and depression is mediated by objective and subjective sleep characteristics in fibromyalgia patients. Clin J Pain 2014; 30: 852-859.

Diaz-Piedra C, Catena A, Sánchez AI, Miró E, Pilar Martínez M, Buela-Casal G. Sleep disturbances in fibromyalgia syndrome: The role of clinical and polysomnographic variables explaining poor sleep quality in patients. Sleep Med 2015; 16: 917-925.

Theadom A, Cropley M, Humphrey KL. Exploring the role of sleep and coping in quality of life in fibromyalgia. J Psychosom Res 2007; 62: 145-151.

Theadom A, Cropley M. Dysfunctional beliefs, stress and sleep disturbance in fibromyalgia. Sleep Med 2008; 9: 376-381.

Ağargün MY, Tekeoğlu I, Güneş A, Adak B, Kara H, Ercan M. Sleep quality and pain threshold in patients with fibromyalgia. Compr Psychiatry 1999; 40: 226-228.

Love A, Leboeuf C, Crisp TC. Chiropractic chronic low back pain sufferers and self-report assessment methods. Part I. A reliability study of the Visual Analogue Scale, the Pain Drawing and the McGill Pain Questionnaire. J Manipulative Physiol Ther 1989; 12: 21-25.

Pearce J, Morley S. An experimental investigation of the construct validity of the McGill Pain Questionnaire. Pain 1989; 39: 15-121.

Burckhardt CS, Clark S, Bennett RM. The Fibromyalgia Impact Questionnaire: development and validation. J Rheumatol 1991; 18: 728-733.

Bryce TN, Budh CN, Cardenas DD, Dijkers M, Felix ER, Finnerup NB et al. Pain after spinal cord injury: an evidence-based review for clinical practice and research. Report of the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures meeting. J Spinal Cord Med 2007; 30: 421-440.

Jensen MP. Measurement of Pain. In: Fishman SM, Ballantyne JC, Rathmell JP, editors. Bonica’s management of pain. Philadelphia (PA): Williams & Wilkins; 2010. p. 251-270.

Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain 2011; 152: 2399-2404.

Raymond NC, de Zwaan M, Fails PL, Nugent SM, Ackard DM, Crosby RD, et al. Pain thresholds in obese binge-eating disorders subjects. Biol Psychiatry 1995; 37: 202-204.

Ağargün MY, Tekeooğu I, Kara H, Adak B, Ercan M. Hypnotizability, pain threshold, and dissociative experiences. Biol Psychiatry 1998; 44: 69-71.

Nicassio, PM, Radojevic V, Schoenfeld-Smith K, Dwyer K. The contribution of family cohesion and the pain-coping process to depressive symptoms in fibromyalgia. Ann Behav Med 1995; 17: 349-356.

Nicassio PM, Schoenfeld-Smith K, Radojevic V, Schuman C. Pain coping mechanisms in fibromyalgia: relationship to pain and functional outcomes. J Rheumatol 1995; 22: 1552-1558.

Nicassio PM, Schuman C, Radojevic V, Weisman MH. Helplessness as a mediator of health status in fibromyalgia. Cognit Ther Res 1999; 23: 181-196.

Stone A, Shiffman S. Ecological momentary assessment (EMA) in behavioral medicine. Ann Behav Med 1994; 16: 199-202.

Stone AA, Broderick JE, Porter LS, Kaell AT. The experience of rheumatoid arthritis pain and fatigue: Examining momentary reports and correlates over one week. Arthritis Care Res 1997; 10: 185-193.

Mason JH, Silverman SL, Weaver AL, Simms RW. Impact of fibromyalgia on multiple aspects of health status. Scand J Rheumatol 1992; 94: 33.

Jenkinson C, Stewart-Brown S, Petersen S, Paice C. Assessment of the SF-36 version 2 in the United Kingdom. J Epidemiol 1999; 53: 46-50.

Nicassio PM, Ormseth SR, Custodio MK, Olmstead R, Weisman MH, Irwin MR. Confirmatory factor analysis of the Pittsburgh Sleep Quality Index in rheumatoid arthritis patients. Behav Sleep Med 2014; 12: 1-12.

Cole JC, Motivala SJ, Buysse DJ, Oxman MN, Levin MJ, Irwin MR. Validation of a 3-factor scoring model for the Pittsburgh sleep quality index in older adults. Sleep 2006; 29:112.

Edinger JD, Wohlgemuth WK. Psychometric comparisons of the standard and abbreviated DBAS-10 versions of the dysfunctional beliefs and attitudes about sleep questionnaire. Sleep Med 2001; 2: 493-500.

Johns MW. Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep 1992; 15: 376-381.

Tennen H, Affleck G. Daily processes in coping with chronic pain: methods and analytic strategies, In: Zeidner M, Endler N, editors. Handbook of Coping. New York (NY): John Wiley & Sons, Inc.; 1996. p. 151-180.

Moskowitz DS, Young SN. Ecological momentary assessment: what it is and why it is a method of the future in clinical psychopharmacology. J Psychiatry Neurosci 2006; 31: 13-20.

McCall WV, Erwin CW, Edinger JD, Krystal AD, Marsh GR. Ambulatory polysomnography: technical aspects and normative values. J Clin Neurophysiol 1992; 9: 68-77.

O’Donoghue GM, Fox N, Heneghan C, Hurley DA. Objective and subjective assessment of sleep in chronic low back pain patients compared with healthy age and gender matched controls: a pilot study. BMC Musculoskelet Disord 2009; 2: 101-122.

Pejovic S, Natelsonö BH, Basta M, Fernandez-Mendoza J, Mahr F, Vgontzas AV. Chronic fatigue syndrome and fibromyalgia in diagnosed sleep disorders: a further test of the ‘unitary’ hypothesis. BMC Neurol 2015; 15: 53.

Lichstein KL, Stone KC, Donaldson J, Nau SD, Soeffing JP, Murray D, et al. Actigraphy validation with insomnia. Sleep 2006; 29: 232-239.

Ancoli-Israel S, Cole R, Alessi C, Chambers M, Moorcroft M, Pollak CP. The role of actigraphy in the study of sleep and circadian rhythms. American Academy of Sleep Medicine Review Paper. Sleep 2003; 26: 342-392.

Lentz MJ, Landis CA, Rothermel J, Shaver JL. Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women. J Rheumatol 1999; 26: 1586-1592.

Older SA, Battafarano DF, Danning CL, Ward JA, Grady EP, Derman S, et al. The effects of delta wave sleep interruption on pain thresholds and fibromyalgia-like symptoms in healthy subjects; correlations with insulin-like growth factor I. J Rheumatol 1998; 25: 1180-1186.

Lautenbacher S, Kundermann B, Krieg JC. Sleep deprivation and pain perception. Sleep Med Rev 2006; 10: 357-369.

Wilson KG, Watson ST, Currie SR. Daily diary and ambulatory activity monitoring of sleep in patients with insomnia associated with chronic musculoskeletal pain. Pain 1998; 75: 75-84.

Onen SH, Alloui A, Gross A, Eschallier A, Dubray C. The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects. J Sleep Res 2001; 10: 35-42.

Edwards RR, Almeida DM, Klick B, Haythornthwaite JA, Smith MT. Duration of sleep contributes to next-day pain report in the general population. Pain 2008; 137: 202-207.

Dzierzewski JM, Williams JM, Roditi D, Marsiske M, McCoy K, McNamara J, et. al. Daily variations in objective night time sleep and subjective morning pain in older adults with insomnia: Evidence of covariation over time. J Am Geriatr Soc 2010; 58: 925-930.

Marty M, Rozenberg S, Duplan B, Thomas P, Duquesnoy B, Allaert, F. Quality of sleep in patients with chronic low back pain: a case-control study. Eur Spine J 2008; 17: 839-844.

Parrino L, Zucconi M, Terzano M. Sleep fragmentation and arousal in the pain patient. In: Lavigne G, Sessle B, Choiniere M, et al, editors. Sleep and Pain. Seattle: IASP Press; 2007. p. 213-231.

Moldofsky H. The contribution of sleep-wave physiology for fibromyalgia. Adv Pain Res Ther 1990; 17: 227-240.

Perlis ML, Giles DE, Bootzin RR, Dikman ZV, Fleming GM, Drummond SPA, et. al. Alpha sleep and information processing, perception of sleep, pain and arousability in fibromyalgia. Int J Neurosci 1997; 89: 265-280.

MacDonald S, Linton SJ, Jansson-Frojmark M. Cognitive vulnerability in the development of concomitant pain and sleep disturbances. Br J Health Psychol 2010; 15: 417-434.

Moldofsky H. Rheumatic manifestations of sleep disorders. Curr Opin Rheumatol 2010; 22: 59-63.

Moldofsky H. Management of sleep disorders in fibromyalgia. Rheum Dis Clin North Am 2002; 28: 353-365.

White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: Comparing the demographic and clinical characteristics in 100 random community cases of fibromyalgia versus controls. J Rheumatol 1999; 26: 1577-1585.

Cohen MJM, Menefee LA, Doghramji l, Anderson WR, Frank ED. Sleep in chronic pain: Problems and treatments. Int Rev Psychiatry 2000; 12: 115-127.

Landis CA, Lentz MJ, Rothermel J, Buchwald D, Shaver JL. Decreased sleep spindles and spindle activity in midlife women with fibromyalgia and pain. Sleep 2004; 27: 741-750.

Wilson KG, Eriksson MY, D’Eon JL, Mikail SF, Emery PC. Major depression and insomnia in chronic pain. Clin J Pain 2002; 18: 77-83.

Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain interrelate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev 2004; 8: 119-132.

Deardorff W. Breaking the cycle of chronic pain and insomnia. [cited 2005]. Available from

Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain 2013; 14: 1539-1552.

Ohayon MM. Relationship between chronic painful physical condition and insomnia. J Psychiatr Res 2005; 39: 151-159.

Carrette S. Fibromyalgia 20 years later: what have we really accomplished? J Rheumatol 1995; 22: 590-594.

Tang NK, Goodchild CE, Sanborn AN, Howard J, Salkovskis PM. Deciphering the temporal link between pain and sleep in a heterogeneous chronic pain patient sample: a multilevel daily process study. Sleep 2012; 35: 675A-687A.

Harrison L, Wilson S, Heron J, Stannard C, Munafò MR. Exploring the associations shared by mood, pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample. Psychol Health 2016; 446: 1-13.

Hall M, Buysse DJ, Nowell PD, Nofzinger EA, Houck P, Reynolds CF et al. Symptoms of stress and depression ascorrelates of sleep in primary insomnia. Psychosom Med 2000; 62: 227-230.

Engel CC, von Korff M, Katon WJ. Back pain in primary care: Predictors of high health-care costs. Pain 1996; 65: 197-204.

Okifuji A, Turk DC, Sherman JJ. Evaluation of the relationship between depression and fibromyalgia syndrome: Why aren’t all patients depressed? J Rheumatol 2000; 27: 212-219.

Berber JSS, Kupek E, Berber SC. Prevalence of depression and its relationship with quality of life in patients with fibromyalgia syndrome. The Brazilian Journal of Rheumatology 2005; 45: 47-54.

Börsbo B, Peolsson M, Gerdle B. The complex interplay between pain intensity, depression, anxiety and catastrophising with respect to quality of life and disability. Disabil Rehabil 2009; 31: 1605-1613.

Lepine JP, Briley M. The epidemiology of pain in depression. Hum Psychopharmacol 2004; 19: 3-7.

Aalto TJ, Malmivaara A, Kovacs F, Herno A, Alen M, Salmi L. et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine 2006; 31: E648-E663.

Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine 2000; 25: 2616-2621.

Walker MP, Harvey AG. Obligate symbiosis: sleep and affect. Sleep Med Rev 2010; 14: 215-217.

Prather AA, Bogdan R, Hariri AR. Impact of sleep quality on amygdala reactivity, negative affect, and perceived stress. Psychosom Med 2013; 75: 350-358.

Davis MC, Zautra AJ, Reich JW. Vulnerability to stress among women with chronic pain from fibromyalgia and osteoarthritis. Ann Behav Med 2001; 23: 215-226.

Zautra AJ, Johnson LM, Davis MC. Positive affect as a source of resilience for women in chronic pain. J Consult Clin Psychol 2005; 73: 212-220.

Rutledge DN, Jones K, Jones CJ. Predicting high physical function in people with fibromyalgia. J Nurs Scholarsh 2007; 39: 319-324.

Morin CM, Gibson D, Wade J. Self-reported sleep and mood disturbance in chronic pain patients. Clin J Pain 1998; 14: 311-314.

Pilowsky I, Crettenden I, Townley M. Sleep disturbance in pain clinic patients. Pain 1985; 23: 27-33.

Vitello MV, Moe KE, Larsen LH, Prinz PN. Age related sleep change: relationships of objective and subjective measures of sleep in healthy older men and women. Sleep Research 1997; 26: 220.


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