Original article| Volume 95, ISSUE 2, P309-315, February 2014

Negative Affect and Sleep Disturbance May Be Associated With Response to Epidural Steroid Injections for Spine-Related Pain

Published:September 23, 2013DOI:



      To describe whether negative affect and sleep impairment are associated with the clinical effect of epidural steroid injections (ESIs) for low back pain.


      Observational study; patients were evaluated before ESI and 1 and 3 months after ESI.


      Spine center and related treatment sites.


      Participants (N=158) seeking treatment for low back pain with or without radiculopathy.


      ESI for low back pain with or without radiculopathy.

      Main Outcome Measures

      We assessed the dependent (global pain severity for back and leg pain, pain behavior, pain interference) and independent variables (depression, sleep disturbance, and covariates of back pain response) with the Patient-Reported Outcome Measurement Information System (PROMIS) and legacy measures. Outcome was assessed cross-sectionally using multiple regression and longitudinally with path analysis.


      After 1 month, sleep disturbance was the only predictor for the global ratings of improvement in back pain (R2=16.8%) and leg pain (R2=11.4%). The proportions of variance explained by sleep disturbance and negative affect for all dependent variables were greater at 3 months than 1 month. Mediation analysis was significant for negative affect for the 3-month outcomes on PROMIS pain behavior (β=.87, P<.01) and pain interference (β=.37, P<.01). There was no evidence of mediation by sleep disturbance for any outcome.


      Negative affect and sleep disturbance are associated with worse outcomes after ESI. Further research is needed to determine if treatment of negative affect and sleep disturbance prior to or concurrently with ESI will improve outcomes.


      List of abbreviations:

      CAT (computerized adaptive testing), CES-D (Center for Epidemiologic Studies-Depression), ESI (epidural steroid injection), MOS (Medical Outcomes Study), PROMIS (Patient-Reported Outcome Measurement Information System), RMDQ (Roland-Morris Disability Questionnaire)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Deyo R.A.
        • Weinstein J.N.
        Low back pain.
        N Engl J Med. 2001; 344: 363-370
        • Carey T.S.
        • Evans A.T.
        • Hadler N.M.
        • et al.
        Acute severe low back pain. A population-based study of prevalence and care-seeking.
        Spine. 1996; 21: 339-344
        • Hart L.G.
        • Deyo R.A.
        • Cherkin D.C.
        Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey.
        Spine. 1995; 20: 11-19
        • Andersson G.B.
        Epidemiological features of chronic low-back pain.
        Lancet. 1999; 354: 581-585
        • Frymoyer J.
        • Durett C.L.
        The economics of spinal disorders.
        in: Frymoyer J. Ducker T. Hadler N. Kostuik J. Weinstein J. Whitecloud T. The adult spine: principles and practice. Lippincott-Raven, Philadelphia1997: 143-150
        • Friedly J.
        • Chan L.
        • Deyo R.
        Increases in lumbosacral injections in the Medicare population: 1994 to 2001.
        Spine. 2007; 32: 1754-1760
        • Arden N.K.
        • Price C.
        • Reading I.
        • et al.
        A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study.
        Rheumatology. 2005; 44: 1399-1406
        • Armon C.
        • Argoff C.E.
        • Samuels J.
        • Backonja M.M.
        • Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology
        Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
        Neurology. 2007; 68: 723-729
        • Aalto T.J.
        • Malmivaara A.
        • Kovacs F.
        • et al.
        Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review.
        Spine. 2006; 31: E648-E663
        • Trief P.M.
        • Grant W.
        • Fredrickson B.
        A prospective study of psychological predictors of lumbar surgery outcome.
        Spine. 2000; 25: 2616-2621
        • Haig A.J.
        • Tong H.C.
        • Yamakawa K.S.
        • et al.
        Predictors of pain and function in persons with spinal stenosis, low back pain, and no back pain.
        Spine. 2006; 31: 2950-2957
        • Tang N.K.
        • Wright K.J.
        • Salkovskis P.M.
        Prevalence and correlates of clinical insomnia co-occurring with chronic back pain.
        J Sleep Res. 2007; 16: 85-95
        • Wilson K.G.
        • Eriksson M.Y.
        • D'Eon J.L.
        • Mikail S.F.
        • Emery P.C.
        Major depression and insomnia in chronic pain.
        Clin J Pain. 2002; 18: 77-83
        • Inman S.L.
        • Faut-Callahan M.
        • Swanson B.A.
        • Fillingim R.B.
        Sex differences in responses to epidural steroid injection for low back pain.
        J Pain. 2004; 5: 450-457
        • Amtmann D.
        • Cook K.F.
        • Jensen M.P.
        • et al.
        Development of a PROMIS item bank to measure pain interference.
        Pain. 2010; 150: 173-182
        • Ridley M.G.
        • Kingsley G.H.
        • Gibson T.
        • Grahame R.
        Outpatient lumbar epidural corticosteroid injection in the management of sciatica.
        Br J Rheumatol. 1988; 27: 295-299
        • Pilkonis P.A.
        • Choi S.W.
        • Reise S.P.
        • et al.
        Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
        Assessment. 2011; 18: 263-283
        • Buysse D.J.
        • Yu L.
        • Moul D.E.
        • et al.
        Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments.
        Sleep. 2010; 33: 781-792
        • Revicki D.
        • Chen W.
        • Harnam N.
        • et al.
        Development and psychometric analysis of the PROMIS pain behavior item bank.
        Pain. 2009; 146: 158-169
        • Roland M.
        • Morris R.
        A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain.
        Spine. 1983; 8: 141-144
        • Radloff L.
        The CES-D scale: a self-report depression scale for research in the general population.
        Appl Psychol Meas. 1977; 1: 385-401
        • Hays R.D.
        • Martin S.A.
        • Sesti A.M.
        • Spritzer K.L.
        Psychometric properties of the Medical Outcomes Study Sleep measure.
        Sleep Med. 2005; 6: 41-44
        • Wolfe F.
        • Smythe H.A.
        • Yunus M.B.
        • 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
        • Pearson A.
        • Lurie J.
        • Tosteson T.
        • et al.
        Who should have surgery for an intervertebral disc herniation? Comparative effectiveness evidence from the spine patient outcomes research trial.
        Spine. 2012; 37: 140-149
        • Demyttenaere K.
        • Bruffaerts R.
        • Lee S.
        • et al.
        Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys.
        Pain. 2007; 129: 332-342
        • Johansson Y.
        • Ek A.
        • Bachrach-Lindström M.
        Self-perceived health among older women living in their own residence.
        Int J Older People Nurs. 2007; 2: 111-118
        • Haskell S.G.
        • Ning Y.
        • Krebs E.
        • et al.
        Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom.
        Clin J Pain. 2012; 28: 163-167
        • Chou Y.
        • Shih C.
        • Lin J.
        • Chen T.
        • Liao C.
        Low back pain associated with sociodemographic factors, lifestyle and osteoporosis: a population-based study.
        J Rehabil Med. 2013; 45: 76-80
        • Knox J.
        • Orchowski J.
        • Scher D.L.
        • Owens B.D.
        • Burks R.
        • Belmont P.J.
        The incidence of low back pain in active duty United States military service members.
        Spine. 2011; 36: 1492-1500
        • Geisser M.E.
        • Roth R.S.
        • Theisen M.E.
        • Robinson M.E.
        • Riley 3rd, J.L.
        Negative affect, self-report of depressive symptoms, and clinical depression: relation to the experience of chronic pain.
        Clin J Pain. 2000; 16: 110-120
        • Alexandre N.M.
        • Nordin M.
        • Hiebert R.
        • Campello M.
        Predictors of compliance with short-term treatment among patients with back pain.
        Rev Panam Salud Publica. 2002; 12: 86-94
        • Lee Y.C.
        • Chibnik L.B.
        • Lu B.
        • et al.
        The relationship between disease activity, sleep, psychiatric distress and pain sensitivity in rheumatoid arthritis: a cross-sectional study.
        Arthritis Res Ther. 2009; 11: R160
        • Baglioni C.
        • Battagliese G.
        • Feige B.
        • et al.
        Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies.
        J Affect Disord. 2011; 135: 10-19
        • Dworkin R.H.
        • Turk D.C.
        • Wyrwich K.W.
        • et al.
        Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.
        J Pain. 2008; 9: 105-121
        • Dew M.A.
        • Hoch C.C.
        • Buysse D.J.
        • et al.
        Healthy older adults' sleep predicts all-cause mortality at 4 to 19 years of follow-up.
        Psychosom Med. 2003; 65: 63-73
        • Gallo J.J.
        • Bogner H.R.
        • Morales K.H.
        • Post E.P.
        • Lin J.Y.
        • Bruce M.L.
        The effect of a primary care practice-based depression intervention on mortality in older adults: a randomized trial. [Summary].
        Ann Intern Med. 2007; 146: 689-698
        • Karp J.F.
        • Rollman B.L.
        • Reynolds 3rd, C.F.
        • et al.
        Addressing both depression and pain in late life: the methodology of the ADAPT study.
        Pain Med. 2012; 13: 405-418
        • Stratford P.W.
        • Binkley J.
        • Solomon P.
        • Gill C.
        • Finch E.
        Assessing change over time in patients with low back pain.
        Phys Ther. 1994; 74: 528-533
        • Leclaire R.
        • Blier F.
        • Fortin L.
        • Proulx R.
        A cross-sectional study comparing the Oswestry and Roland-Morris Functional Disability scales in two populations of patients with low back pain of different levels of severity.
        Spine. 1997; 22: 68-71