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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

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Volume 19, Issue 4


The association between insomnia, c-reactive protein, and chronic low back pain: cross-sectional analysis of the HUNT study, Norway

Kevin Kwan Ngai Ho
  • Corresponding author
  • The University of Sydney, Musculoskeletal Research Group, Faculty of Health Sciences, Sydney, Australia
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/ Milena Simic
  • The University of Sydney, Musculoskeletal Research Group, Faculty of Health Sciences, Sydney, Australia
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/ Milada Cvancarova Småstuen
  • Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
  • Oslo Metropolitan University, Department of Health Science, Institute of Nursing Science, Oslo, Norway
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/ Marina de Barros Pinheiro
  • The University of Sydney, Musculoskeletal Research Group, Faculty of Health Sciences, Sydney, Australia
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/ Paulo Herrique Ferreira
  • The University of Sydney, Musculoskeletal Research Group, Faculty of Health Sciences, Sydney, Australia
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/ Marianne Bakke Johnsen
  • Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
  • Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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/ Ingrid Heuch
  • Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
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/ Margaret Grotle
  • Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
  • Oslo Metropolitan University, Department of Physiotherapy, Oslo, Norway
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/ John Anker Zwart
  • Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
  • Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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/ Kristian Bernhard Nilsen
  • Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
  • NTNU, Department of Neuromedicine and Movement Science, Trondheim, Norway
  • Department of Neurology, Oslo University Hospital, Oslo, Norway
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Published Online: 2019-07-09 | DOI: https://doi.org/10.1515/sjpain-2019-0033


Background and aims

Chronic low back pain (chronic LBP) is the number one cause for years lived with disability among 301 diseases and injuries analyzed by The Global Burden of Disease study 2013. Insomnia is highly prevalent among people with chronic LBP. To explain the sleep-pain relationship, theoretical models propose that insomnia symptoms may be associated with increased basal inflammation, operationalized as c-reactive protein (CRP) and lead to further pain and disrupted sleep. We aimed to determine the associations between insomnia, chronic LBP, and inflammation (operationalized as CRP), whilst controlling for age, body mass index, smoking, physical activity, depression, anxiety and osteoarthritis.


A cross-sectional analysis of the third Nord-Trøndelag Health Study (2006–2008), a rural population survey of 50,666 participants in Norway aged 20–96 years. Insomnia (dichotomous) was defined according to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition, and chronic LBP (dichotomous) as low back pain or stiffness lasting at least 3 months. Data for CRP were obtained from non-fasting serum samples and assessed via latex immunoassay methodology. We excluded participants with the following self-reported chronic somatic diseases: chronic heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, fibromyalgia or ankylosing spondylosis. Possible associations between presence of insomnia and presence of chronic LBP (dependent), and the level of CRP and presence of chronic LBP (dependent), were assessed using logistic regression models. The possible association between insomnia and CRP (dependent) was assessed using linear regression. Multivariable analyses were conducted adjusting for confounders stated in our aim that achieved p ≤ 0.2 in univariate regressions. We performed stratified analyses for participants with “Normal” (<3 mg/L) “Elevated” (3–10 mg/L) and “Very High” (>10 mg/L) levels of CRP.


In our total included sample (n = 30,669, median age 52.6, 54% female), 6.1% had insomnia (n = 1,871), 21.4% had chronic LBP (n = 6,559), and 2.4% had both (n = 719). Twenty four thousand two hundred eighty-eight (79%) participants had “Normal” CRP, 5,275 (17%) had “Elevated” CRP, and 1,136 (4%) had “Very High” CRP. For participants with “Normal” levels of CRP, insomnia was associated with higher levels of CRP (adjusted B = 0.04, 95%CI [0.00–0.08], p = 0.046), but not for people with “Elevated” or “Very High” levels of CRP. There was an association between CRP and presence of chronic LBP in the total sample (adjusted OR = 1.01, [1.00–1.01], p = 0.013) and for people with “Normal” CRP (1.05, [1.00–1.10, p = 0.034]. Insomnia was associated with the presence of chronic LBP in the total sample (adjusted OR = 1.99, 95%CI [1.79–2.21], <0.001) and for people with “Normal”, “Elevated” and “Very High”.


Individuals with insomnia have twice the odds of reporting chronic LBP. Insomnia, CRP and chronic LBP appear to be linked but the role of CRP appears to be limited. Longitudinal studies may help further explore the causal inference between insomnia chronic LBP, and inflammation.


Given the strong relationship between insomnia and chronic LBP, screening and management of comorbid insomnia and chronic LBP should be considered in clinical practice. Further longitudinal studies are required to explore whether the presence of insomnia and increased inflammation affects the development of chronic LBP.

Keywords: chronic low back pain; insomnia; c-reactive protein; inflammation; epidemiology


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About the article

Received: 2019-02-20

Revised: 2019-04-26

Accepted: 2019-06-06

Published Online: 2019-07-09

Published in Print: 2019-10-25

Authors’ statements

Research funding: The authors state there was no specific funding involved for this project. PHF is funded by an Australian National and Health Medical Research Council (NHMRC) fellowship. MS is funded by a Sydney University Research Accelerator Fellowship.

Conflict of interest: The authors state no conflict of interest.

Informed consent: Informed consent has been obtained from all individuals included in this study.

Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

Citation Information: Scandinavian Journal of Pain, Volume 19, Issue 4, Pages 765–777, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2019-0033.

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