Are opioids associated with sleep apnea? A review of the evidence

Chronic opioid use for nonmalignant pain has increased dramatically; nonillicit unintentional deaths have also increased. This article reviews the physiology of breathing, effects of sleep on respiration, effects of opioids on respiration, potential interactions between sleep and opioids on respiration, and current evidence that chronic opioid use is associated with sleep-disordered breathing.     

Does respiration perturb body balance more in chronic low back pain subjects than in healthy subjects?

OBJECTIVE: To determine whether body balance is perturbed more in low back pain patients than in healthy subjects, under the concept of posturo-kinetic capacity. DESIGN: Comparison of posturographic and respiratory parameters between low back pain and healthy subjects. BACKGROUND: It has been demonstrated that respiratory movements constitute a perturbation to posture, compensated by movements of the spine and of the hips, and that low back pain is frequently associated with a loss of back mobility. METHOD: Ten low back pain patients and ten healthy subjects performed five posturographic tests under three different respiratory rate conditions: quiet breathing (spontaneous), slow breathing (0.1 Hz) and fast breathing (0.5 Hz). RESULTS: Intergroup comparison showed that the mean displacements of the center of pressure were greater for the low back pain group, especially along the antero-posterior axis, where respiratory perturbation is primarily exerted. Inter-condition comparison showed that in slow and fast breathing relatively to quiet breathing, the mean displacement of the center of pressure along the antero-posterior axis was significantly increased only for the low back pain group. CONCLUSION: According to the results, respiration presented a greater disturbing effect on body balance in low back pain subjects. RELEVANCE: This study provides information on the causes of the impaired body balance associated with chronic low back pain, which could be used to improve treatment strategy.     

Can Slow Deep Breathing Reduce Pain? An Experimental Study Exploring Mechanisms

Slow deep breathing (SDB) is commonly employed in the management of pain, but the underlying mechanisms remain equivocal. This study sought to investigate effects of instructed breathing patterns on experimental heat pain and to explore possible mechanisms of action. In a within-subject experimental design, healthy volunteers (n = 48) performed 4 breathing patterns: 1) unpaced breathing, 2) paced breathing (PB) at the participant's spontaneous breathing frequency, 3) SDB at 6 breaths per minute with a high inspiration/expiration ratio (SDB-H), and 4) SDB at 6 breaths per minute with a low inspiration/expiration ratio (SDB-L). During presentation of each breathing pattern, participants received painful heat stimuli of 3 different temperatures and rated each stimulus on pain intensity. Respiration, heart rate, and blood pressure were recorded. Compared to unpaced breathing, participants reported less intense pain during each of the 3 instructed breathing patterns. Among the instructed breathing patterns, pain did not differ between PB and SDB-H, and SDB-L attenuated pain more than the PB and SDB-H patterns. The latter effect was paralleled by greater blood pressure variability and baroreflex effectiveness index during SDB-L. Cardiovascular changes did not mediate the observed effects of breathing patterns on pain.PerspectivesSDB is more efficacious to attenuate pain when breathing is paced at a slow rhythm with an expiration that is long relative to inspiration, but the underlying mechanisms remain to be elucidated.     

THE VALUE OF BLOWING UP A BALLOON

Suboptimal breathing patterns and impairments of posture and trunk stability are often associated with musculoskeletal complaints such as low back pain. A therapeutic exercise that promotes optimal posture (diaphragm and lumbar spine position), and neuromuscular control of the deep abdominals, diaphragm, and pelvic floor (lumbar-pelvic stabilization) is desirable for utilization with patients who demonstrate suboptimal respiration and posture. This clinical suggestion presents a therapeutic exercise called the 90/90 bridge with ball and balloon. This exercise was designed to optimize breathing and enhance both posture and stability in order to improve function and/or decrease pain. Research and theory related to the technique are also discussed.     

"Ineffective breathing pattern" care for COPD patients

Chronic obstructive pulmonary disease (COPD) is a long-term, chronic respiratory disease from which patients never fully recover. COPD patients usually face abnormal aeration caused by the disease. Patients that are unable to breathe and aspirate adequately and maintain lung appropriate expansion and contraction are considered to have ineffective breathing patterns. This causes physical, psychological and behavioral changes in COPD patients and impacts their emotional condition, daily activities and quality of life. Nurses who care for COPD patients with ineffective breathing patters can improve breathing muscle functions, improve respiration and keep the airway clean. In this paper, the author reviews and integrates relevant findings on this subject from the empirical literature in order to assist clinical nurses responsible for the care of COPD patients.     

Respiratory variability and associated cardiovascular changes in adults at rest

Summary. Breathing patterns and associated circulatory fluctuations may reflect the action of various regulatory mechanisms as well as mechanical influences of breathing on the circulation. Thus, the study of such patterns can enhance our knowledge of these mechanisms, both in normal and pathological conditions. In this review, literature is evaluated that provides insight into the breath-to-breath variation of respiration in quietly breathing adults. Also when respiration is seemingly random, deterministic patterns in the respiratory variability can often be discerned. The various methods used in the recognition of such patterns and their possible interpretation are discussed. Furthermore, the question is addressed how respiratory variability can affect the circulation and how this can be studied by analysing the time relationships of respiratory and circulatory parameters. This may add to both the understanding of normal cardiovascular regulation and to insight into cardiovascular disturbances under unstable respiratory conditions. As examples of such circumstances, some common conditions are discussed that are often, though not always, associated with pathology, viz. Cheyne-Stokes respiration, snoring and the sleep apnoea syndrome.     

Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity

Although obesity and physical activity have been argued to predict back pain, these factors are also related to incontinence and breathing difficulties. Breathing and continence mechanisms may interfere with the physiology of spinal control, and may provide a link to back pain. The aim of this study was to establish the association between back pain and disorders of continence and respiration in women. We conducted a cross-sectional analysis of self-report, postal survey data from the Australian Longitudinal Study on Women's Health. We used multinomial logistic regression to model four levels of back pain in relation to both the traditional risk factors of body mass index and activity level, and the potential risk factors of incontinence, breathing difficulties, and allergy. A total of 38,050 women were included from three age-cohorts. When incontinence and breathing difficulties were considered, obesity and physical activity were not consistently associated with back pain. In contrast, odds ratios (OR) for often having back pain were higher for women often having incontinence compared to women without incontinence (OR were 2.5, 2.3 and 2.3 for young, mid-age and older women, respectively). Similarly, mid-aged and older women had higher odds of having back pain often when they experienced breathing difficulties often compared to women with no breathing problems (OR of 2.0 and 1.9, respectively). Unlike obesity and physical activity, disorders of continence and respiration were strongly related to frequent back pain. This relationship may be explained by physiological limitations of co-ordination of postural, respiratory and continence functions of trunk muscles.     

Céphalées et sommeil: un survol diagnostique et un guide pour le clinicien

Sleep is a physiological and behavioral state where the person is partly isolated from the external environment. In the presence of sleep intrusions such as pain, sleep becomes fragmented. The non REM to REM ultradian oscillations, occurring every 90 to 110 minutes, are then disrupted by several brief and transient arousals (rise in cardiac, brain, muscle, and respiratory activities). The pain reports from these individuals tend to be exacerbated by the loss of sleep continuity. Tension headache, migraine, and cluster headache may occur before sleep (delaying sleep onset), during sleep (e.g., migraine, hypnic headache, cluster headache, and chronic paroxysmal hemicrania), or upon awakening (e.g., breathing disorder, bruxism, pain medication overuse, and arterial hypertension). Minor traumatic brain injury is frequently associated with headache and circadian sleep disturbances. Little is known on how to manage sleep-related headaches. A polygraphic search for breathing disturbances or periodic limb movements is recommended if the complaints are recurrent and associated with daytime somnolence. Use of breathing or oral devices is helpful if an upper airway resistance is present or if apnea-hypopnea is observed. Cognitive and behavioral approaches related to sleep hygiene and lifestyle are valuable. Hypnotic medications probably have limited long-term value.     

Musculoskeletal pain in adults with cerebral palsy compared with the general population.

OBJECTIVE: To examine prevalence and localization of musculo-skeletal pain in adults with cerebral palsy compared with the general population and to investigate variables potentially associated with pain. DESIGN: A postal survey. SUBJECTS: Persons with cerebral palsy and no intellectual disabilities, 18 years or more, living in Norway. METHODS: A multidimensional questionnaire, including items on musculo-skeletal pain, was sent to 766 adults with cerebral palsy. RESULTS: In total 406 persons responded, 49% females and 51% males age range 18-72 years (mean 34 years). All categories of cerebral palsy were represented. Nearly one-third of the adults with cerebral palsy had chronic pain, vs 15% in the general population. Mean scores of domain of bodily pain on Short Form 36 were significantly lower from an earlier age in adults with cerebral palsy. Back pain was the most common in both groups. Pain in adults with cerebral palsy was significantly associated with gender, chronic fatigue, low life satisfaction and deteriorating physical function. CONCLUSION: Musculo-skeletal pain is a pronounced problem in adults with cerebral palsy from an early age, and should be addressed specifically in the follow-up programs, and in further clinical studies on potential causal pathways.     

Recent advance in evaluation of lung function of obstructive lung disease]

Chaos of the abdominal movement was examined in obstructive lung disease. Body inductive plethysmograph was used and the analog record was digitized at sampling interval of 100 ms. Correlation dimension was calculated according to the method of Grassberger-Procaccia. In chronic obstructive lung disease and chronic pulmonary emphysema (CPE), correlation dimension was positively correlated with respiratory frequency. The degrees of freedom were between 3-6. The subjects with CPE with periodic breathing showed a lower correlation dimension, which was comparable with Cheyne-Stokes respiration. One subject with dyspnea due to asthmatic attack showed a higher dimension than at the time of remission. Assessment of respiratory chaos may provide a new way of approach to elucidate breathing impairment in obstructive lung disease.     

Reversal of Sleep-Disordered Breathing with Opioid Withdrawal

Obstructive sleep apnea, central sleep apnea, sleep related hypoventilation, Biot's or ataxic breathing, and cluster breathing are some of the commonly described sleep disorders in patients who are on long-term opioids. Continuous positive airway pressure that is commonly used to treat obstructive sleep apnea may not be effective in treating sleep-disordered breathing in long-term opioid users, and an adaptive servoventilator (ASV) may be needed. We present a 30-year-old woman with excessive daytime sleepiness and sleep-disordered breathing for the past 4 years. Medical history was complicated by chronic osteomyelitis, periorbital abscess, and chronic facial pain requiring methadone for pain control for the last 4 years. In this case, ASV, though effective, was not tolerable due to chronic facial pain, and successful withdrawal of methadone at our pain rehabilitation center resolved the sleep-disordered breathing and improved daytime sleepiness. This is to our knowledge the first case report of resolution of sleep-disordered breathing and improvement in daytime sleepiness after withdrawal of long-term opioid use.     

Biofeedback training for reduced respiratory rate in chronic obstructive pulmonary disease: a preliminary study

The overall objective of this preliminary investigation was to determine whether breathing patterns of patients with chronic obstructive pulmonary disease could be altered by training patients to voluntarily change their breathing, using techniques of biofeedback training. The specific aims were (1) to develop a method of monitoring respiratory rate and tidal volume with a device that was both accurate and usable without discomfort or inconvenience to the patient; (2) to use the method with patients having chronic obstructive pulmonary disease to determine whether respiratory rate could be slowed by voluntary controls; and (3) to determine whether patients who could slow their breathing rate would increase their tidal volume and demonstrate other respiratory changes.     

Development and Validation of an Evidence-Based Breathing Exercise Intervention Protocol for Chronic Pain Management in Breast Cancer Survivors

BackgroundBreathing exercise has been utilized as a promising approach to pain management in cancer survivors. However, the development process of the breathing exercise intervention protocol was rarely reported.AimTo develop an evidence-based breathing exercise intervention protocol for chronic pain management in breast cancer survivors and to provide a detailed account of the intervention development process.MethodsThe study design was guided by the Medical Research Council Framework for Developing and Evaluating Complex Intervention. The breathing exercise intervention development process adopted phase one of the Medical Research Council Framework for Developing and Evaluating Complex Intervention framework. The content validity index was applied to determine the consensus of the appropriateness of the breathing exercise intervention protocol among the panel experts.ResultsThe preliminary breathing exercise intervention protocol was developed based on fight-or-flight theory and vagus nerve theory, and the best available research evidence identified from seven systematic reviews, three clinical trials, and four practice recommendations. The breathing exercise intervention was designed as slow deep pursed-lip breathing with a time ratio of inspiration to expiration 1:2-3. The intensity of the breathing exercise was determined as 3 to 5 sessions a day, 5 minutes per session, for 4 weeks. The content validity of the breathing exercise intervention protocol was excellent as consensus was achieved among all panel experts with both the item-level and scale-level CVIs reaching 1.0.ConclusionsThis study developed an evidence-based breathing exercise intervention protocol for chronic pain management in breast cancer survivors. The protocol is well-supported by the relevant theories, research evidence, practice recommendations, and experts’ consensus.     

慢性鼻窦炎伴鼻息肉行鼻内镜术后睡眠障碍影响因素及护理干预

目的探讨慢性鼻窦炎伴鼻息肉行鼻内镜术后睡眠障碍影响因素,依此制订护理干预措施。方法选择我院2018年1月至2019年6月收治的慢性鼻窦炎伴鼻息肉行鼻内镜术患者70例,采用匹兹堡睡眠质量指数评价患者术后睡眠质量,统计术后睡眠障碍例数,采用单因素和多因素logistic回归分析患者术后睡眠障碍影响因素,据此确定护理干预措施。结果多因素logistic回归分析显示,焦虑评分≥50分、抑郁评分≥53分、疼痛评分≥4分、呼吸方式改变不适、睡眠环境改变不适为术后睡眠障碍独立影响因素(P<0.05)。结论慢性鼻窦炎伴鼻息肉行鼻内镜术后患者因负性心理、疼痛干扰、呼吸方式改变不适、睡眠环境改变不适而出现睡眠障碍,护理人员需加强心理调节、疼痛控制,促进其尽快适应呼吸方式及睡眠环境变化。     

Respiratory characteristics of individuals with non‐specific low back pain: A cross‐sectional study

Non‐specific low back pain (NS‐LBP) is known to cause respiratory dysfunction. In this study, we investigated alterations in breathing, respiratory strength and endurance, core stability, diaphragm mobility, and chest expansion among patients with NS‐LBP and healthy individuals. The specific aim of the study was to correlate between respiratory function and other variables among NS‐LBP patients. Thirty four patients with NS‐LBP were matched with 34 healthy participants before undergoing total faulty breathing scale, spirometer, respiratory pressure meter, chest expansion, ultrasound, and pressure biofeedback measurements. There were signs of faulty breathing in the NS‐LBP patients when compared to the healthy participants. Diaphragmatic mobility and respiratory muscle endurance were lower in the NS‐LBP group. Chest expansion exhibited a significant decrease at the level of the fourth intercostal space in the NS‐LBP group, but respiratory muscle strength and core stability were not significant between the two groups. Positive correlations were found to be fairly significant regarding respiratory muscle strength. The findings of this study indicated altered respiratory characteristics in the NS‐LBP patients, and suggested that they would improve through respiratory exercises.     

The reliability and validity of the standardized Mensendieck test in relation to disability in patients with chronic pain

The standardized Mensendieck test (SMT) was developed to quantify posture, movement, gait, and respiration. In the hands of an experienced therapist, the SMT is proven to be a reliable tool. It is unclear whether posture, movement, gait, and respiration are related to the degree of functional disability in patients with chronic pain. The objective of this study was to assess the reliability and convergent validity of the SMT in a heterogeneous sample of 50 patients with chronic pain. Methods: Internal consistency was determined by Cronbach’s α and interrater reliability by the intraclass correlation coefficient (ICC). Convergent validity was assessed by determining the Spearman rank correlation coefficient between the movement quality measured in the SMT and functional limitation measured on the disability rating index (DRI). Results: The internal consistency was Cronbach’s α 0.91. Substantial reliability was found for the items: movement (ICC = 0.68), gait (ICC = 0.69), sitting posture (ICC = 0.63), and respiration (ICC = 0.64). Insufficient reliability was found for standing posture (ICC = 0.23). A moderate correlation was found between average test score SMT and the DRI (r = ?0.37) and respiration and DRI (r = ?0.45). Discussion: The SMT is a reasonably reliable tool to assess movement, gait, sitting posture, and respiration. None of the items in the domain standing posture has sufficient reliability. A thorough study of this domain should be considered. The results show little evidence for convergent validity. Several items of the SMT correlated moderately with functional limitation with the DRI. These items were global movement, hip flexion, pelvis rotation, and all respiration items.