Cognitive‐Behavioral Treatment for Comorbid Insomnia and Osteoarthritis Pain in Primary Care: The Lifestyles Randomized Controlled Trial

Abstract

OBJECTIVES To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive–behavioral therapy for pain and insomnia (CBT-PI), a cognitive–behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes. DESIGN Double-blind, cluster-randomized controlled trial with 9-month follow-up. SETTING Group Health and University of Washington, 2009 to 2011. PARTICIPANTS Three hundred sixty-seven older adults with OA pain and insomnia. INTERVENTIONS Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants’ primary care clinics. MEASUREMENTS Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms. RESULTS CBT-PI reduced insomnia severity (score range 0–28) more than EOC (adjusted mean difference = −1.89, 95% confidence interval = −2.83 to −0.96; P < .001) and CBT-P (adjusted mean difference = −2.03, 95% CI = −3.01 to −1.04; P < .001) and improved sleep efficiency (score range 0−100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44−4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85−4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results. CONCLUSION Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes. J Am Geriatr Soc 2013.

The association of comorbid conditions with patient-reported outcomes in Veterans with hip and knee osteoarthritis

“…Another research suggests that fatigue tends to be more severe as the number of comorbid conditions increases [21]. We assessed fatigue with a 10-cm visual analog scale that asked patients to indicate how severely fatigue had been a problem for them over the past week, using anchors of “no problem” to “major problem.” At least half of the patients with OA report sleep disturbances [22, 23], making sleep another key PRO in this group of patients. We measured global perceived insomnia symptoms with the Insomnia Severity Index, which includes seven items measured on 5-point Likert scales, for a total range of 0–28.…”

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“…To this end, the use of whole body mass impedance measures and the ability to examine local and general body fat distribution versus lean muscle mass, which can contribute to a high body mass index value along with periodic vitamin D assays, followed by long term carefully designed tailored multi pronged interventions as outlined by Janke et al 59 and Barlow, 60 as well as a focus on diet content, 61 stress control, 62 glucose control 63 and avoidance of reduced bone mineral density effects that can occur post weight loss 64 is highly recommended in this respect, as is careful attention to maximizing mental health through cognitive behavioral therapy 65,66 ( Figure 3) and behavioral therapy combined, 67,68 as well as overall health status, muscle and physical function through non pharmacologic approaches. 69,70 Finally ascertaining the cause of prevailing obesity and intervening accordingly in this respect is strongly advocated. …”

Obesity, Osteoarthritis and Pain

“…Hence avoiding such extreme measures in efforts to reduce osteoarthritis pain in obese cases seems highly recommended. To this end, the use of whole body mass impedance measures and the ability to examine local and general body fat distribution versus lean muscle mass, which can contribute to a high body mass index value along with periodic vitamin D assays, followed by long term carefully designed tailored multi pronged interventions as outlined by Janke et al [59] and Barlow [60], as well as a focus on diet content [61], stress control [62], glucose control [63] and avoidance of reduced bone mineral density effects that can occur post weight loss [64] is highly recommended in this respect, as is careful attention to maximizing mental health through cognitive behavioral therapy [65,66] (Figure 3) and behavioral therapy combined [67,68], as well as overall health status, muscle and physical function through non pharmacologic approaches [69,70]. Finally ascertaining the cause of prevailing obesity and intervening accordingly in this respect is strongly advocated.…”