Telephone cognitive behavioral therapy for insomnia in adults With osteoarthritis pain

1. Telephone cognitive behavioral therapy for insomnia (CBT-I) was an effective treatment for sleep issues among patients with osteoarthritis pain (OA).

2. Fatigue was significantly reduced among the CBT-I group, compared to the education-only group.

3. CBT-I demonstrated evidence of short-term pain reduction, but this was not sustained at 12-month follow-up.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Cognitive behavioral therapy is an effective treatment for insomnia (CBT-I). However, treatment delivery to rural and underserved populations has been limited. Utilizing telephone methods that can be more easily accessed by these groups of people could allow for better treatment and reduced disparities among individuals with insomnia and pain conditions, such as osteoarthritis pain (OA).

This randomized clinical trial of 327 older adults were randomly assigned to be exposed to six 20-30-minute telephone CBT-I sessions or group-specific educational materials. CBT-I was found to improve fatigue and sleep, as well as pain among older adults. Pain reductions did not remain significant at 12-month follow-up, but posttreatment differences in the earlier stages were significant.

Overall, this study demonstrated that telephone CBT-I is an effective treatment for sleep disturbances and fatigue in pain patients, with some evidence for short-term pain reduction. Further, this treatment can be conducted via telephone to reach a broader group of patients in need of care. At a time when virtual healthcare is an important component of treatment, this study confirms that CBT-I is one such treatment that can be effectively delivered through technological means.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Cognitive Behavioral Therapy for Insomnia Improves Sleep and Decreases Pain in Older Adults with Co-Morbid Insomnia and Osteoarthritis

In-Depth [ prospective cohort]:

CBT-I has proven effectiveness and this may be extended to individuals with comorbid pain conditions, such as OA. Further, delivering CBT-I via telephone would allow for rural and underserved populations to have greater accessibility to effective treatment. This randomized clinical trial of adults over the age of 60 years with OA and moderate-to-severe insomnia sought to investigate the effectiveness of telephone CBT-I compared to education-only controls (EOC). Participants 60 years of age and older were recruited through Kaiser Permanente Washington between September 2016 and December 2018, being screened twice at least three weeks apart for moderate-to-severe insomnia and OA pain symptoms. Blind assessments of patients in both the CBT-I and EOC groups were conducted at baseline, two months posttreatment, and 12 months posttreatment. Treatment included six 20-30-minute sessions conducted via telephone over eight weeks. While the CBT-I group was educated on sleep restriction, stimulus control, cognitive restructuring, and sleep hygiene, the EOC group only received information about sleep and OA.

Participants were assessed via the Insomnia Severity Index (ISI) at two months and 12 months follow-up. They were also assessed for pain via the Brief Pain Inventory-short form, depression via the Patient Health Questionnaire (8-item), and fatigue via the Flinders Fatigue Scale. Of the 327 older adult participants (M [SD] age = 70.2 [6.8] years, 74.6% female), 282 had follow-up ISI data at the two-month follow-up. The ISI scores decreased in both groups, with CBT-I proving more effective (adjusted mean difference = -3.5 points, 95% CI -4.4 to -2.6, p<.001). These results retained significance at 12-month follow-up (adjusted mean difference = -3.0, 95% CI -4.1 to 02.0, p<.001). Approximately 56.3% of participants in the CBT-I group were still in remission at 12 months, compared to 25.8% of the EOC group. Fatigue was another area of improvement, with CBT-I proving superior in its posttreatment effects at two months (mean difference = -2.0, 95% CI -3.1 to -0.9, p<.001) and 12 months (mean difference = -1.8, 95% CI -3.1 to -.06, p = .003). Lastly, pain was significantly reduced during posttreatment follow-up but these differences between groups did not remain significant at 12-month follow-up.

Image: PD

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