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.

Trial registration: ClinicalTrials.gov NCT01142349.

Figure 1

CONSORT flow diagram for enrollment of potentially eligible participants. Eligible individuals were identified by screening survey of persons with osteoarthritis visits (N = 3,321); 1,210 respondents (36%) reported clinically significant arthritis pain and insomnia, and 998 of 1,210 persons initially eligible (82.5%) agreed to medical record review and contact by the study. “Baseline missing” is the number of individuals excluded because of missing baseline information; “2, 9 mo missing” is the number excluded because they were missing 2- and 9-month follow-up information. CBT-P = cognitive–behavioral therapy for pain; CBT-PI = cognitive–behavioral therapy for pain and insomnia; EOC = education-only control.

Figure 2

Mean primary and secondary sleep and pain outcome scores at baseline, posttreatment, and 9-month assessments for the education-only control (EOC), cognitive–behavioral therapy for pain (CBT-P), and cognitive–behavioral therapy for pain and insomnia (CBT-PI) groups. Lower scores indicate improvement on Insomnia Severity Index and pain severity; higher scores indicated improvement on sleep efficiency and arthritis symptoms.