Cognitive Behavioral Therapy Improves Sleep, Pain in Knee OA

Jennifer Garcia

February 11, 2015

Treatment with cognitive behavioral therapy (CBT) may help relieve insomnia and pain among patients with knee osteoarthritis (KOA), according to a new double-blind, randomized placebo-controlled clinical trial. The study findings were published online January 26 in Arthritis and Rheumatology.

Researchers led by Michael T. Smith, PhD, from the Johns Hopkins Center for Behavior and Health, Baltimore, Maryland, enrolled 100 patients between September 2008 and April 2013 who had been diagnosed with KOA, as determined by a rheumatologist. Eligible patients had radiographic evidence of KOA, knee pain ratings of 2 or more out of 10, and pain more than 5 days/week for more than 6 months and were receiving a stable dose of nonsteroidal anti-inflammatory drugs, if required. In addition, eligible patients met criteria for insomnia disorder, with "symptom duration > 1 month...> 2 nocturnal awakenings of >15 minutes duration...or self-reported wake after sleep onset time and/or latency to sleep onset >30 minutes."

The researchers randomly assigned the patients to receive eight sessions of CBT or behavioral desensitization placebo and evaluated sleep duration and quality using in-home polysomnograms (PSG), patient diaries, actigraphy, and baseline and posttreatment assessments of pain at 3 and 6 months. Pain assessments included a Pain Intensity Index and a sliding visual analog scale, as well as the Western Ontario McMaster Universities Osteoarthritis Scale.

According to diary, PSG, and actigraphy readings, patients in the CBT intervention group experienced a decrease in sleep maintenance insomnia, measured as wake after sleep onset time. Approximately 80% of patients in the CBT group "achieved normative clinical values for diary [wake after sleep onset time] (<30 mins.) compared to [behavioral desensitization] (50%) at posttreatment and 3 months." These rates were similar (60%) between the groups at 6 months, and the authors posit whether periodic booster sessions or reinforcement of coping skills may be used to address this attenuation of the effects of CBT.

In addition, the researchers found that reductions in diary and PSG wake after sleep onset time predicted a decrease in clinical pain at posttreatment and at 3- and 6-month follow-up among patients receiving CBT. Laboratory measures of pain modulation were similar between the two groups. Both groups reported significant and comparable reductions in pain over 6 months with a third demonstrating more than 30% reduction in pain severity.

Dr Smith and colleagues also note that the effects of CBT on insomnia were similar to what has previously been demonstrated with the use of benzodiazepine receptor agonist sedative hypnotics, and therefore suggest "that CBT [for insomnia] should be considered a first line treatment option for insomnia in older adults with KOA."

When asked to comment on these study findings, William J. Robb III, MD, from the Department of Orthopedic Surgery at the University of Chicago, Illinois, told Medscape Medical News that with respect to the possible risks associated with pharmacologic interventions, "[u]nderstanding and using effective alternatives would be valuable for some patients unable to use medications and decrease [the] harmful addictive effects of opioids."

Dr Robb went on to say that although the effects of CBT in this study were positive, "CBT does appear to be an expensive intervention, both in terms of time and costs associated with therapy sessions."

"As KOA is a common condition, applying [CBT] widely would likely be expensive," and "the time and commitment required from the patient's perspective might limit its general application," he noted.

Offering an alternative perspective, Joanne M. Jordan, MD, MPH, director of the Thurston Arthritis Research Center at the University of North Carolina, Chapel Hill, told Medscape Medical News that "Failure to assess and treat sleep disorders is a vital missed opportunity for intervention to improve pain and quality of life of our patients."

"The first thing that needs to happen is that care providers need to ask patients about sleep," added Dr Jordan. "Assessment of these issues does not need to require significant time during a clinic visit," she noted. Dr Jordan also suggests that use of the electronic medical records, engagement of members of the care team, and collection of patient-reported outcomes, even in the waiting room, could expedite collection of vital information so that appropriate referrals for CBT could be made.

The authors acknowledge study limitations such as the possibility of enhanced placebo effects resulting from the interventionists believing that the behavioral desensitization group of the study was the active group. The researchers also acknowledge a high dropout rate (27%), which may have been a result of the perceived burdensome nature of sleep assessments and CBT among patients.

"This trial is the largest to date to evaluate the efficacy of CBT [for insomnia] as a sole intervention for insomnia in chronic pain and the only study to include PSG measures of outcome," write Dr Smith and colleagues. The authors go on to point out that, "[g]iven that only a few studies have endeavored to test CBT [for insomnia] with a behavioral placebo, our finding of a large placebo effect requires continued investigation."

Funding for this study was provided by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Disease. The authors and Dr Robb have disclosed no relevant financial relationships. Dr Jordan is a consultant for Polyactiva, Samumed, and Johnson & Johnson.

Arthritis Rheumatol. Published online January 26, 2015. Abstract

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