Sleep interventions for osteoarthritis and spinal pain: a systematic review and meta-analysis of randomized controlled trials

High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life

BACKGROUND AND AIMS

Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively.

METHODS

A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain.

RESULTS

There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01).

CONCLUSIONS

Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery.

TRIAL REGISTRATION

The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain: A systematic review with network meta-analysis

This network meta-analysis aimed to estimate the comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain. Seven databases were systematically searched up to February 2023. A random-effects network meta-analysis in a frequentist framework was performed to synthesize continuous data as standardized mean differences (SMD) along with a 95% confidence interval (95% CI). A total of 15,641 records were identified, and 107 randomized controlled trials involving 8,121 participants were included. Of 14 identified interventions, eight were significantly more effective than passive control in improving sleep quality at immediate post-intervention (SMDs = 0.67-0.74), with cognitive behavioral therapy (CBT) being the most effective treatment (SMD = 0.74, 95% CI: 0.45-1.03). Only CBT demonstrated sustained effects at short-term (SMD = 1.56; 95% CI: 0.62-2.49) and mid-term (SMD = 1.23; 95% CI: 0.44-2.03) follow-ups. Furthermore, CBT significantly improved subjective (SMD = 0.64; 95% CI: 0.25-1.03) and objective (SMD = 0.30; 95% CI: 0.01-0.59) sleep efficiency compared with passive control at immediate post-intervention. Our findings support CBT as the first-line treatment for improving sleep in individuals with chronic musculoskeletal pain, given its superior effectiveness across multiple sleep outcomes and its sustainable effects until mid-term follow-up. However, the certainty of evidence for these interventions in improving sleep quality was very low to low.

Measures of sleep are not routinely captured in trials assessing treatment outcomes in knee osteoarthritis - A scoping systematic review and call to action

Objective

To identify and map the extent to which trials for pain interventions in individuals with knee osteoarthritis (OA) track measures of sleep, characterize the type of sleep measure assessed, and assess their influence on pain-related effect sizes.

Design

A scoping review was conducted, searching seven bibliometric databases from 2000 to 2022. We included all randomized controlled trials with a primary purpose of assessing non-surgical pain management interventions for adults with knee OA. All non-surgical interventions and any comparator or control were included. Demographic data were pooled from all trials.

Results

926 trials conducted in 61 countries met eligibility. Nineteen trials (2.1%) recorded some form of sleep assessment. Eleven trials (1.2%) assessed a formal index of sleep disturbance collected at multiple time points. No trials formally assessed the influence of sleep on the primary pain outcome (e.g., as a potential mediator), nor met the most recent guidelines for core data element recommendations regarding sleep assessment.

Conclusion

This review highlights the paucity of sleep data captured and reported in randomized controlled trials for knee OA. The vast majority of trials addressing symptomatic knee OA do not capture sleep measures, significantly limiting the ability to accurately determine an intervention's effect on pain. Future research should include formal sleep-centric assessments measured at multiple time points to analyze sleep dysfunction and its relationship on treatment effects.

Association of meeting 24-hour movement guidelines with low back pain among adults

Background

According to recently published 24-hour movement guidelines, adults should spend: ≥150 minutes/week in moderate-to-vigorous physical activity (MVPA); <8 hours/day in sedentary behaviour (SB); and 7-9 hours/day sleeping.

Objective

We explored the association between meeting these recommendations and low back pain (LBP)-the most common musculoskeletal disorder.

Methods

We collected self-reported data from 2333 adults about: MVPA, SB and sleep duration; frequency and intensity of LBP; and sociodemographic and lifestyle characteristics.

Results

Meeting a combination of SB and sleep recommendations was associated with lower odds of LBP in the past week and past month (adjusted odds ratio [OR]: 0.64 and 0.52, respectively; p < 0.05 for both). Among LBP sufferers, meeting any combination of recommendations that includes sleep was associated with lower odds of frequent (OR range: 0.49-0.61; p < 0.05 for all) and intense (OR range: 0.39-0.66; p < 0.05 for all) LBP in the past week, while meeting a combination of SB and sleep recommendations or all three recommendations was associated with lower odds of intense LBP in the past month and past year (OR range: 0.50-0.68; p < 0.05 for all). The likelihood of experiencing higher frequency and intensity of LBP decreased with the number of recommendations met (p for linear trend < 0.05).

Conclusion

Meeting the SB and sleep recommendations in combination is associated with a lower likelihood of LBP, while adhering to the overall 24-hour movement guidelines or any combination of recommendations that includes sleep is associated with lower frequency and intensity of LBP among LBP sufferers.

Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials

STUDY OBJECTIVES

To investigate the extent to which sleep measures are reported in intervention trials for chronic low back pain.

METHODS

A systematic scoping review was conducted. Ovid MEDLINE, Cochrane CENTRAL, and CINAHL were queried for trials published between January 2010 and December 2022 using keywords related to chronic low back pain. Two reviewers screened and reviewed abstracts and full texts for eligibility criteria and extracted data. Randomized intervention trials with the aim to treat pain or disability related to chronic low back pain in adults were included. Data were pooled and synthesized from trials that included a measure of sleep.

RESULTS

Two hundred eighty-two trials conducted in 40 different countries were included in the final review. Twenty-six trials (9.2%) assessed any sleep measure, and 13 (4.6%) collected a formal sleep disturbance measure at multiple time points. Three trials analyzed the mediating effects of sleep disturbance on pain. Reporting of sleep measures was no better in more recently published trials; trials published in 2010 (22%; n = 2/9) and 2022 (23%; n = 3/13) had the highest reporting rates.

CONCLUSIONS

The poor adherence to guideline recommendations for capturing measures of sleep quality or disturbance limits clinicians' and researchers' understanding of how sleep may influence treatment effects for chronic low back pain. There is an opportunity to improve the understanding of the relationship between sleep and pain with improved collection and reporting of sleep disturbance measures.

CITATION

Neilson BD, Dickerson C, Young JL, Shepherd MH, Rhon DI. Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials. J Clin Sleep Med. 2023;19(11):1961-1970.

Association of Sleep Disturbance With Catastrophizing and Knee Pain: Data From the Osteoarthritis Initiative

OBJECTIVE

To investigate the relationship between sleep disturbance, catastrophizing, and knee pain in middle-aged and older individuals.

METHODS

Data from the Osteoarthritis Initiative cohort from months 48 to 96 were used, where month 48 was treated as baseline. Knee pain (Western Ontario and McMaster Universities Osteoarthritis Index pain scale score ≥5 [range 0-20]), catastrophizing (extracted from Coping Strategies Questionnaire score ≥3 [range 0-6]), and sleep quality (extracted from Center for Epidemiologic Studies Depression Scale [range 1-4]) were assessed annually. We described the association of sleep disturbance with the presence and risk of knee pain and catastrophizing. The mediation effect of knee pain and catastrophizing on the sleep-catastrophizing and sleep-pain association was evaluated, respectively.

RESULTS

Catastrophizing and knee pain were reported in 346 (10%) and 917 (24%) of the 3,813 participants (mean 64.9 years, 58% female) at baseline. Participants with worse sleep disturbance were more likely to have knee pain (prevalence ratio [PR] 1.4-2.0, P for trend <0.001) and catastrophizing (PR 1.4-3.1, P for trend <0.001). Sleep disturbance at baseline predicted the risk of knee pain (risk ratio [RR] 1.1, P for trend <0.001) and catastrophizing (RR 1.2-1.7, P for trend <0.001) during follow-up. No statistically significant interactions between sleep disturbance and knee pain or catastrophizing were observed. Knee pain and catastrophizing mediated the sleep-catastrophizing and sleep-pain association, respectively, at baseline, and knee pain negatively mediated the sleep-catastrophizing association longitudinally.

CONCLUSION

Sleep disturbance was associated with the presence and risk of catastrophizing and knee pain. Sleep interventions may have a universal and independent effect in preventing incident knee pain.

The effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis - A systematic review with meta-analysis

This systematic review aimed to systematically investigate the literature on the effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis. For that, seven databases were searched for relevant randomized controlled trials. After the searches, 36 studies investigating 2281 participants were included. Risk of bias assessments were done by two independent reviewers using the Cochrane Risk of Bias tool 2. Random-effects meta-analyses were performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to judge the certainty of evidence. The evidence on benefits of exercise and physical activity programs on fatigue and sleep parameters in people with osteoarthritis and psoriatic arthritis was either lacking or inconclusive. There was very low to low certainty evidence for a slight benefit of exercise and physical activity programs on fatigue at short-term in people with ankylosing spondylitis and rheumatoid arthritis. However, the evidence was very uncertain for the medium- and long-term as well as for any sleep parameters. The results indicate that exercise and physical activity programs may offer some benefits on fatigue for people with arthritis in the short-term, although the best type of exercise remains uncertain. The available evidence on improvements in sleep was insufficient to draw strong conclusions.

Clinical reasoning in managing chronic hip pain: One in two Australian and New Zealand physiotherapists diagnosed a case vignette with clinical criteria for hip OA as hip OA. A cross-sectional survey

OBJECTIVES

Using a case vignette of an adult (George) presenting with hip pain consistent with hip OA, this study aimed to describe: (a) whether physiotherapists make diagnoses and identify bodily structures using either patient history and/or physical examination findings; (b) which diagnoses and bodily structures physiotherapists attribute to the hip pain; (c) how confident physiotherapists were in their clinical reasoning using patient history and physical examination findings; (d) what treatments physiotherapists would offer to George.

METHODS

We conducted a cross-sectional online survey of physiotherapists in Australia and New Zealand. We used descriptive statistics to analyse closed questions and content analysis for open-text responses.

RESULTS

Two hundred and twenty physiotherapists completed the survey (39% response-rate). After receiving the patient history, 64% diagnosed George's pain and 49% of these as hip OA; 95% attributed George's pain to a bodily structure(s). After receiving the physical examination, 81% diagnosed George's hip pain and 52% of these as hip OA; 96% attributed George's hip pain to a bodily structure(s). Ninety-six percent of respondents were at least somewhat confident in their diagnosis after the patient history, and 95% were similarly confident after the physical examination. Most respondents offered advice (98%) and exercise (99%), but fewer offered treatments for weight loss (31%), medication (11%), and psychosocial factors (<15%).

DISCUSSION

About half of the physiotherapists that diagnosed George's hip pain made a diagnosis of hip OA, despite the case vignette including clinical criteria for a diagnosis of OA. Physiotherapists offered exercise and education, but many physiotherapists did not offer other clinically indicated and recommended treatments, such as weight loss and sleep advice.

Does poor sleep quality lead to increased low back pain the following day?

OBJECTIVES

This study explored the relationship between sleep quality and next-day pain intensity for people with low back pain and investigated whether there was any evidence that this relationship was causal.

METHODS

We conducted a secondary analysis of an observational study that investigated sleep quality in people with low back pain. People with low back pain were recruited from primary care and the community. Sleep quality was measured with subjective (self-report) and objective (polysomnography (PSG)) measures. PSG analysis classifies sleep into stages, of which slow-wave sleep (SWS) is thought to have a key role in maintaining or increasing pain intensity. We drew directed acyclic graphs to identify possible confounders of the relationship between both measures of sleep quality, and pain intensity. We constructed two linear regression models to explore the effect of subjective and objective sleep quality on next-day pain intensity before and after confounder adjustment.

RESULTS

Thirty-nine participants were included in the study. For participants with low back pain, self-reported better quality sleep β=-0.38 (95% CI -0.63 to -0.13), or spending a greater proportion of time in SWS β=-0.12 (95% CI -0.22 to -0.02) was associated with lower next day pain intensity. After confounder adjustment, the effect reduced and was no longer significant for either self-reported β=-0.18 (95% CI -0.46 to 0.10), or SWS β=-0.08 (95% CI -0.18 to 0.03).

CONCLUSIONS

Sleep quality, whether measured by self-report or proportion of time in SWS, was associated with next day pain intensity for people with low back pain. However, this relationship is likely to be confounded and therefore not likely to be causal.

Virtual Tools to Enable Management of Knee Osteoarthritis

Purpose of review

There is increasing recognition that virtual tools, enabled by the internet and telecommunications technology, can increase access to health care. We review evidence about the clinical effectiveness and acceptability of telephone-delivered and videoconferencing clinician consultations, websites and internet-delivered programs, and SMS and mobile applications in enabling the management of people with knee osteoarthritis (OA). We discuss barriers to using virtual tools and suggest strategies to facilitate implementation in clinical settings.

Recent findings

An increasing number of systematic reviews, meta-analyses, and clinical trials provide evidence showing the effectiveness of virtual tools for improving knee OA management. Qualitative research shows that virtual tools increase patient access to knee OA care, are generally acceptable and convenient for patients, but can be associated with barriers to use from patient and clinician perspectives.

Summary

Virtual tools offer new opportunities to enable people with knee OA to manage their condition and receive care that may otherwise be difficult or not possible to access. Telephone calls and videoconferencing can be used for real-time synchronous consultations between clinicians and patients, increasing the geographic reach of health services. Websites and internet-based programs can be used to educate patients about their condition, as well as deliver exercise, weight management, and psychological interventions. Mobile apps can monitor and track OA symptoms, exercise, and physical activity, while SMS can facilitate positive behaviour changes for self-management over the long-term when sustained clinician contact may not be possible.

Effects of non-pharmacological interventions on sleep in chronic low back pain: A systematic review and meta-analysis of randomised controlled trials

Low back pain is a leading cause of disability worldwide and adults with chronic low back pain (≥12weeks) commonly experience sleep impairments (e.g., insomnia, sleep disturbance). This study examined the effects of non-pharmacological interventions on sleep in adults with chronic low back pain. Six databases (PubMed, CINAHL, SPORTDiscus, PsycINFO, EMBASE, CENTRAL) were searched from inception to 2 June 2021 for randomised controlled trials. Pairwise random-effect meta-analysis estimated standardised mean difference (Hedges' g) at end-of-intervention follow-up. Nineteen studies (participants: 1348) were included. When compared to control, non-pharmacological interventions improved sleep (g [95%CI]: -0.33 [-0.56, -0.11], p = 0.004, small effect, I² = 59.3%; n = 879; studies: n = 13; GRADE: low). This small improvement in sleep was associated with a moderate reduction in pain intensity (-0.69 [-1.00, -0.38], p < 0.001, I² = 75.3%; n = 812; studies: n = 12; GRADE: very low) and no changes in back-related disability (-0.50 [-1.13, 0.14], p = 0.129, I² = 91.4%; n = 517; studies: n = 6; GRADE: low). Notably, all eligible studies reported interventions primarily aimed to reduce pain, although our search criteria were not limited to pain interventions. Key limitations were data paucity and high risk of bias. Future research should investigate sleep-based interventions (i.e., those purposely designed to improve sleep) using subjective and objective measures across a range of sleep domains (CRD42021275227).

Impact of cognitive behavior therapy on osteoarthritis-associated pain, insomnia, depression, fatigue, and physical function in patients with knee/hip osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Background

This meta-analysis aimed at evaluating the efficacy of cognitive behavior therapy (CBT) against osteoarthritis-associated symptoms in patients with knee/hip osteoarthritis.

Methods

Medline, PubMed, Cochrane Library, and EMBASE databases were searched from inception to July 2022 to identify randomized controlled trials (RCTs) comparing the efficacy of CBT with other treatment approaches in adults with confirmed knee/hip osteoarthritis. The pain intensity (primary outcome) and the secondary outcomes including insomnia severity, sleep efficiency, physical function as well as the severity of depression and fatigue were assessed at two time points (i.e., immediately after treatment and during the follow-up period). The effect size is expressed as standardized mean difference (SMD) with SMDs of < 0.2, 0.2-0.5, and 0.5-0.8, and > 0.8 representing negligible, small, medium, and large effect sizes, respectively.

Results

Fifteen RCTs were included for analysis. Immediately after CBT intervention, meta-analysis showed similar treatment effect in pain severity [SMD = -0.46, 95% confidence interval (CI): -0.95 to 0.04, 11 studies, 1557 participants] and other symptoms including depression (SMD = -0.26, 95% CI: -0.58 to 0.06, five studies, 735 participants), fatigue (SMD = -2.44, 95% CI:-6.53 to 1.65, two RCTs, 511 participants), and physical function (SMD = -0.11, 95% CI:-0.25 to 0.02, five RCTs, 720 participants) between CBT and control groups, while there was an improvement in insomnia severity (SMD = -0.65, 95% CI: -1.06 to -0.24, four RCTs, 639 participants, medium treatment effect) and sleep efficiency (SMD = 0.32, 95% CI: 0.04 to 0.59, three RCTs, 352 patients, small treatment effect). During follow-up, CBT improved pain severity (SMD = -0.52, 95% CI: -1.03 to -0.01, eight studies, 1447 participants, medium treatment effect), insomnia (SMD = -0.43, 95% CI: -0.85 to -0.01, three RCTs, 571 participants, small treatment effect), and depression (SMD = -0.39, 95% CI: -0.59 to -0.18, four RCTs, 791 participants, small treatment effect). Nevertheless, sleep efficiency, fatigue, and physical function were not improved in the follow-up period.

Conclusion

Our results may suggest the durability of CBT-associated treatment benefits, supporting its role as a potential promising alternative or complementary intervention for patients with knee/hip osteoarthritis, especially against pain and insomnia. Future large-scale investigations are warranted to verify our findings.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022331165].

Comparison of the effectiveness of cognitive behavioral therapy for insomnia, cognitive behavioral therapy for pain, and hybrid cognitive behavioral therapy for insomnia and pain in individuals with comorbid insomnia and chronic pain: A systematic review and network meta-analysis

Considering that insomnia and chronic pain are often comorbid, we aimed to compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), cognitive behavioral therapy for pain (CBT-P), and cognitive behavioral therapy for insomnia and pain (CBT-IP) in individuals with comorbid insomnia and chronic pain. We used PubMed, PsycINFO, CENTRAL, and Web of Science for our literature search. The outcomes included sleep, pain, disability, and depression at post-treatment and follow-up (3-12 months). Sixteen randomized controlled trials with 1094 participants were included. In the Bayesian network meta-analysis, CBT-I [standard mean difference (SMD) = -0.99, 95% credible interval (CrI) = -1.50 to -0.54] and CBT-IP (SMD = -0.70, 95% CrI = -1.60 to -0.08) were significantly more effective than the control for sleep at post-treatment. Additionally, CBT-I was significantly more effective than the control for pain, disability, and depression at post-treatment and sleep at follow-up. However, there were no significant differences in effectiveness between CBT-P and the control for any outcomes. Thus, CBT-I might be the most effective treatment option for individuals with comorbid insomnia and chronic pain. However, given the small sample sizes and high risk of bias of the included studies, these results must be interpreted with caution.

Osteoarthritis is positively associated with self-reported sleep trouble in older adults

BACKGROUND

Osteoarthritis (OA) is a leading cause of disability in older adults. Most research has focused on minimizing pain and maximizing physical function so as to maintain patient mobility preceding joint arthroplasty. However, few studies have formally studied the relationship between OA and sleep trouble, although it is clinically recognized that OA may affect sleep.

METHODS

The study was based on the National Health and Nutrition Examination Survey (NHANES) database from 2011-2018. Participants were defined as adults aged 60 years or older with diagnoses of OA and self-reported sleep trouble. Multivariable regression analyses were applied to assess the association between OA and sleep trouble, adjusting for age, sex, body mass index, race/ethnicity, education level, marital status, income, depression level, etc. RESULTS: This study included 4154 participants, consisting of the control group (n = 2966) and the OA group (n = 1188). OA individuals were 2.11 (95% CI 1.79-2.47, p < 0.001) times more likely to have sleep trouble compared with those without OA. On subgroup analyses, there was lower odds ratio value of sleep trouble in men compared with women, and in the highest income group compared with the other income groups.

CONCLUSIONS

OA was positively associated with sleep trouble in older adults, with different odds ratio values among different subgroups. Our results suggest that older adults with OA should be aggressively screened for sleep problems.

Efficacy of a digital cognitive behavioral therapy for insomnia in people with low back pain: a feasibility randomized co-twin and singleton-controlled trial

Background

Digital cognitive behavioral therapy for insomnia (CBT-i) in people with low back pain (LBP) may be efficacious in improving both sleep and pain; and twin trial designs provide greater precision of treatment effects by accounting for genetic and early environmental factors. We aimed to determine the feasibility of a trial investigating the efficacy of a digital CBT-i program in people with comorbid symptoms of insomnia and LBP, in twins and people from the general community (singletons).

Methods

Thirty-two twins (16 pairs) and 66 singletons with comorbid symptoms of insomnia and LBP (> 6 weeks duration) were randomized to digital CBT-i (intervention) or educational program (control) for 6 weeks. The digital CBT-I, Sleepio (developed by Big Health Inc.), was an online interactive, automated, personalized course comprising of six sessions, once a week. The education program was six emails with general sleep information, once a week. Participants were blinded to their group allocation and offered the alternative intervention at the completion of the study. Feasibility outcomes included recruitment and follow-up rates, data collection and outcome measure completion, contamination (communication about trial interventions), acceptability (adherence), credibility, and participants’ experience of the intervention.

Results

Sixteen out of 722 contacted twin pairs were recruited (recruitment rate = 2.2%). Twins were recruited between September 2015 and August 2018 (35 months) and singletons between October 2017 and Aug 2018 (10 months). Follow-up rates for post-intervention and 3-month follow-up were 81% and 72% for twins and 82% and 78% for singletons respectively. Adherence rates (percentage of sessions completed out of six) for the digital CBT-i were 63% for twins and 55% for singletons. Contamination (speaking about the study to each other) was present in two twin pairs (13%). Written or verbal feedback (n = 21) regarding the digital CBT-i intervention from participants were positive (n = 11), neutral (n = 5), or negative (n = 6).

Conclusions

Online CBT-i was received favorably with people with comorbid symptoms of insomnia and LBP. While the online data collection was successful, strategies need to be implemented to improve adherence, follow-up, control group credibility (for digital CBT-i), and twin recruitment rates (for twin trials).

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12615000672550). Registered 29 June 2015

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01087-z.

The importance of sleep for people with chronic pain: current insights and evidence

We are currently in the midst of a sleep crisis. Our current work and lifestyle environments are normalizing poor sleep with substantial negative impact on our health. Research on sleep has linked sleep deprivation to poorer mental health, obesity, cancer, diabetes, heart disease, and a myriad of other health conditions. Sleep deprivation is an even greater issues for people with musculoskeletal conditions and chronic pain. Between 67% and 88% of individuals with chronic pain experience sleep disruption and insomnia, and at least 50% of people with insomnia report chronic pain. The link between sleep and pain is well documented. Experimental, cohort, and longitudinal studies have all demonstrated that restricted sleep is linked to greater pain. Poor sleep therefore not only affects general health but has a direct impact on inflammation, pain response, and experience. Improving sleep in people living with musculoskeletal conditions and with chronic pain has the potential to deliver great benefit to many. This article describes the evidence base that can underpin such work, including research about the link between pain and sleep as well as theories and approaches to intervention that may help. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The effectiveness of non-pharmacological sleep interventions for people with chronic pain: a systematic review and meta-analysis

Objective

About two thirds of people with chronic pain report problems sleeping. We aimed to evaluate the effectiveness of non-pharmacological sleep interventions for improving sleep in people with chronic pain.

Design

We conducted a systematic review of non-pharmacological and non-invasive interventions to improve sleep quality or duration for adults with chronic non-cancer pain evaluated in a randomised controlled trial. Our primary outcome of interest was sleep; secondary outcomes included pain, health-related quality of life, and psychological wellbeing. We searched the Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL from inception to April 2020. After screening, two reviewers evaluated articles and extracted data. Meta-analysis was conducted using a random effects model. Risk of bias was assessed with the Cochrane tool.

Results

We included 42 trials involving 3346 people randomised to 94 groups, of which 56 received an intervention targeting sleep. 10 studies were of fair and 32 of good methodological quality. Overall risk of bias was judged to be low in 11, high in 10 and unclear in 21 studies. In 9 studies with 385 people randomised, cognitive behavioural therapy for insomnia showed benefit post-treatment compared with controls for improved sleep quality, standardised mean difference − 1.23 (95%CI -1.76, − 0.70; p < 0.00001). The effect size was only slightly reduced in meta-analysis of 3 studies at low risk of bias. The difference between groups was lower at 3 and 6 months after treatment but still favoured cognitive behavioural therapy for insomnia. Pain, anxiety and depression were reduced post-treatment, but evidence of longer term benefit was lacking. There was no evidence that sleep hygiene interventions were effective in improving sleep and there was some evidence in comparative studies to suggest that cognitive behavioural therapy for insomnia was more effective than sleep hygiene.

Numerous other interventions were evaluated in small numbers of studies, but evidence was insufficient to draw conclusions about effectiveness.

Conclusions

Cognitive behavioural therapy for insomnia is an effective treatment to improve sleep for people with chronic pain, but further high-quality primary research is required to explore combined CBT content that will ensure additional improvements to pain, quality of life and psychological health and longer-term maintenance of benefits. Primary research is also needed to evaluate the effectiveness of interventions for which insufficient evidence exists.

Trial registration

PROSPERO registration number: CRD42019093799.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05318-5.

"I Don't Know Why I've Got this Pain!" Allostasis as a Possible Explanatory Model

Explaining the onset and maintenance of pain can be challenging in many clinical presentations. Allostasis encompasses the mechanisms through which humans adapt to stressors to maintain physiological stability. Due to related neuro-endocrine-immune system effects, allostasis and allostatic load (the cumulative effects on the brain and body that develop through the maintenance of physiological stability) offer the potential to explain the development and maintenance of musculoskeletal pain in certain cases. This paper outlines the concept of allostatic load, highlights the evidence for allostatic load in musculoskeletal pain conditions to date, and discusses mechanisms through which allostatic load influences pain, with particular focus on hypothalamic-pituitary-adrenal axis and sympathetic nervous system function and central, brain-driven governance of these systems. Finally, through case examples, consideration is given as to how allostatic load can be integrated into clinical reasoning and how it can be used to help explain pain to individuals and guide clinical decision-making.

IMPACT

Awareness of the concept of allostatic load, and subsequent assessment of physical and psychological stressors potentially contributing to allostatic load, may facilitate a broader understanding of the multidimensional presentations of many people with pain, both acute and persistent. This may facilitate discussion between clinicians and their patients regarding broader influences on their presentations and drive more targeted and inclusive pain management strategies.

Lower thoracic spine extension mobility is associated with higher intensity of thoracic spine pain

Objectives

To evaluate the association of thoracic spine (TS) posture and mobility with TS pain.

Methods

Participants with TS pain reported maximum, average, and night pain in TS area, and pain summary score was calculated. Upright and sitting TS postures were evaluated by inspection. TS posture and mobility (flexion and extension) were recorded using an inclinometer and a tape measure, respectively. Correlations between posture and mobility assessments were calculated using Spearman rank correlation, the association of TS posture and mobility with TS pain by logistic regression analysis.

Results

The participants’ (n = 73, 52 females, age range 22–56) TS pain duration was 12 weeks on average. The correlations for measurements of TS posture and flexion mobility were higher than correlations of other TS measurements being between 0.53 and 0.82. Decreased extension mobility of the upper (from 1^st to 6^th TS segments; Th1–Th6) TS was associated with higher worst pain (OR 1.04, 95% CI 1.00–1.07) and whole TS with pain sum score (OR 1.05, 95% CI 1.01–1.08). Less kyphotic whole TS was associated with lower pain sum score (OR 0.96, 95% CI 0.92–1.00). Greater flexion mobility of upper and lower (Th6–Th12) TS were associated with lower pain sum score (OR 0.96, 95% CI 0.91–1.00, and OR 0.96, 95% CI 0.91–1.00, respectively).

Conclusions

Reduced thoracic extension mobility was associated with higher pain scores and the greater flexion mobility with lower pain scores. Future research is warranted to evaluate if treatments geared toward TS extension mobility improvements would result in lower TS pain.

Predicting nonrecovery in adults with incident traffic injuries including post-traumatic headache

IMPORTANCE

The management of traffic injuries is challenging for clinicians. Knowledge about predictors of nonrecovery from traffic injuries may help to improve patient care.

OBJECTIVE

To develop a prediction model for self-reported overall nonrecovery from traffic injuries six months post-collision in adults with incident traffic injuries including post-traumatic headache (PTH).

DESIGN

Inception cohort studies of adults with incident traffic injuries (including PTH) injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada; and between January 2004 and January 2005 in Sweden.

METHODS

Prediction model development and geographical external validation.

SETTING

The Saskatchewan cohort (development) was population-based (N = 4,162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20% of cars driven in Sweden in 2004.

PARTICIPANTS

All adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized > 2 days, lost consciousness > 30 min, or reported headache < 3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80%.

PREDICTORS

Baseline sociodemographic, pre-injury, and injury factors.

OUTCOME

Self-reported nonrecovery from all injuries (not "all better (cured)" on the self-perceived recovery scale) six months after traffic collision.

RESULTS

Both cohorts were predominantly female (69.8% in Saskatchewan, 65.2% in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, low back pain, symptoms in arms or hands, hearing problems, sleeping problems, pre-existing headache, and lower recovery expectations. With a positive score (i.e., ≥0.85 probability), the model can rule in the presence of self-reported nonrecovery from all injuries at six months (development: specificity = 91.3%, 95% CI 89.2%-93.0%; sensitivity = 27.8%, 95% CI 26.0%-29.7%; positive likelihood ratio (LR + ) = 3.2, 95% CI 2.5-4.0; negative likelihood ratio (LR-) = 0.79, 95% CI 0.76-0.82; validation: specificity = 72.6%, 95% CI 61.4%-81.5%; sensitivity = 60.5%, 95% CI 53.9%-66.7%); LR+ = 2.2, 95% CI 1.5-3.3; LR- = 0.5, 95% CI 0.4-0.7).

CONCLUSIONS AND RELEVANCE

In adults with incident traffic injuries including PTH, predictors other than those related to baseline head and neck pain drive overall nonrecovery. Developing and testing interventions targeted at the modifiable predictors may help to improve outcomes for adults after traffic collision.

Effectiveness of non-pharmacological interventions on sleep characteristics among adults with musculoskeletal pain and a comorbid sleep problem: a systematic review

Sleep problems are common and may be associated with persistent pain. It is unclear whether non-pharmacological interventions improve sleep and pain in adults with comorbid sleep problems and musculoskeletal (MSK) pain. We conducted a systematic review on the effectiveness of non-pharmacological interventions on sleep characteristics among adults with MSK pain and comorbid sleep problems. We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and PsycINFO from inception to April 2, 2021 for randomized controlled trials (RCTs), cohort, and case-control studies. Pairs of independent reviewers critically appraised and extracted data from eligible studies. We synthesized the findings qualitatively. We screened 8459 records and identified two RCTs (six articles, 467 participants). At 9 months, in adults with insomnia and osteoarthritis pain, cognitive behavioral therapy for pain and insomnia (CBT-PI) was effective at improving sleep (Insomnia Severity Index, ISI) when compared to education (OR 2.20, 95% CI 1.25, 3.90) or CBT for pain (CBT-P) (OR 3.21, 95% CI 1.22, 8.43). CBP-P vs. education was effective at increasing sleep efficiency (wrist actigraphy) in a subgroup of participants with severe pain at baseline (mean difference 5.45, 95% CI 1.56, 9.33). At 18 months, CBT-PI, CBT-P and education had similar effectiveness on sleep and pain or health outcomes. In adults with insomnia and knee osteoarthritis, CBT-I improved some sleep outcomes including sleep efficiency (diary) at 3 months (Cohen's d 0.39, 95% CI 0.24, 1.18), and self-reported sleep quality (ISI) at 6 months (Cohen's d - 0.62, 95% CI -1.01, - 0.07). The intervention was no better than placebo (behavioural desensitization) for improving other sleep outcomes related to sleep onset or pain outcomes. Short-term improvement in sleep was associated with pain reduction at 6 months (WOMAC pain subscale) (sensitivity 54.8%, specificity 81.4%). Overall, in two acceptable quality RCTs of adults with OA and comorbid insomnia, CBT-PI/I may improve some sleep outcomes in the short term, but not pain outcomes in the short or long-term. Clinically significant improvements in sleep in the short term may improve longer term pain outcomes. Further high-quality research is needed to evaluate other non-pharmacological interventions for people with comorbid sleep problems and a range of MSK conditions.

Factors associated with care-seeking for low back pain when genetics and the familial environment are considered

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide. Care-seekers for LBP cause substantial economic burden to governments and the healthcare system.

OBJECTIVE

To investigate lifestyle and health-related factors associated with care-seeking (including pain medication use) in individuals experiencing LBP, after controlling for important genetic and early environmental confounders through the use of a within-twin pair case-control design.

DESIGN

A secondary analysis of observational longitudinal data, derived from the Australian Twin low BACK pain (AUTBACK) study, was performed on 66 twin pairs that presented with similar symptoms of LBP at baseline but became discordant for care-seeking behaviour over one month.

METHODS

Subjective and objective assessment of pain intensity, disability, depression, sleep quality, physical activity and body mass index were performed. Data was analysed using stepwise conditional logistic regression in two stages: within-pair case-control for monozygotic and dizygotic twins together; and within-pair case-control analysis of monozygotic twins only. Results were expressed as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Higher LBP intensity (OR 2.9; 95% CI 1.3-6.8) and poorer sleep quality (OR 10.9; 95% CI 1.5-77.7) were the main factors that increased the likelihood of care-seeking for LBP. These associations remained significant and increased in magnitude after adjusting for genetic confounding.

CONCLUSIONS

Individuals with higher LBP intensity and worse sleep quality are more likely to seek care for LBP, and this relationship is likely to be causal after adjustment of familial and genetic confounding.

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

IMPORTANCE

Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

OBJECTIVE

To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

DESIGN, SETTING, AND PARTICIPANTS

This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

INTERVENTIONS

Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

MAIN OUTCOMES AND MEASURES

The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

RESULTS

Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of -3.5 points (95% CI, -4.4 to -2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, -3.0 points; 95% CI, -4.1 to -2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, -2.0 points; 95% CI, -3.1 to -0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, -1.8 points; 95% CI, -3.1 to -0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT02946957.

Factors associated with seeking medical care for low back pain in a twin adult sample

BACKGROUND

Previous studies have only investigated how symptom presentation and socio-demographic factors influence care-seeking for low back pain (LBP). However, the influence of health and lifestyle factors remains unclear, and the potential confounding effects of aggregated familial factors (including genetics and the early shared environment) has not been considered extensively.

METHODS

A cross-sectional analysis was performed on 1605 twins enrolled in the Murcia Twin Registry (Spain). The outcome was seeking medical care for LBP and various self-reported demographic, health and lifestyle factors were considered predictors. All variables except sleep quality and diabetes were collected in 2013, which were cross-referenced from 2009 to 2010. A multivariate logistic regression model was performed on the total sample, followed by a co-twin case-control analysis.

RESULTS

The only significant factor found to increase the odds of seeking medical care for LBP without being affected by familial factors was poor sleep quality (total sample OR = 1.58, 95%CI 1.24-2.01; case-control OR = 1.75, 95%CI 1.14-2.69). The factors that were associated with reduced odds of seeking medical care for LBP and not confounded by familial factors were male sex (case-control OR = 0.55, 95%CI 0.33-0.93), alcohol intake (case-control OR = 0.90, 95%CI 0.82-0.99) and a history of diabetes (case-control OR = 0.50, 95%CI 0.25-0.97). No other factors significantly influenced medical care-seeking for LBP.

CONCLUSIONS

People reporting poor sleep quality are more likely to seek medical care for LBP in the long term, with this relationship being independent from aggregated familial factors. Conversely, males, people reporting higher alcohol intake, and people with a history of diabetes are less likely to seek medical care for LBP.

SIGNIFICANCE

This is the first study investigating the factors that influence seeking medical care for LBP, while adjusting for the influence of familial factors using a co-twin control design. Poor sleep quality is associated with seeking medical care for LBP in the long term and does not appear to be confounded by familial factors. Early screening for indicators of poor sleep quality and appropriate referral to interventions for improving sleep quality or reducing pain in sleep may improve LBP management.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Sleep Disturbance and Its Association with Pain Severity and Multisite Pain: A Prospective 10.7-Year Study

INTRODUCTION

Sleep disturbance is often comorbid with chronic pain disorders, with emerging evidence suggesting a stronger effect of sleep disturbance on pain than vice versa; however, few studies have evaluated the long-term associations between sleep disturbance and pain. This study was to examine the associations of sleep disturbance with knee pain severity, number of painful sites (NPS) and persistent pain in a 10.7-year cohort study.

METHODS

A total of 1099 community-dwelling older adults (age mean ± SD, 63 ± 7.5 years; 51% female) were recruited and followed up at 2.6, 5.1 and 10.7 years later. Data on demographics, body mass index, physical activity and comorbidities were collected. At each time point, sleep disturbance, knee pain severity and NPS were assessed by using questionnaires. Multisite pain (MSP) was defined as NPS ≥ 2. Persistent knee pain or MSP was defined as having knee pain or MSP at all time points, respectively. Multivariable mixed-effects models and log-binomial regression were applied.

RESULTS

In multivariable analyses, sleep disturbance was associated with greater knee pain severity (β 0.91/unit, 95% CI 0.70-1.11) and more NPS [(relative risk (RR) 1.10/unit, 95% CI 1.07-1.14] in a dose-response manner. Persistent sleep disturbance was associated with persistent knee pain (RR 1.90, 1.26-2.87) and MSP (RR 1.29, 1.07-1.56). Persistent knee pain and MSP were also associated with persistent sleep disturbance (knee pain: RR = 1.99; MSP: RR = 2.71, both P < 0.05).

CONCLUSIONS

Sleep disturbance was independently associated with greater pain severity and NPS in a dose-response manner. A reciprocal relationship between persistent sleep disturbance and persistent pain suggests treating either problem could help the other.

Low back pain rehabilitation in 2020: new frontiers and old limits of our understanding

Low back pain (LBP) is the most common musculoskeletal condition affecting the quality of life of individuals, especially if persistent. Over the decades, a lot of work has been done in an attempt to reduce the negative impact of back pain, and help patients recover and maintain a better quality of life. New insights are coming from different fields of research, with a lot of work being done in searching for the etiology of LBP, describing the different phenotypes of symptomatic spines, and identifying factors involved in the persistence of the disease. Nevertheless, still a lot remains to be done to fully understand the problem of back pain and its causes. Even today, there appears to be a wide gap between basic science and applied rehabilitation research on LBP. The first is still searching in many different ways for the "holy grail" of the pain generator and providing very interesting results with particular relevance to surgical, drug-related and other biological approaches, while the second is pragmatically focusing on modifiable factors that may influence back pain outcomes. Yet, personalized, effective spine care has not been fully realized. While we recognize the potential of basic science advances, there is an immediate need for more translational rehabilitation research, as well as studies focused on the effectiveness of rehabilitation approaches.

Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55

Introduction. Osteoarthritis, which is a cause of chronic pain and disability with manifestation in any joint, with greater frequency in the joints of the lower limbs, upper limbs, but also at the spine level , affects around 250 million people in the entire world. This condition affects around 10% of the global population (18) and has an impressive impact on people, as it is one of the first 5 causes of disability. Material and method. The objectives of the treatment made by the patients diagnosed with knee osteoarthritis were: pain reduction, increased joint amplitude, increased muscle strength, increased muscle tone, increased quality of life and reintegration into the family and social environment. In the study, there were discussed demographic data regarding the patients. In order to assess the pain parameter, the VAS scale was used, as well as WOMAC subscales. To assess the quality of life of patients with knee osteoarthritis, the QOL scale (Quality of Life) was used. Anxiety was assessed with the help of a test that comprises the evaluation of symptoms at the cognitive, behavioral and physical level. Results and discussions. The pain was evaluated on the VAS scale, having a statistically significant evolution for the evaluation moments. Also with the help of the WOMAC index, two other parameters were evaluated, namely joint rigidity and functional capacity, the results being statistically significant in the 3 evaluation moments. The patients’ anxiety was evaluated with the help of the anxiety test; the results obtained were statistically significant at the 3 evaluation moments. Conclusions. It is vital that the recovery treatment in osteoarthritis be individualized and adapted to the age group. In our group, it enabled the reduction of pain and anxiety, the increase of the functional capacity and the quality of the patients’ lives.Taking into account the fact that the most affected group in the study group was the active professional one, we can evaluate the size of the recovery and the social, family and professional integration for these patients.

Yoga, Physical Therapy, and Back Pain Education for Sleep Quality in Low-Income Racially Diverse Adults with Chronic Low Back Pain: a Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Poor sleep is common among adults with chronic low back pain (cLBP), but the influence of cLBP treatments, such as yoga and physical therapy (PT), on sleep quality is under studied.

OBJECTIVE

Evaluate the effectiveness of yoga and PT for improving sleep quality in adults with cLBP.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Academic safety-net hospital and 7 affiliated community health centers.

PARTICIPANTS

A total of 320 adults with cLBP.

INTERVENTION

Twelve weekly yoga classes, 1-on-1 PT sessions, or an educational book.

MAIN MEASURES

Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) global score (0-21) at baseline, 12 weeks, and 52 weeks. Additionally, we also evaluated how the proportion of participants who achieved a clinically meaningful improvement in sleep quality (> 3-point reduction in PSQI) at 12 weeks varied by changes in pain and physical function at 6 weeks.

KEY RESULTS

Among participants (mean age = 46.0, 64% female, 82% non-white), nearly all (92%) reported poor sleep quality (PSQI > 5) at baseline. At 12 weeks, modest improvements in sleep quality were observed among the yoga (PSQI mean difference [MD] = - 1.19, 95% confidence interval [CI] - 1.82, - 0.55) and PT (PSQI MD = - 0.91, 95% CI - 1.61, - 0.20) groups. Participants who reported a ≥ 30% improvement in pain or physical function at 6 weeks, compared with those who improved < 10%, were more likely to be a sleep quality responder at 12 weeks (odds ratio [OR] = 3.51, 95% CI 1.73, 7.11 and OR = 2.16, 95% CI 1.18, 3.95, respectively). Results were similar at 52 weeks.

CONCLUSION

In a sample of adults with cLBP, virtually all with poor sleep quality prior to intervention, modest but statistically significant improvements in sleep quality were observed with both yoga and PT. Irrespective of treatment, clinically important sleep improvements at the end of the intervention were associated with mid-intervention pain and physical function improvements.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01343927.

Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis

Osteoarthritis (OA) is a leading cause of chronic pain and disability in older adults, which most commonly affects the joints of the knee, hip, and hand. To date, there are no established disease modifying interventions that can halt or reverse OA progression. Therefore, treatment is focused on alleviating pain and maintaining or improving physical and psychological function. Rehabilitation is widely recommended as first-line treatment for OA as, in many cases, it is safer and more effective than the best-established pharmacological interventions. In this article, we describe the presentation of OA pain and give an overview of its peripheral and central mechanisms. We then provide a state-of-the-art review of rehabilitation for OA pain—including self-management programs, exercise, weight loss, cognitive behavioral therapy, adjunct therapies, and the use of aids and devices. Next, we explore several promising directions for clinical practice, including novel education strategies to target unhelpful illness and treatment beliefs, methods to enhance the efficacy of exercise interventions, and innovative, brain-directed treatments. Finally, we discuss potential future research in areas, such as treatment adherence and personalized rehabilitation for OA pain.

The association between insomnia, c-reactive protein, and chronic low back pain: cross-sectional analysis of the HUNT study, Norway

BACKGROUND AND AIMS

Chronic low back pain (chronic LBP) is the number one cause for years lived with disability among 301 diseases and injuries analyzed by The Global Burden of Disease study 2013. Insomnia is highly prevalent among people with chronic LBP. To explain the sleep-pain relationship, theoretical models propose that insomnia symptoms may be associated with increased basal inflammation, operationalized as c-reactive protein (CRP) and lead to further pain and disrupted sleep. We aimed to determine the associations between insomnia, chronic LBP, and inflammation (operationalized as CRP), whilst controlling for age, body mass index, smoking, physical activity, depression, anxiety and osteoarthritis.

METHODS

A cross-sectional analysis of the third Nord-Trøndelag Health Study (2006-2008), a rural population survey of 50,666 participants in Norway aged 20-96 years. Insomnia (dichotomous) was defined according to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition, and chronic LBP (dichotomous) as low back pain or stiffness lasting at least 3 months. Data for CRP were obtained from non-fasting serum samples and assessed via latex immunoassay methodology. We excluded participants with the following self-reported chronic somatic diseases: chronic heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, fibromyalgia or ankylosing spondylosis. Possible associations between presence of insomnia and presence of chronic LBP (dependent), and the level of CRP and presence of chronic LBP (dependent), were assessed using logistic regression models. The possible association between insomnia and CRP (dependent) was assessed using linear regression. Multivariable analyses were conducted adjusting for confounders stated in our aim that achieved p ≤ 0.2 in univariate regressions. We performed stratified analyses for participants with "Normal" (<3 mg/L) "Elevated" (3-10 mg/L) and "Very High" (>10 mg/L) levels of CRP.

RESULTS

In our total included sample (n = 30,669, median age 52.6, 54% female), 6.1% had insomnia (n = 1,871), 21.4% had chronic LBP (n = 6,559), and 2.4% had both (n = 719). Twenty four thousand two hundred eighty-eight (79%) participants had "Normal" CRP, 5,275 (17%) had "Elevated" CRP, and 1,136 (4%) had "Very High" CRP. For participants with "Normal" levels of CRP, insomnia was associated with higher levels of CRP (adjusted B = 0.04, 95%CI [0.00-0.08], p = 0.046), but not for people with "Elevated" or "Very High" levels of CRP. There was an association between CRP and presence of chronic LBP in the total sample (adjusted OR = 1.01, [1.00-1.01], p = 0.013) and for people with "Normal" CRP (1.05, [1.00-1.10, p = 0.034]. Insomnia was associated with the presence of chronic LBP in the total sample (adjusted OR = 1.99, 95%CI [1.79-2.21], <0.001) and for people with "Normal", "Elevated" and "Very High".

CONCLUSIONS

Individuals with insomnia have twice the odds of reporting chronic LBP. Insomnia, CRP and chronic LBP appear to be linked but the role of CRP appears to be limited. Longitudinal studies may help further explore the causal inference between insomnia chronic LBP, and inflammation.

IMPLICATIONS

Given the strong relationship between insomnia and chronic LBP, screening and management of comorbid insomnia and chronic LBP should be considered in clinical practice. Further longitudinal studies are required to explore whether the presence of insomnia and increased inflammation affects the development of chronic LBP.

The association of pain locus of control with pain outcomes among older adults

Our primary objective was to 1) determine the prevalence of pain locus of control (LOC) subscales in a population of older adults with pain conditions, and 2) estimate their associated protective effects on pain outcomes. A mailed survey was sent to a stratified sample of older adults age≥65 with diagnosed back pain, osteoarthritis and/or rheumatoid arthritis. Multivariate logistic regression modeling was used to determine the relative protective associations of positive resources, including LOC, resilience and social networks, on pain outcomes. Among respondents (N = 3,824), 31% were identified as internal; 34% as powerful others; and 35% as chance. In adjusted models, internal was associated with outcomes of lower pain severity, reduced chronic opioid use and increased physical functionality. Powerful others was partially protective; chance was associated with the poorest outcomes. Multidimensional pain programs should incorporate the enhancement of positive resources, including LOC, to maximize the effectiveness of pain management strategies.