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Valentijn PP, Tymchenko L, Jacobson T, Kromann J, Biermann CW, AlMoslemany MA, Arends RY. Digital Health Interventions for Musculoskeletal Pain Conditions: Systematic Review and Meta-analysis of Randomized Controlled Trials. J Med Internet Res 2022; 24:e37869. [PMID: 36066943 PMCID: PMC9490534 DOI: 10.2196/37869] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/17/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Digital health solutions can provide populations with musculoskeletal pain with high-reach, low-cost, easily accessible, and scalable patient education and self-management interventions that meet the time and resource restrictions. Objective The main objective of this study was to determine the effectiveness of digital health interventions for people with musculoskeletal pain conditions (ie, low back pain, neck pain, shoulder pain, knee pain, elbow pain, ankle pain, and whiplash). Methods A systematic review and meta-analysis was conducted. We searched PubMed and Cochrane Central Register of Controlled Trials (from 1974 to August 2021) and selected randomized controlled trials of digital health interventions in the target population of patients with musculoskeletal pain with a minimum follow-up of 1 month. A total of 2 researchers independently screened and extracted the data. Results A total of 56 eligible studies were included covering 9359 participants, with a mean follow-up of 25 (SD 15.48) weeks. In moderate-quality evidence, digital health interventions had a small effect on pain (standardized mean difference [SMD] 0.19, 95% CI 0.06-0.32), disability (SMD 0.14, 95% CI 0.03-0.25), quality of life (SMD 0.22, 95% CI 0.07-0.36), emotional functioning (SMD 0.24, 95% CI 0.12-0.35), and self-management (SMD 0.14, 95% CI 0.05-0.24). Conclusions Moderate-quality evidence supports the conclusion that digital health interventions are effective in reducing pain and improving functioning and self-management of musculoskeletal pain conditions. Low-quality evidence indicates that digital health interventions can improve the quality of life and global treatment. Little research has been conducted on the influence of digital health on expenses, knowledge, overall improvement, range of motion, muscle strength, and implementation fidelity. Trial Registration PROSPERO CRD42022307504; https://tinyurl.com/2cd25hus
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Affiliation(s)
- Pim Peter Valentijn
- Essenburgh Research & Consultancy, Essenburgh Group, Harderwijk, Netherlands.,Department of Health Services Research, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Liza Tymchenko
- Essenburgh Research & Consultancy, Essenburgh Group, Harderwijk, Netherlands
| | | | | | | | | | - Rosa Ymkje Arends
- Essenburgh Research & Consultancy, Essenburgh Group, Harderwijk, Netherlands.,University of Applied Sciences Utrecht, Utrecht, Netherlands
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Yeung K, Zhu W, McCurry SM, Von Korff M, Wellman R, Morin CM, Vitiello MV. Cost-effectiveness of telephone cognitive behavioral therapy for osteoarthritis-related insomnia. J Am Geriatr Soc 2022; 70:188-199. [PMID: 34633061 PMCID: PMC8742775 DOI: 10.1111/jgs.17469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/22/2021] [Accepted: 08/23/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Osteoarthritis-related insomnia is the most common form of comorbid insomnia among older Americans. A randomized clinical trial found that six sessions of telephone-delivered cognitive behavioral therapy for insomnia (CBT-I) improved sleep outcomes in this population. Using these data, we evaluated the incremental cost-effectiveness of CBT-I from a healthcare sector perspective. METHODS The study was based on 325 community-dwelling older adults with insomnia and osteoarthritis pain enrolled with Kaiser Permanente of Washington State. We measured quality-adjusted life years (QALYs) using the EuroQol 5-dimension scale. Arthritis-specific quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Insomnia-specific quality of life was measured using the Insomnia Severity Index (ISI) and nights without clinical insomnia (i.e., "insomnia-free nights"). Total healthcare costs included intervention and healthcare utilization costs. RESULTS Over the 12 months after randomization, CBT-I improved ISI and WOMAC by -2.6 points (95% CI: -2.9 to -2.4) and -2.6 points (95% CI: -3.4 to -1.8), respectively. The ISI improvement translated into 89 additional insomnia-free nights (95% CI: 79 to 98) over the 12 months. CBT-I did not significantly reduce total healthcare costs (-$1072 [95% CI: -$1968 to $92]). Improvements in condition-specific measures were not reflected in QALYs gained (-0.01 [95% CI: -0.01 to 0.01]); at a willingness-to-pay of $150,000 per QALY, CBT-I resulted in a positive net monetary benefit of $369 with substantial uncertainty (95% CI: -$1737 to $2270). CONCLUSION CBT-I improved sleep and arthritis function without increasing costs. These findings support the consideration of telephone CBT-I for treating insomnia among older adults with comorbid OA. Our findings also suggest potential limitations of the general quality of life measures in assessing interventions designed to improve sleep and arthritis outcomes.
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Affiliation(s)
- Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA,University of Washington, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Seattle, Washington, USA
| | - Weiwei Zhu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Susan M. McCurry
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, Washington, USA
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Robert Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Charles M. Morin
- Department of Psychology, Université Laval, Quebec City, Quebec, Canada
| | - Michael V. Vitiello
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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Vitiello MV, Zhu W, Von Korff M, Wellman R, Morin CM, Yeung K, McCurry SM. Short-term Improvements in Insomnia or Pain Predict Long-term Improvements in Sleep, Pain, Depression, and Fatigue in Older Adults with Co-Morbid Osteoarthritis Pain and Insomnia. Sleep 2021; 45:6369576. [PMID: 34516646 DOI: 10.1093/sleep/zsab231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/07/2021] [Indexed: 11/14/2022] Open
Abstract
In a primary care population of 327 older adults (age 60+) with chronic osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep or pain and long-term sleep, pain, depression, and fatigue by secondary analyses of randomized controlled trial data. Study participants, regardless of trial arm, were classified as Sleep or Pain Improvers with ≥30% baseline to 2-month reduction on the Insomnia Severity Index or the Brief Pain Inventory, respectively, or Sleep or Pain Non-Improvers. After controlling for trial arm and potential confounders, both Sleep and Pain Improvers showed significant (p <.01) sustained improvements across 12 months compared to respective Non-Improvers for the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality index, Brief Pain Inventory-short form (total, Interference, and Severity subscales), Patient Health Questionnaire, and Flinders Fatigue Scale.The effect sizes (Cohen's f 2) for the sustained benefits in both Sleep and Pain Improvers compared to their respective Non-Improvers for all variables were small (<0.15) with the exception of a medium effect size for sustained reduction in insomnia symptoms for the Sleep Improvers. We conclude that short-term sleep improvements in pain populations with co-morbid insomnia precede benefits not only for long-term improvement in sleep but also for reduced pain over the long-term, along with associated improvements in depression and fatigue. Short-term improvements in pain appear to have similar long-term sequelae. Successfully improving sleep in pain populations with co-morbid insomnia may have the additional benefits of improving both short and long term pain, depression and fatigue.
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Affiliation(s)
- Michael V Vitiello
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA , USA
| | - Weiwei Zhu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Robert Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Charles M Morin
- Department of Psychology, Université Laval, Quebec City, Quebec, Canada
| | - Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Susan M McCurry
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, WA, USA
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McCurry SM, Zhu W, Von Korff M, Wellman R, Morin CM, Thakral M, Yeung K, Vitiello MV. Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:530-538. [PMID: 33616613 PMCID: PMC7900930 DOI: 10.1001/jamainternmed.2020.9049] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Susan M McCurry
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle
| | - Weiwei Zhu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | | | - Robert Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Charles M Morin
- Department of Psychology, Université Laval, Quebec City, Quebec, Canada
| | - Manu Thakral
- Kaiser Permanente Washington Health Research Institute, Seattle.,College of Nursing and Health Sciences, University of Massachusetts Boston, Boston
| | - Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Michael V Vitiello
- Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Seattle
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Selvanathan J, Pham C, Nagappa M, Peng PWH, Englesakis M, Espie CA, Morin CM, Chung F. Cognitive behavioral therapy for insomnia in patients with chronic pain - A systematic review and meta-analysis of randomized controlled trials. Sleep Med Rev 2021; 60:101460. [PMID: 33610967 DOI: 10.1016/j.smrv.2021.101460] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/24/2022]
Abstract
Several randomized controlled trials have implemented cognitive behavioral therapy for insomnia (CBT-I) for patients with comorbid insomnia and chronic pain. This systematic review and meta-analysis investigated the effectiveness of CBT-I on patient-reported sleep, pain, and other health outcomes (depressive symptoms, anxiety symptoms, and fatigue) in patients with comorbid insomnia and chronic non-cancer pain. A systematic literature search was conducted using eight electronic databases. Upon duplicate removal, 6374 records were screened against the inclusion criteria. Fourteen randomized controlled trials were selected for the review, with twelve (N = 762 participants) included in the meta-analysis. At post-treatment, significant treatment effects were found on global measures of sleep (standardized mean difference = 0.89), pain (0.20), and depressive symptoms (0.44). At follow-up (up to 12 mo), CBT-I significantly improved sleep (0.56). Using global measures of sleep, we found a probability of 81% and 71% for having better sleep after CBT-I at post-treatment and final follow-up, respectively. The probability of having less pain after CBT-I at post-treatment and final follow-up was 58% and 57%, respectively. There were no statistically significant effects on anxiety symptoms and fatigue at either assessment point. Future trials with sufficient power, longer follow-up periods, and inclusion of CBT for pain components are warranted.
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Affiliation(s)
- Janannii Selvanathan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Chi Pham
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph Health Care, Western University, London, ON, Canada
| | - Philip W H Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Canada
| | - Colin A Espie
- Nuffield Department of Clinical Neurosciences, Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, Oxfordshire, UK
| | - Charles M Morin
- Department of Psychology, Laval University, Québec, QC, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada.
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Unruh M, Cukor D, Rue T, Abad K, Roumelioti ME, McCurry SM, Heagerty P, Mehrotra R. Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis. BMC Nephrol 2020; 21:443. [PMID: 33081705 PMCID: PMC7574396 DOI: 10.1186/s12882-020-02107-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/14/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD. METHODS This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy. DISCUSSION This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD. TRIAL REGISTRATION NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).
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Affiliation(s)
- Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
- Nephrology Section, New Mexico Veterans Hospital, Albuquerque, NM, USA.
| | | | - Tessa Rue
- Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Kashif Abad
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Susan M McCurry
- Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Patrick Heagerty
- Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Rajnish Mehrotra
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA, USA
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