Telephone CBT-I Shown to Improve Sleep, Fatigue in Older Adults With Osteoarthritis Pain

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Patients with osteoarthritis-related pain were shown to benefit from cognitive behavioral therapy for insomnia (CBT-I) via telephone, in which the treatment significantly improved sleep and fatigue after 12 months, with pain temporarily relieved as well.

Cognitive behavioral therapy for insomnia (CBT-I) was shown to improve sleep and fatigue among patients with osteoarthritis-related pain, according to study findings published this week in JAMA Internal Medicine.

Insomnia is a common comorbidity in older adults alongside other chronic conditions. Notably, more than half of patients with osteoarthritis, which affects 50% of older adults, report symptoms of disturbed sleep.

“Insomnia and chronic pain have reciprocal effects, each initiating, maintaining, and exacerbating one another,” noted the study authors

Recently, CBT-I has emerged as an effective therapeutic intervention for people with comorbid conditions and was recommended for use in recent clinical practice guidelines issued by the American Academy of Sleep Medicine. More noteworthy amid the pandemic, CBT-I delivered via telemedicine was found to be noninferior to in-person delivery in managing severity of insomnia and improving daytime functioning.

As the first large randomized trial to assess CBT-I delivered via telephone among older adults with comorbid moderate to severe insomnia and chronic osteoarthritis pain, the Osteoarthritis and Therapy for Sleep study compared the efficacy of the remote therapy with education-only control (EOC) in 327 participants 60 years and older from Kaiser Permanente Washington (mean [SD] age, 70.2 [6.8] years; 244 [74.6%] women).

The study was conducted from September 2016 to December 2018, with participants undergoing six 20- to 30-minute telephone sessions (n = 163) or EOC (n = 164) over 8 weeks. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis pain symptoms, and were blindly assessed for the primary outcome of Insomnia Severity Index (ISI) score at baseline, 2 months posttreatment, and at 12-month follow-up.


In addition to the ISI, secondary outcomes included pain (Brief Pain Inventory-short form), depression (8-item Patient Health Questionnaire), and fatigue (Flinders Fatigue Scale).

“Participants submitted daily diaries and received group-specific educational materials,” explained study authors. “The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and osteoarthritis.”

Among the 282 participants who provided follow-up ISI data, total 2-month posttreatment ISI scores exhibited a significant adjusted mean between-group difference of −3.5 points between the CBT-I group and the EOC group (95% CI, −4.4 to −2.6 points; P < .001), which was sustained at 12-month follow-up (adjusted mean difference, −3.0 points; 95% CI, −4.1 to −2.0 points; P < .001).

Additionally, at 12-month follow-up, 56.3% of participants receiving CBT-I remained in remission (ISI score ≤ 7), compared with 25.8% of those receiving EOC.

Secondary outcome measures indicated:

  • Participants of the CBT-I group exhibited significant reductions in fatigue compared with the EOC group at 2 months post-treatment (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 after 2 months, but these differences were not sustained at 12-month follow-up

“Telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and osteoarthritis pain in a large statewide health plan,” concluded study authors. “Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.”


McCurry SM, Zhu W, Korff MV, et al. Effect of telephone cognitive behavioral therapy for insomnia in older adults with osteoarthritis pain. JAMA Intern Med. Published online February 22, 2021. doi:10.1001/jamainternmed.2020.9049