Study: Integrated Cognitive Behavioral Therapy Enhances Sleep Outcomes in Chronic Spinal Pain

A randomized clinical trial found that integrating cognitive behavioral therapy for insomnia (CBTi) into best-evidence pain management (BEPM) improved sleep outcomes in patients with nonspecific chronic spinal pain (nCSP) and comorbid insomnia, although it did not lead to additional reductions in pain intensity compared to BEPM alone.

Insomnia is a common issue in patients with nCSP, and its close interaction with pain suggests that addressing sleep disturbances may improve clinical results. This study aimed to evaluate whether the integration of CBTi with BEPM could offer additional benefits for both pain and sleep outcomes,

Conducted at two university hospitals in Belgium between April 2018 and April 2022, the trial enrolled 123 patients with both nCSP and insomnia, confirmed through self-reports and at-home polysomnography. Participants were randomized into two groups: one receiving CBTi integrated with BEPM (CBTi-BEPM) and the other receiving BEPM alone. Both groups underwent 18 sessions over 14 weeks. The CBTi-BEPM intervention included 6 CBTi sessions focusing on sleep improvement and 12 sessions of pain neuroscience education and exercise therapy. Outcomes were assessed at baseline, immediately post-treatment, and at 3-, 6-, and 12-month follow-ups.

Patients receiving the combined intervention reported a 40% reduction in pain intensity after 12 months, versus a 24% reduction in the BEPM-only group. Patients in the CBTi-BEPM group demonstrated a mean pain intensity reduction of 1.976 points compared to 1.006 points in the BEPM-only group, though the difference between groups was not statistically significant (mean group difference, 0.970 points; 95% CI, -0.051 to 1.992). Despite this, CBTi-BEPM consistently outperformed BEPM alone in secondary outcomes, including insomnia severity (Cohen d, 4.319–8.961), sleep quality (Cohen d, 3.654–6.066), beliefs about sleep (Cohen d, 5.324–6.657), depressive symptoms (Cohen d, 2.935–3.361), and physical fatigue (Cohen d, 2.818–3.770). The number needed to treat for insomnia severity response was as low as 2, and no serious adverse effects were reported.

“In this randomized clinical trial, adding CBTi to BEPM did not further improve pain intensity reduction for patients with nCSP and comorbid insomnia more than BEPM alone,” the study authors concluded. “Yet, as CBTi-BEPM led to significant and clinically important changes in insomnia severity and sleep quality, CBTi integrated in BEPM should be considered in the treatment of patients with nCSP and comorbid insomnia.”

Reference

Malfliet A, De Baets L, Bilterys T, et al. Cognitive behavioral therapy for insomnia in pain management for nonspecific chronic spinal pain. JAMA Netw Open. 2024;7(8):e2425856. doi:10.1001/jamanetworkopen.2024.25856