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Table 1 Included studies: n = 6 studies (representing 2 randomized controlled trials)

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

Author, year, country, study design Musculoskeletal condition and participants Sleep problem criteria Intervention arms Intervention content Intervention delivery, dosage, duration Outcome measures Key findings
Vitiello et al. 2013 [31]
USA
Lifestyles RCT (9-mo FU)
Osteoarthritis
Grade II to IV pain on Graded Chronic Pain Scale (GCPS)
N = 367
78% female
Mean age = 73y (SD 8.2)*
DSM-IV-TR for insomnia: self-reported sleep difficulties ≥3 nights/week during past month with ≥1 daytime sleep related problem CBT pain and insomnia (CBT-PI)
(n = 122)
CBT pain (CBT-P)
(n = 122)
Education only control (EOC)
(n = 123)
CBT pain as below and standard CBT for insomnia (sleep hygiene education, stimulus control, sleep restriction, daily sleep monitoring).
Pain education, physical education, goal setting, relaxation, activity pacing, guided imagery, cognitive restructuring).
Educational content related to pain and sleep management. Classes facilitated in nondirective, self-help format.
All interventions delivered as group interventions by mental health professionals; 90-min group sessions (5–12 individuals) 1x/week, for 6 weeks Sleep
Insomnia severity:
Insomnia Severity Index (ISI): 0–28 (lower is better)
MCID: 3.45 (defined as 30% reduction from baseline)
Sleep efficiency (SE): wrist actigraphy (over 1 week): 0–100% (higher is better)
MCID: 5%*
Pain
Pain severity:
Graded Chronic Pain Scale (GCPS): 0–10 (lower is better)
MCID: 1.3 (defined as 30% reduction from baseline)
Arthritis symptoms:
Arthritis Impact Measurement Scale V2 (AIMS): 1–10 (lower is better)
MCID: 1.8* (defined as 30% reduction from baseline)
9-mo FU
Treatment effect estimate [95%CI]:
CBT-P vs. EOC
ISI: 0.13 [− 0.89,1.16] (no statistically significant difference)
GCPS: 0.08 [− 0.21, 0.38] (no statistically significant difference)
SE: 2.91% [0.85, 4.97] (non-clinically important difference favouring CBT-P)
AIMS: − 0.06 [− 0.39, 0.28] (no statistically significant difference)
CBT-PI vs. EOC
ISI: − 1.89 [− 2.83, − 0.96] (non-clinically important difference favouring CBT-PI)
GCPS: − 0.09 [− 0.37, 0.18] (no statistically significant difference)
SE: 2.64% [0.44, 4.84] (non-clinically important difference favouring CBT-PI)
AIMS: 0.20 [− 0.26, 0.66] (no statistically significant difference)
CBT-PI vs. CBT-P
ISI: − 2.03 [− 3.01, − 1.04] (non-clinically important difference favouring CBT-PI)
SE: − 0.26% [− 2.82, 2.29] (no statistically significant difference)
Clinically significant treatment effect (OR [95% CI]):
CBT-P vs. EOC
ISI: 0.81 (0.48, 1.36) (no statistically significant difference)
GCPS: 0.79 (0.39, 1.60) (no statistically significant difference)
CBT-PI vs. EOC
ISI: 2.20 (1.25, 3.90) (clinically important difference favouring CBT-PI)
GCPS: 0.96 (0.55, 1.68) (no statistically significant difference)
CBT-PI vs. CBT-P
ISI: 2.72 (1.59, 4.64) (clinically important difference favouring CBT-PI)
Treatment effect estimate [95%CI] for participants with severe pain at baseline:
CBT-P vs. EOC
ISI: − 0.29 (− 2.36, 1.77) (no statistically significant difference)
GCPS: − 0.16 (− 0.68, 0.37) (no statistically significant difference)
SE: 5.45% (1.56, 9.33) (clinically important difference favouring CBT-P)
AIMS: 0.05 (− 0.60, 0.69) (no statistically significant difference)
CBT-PI vs. EOC
ISI: − 2.71 (− 4.91, − 0.51) (non-clinically important difference favouring CBT-PI)
GCPS: − 0.44 (− 1.00, 0.11) (no statistically significant difference)
SE: 3.69% (0.72, 6.66%) (non-clinically important difference favouring CBT-PI)
AIMS: 0.28 (− 0.55, 1.10) (no statistically significant difference)
CBT-PI vs. CBT-P
ISI: − 2.42 (− 4.15, 0.68) (no statistically significant difference)
SE: − 1.76% (− 6.10, 2.58%) (no statistically significant difference)
Clinically significant treatment effect (OR [95% CI]) for participants with severe pain at baseline:
CBT-P vs. EOC
ISI: 0.75 (0.27, 2.07) (no statistically significant difference)
GCPS: 1.18 (0.49, 2.85) (no statistically significant difference)
CBT-PI vs. EOC
ISI: 2.41 (0.93, 6.21) (no statistically significant difference)
GCPS: 1.36 (0.57, 3.24) (no statistically significant difference)
CBT-PI vs. CBT-P
ISI: 3.21 (1.22, 8.43) (clinically important difference favouring CBT-PI)
McCurry et al. 2014 [42]
USA
Lifestyles RCT (18-mo FU)
  18-mo FU
Treatment effect estimate [95%CI]:
CBT-P vs. EOC
ISI: 0.32 [− 0.97, 1.61] (no statistically significant difference)
GCPS: − 0.04 [− 0.53, 0.45] (no statistically significant difference)
SE: 0.91% [− 2.10, 3.91%] (no statistically significant difference)
AIMS: − 0.09 [− 0.63, 0.45] (no statistically significant difference)
CBT-PI vs. EOC
ISI: − 0.86 [− 2.13, 0.40] (no statistically significant difference)
GCPS: − 0.36 [− 0.82, 0.10] (no statistically significant difference)
SE: 2.10% [− 1.39, 5.59%] (no statistically significant difference)
AIMS: 0.07 [− 0.55, 0.68] (no statistically significant difference)
CBT-P vs. CBT-PI*
ISI: − 0.53 [− 3.08, 2.02] (no statistically significant difference)
GCPS: − 0.54 [− 1.63, 0.55] (no statistically significant difference)
SE: 2.59% [− 4.63, 9.81%] (no statistically significant difference)
AIMS: − 0.01 [− 1.16, 1.15] (no statistically significant difference)
Clinically significant treatment effect (OR [95% CI]):
CBT-P vs. EOC
ISI: 1.06 (0.59, 1.90) (no statistically significant difference)
GCPS: 1.05 (0.52, 2.13) (no statistically significant difference)
CBT-PI vs. EOC
ISI: 1.51 (0.72, 3.12) (no statistically significant difference)
GCPS: 1.21 (0.52, 2.82) (no statistically significant difference)
Treatment effect estimate [95%CI]) for participants with severe pain at baseline:
CBT-P vs. EOC
ISI: 0.45 (− 1.84, 2.74) (no statistically significant difference)
GCPS: 0.09 (− 0.78, 0.96) (no statistically significant difference)
SE: 1.75% (− 2.36, 5.86) (no statistically significant difference)
AIMS: 0.14 (− 0.88, 1.16) (no statistically significant difference)
CBT-PI vs. EOC
ISI: − 1.63 (− 3.77, 0.50) (no statistically significant difference)
GCPS: − 0.55 (− 1.48, 0.39) (no statistically significant difference)
SE: 2.53% (− 3.29, 8.35) (no statistically significant difference)
AIMS: 0.42 (− 0.69, 1.52) (no statistically significant difference)
Clinically significant treatment effect (OR [95% CI]) for participants with severe pain at baseline:
CBT-P vs. EOC
ISI: 0.59 (0.17, 2.11) (no statistically significant difference)
GCPS: 1.01 (0.35, 2.92) (no statistically significant difference)
CBT-PI vs. EOC
ISI: 2.06 (0.51, 8.41) (no statistically significant difference)
GCPS: 1.64 (0.40, 6.80) (no statistically significant difference)
Vitiello et al. 2014 [41]
USA
Secondary analysis of Lifestyles RCT
  Sleep
Insomnia severity:
Insomnia Severity Index (ISI): 0–28 (lower is better)
MCID: 3.47 (defined as 30% reduction from baseline)
Sleep efficiency (SE): wrist actigraphy (over 1 week): 0–100% (higher is better)
MCID: 5%*
Sleep quality: Pittsburgh Sleep Quality Index (PSQI): 0–21 (lower is better)
MCID: 3*
Sleep beliefs and attitudes: Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS-10): 0–100 (lower is better)
MCID: 14.6* (defined as 30% reduction from baseline)
Fatigue: Flinders Fatigue Scale (FFS): 0–31 (lower is better)
MCID: 3.4* (defined as 30% reduction from baseline)
Daytime sleepiness: 8-item Epworth Sleepiness Scale (ESS): 0–24 (lower is better)
MCID: 2*
Daytime function: 10-item Functional Outcomes of Sleep Questionnaire (FOSQ-10): 5–20 (higher is better)
MCID: 5.22* (defined as 30% higher from baseline)
Pain
Pain severity:
Graded Chronic Pain Scale (GCPS): 0–10 (lower is better)
MCID: 1.3 (defined as 30% reduction from baseline)
Arthritis symptoms:
Arthritis Impact Measurement Scale V2 (AIMS): 1–10 (lower is better)
MCID: 1.8* (defined as 30% reduction from baseline)
Catastrophizing:
Pain Catastrophizing Scale (PCS): 0–52 (lower is better)
MCID: 3.36* (defined as 30% reduction from baseline)
Fear avoidance:
Tampa Scale for Kinesiophobia (TSK): 17–68 (lower is better)
MCID: 4*
Depression:
Geriatric Depression Scale (GDS): 0–30 (lower is better)
MCID: 2.1* (defined as 30% reduction from baseline)
Improvers: ≥30% reduction on Insomnia Severity Index (ISI) from baseline to 2 months
9-mo & 18-mo FU
Mean difference improvers vs. non-improvers [95% CI]:
9mo:
ISI: 3.33 (1.35, 5.31) (non-clinically important difference favouring non-improvers)
SE: − 2.49% (− 8.15, 3.17%) (no statistically significant difference)
PSQI: 1.05 (− 0.40, 2.50) (no statistically significant difference)
PSQI-1: 0.17 (− 0.16, 0.50) (no statistically significant difference)
DBAS: 1.24 (− 7.91, 10.39) (no statistically significant difference)
FOSQ: − 0.2 (− 0.92, 0.52) (no statistically significant difference)
FFS: 2.3 (− 1.08, 5.68) (no statistically significant difference)
ESS: − 0.05 (− 1.85, 1.75) (no statistically significant difference)
GCPS: 0.7 (− 0.22, 1.62) (no statistically significant difference)
AIMS: − 0.83 (− 1.80, 0.14) (no statistically significant difference)
PCS: 2.73 (− 0.62, 6.08) (no statistically significant difference)
Tampa Scale for Kinesiophobia: 2.97 (− 1.01, 6.95) (no statistically significant difference)
GDS: 1.12 (− 1.21, 3.45) (no statistically significant difference)
Mean difference improvers vs. non-improvers [95% CI]:
18mo:
ISI: 3.33 (1.26, 5.42) (non-clinically important difference favouring non-improvers)
SE: − 2.49% (− 8.71, 3.73%) (no statistically significant difference)
PSQI: 1.05 (− 0.47, 2.57) (no statistically significant difference)
PSQI-1: 0.18 (− 0.17, 0.53) (no statistically significant difference)
DBAS: 1.24 (− 7.91, 10.39) (no statistically significant difference)
FOSQ: − 0.2 (− 0.96, 0.56) (no statistically significant difference)
FFS: 2.3 (− 1.42, 6.02) (no statistically significant difference)
ESS: − 0.04 (− 2.2, 1.94) (no statistically significant difference)
GCPS: − 0.3 (− 1.30, 0.70) (no statistically significant difference)
AIMS: − 0.83 (− 1.96, 0.30) (no statistically significant difference)
PCS: 2.73 (− 0.86, 6.32) (no statistically significant difference)
TSK: 2.97 (− 1.28, 7.22) (no statistically significant difference)
GDS: 1.12 (− 1.42, 3.66) (no statistically significant difference)
Mean difference improvers vs. non-improvers [95% CI]:
Sleep and fatigue outcomes:
ISI: − 3.03 (− 3.74, − 2.32) (non-clinically important difference favouring improvers)
SE: 1.29% (− 0.18, 2.76) (no statistically significant difference)
PSQI: − 1.45 (− 1.97, − 0.93) (non-clinically important difference favouring improvers)
DBAS: − 2.44 (− 4.74, − 0.15) (non-clinically important difference favouring improvers)
FOSQ: 0.20 (− 0.03, 0.43) (no statistically significant difference)
FFS: − 1.99 (− 3.01, − 0.98) (non-clinically important difference favouring improvers)
ESS: − 0.35 (− 1.00, 0.29) (no statistically significant difference)
Pain and depression outcomes:
GCPS: − 0.51 (− 0.80, − 0.21) (non-clinically important difference favouring improvers)
AIMS: 0.63 (0.26, 1.00) (non-clinically important difference favouring non-improvers)
PCS: 1.33 (− 2.94, 0.29) (no statistically significant difference)
TSK: − 2.27 (− 3.95, − 0.58) (non-clinically important difference favouring improvers)
GDS: − 0.52 (− 1.36, 0.32) (no statistically significant difference)
Smith et al. 2015 [32]
USA
RCT
Knee OA
American College of Rheumatology criteria for classification of knee OA Kellgren/Lawrence Grade ≥ 1
Typical knee pain ratings ≥2 of 10 experienced > 5 days/week for > 6 months
N = 100
79% female
Mean age = 59.4y (SD 9.5)
DSM-IV-TR for insomnia
Level of sleep difficulty: moderate-severe insomnia
CBT insomnia (CBT-I)
Behavioral desensitization (BD) (placebo)
Sleep restriction therapy, stimulus control therapy, cognitive therapy for insomnia, sleep hygiene education
Presented as means of eliminating the conditioned arousal through imagery
Individual 45 min sessions 1 x/week, for 8 weeks delivered by mental health professionals Sleep
Sleep continuity: all measures recorded by diary, actigraphy, or PSG (polysomnography)
Wake after sleep onset (WASO):
(lower is better)
MCID: ≥0.2*
Total Sleep Time (TST): (higher is better)
MCID: ≥0.2*
Sleep-onset latency (SOL): (lower is better)
MCID: ≥0.2*
Sleep efficiency (SE): 0–100% (higher is better)
MCID: ≥0.2*
Insomnia Severity Index (ISI): 0–28 (lower is better)
MCID: ≥0.2*
Pain
Pain intensity:
Visual Analogue Scale (VAS): 0–100 (lower is better)
MCID: ≥0.2*
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC pain): 0–10 (lower is better)
MCID: ≥0.2*
Conditioned Pain Modulation (CPM): (> 1 better)
Temporal summation: (lower is better)
MCID: ≥0.2*
Post-treatment, 3 and 6 months FU
Between-group treatment effect sizes CBT-I vs. BD (cohen’s d [95%CI*])
WASO:
Diary
Posttreatment: − 0.28 (− 0.93, − 0.09) (clinically important difference favouring CBT-I)
3 mo: − 0.38 (− 1.16, − 0.21) (clinically important difference favouring CBT-I)
6 mo: − 0.15 (− 0.67, 0.27) (no statistically significant difference)
Actigraphy
Posttreatment: − 0.42 (− 0.83, 0.04) (no statistically significant difference)
3 mo: − 0.27 (− 0.75, 0.19) (no statistically significant difference)
6 mo: − 0.21 (− 0.57, 0.45) (no statistically significant difference)
PSG
Posttreatment: − 0.31 (− 1.09, − 0.21) (clinically important difference favouring CBT-I)
3 mo: 0.45 (− 0.32, 0.63) (no statistically significant difference)
6 mo: 0.00 (− 0.79, 0.16) (no statistically significant difference)
TST:
Diary
Posttreatment: − 0.49 (− 1.03, − 0.18) (clinically important difference favouring BD)
3 mo: 0.01 (− 0.46, 0.46) (no statistically significant difference)
6 mo: 0.03 (− 0.56, 0.38) (no statistically significant difference)
Actigraphy
Posttreatment: − 0.44 (− 1.08, − 0.19) (clinically important difference favouring BD)
3 mo: 0.09 (− 0.53, 0.39) (no statistically significant difference)
6 mo: − 0.25 (− 0.99, 0.05) (no statistically significant difference)
PSG
Posttreatment: − 0.40 (− 0.78, 0.08) (no statistically significant difference)
3 mo: − 0.04 (− 0.47, 0.48) (no statistically significant difference)
6 mo: − 0.22 (− 0.74, 0.22) (no statistically significant difference)
SOL:
Diary
Posttreatment: 0.07 (− 0.67, 0.16) (no statistically significant difference)
3 mo: − 0.15 (− 1.17, − 0.22) (non-clinically significant difference favouring CBT-I)
6 mo: 0.01 (− 0.79, 0.16) (no statistically significant difference)
Actigraphy
Posttreatment: 0.20 (− 0.19, 0.69) (no statistically significant difference)
3 mo: 0.24 (− 0.28, 0.65) (no statistically significant difference)
6 mo: 0.06 (− 0.52, 0.50) (no statistically significant difference)
PSG
Posttreatment: 0.42 (− 0.16, 0.70) (no statistically significant difference)
3 mo: − 0.09 (− 0.89, 0.07) (no statistically significant difference)
6 mo: 0.06 (− 0.53, 0.42) (no statistically significant difference)
SE:
Diary
Posttreatment: 0.22 (− 0.14, 0.69) (no statistically significant difference)
3 mo: 0.39 (0.24, 1.18) (clinically important difference favouring CBT-I)
6 mo: 0.20 (− 0.12, 0.82) (no statistically significant difference)
Actigraphy
Posttreatment: − 0.06 (− 0.43, 0.43) (no statistically significant difference)
3 mo: 0.11 (− 0.33, 0.60) (no statistically significant difference)
6 mo: − 0.09 (− 0.65, 0.37) (no statistically significant difference)
PSG
Posttreatment: 0 (− 0.14, 0.72) (no statistically significant difference)
3 mo: − 0.12 (− 0.40%, 0.56) (no statistically significant difference)
6 mo: 0.01 (− 0.23, 0.73) (no statistically significant difference)
ISI:
Posttreatment: − 0.44 (− 0.86, − 0.03) (clinically important difference favouring CBT-I)
3 mo: − 0.24 (− 0.58, 0.35) (no statistically significant difference)
6 mo: − 0.62 (− 1.01, − 0.07) (clinically important difference favouring CBT-I)
VAS:
Posttreatment: 0.04 (1.45, 2.45) (non-clinically important difference favouring BD)
3 mo: − 0.17 (− 0.64, 0.25) (no statistically significant difference)
6 mo: 0.09 (− 0.43, 0.51) (no statistically significant difference)
WOMAC pain:
Posttreatment: 0.12 (− 0.44, 0.38) (no statistically significant difference)
3 mo: 0.01 (− 0.48, 0.42) (no statistically significant difference)
6 mo: 0.25 (− 0.26, 0.64) (no statistically significant difference)
CPM:
Posttreatment: − 0.19 (− 0.52, 0.33) (no statistically significant difference)
3 mo: 0.31 (− 0.04, 0.91) (no statistically significant difference)
6 mo: − 0.03 (− 0.40, 0.60) (no statistically significant difference)
Temporal summation:
Posttreatment: − 0.20 (− 0.52, 0.34) (no statistically significant difference)
3 mo: − 0.13 (− 0.45, 0.50) (no statistically significant difference)
6 mo: − 0.17 (− 0.52, 0.43) (no statistically significant difference)
Lerman et al. 2017 [43]
USA
Secondary analysis of RCT by Smith et al. 2015 [32]
  Pain
Catastrophizing:
Pain Catastrophizing Scale (PCS): 0–52 (lower is better)
MCID: 4.5* (defined as 30% reduction from baseline)
Daytime catastrophizing: 0–100 (lower is better)
MCID: 8.9* (defined as 30% reduction from baseline)
Nocturnal catastrophizing: 0–100 (lower is better)
MCID: 7.1* (defined as 30% reduction from baseline)
Post-treatment, 3 and 6 months FU
Between-group mean differences (CBT-I vs. BD) [95% CI]*
PCS:
Posttreatment: 1.04 (− 3.07, 5.15) (no statistically significant difference)
3 mo: − 1.28 (− 5.43, 2.87) (no statistically significant difference)
6 mo: 0.54 (− 3.64, 4.72) (no statistically significant difference)
Daytime catastrophizing:
Posttreatment: 2.09 (− 4.85, 9.03) (no statistically significant difference)
3 mo: 2.75 (− 4.58, 10.08) (no statistically significant difference)
6 mo: 0.37 (− 7.11, 7.85) (no statistically significant difference)
Nocturnal catastrophizing:
Posttreatment: − 0.32 (− 6.82, 6.18) (no statistically significant difference)
3 mo: 0.65 (− 5.82, 7.12) (no statistically significant difference)
6 mo: − 2.73 (− 9.63, 4.17) (no statistically significant difference)
Salwen et al. 2017 [36]
USA
Secondary analysis of RCT by Smith et al. 2015 [32]
Knee OA
American College of Rheumatology criteria for classification of knee OA. Kellgren/Lawrence Grade ≥ 1
Typical knee pain ratings ≥2 of 10 experienced > 5 days/week for > 6 months
N = 74
77% female
Mean age = 59.5y (SD 9.9)
Sleep
Sleep continuity:
Total sleep time (TST): self-reported, actigraphy (higher better)
MCID: 40 min*
Sleep efficiency (SE): 0–100% (higher better)
MCID: 5%*
Sleep onset latency (SOL): (lower better)
MCID: > 30 min
Wake after sleep onset (WASO):
(lower better)
MCID: 30 min
Pain
Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC pain): 0–10 (lower is better)
MCID: 1.4* (defined as 30% reduction from baseline)
Responders: reported ≥30% improvement in self-reported pain from baseline to 6 m follow-up
6 months FU
Pain responders: 31/74 (42%)
Nonresponders: 43/74 (58%)
Mean difference mid-treatment (pain responders – nonresponders) [95% CI]*)
SE: − 0.02 (− 0.06, 0.02) (no statistically significant difference)
SOL: − 4.24 (− 15.13, 6.65) (no statistically significant difference)
TST: − 14.67 (− 43.04, 13.70) (no statistically significant difference)
WASO: 8.89 (− 6.14, 23.92) (no statistically significant difference)
Patients who achieved 382 min (6 h) TST per night by mid-treatment (4 weeks) were more likely to report clinically significant pain reduction (≥30% reduction) at FU regardless of treatment group (sensitivity 54.8%, specificity 81.4%)
  1. Notes: CI Confidence Interval; FU follow-up; MCID minimal clinically important difference; mo months; OA osteoarthritis; SD standard deviation; vs: versus; y years
  2. *Calculated or reported by review authors