A Cognitive-Behaviour Therapy (CBT) Self-Management Approach for Insomnia in Chronic Pain: A Randomized Control Trial

This study will test the impact of a cognitive-behavioural self-management approach for the management of insomnia among patients with chronic pain. This self-management approach consists of a manual describing cognitive behavioural techniques for the management of insomnia. In terms of primary outcomes, it is anticipated that there would be improvements in sleep-related dimensions such as sleep quality, sleep efficiency, and night-time awakenings in the sample group receiving a copy of the self-help manual intervention to be implemented by participants in their home (intervention group), relative to the group receiving treatment as usual (control group). In terms of secondary outcomes, it is anticipated that the intervention group will show improvements in mood, fatigue, pain severity, and pain-related disability relative to the control group. The tertiary outcome variable of pre-sleep arousal is anticipated to have a moderating or mediating relationship with the sleep variables investigated.

Study Overview

• Status: Completed
• Conditions: Chronic Pain; Insomnia
• Intervention / Treatment: Behavioral: Sleep diary; Behavioral: Self-help manual for insomnia

Detailed Description

In summary therefore, insomnia and other sleep difficulties have been reported to frequently occur in conjunction with other medical or psychiatric disorders, however insomnia co-occurring with other medical or psychiatric conditions has received less attention relative to primary insomnia with no such concurrent conditions (e.g., Lichstein, 2006; McCrae, & Lichstein, 2001; Taylor, Mallory, Lichstein, Durrence, Riedel, & Bush, 2007). In chronic pain, there have not been many well-controlled studies involving insomnia existing with a concurrent chronically painful condition. Research thus far has found multi-component cognitive-behavioural approaches to be successful in treating primary insomnia, and there have been some studies applying these approaches in the context of insomnia and concurrent medical conditions (Currie, Wilson, Pontefract, & deLaplante, 2000; Morin, 1993). Based on Morin's work (Morin, 1993; Morin, Beaulieu-Bonneau, LeBlanc, & Savard, 2005) involving a cognitive-behaviour therapy (CBT) protocol for patients with sleep problems related to chronic pain, a self-help format of such an intervention has also been developed (Currie & Wilson, 1997). However, this has thus far only been delivered within a group-based treatment programme (Currie, 1998; Currie & Wilson, 1997; Currie, Wilson, Pontefract, & deLaplante, 2000). From this context, and building on a prior study involving a group treatment format (Currie, 1998; Currie, Wilson, Pontefract, & deLaplante, 2000), the usefulness of a manualized self-management approach in manageing insomnia will be investigated, including the impact of this approach with regard to other salient measures of improved functioning (such as pain severity or pain-related disability) for individuals with chronic pain. The proposed study will involve a randomized control trial of this self-help treatment strategy for comorbid insomnia in chronically painful medical conditions among an adult outpatient sample at a hospital rehabilitation centre and pain clinic. This study thus seeks to investigate how successful a cognitive-behaviour therapy (CBT) self-help management approach is for manageing insomnia amongst people with chronic pain. Given the public health implications of the relationship of poor sleep to quality of life (e.g., Morin, Stone, McDonald, & Jones, 1994; Quesnel, Savard, Simard, Ivers, & Morin, 2003), a self-management approach to insomnia in the context of chronic pain may offer an accessible and cost-effective treatment option.

The following hypotheses will be tested:

The first hypothesis predicts that participants in the intervention group will show changes in their scores on psychological measures in terms of greater improvements in sleep-related dimensions, in comparison with controls between the baseline and post-treatment periods.

The second hypothesis predicts that participants in the intervention group will show changes in their scores on psychological measures in terms of lower levels of anxiety, depression, fatigue, pain severity, and pain-related disability, in comparison with controls between the baseline and post-treatment periods. These secondary outcome variables are not directly targeted by the intervention, however it is proposed that if improvements in sleep are experienced, there would be subsequent improvements in the variables of mood, fatigue, pain severity, and pain-related disability among chronic pain patients who experience insomnia.

The third hypothesis predicts that the variable of pre-sleep arousal will have a moderating or mediating influence on the sleep-related variables (which will be the primary outcome variables). The moderating or mediating variable of pre-sleep arousal is proposed to assess dimensions related to sleep that are not tapped into by the primary outcome, sleep-related variables, but that may be of salience in the context of insomnia that is comorbid with chronically painful conditions.

• Study Type: Interventional
• Enrollment (Actual): 48
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Ontario
    • Ottawa, Ontario, Canada, K1H 8M2
      • The Ottawa Hospital Rehabilitation Centre
    • Ottawa, Ontario, Canada, K1H 8L6
      • The Ottawa Hospital, Pain Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• 18 to 65 years of age
• Not in state of crisis
• Able to read and understand English
• Experiences sleep difficulties or insomnia
• Has chronic pain

Exclusion Criteria:

• Under 18 or over 65 years of age
• In a state of crisis
• Does not read or understand English
• Does not experience sleep difficulties or insomnia
• Does not have chronic pain

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Control Group; Receive one weekly telephone follow-up call per week to monitor sleep progress, complete 7 weeks of sleep diaries only (sleep diary measures Total Sleep Time in hours, Time to Fall Asleep in minutes, Number of Nocturnal Awakenings, Sleep Efficiency as a percentage, and Sleep Quality as units on a scale), complete questionnaires at three study timepoints	Behavioral: Sleep diary
Experimental: Experimental Group; Receive one weekly telephone call to monitor sleep progress, complete 7 weeks of sleep diaries (sleep diary measures Total Sleep Time in hours, Time to Fall Asleep in minutes, Number of Nocturnal Awakenings, Sleep Efficiency as a percentage, and Sleep Quality as units on a scale), implement one chapter per week of self-help manual for insomnia over 7 weeks at home, complete questionnaires at three study timepoints	Behavioral: Sleep diary; Behavioral: Self-help manual for insomnia; Implementation of chapters of self-help manual at home, and completion of sleep diary in terms of time in bed, hours of sleep, time to fall asleep, number of awakenings, and sleep quality; Other Names: Intervention Group

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Insomnia Severity Index (ISI)	Measures insomnia symptoms, scores range from 0-28 with higher scores (ranging from 15-28) indicating clinical insomnia and therefore worse outcomes	Timepoint 2 (week 7 of study participation)
Sleep Diary- Total Sleep Time	Measures: Total Sleep Time in hours, higher scores indicate better outcomes	Timepoint 2 (week 7 of study participation).
Sleep Diary- Time to Fall Asleep	Measures: Time to Fall Asleep in minutes, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).
Sleep Diary- Number of Nocturnal Awakenings	Measures: Number of Nocturnal Awakenings, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).
Sleep Diary- Sleep Efficiency	Measures: Sleep Efficiency (percentage)- higher scores indicate better outcomes	Timepoint 2 (week 7 of study participation).
Sleep Diary- Sleep Quality	Measures: Sleep Quality (units on a scale from 0-10), higher scores indicate better outcomes	Timepoint 2 (week 7 of study participation).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Severity Rating	Measures pain severity, rated on scale from 0-10, total scores range from 0-40, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).
Pain Disability Index (PDI)	Measures pain disability impact on various life domains, scores range from 0-70, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).
Hospital Anxiety and Depression Scale (HADS)	Measures symptoms of depression and anxiety, total scores range from 0-42, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).
Pre-Sleep Arousal Scale (PSAS)	Measures pre-sleep hyperarousal, total scores range from 16-80, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).
Fatigue Severity Scale (FSS)	Measures symptoms of fatigue, total scores range from 9-63, higher scores indicate worse outcomes	Timepoint 2 (week 7 of study participation).

Collaborators and Investigators

• Sponsor: Ottawa Hospital Research Institute
• Collaborators: The Ottawa Hospital
• Investigators: Principal Investigator: Keith E Wilson, PhD, The Ottawa Hospital Rehabilitation Centre

Study record dates

Study Major Dates

• Study Start: April 1, 2010
• Primary Completion (Actual): January 1, 2012
• Study Completion (Actual): March 1, 2012

Study Registration Dates

• First Submitted: August 19, 2010
• First Submitted That Met QC Criteria: August 23, 2010
• First Posted (Estimate): August 25, 2010

Study Record Updates

• Last Update Posted (Actual): February 19, 2018
• Last Update Submitted That Met QC Criteria: August 10, 2017
• Last Verified: August 1, 2017

More Information

Terms related to this study

• Keywords: Chronic pain; Insomnia
• Additional Relevant MeSH Terms: Mental Disorders; Nervous System Diseases; Sleep Disorders, Intrinsic; Dyssomnias; Sleep Wake Disorders; Pain; Neurologic Manifestations; Chronic Pain; Sleep Initiation and Maintenance Disorders
• Other Study ID Numbers: 2009902

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO