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The CBT-I–treated group showed no reductions in pain report on the McGill Pain Questionnaire (MPQ) across the 3 co-morbid medical illnesses, or for the osteoarthritis group alone, relative to an attention-control group. However, the study investigated the hypothesis that improvements in sleep would result in improvements in daytime functioning, so a broad array of measures were included in their analyses. Rybarczyk and colleagues' CBT-I treatment protocol did not specifically address pain management. Until recently, the assumption has been that such insomnias usually had medical causes and that the best approach to correcting the insomnia was to treat the medical condition. 15 Although CBT-I has been shown to achieve high levels of efficacy when treating insomnia in otherwise healthy populations, 16 prior to the study of Rybarczyk et al., 15 CBT-I was not tested in a well-controlled study of individuals with insomnia and co-morbid chronic medical illnesses. 14 Given this reciprocal relationship between sleep and pain, a question with major clinical implications is whether an intervention that improves sleep, per se, in individuals with disturbed sleep and a co-morbid pain state, such as osteoarthritis, might reduce pain as well.Ī recent randomized controlled trial of cognitive behavioral therapy for insomnia (CBT-I) versus an attention control in a group of older adults with co-morbid illnesses-osteoarthritis, coronary artery disease, or chronic obstructive pulmonary disease-reported clinically significant improvements in sleep quality. 13 The basis for this reciprocal relationship may be the modulation of pain during sleep and waking by reciprocally active neurons in the raphe magnus of the brainstem, providing a potential neural substrate for the reciprocal relationship of chronic pain and sleep disruption. 5, 13 – 14 Sleep disruption, fragmentation, or restriction produces hyperalgesia 6 – 8 and can interfere with analgesic treatments involving opioidergic and serotonergic mechanisms of action. Chronic pain initiates and exacerbates sleep disturbance disturbed sleep in turn maintains and exacerbates chronic pain and related dysfunction. Given the likely reciprocal effects between pain and sleep disturbance, teasing apart unique causal pathways is difficult. 10 Chronic sleep disturbance, so common among older patients with osteoarthritis, is itself associated with impaired daytime function, daytime sleepiness and fatigue, reduced quality of life, and increased health care utilization. 9 Even after treatment with anti-inflammatory medications, patients with osteoarthritis show significantly greater objective sleep disturbance, as compared with age-matched control subjects. 5 Patients with osteoarthritis who report having pain and stiffness in the morning have more sleep-related muscle spasms and objectively assessed sleep disturbance. 6 – 8 Whether sleep disturbance precedes or follows pain onset is unclear, but reciprocal effects are likely. 4 It is well established that pain interferes with sleep 5 and, more recently, that disturbed sleep lowers the pain threshold. 3 In fact, pain secondary to arthritis is the most common factor predicting sleep disturbance in the population at large. Sleep quality is a major concern among persons with osteoarthritis, with 60% of people with osteoarthritis reporting pain during the night. 2 Severity and disability tend to increase with age, although severity can fluctuate markedly over short periods of time. 1 Osteoarthritis demonstrates a broad spectrum of symptom severity, ranging from intermittent aching and joint stiffness to loss of motion and severe chronic pain. 1 Osteoarthritis is characterized by joint degeneration, pain, and dysfunction, with 80% of patients with osteoarthritis experiencing limitations of movement. The prevalence of osteoarthritis is rapidly increasing with the accelerating growth of the older portion of the US population. Osteoarthritis is a common cause of pain and disability among older adults, affecting 20 million Americans.
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