Veterans in a residential functional restoration program for chronic pain demonstrate improvements in sleep symptoms with and without CBT-I enrollment

Veterans in a residential functional restoration program for chronic pain demonstrate improvements in sleep symptoms with and without CBT-I enrollment

Background:

Chronic pain often co-occurs with significant sleep disruption (1) and disrupted sleep has been associated with increased pain severity (2).   Interventions that improve sleep in patients with chronic pain have demonstrated associated improvements in pain and mood symptoms (3) and thus may be a valuable part of a comprehensive pain treatment program.  Importantly, military veterans report a higher prevalence and severity of pain than the general U.S. population (4).  The department of Veterans Affairs currently houses 20 pain rehabilitation programs (5) to target this widespread concern. 

Purpose/Objectives:

The current analysis aims to examine the effectiveness of an intensive pain rehabilitation program on insomnia and related outcomes for a population of veterans with chronic pain. The Residential Functional Rehabilitation Pain Program (rFRPP) located at the VA Puget Sound Healthcare System is an interdisciplinary five-week program consisting of pain psychology, physical therapy, medical, social work, and pharmacy. Within the five weeks, veterans receive 120 hours of programming which includes individualized physical therapy, psychosocial interventions, mind-body interventions, education on pain physiology, and education on pain medication which are primarily delivered in a group setting.

Method:

At the time of this analysis, 109 veterans who completed the program were provided Cognitive Behavioral Therapy for Insomnia (CBT-I) while 30 received Pain Neuroscience Education (PNE) without any intervention targeting insomnia or difficulties directly related to sleep. CBT-I was delivered in five weekly one-hour group sessions focusing on cognitive skills, sleep diaries, relaxation techniques, sleep restriction, and stimulus control. The PNE intervention consisted of five weekly one-hour group sessions focusing on neuroplasticity as it relates to chronic pain.  For both groups, Insomnia Severity Index (ISI) was collected at pre-intervention, post-intervention, and three month follow-up.

Results:

Linear mixed modeling analyses demonstrated improvement in insomnia symptoms for both groups from pre- to post-intervention, though symptoms increased at three month follow-up (F(2,166.6)=6.90, p< 0.01). However, there was no significant group x time interaction effect, indicating improvement in insomnia symptoms did not differ by group (F(2,166.6)=.44, p=.65).

Conclusions: These findings suggest benefit of increasing activity alone on improvement in disrupted sleep, even without the addition of CBT-I specific skills training. The highly structured residential treatment context likely supported consistent sleep/wake schedules, increased physical activity, increased social contact, and routine class attendance, with somewhat limited opportunity for sleep during the day. Future analyses should assess group differences in measures of mood as well as durability of gains at follow-up to better understand the added long-term benefit of CBT-I.

References: (1) Nahin RL. Severe pain in veterans: the impact of age and sex, and comparisons to the general population. Journal of Pain. 2017; 18 (3): 247-254
(2) Wilson, Keith G. Ph.D.*; Eriksson, Mariane Y. B.A.†; D'Eon, Joyce L. Ph.D.*; Mikail, Samuel F. Ph.D.‡; Emery, Patricia C. B.A.†. Major Depression and Insomnia in Chronic Pain. The Clinical Journal of Pain 18(2):p 77-83, March 2002.
(3) Selvanathan, J., Pham, C., Nagappa, M., Peng, P., Englesakis, M., Espie, C. A., Morin, C. M., & Chung, F. (2021). Cognitive behavioral therapy for insomnia in patients with chronic pain – A systematic review and meta-analysis of randomized controlled trials, Sleep Medicine Reviews, 60, https://doi.org/10.1016/j.smrv.2021.101460.
(4) 1Dahlhamer, J., Lucas, J., Zelaya, C., Zelaya, C., Nahin, R., Mackey, S., Debar, L., Kerns, R., Von Korff, M., Porter, L., & Helmick, C. (2018). Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. Morbidity and Mortality Weekly Report, Center for Disease Control and Prevention, 67(36), 1001–1006. http://dx.doi.org/10.15585/mmwr.mm6736a2
(5) U.S. Department of Veterans Affairs. (2019) Central Office Statistical Data. Washington, D.C.