OBJECTIVES To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive–behavioral therapy for pain and insomnia (CBT-PI), a cognitive–behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes. DESIGN Double-blind, cluster-randomized controlled trial with 9-month follow-up. SETTING Group Health and University of Washington, 2009 to 2011. PARTICIPANTS Three hundred sixty-seven older adults with OA pain and insomnia. INTERVENTIONS Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants’ primary care clinics. MEASUREMENTS Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms. RESULTS CBT-PI reduced insomnia severity (score range 0–28) more than EOC (adjusted mean difference = −1.89, 95% confidence interval = −2.83 to −0.96; P < .001) and CBT-P (adjusted mean difference = −2.03, 95% CI = −3.01 to −1.04; P < .001) and improved sleep efficiency (score range 0−100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44−4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85−4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results. CONCLUSION Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes. J Am Geriatr Soc 2013.

Scientific inveStigationSStudy Objectives: Osteoarthritis pain affects more than half of all older adults, many of whom experience co-morbid sleep disturbance. Pain initiates and exacerbates sleep disturbance, whereas disturbed sleep maintains and exacerbates pain, which implies that improving the sleep of patients with osteoarthritis may also reduce their pain. We examined this possibility in a secondary analysis of a previously published randomized controlled trial of cognitive behavioral therapy for insomnia (CBT-I) in patients with osteoarthritis and co-morbid insomnia. Methods: Twenty-three patients (mean age 69.2 years) were randomly assigned to CBT-I and 28 patients (mean age 66.5 years) to an attention control. Neither directly addressed pain management. Twelve subjects crossed over to CBT-I after control treatment. Sleep and pain were assessed by self-report at baseline, after treatment, and (for CBT-I only) at 1-year follow-up. Results: CBT-I subjects reported significantly improved sleep and significantly reduced pain after treatment. Control subjects reported no significant improvements. One-year follow-up found maintenance of improved sleep and reduced pain for both the CBT-I group alone and among subjects who crossed over from control to CBT-I. Conclusions: CBT-I but not an attention control, without directly addressing pain control, improved both immediate and long-term selfreported sleep and pain in older patients with osteoarthritis and comorbid insomnia. These results are unique in suggesting the long-term durability of CBT-I effects for co-morbid insomnia. They also indicate that improving sleep, per se, in patients with osteoarthritis may result in decreased pain. Techniques to improve sleep may be useful additions to pain management programs in osteoarthritis, and possibly other chronic pain conditions as well.

The hypothesis that body image and perceived social stigma would be important predictors of psychosocial adjustment to a leg amputation was tested in a sample of 112 clients from five prosthetic offices. Two scales were developed to measure body image disturbance resulting from an amputation and perceived social stigma (the individual’s perception that others hold negative attitudes about him or her due to the amputation). The two scales were internally consistent and only moderately correlated (r =.43). The CES-D depression scale, a quality-of-life scale, and prosthetist ratings were used to measure psychosocial adjustment. Regression analyses indicated that body image was a significant independent predictor of all three adjustment measures after controlling for the effects of age at the time of amputation, time since amputation, site of the amputation, self-rated health, and perceived social support. Perceived social stigma made a significant independent contribution to depression but did not qualify as an independent predictor for the other two measures of adjustment. Based on an established CES-D cutoff score, the overall rate of depression was 28%. Theoretical and clinical implications of these findings are discussed.

To investigate the protective and consolation models of the relationship between religion and health outcomes in medical rehabilitation patients. Design: Longitudinal study, data collected at admission, discharge, and 4 months postadmission. Measures: Religion measures were public and private religiosity, acceptance, positive and negative religious coping, and spiritual injury. Outcomes were self-report of activities of daily living (ADL), mobility, general health, depression, and life satisfaction. Participants: 96 medical rehabilitation inpatients; diagnoses included joint replacement, amputation, stroke, and other conditions. Results: The protective model of the relationship between religion and health was not supported; only limited support was found for the consolation model. In regression analyses, negative religious coping accounted for significant variance in follow-up ADL (5%) over and above that accounted for by admission ADL, depression, social support, and demographic variables. Subsequent item analysis indicated that anger with God explained more variance (9%) than the full negative religious coping scale. Conclusions: Religion did not promote better recovery or adjustment, although it may have been a source of consolation for some patients who had limited recovery. Negative religious coping compromised ADL recovery. Although anger with God was rare, it may be useful in screening for patients who are spiritually at risk for poor recovery.

The present study tested cognitive-behavioral therapy (CBT) for insomnia in older adults with osteoarthritis, coronary artery disease, or pulmonary disease. Ninety-two participants (mean age = 69 years) were randomly assigned to classroom CBT or stress management and wellness (SMW) training, which served as a placebo condition. Compared with SMW, CBT participants had larger improvements on 8 out of 10 self-report measures of sleep. The type of chronic disease had no impact on these outcomes. The hypothesis that CBT would improve daytime functioning more than SMW was only supported by a global rating measure. These results add to findings that challenge the dichotomy between primary and secondary insomnia and suggest that psychological factors are likely involved in insomnias that are presumed to be secondary to medical conditions.