The prescription of benzodiazepines is increasing today, and the important thing is that this tendency is more pronounced in primary care than in psychiatrists 33 , However, the American Geriatrics Society does not recommend the use of benzodiazepines or non-benzodiazepine hypnotics in the elderly 18 , as this vulnerable group may experience greater harms including fatal side effects such as falls and hip fractures 17 — However, further evidence-based strategies still need to be established for discontinuing benzodiazepines in the elderly and some alternatives to complement these drugs In this sense, to overcome the limitations of pharmacotherapies, especially of benzodiazepine in the elderly, a recent systematic review also analyzed the efficacy and safety of non-benzodiazepine and non-Z-drug hypnotic medications in elderly individuals with insomnia The authors analyzed 24 clinical studies, including 21 RCTs, and concluded that limited evidence suggests suvorexant, doxepin, and possibly ramelteon may be effective and safe pharmacological alternatives for treating elderly individuals with insomnia As the authors excluded non-pharmacological interventions at the study selection process, the findings of the study could be complementary to the results of this review.

In summary, this review found some comparatively effective strategies, especially combined non-pharmacological treatments, for insomnia in the elderly, while it did not find any significant comparative advantage in terms of acceptability.

In the safety profile, there was limited evidence that acupuncture is overall safe. However, due to the methodological limitations of the included studies, the inability to conduct sensitivity analysis on high-quality RCTs is a limitation of the reliability of the results.

In particular, strict allocation concealment and assessor blinding seem to be a major issue for further researches in this area to enhance their methodological quality. The most interesting finding of this review was that combined treatments were effective strategies for treating elderly individuals with insomnia in terms of overall effectiveness.

In other words, combined treatments such as acupuncture combined with benzodiazepines and benzodiazepines combined with CBT-I showed excellent effectiveness in improving insomnia in the elderly.

Based on the meanrank and SUCRA, the priorities of combined treatments, including benzodiazepines combined with CBT-I, acupuncture combined with benzodiazepines, and benzodiazepines combined with exercise, were generally confirmed. Moreover, pair-wise meta-analyses of PSQI total score and polysomnography data also confirmed the superiority of combined treatments for sleep quality and sleep architecture, respectively.

The other notable result was the comparative effectiveness of CIM approaches on elderly individuals with insomnia. Especially in the case of acupuncture, it was an efficient adjuvant strategy for benzodiazepines to improve their effectiveness. None of the included studies used acupuncture combined with CBT-I.

However, some previously published studies suggest that CBT-I, known as the first-line treatment for insomnia, and acupuncture may have different therapeutic characteristics. These studies have found that acupuncture showed weaker effects of improving insomnia itself compared to CBT-I, but showed an excellent effect in improving accompanying conditions, especially pain and pain-related insomnia 73 — Although acupuncture may still need more solid evidence to be recommended for routine treatment of elderly individuals with insomnia 77 , the treatment seems to be useful as an adjuvant strategy to complement conventional treatments.

Given that benzodiazepines should be used very carefully in the elderly 18 , these drugs in combination with acupuncture may increase the effectiveness.

This interaction could possibly reduce the dose of benzodiazepines. Also, given the high prevalence of pain in the elderly 78 , acupuncture may have the potential to improve both pain-related insomnia and pain condition in this population.

Another interesting finding is that BT was ranked the most effective in the SUCRA of PSQI total score. According to the results of NMA, BT was significantly superior to wait-list as well as sleep education and relaxation in improving PSQI total score and tended to be superior to benzodiazepines and CBT with borderline significance.

This finding was based on the results of a 4-week RCT comparing multicomponent behavioral treatment and sleep education Two other studies 45 , 58 also used multicomponent behavioral treatments, but they were not included in this analysis because they did not report the PSQI total score.

Buysse et al. They also explain that because CBT-I is limited by the number of specialty-trained clinicians and by its duration or cost of treatment, a simpler and more acceptable BBTI can be more efficient and effective.

Although the PSQI total score was not reported, McCrae et al. Moreover, Chan et al. Although there is still little evidence to conclude, BT, which removes cognitive components from CBT-I and emphasizes behavioral elements, is worth comparing to CBT-I, which is considered as the first-line treatment of elderly individuals with insomnia.

In particular, in older people with cognitive impairments such as dementia, BT with less cognitive components may be more effective, but this is still a hypothesized effect.

It is expected that further studies will be conducted to compare the effectiveness and acceptability of BT and CBT-I according to the characteristics of patients with insomnia. Regarding cognitive impairments, although not included in the outcomes of interest, one of the included studies reported changes in cognitive function using the Montreal Cognitive Assessment MoCA However, since only one study reported changes in cognitive function, the reliability of the findings was low.

Lastly, the difference between BT and sleep education in the pair-wise meta-analysis of polysomnography data should be pointed out. The results are based on one RCT 47 with 4 weeks of treatment and 3 months of follow-up.

After treatment duration at the fourth week , compared with the sleep education group, the BT group showed better results in WASO and sleep efficiency, but showed significantly inferior results in SOL and TST.

In other words, due to the initial strict sleep restriction, the TST temporarily decreased while sleep efficiency increased.

As this sleep restriction was relaxed, the SOL and TST of the BT group were improved at the 6-month follow-up. Based on the effectiveness, acceptability, and safety data found in this review, when treating elderly individuals with insomnia in clinical practice, it may be helpful to combine two or more treatments, and individual treatment strategies can be established based on the patient's preferences and accompanying symptoms.

For example, acupuncture may be an important treatment component for patients with insomnia and pain or with poor cognitive status. CBT-I may be difficult to apply to these individuals.

Moreover, BT without the cognitive component may also be an alternative in elderly individuals with insomnia who suffer from such cognitive difficulties. However, since the treatment may reduce TST in a short period of 4 weeks or fewer, it is necessary to consider other strategies or provide sufficient explanations before treatment in cases where compliance is a concern.

Although not found in our review, adherence to treatments in elderly patients may be related to factors such as disease-related knowledge, health literacy, cognitive function 79 , and frailty syndrome Therefore, compliance with non-pharmacological treatment, pharmacological treatment, or combined treatment strategies in elderly patients with insomnia require further investigation.

NMA is a valuable meta-analysis method that allows the selection of the most efficient options among several treatment options. Although non-pharmacological treatments are very important for elderly individuals with insomnia owing to the limited availability of pharmacotherapy in comparison to adults with insomnia 18 , to the best of our knowledge, no attempt has been made to analyze the comparative effectiveness of the different non-pharmacological treatments available, until recently.

This review has the advantage of using NMA methodology to derive the comparative advantage of several non-pharmacological treatments in terms of effectiveness, acceptability, and safety in elderly individuals with insomnia based on current evidence.

The results can help clinicians, patients, and policymakers to make informed decisions as to the optimal non-pharmacological treatments for the treatment of insomnia in the elderly.

However, several limitations should be pointed out. First, the number of RCTs included is small compared to the interventions covered in this review. This leads to the limitation that most of the results, especially in pair-wise meta-analysis results, are based on one or two RCTs.

This may indicate a lack of relevant trials on this issue. Elderly individuals with insomnia, however, carry huge medical and social burdens 10 — Second, unlike the protocol in this study, SMD, rather than the mean difference MD , was used for continuous outcomes.

This is because the consistency model between some comparisons was not established in the inconsistency test of the PSQI global score.

Instead, SMD was used. Here, a consistency model was established between all comparisons. In addition, in the meta-analysis, SMD has a generalizability advantage over MD, so it may be a better unit for this review Third, the various methods of acupuncture were not considered in the analysis of this review.

This review found that acupuncture may be a promising adjuvant for elderly individuals with insomnia. However, different methods of acupuncture can also have different effects on insomnia. For example, a recent NMA with Bayesian analysis analyzed 52 RCTs and concluded that scale acupuncture is most effective for treating primary insomnia Therefore, in future studies, expert consensus about the most effective acupuncture methods for treating elderly individuals with insomnia in clinical settings should be derived, and acupuncture trials based on the standardized acupuncture methods should be conducted.

Fourth, only nine RCTs 42 , 47 , 48 , 52 , 55 , 56 , 58 , 62 , 64 conducted follow-up and only five 42 , 47 , 48 , 55 , 62 of them reported long-term follow-up data over 6 months.

Like in the case of Buysse et al. Moreover, CBT-I, which corrects dysfunctional beliefs about sleep itself, may have different effects in the long-term than other non-pharmacological interventions, considering its mechanism e.

On the other hand, recent research indicated that the cognitive effects of CBT-I are not significantly associated with improvements in insomnia symptoms Therefore, these issues need to be further clarified through long-term follow-up trials to determine which factors, including cognitive elements of CBT-I, affect long-term insomnia symptoms.

Fifth, in terms of acceptability and safety, there were not enough cases reported in the original RCT included in this review to conclude. This may suggest that non-pharmacological treatments were generally acceptable and safe; however, it also may indicate potentially poor reporting in drop-out and safety profiles among original RCTs.

Given the importance of these outcomes, especially in older people, future studies should report more stringent drop-out and AEs occurrences. Sixth, the overall quality of the RCTs included in this review was low to moderate, particularly at risk of some overestimation due to lack of blinding procedures.

Due to the nature of non-pharmacological interventions, the lack of blinding of participants and personnel seems inevitable. However, the rigorous implementation of assessor blinding can be an important quality assurance procedure that addresses the problem of overestimation.

Future studies should address efforts to minimize the risk of overestimation, with particular emphasis on assessor blinding. Seventh, in this review, pharmacological treatments, including benzodiazepines, were considered in assessing the relative effectiveness of non-pharmacological treatments of interest.

Since this review aimed to investigate the comparative effectiveness of some non-pharmacological treatments or combination treatment strategies for elderly insomnia, the findings should not be interpreted to indicate the effectiveness and safety profile of pharmacological treatment alone.

The results of this review have shown promising results for a CIM modality, acupuncture. Given that the cost-effectiveness of this treatment has been demonstrated in various clinical conditions 88 — 90 , the cost-effectiveness of interventions, including acupuncture for elderly individuals with insomnia, should be further investigated.

In terms of effectiveness in PSQI total score, compared to wait-list, acupuncture, acupuncture combined with benzodiazepines, BT, benzodiazepines, benzodiazepines combined with CBT, and CBT showed superior benefits.

In terms of acceptability, there was not enough data to conclude. In terms of safety, there was limited evidence that acupuncture is overall safe than pharmacological interventions.

However, most of the RCTs included had methodological problems, especially related to the lack of blinding procedure, suggesting the risk of overestimation of their effect size. Therefore, future studies should address efforts to minimize the risk of overestimation, with particular emphasis on the assessor blinding procedure.

The study was conceptualized by C-YK. C-YK and BL searched and selected the trials, and extracted, analyzed, and interpreted the data.

C-YK drafted the manuscript. MC, T-HK, B-HJ, SC, and JK helped with the study design and critically reviewed the manuscript. All authors read and approved the final version of the manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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We conducted a systematic review on the effectiveness of non-pharmacological interventions on sleep characteristics among adults with MSK pain and comorbid sleep problems. We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and PsycINFO from inception to April 2, for randomized controlled trials RCTs , cohort, and case-control studies.

Pairs of independent reviewers critically appraised and extracted data from eligible studies. We synthesized the findings qualitatively. We screened records and identified two RCTs six articles, participants. CBP-P vs. education was effective at increasing sleep efficiency wrist actigraphy in a subgroup of participants with severe pain at baseline mean difference 5.

The intervention was no better than placebo behavioural desensitization for improving other sleep outcomes related to sleep onset or pain outcomes. Clinically significant improvements in sleep in the short term may improve longer term pain outcomes.

Further high-quality research is needed to evaluate other non-pharmacological interventions for people with comorbid sleep problems and a range of MSK conditions.

Musculoskeletal MSK conditions are leading causes of disability worldwide [ 1 ]. MSK conditions are the most common causes of severe long-term pain and are typically characterized by limitations in mobility, dexterity and functional ability affecting social functioning and mental health, further diminishing overall quality of life [ 1 ].

Further to this, sleep disturbances or problems are frequently experienced by individuals suffering from MSK conditions, but are often seen as simply a symptom of pain, and not as an independent problem [ 2 ]. Sleep disturbances include poor quality sleep, reduced sleep efficiency and duration, delayed sleep onset, fragmentation of sleep architecture or sleep continuity, increased activity or movement during sleep, nonrestorative sleep and increased sleepiness during daytime [ 3 , 4 ].

Sleep problems, such as insomnia and poor sleep quality are amongst the most common comorbidities associated with various MSK conditions [ 5 , 6 , 7 , 8 ]. In adults with chronic low back or neck pain, the estimated prevalence of sleep problems is approximately A prevalence of sleep deprivation More than two-thirds of patients with OA have sleep disturbances; sleep disturbances have also been found to be a contributing factor to limitations in daily functioning [ 11 ].

While chronic pain and chronic insomnia exacerbate profound negative consequences individually, when they co-occur, their combined impact in lost productivity and personal suffering is magnified. Compared to those experiencing only chronic pain, those that experience both chronic pain and difficulties with sleep report higher pain intensity, more depressive symptoms, and greater distress [ 2 , 12 , 13 , 14 , 15 ].

Sleep and pain share a complex reciprocal relationship, such that pain disturbs sleep continuity and quality and, conversely, poor sleep can exacerbate pain intensity.

Furthermore, poor sleep may disrupt various physiological processes that can then affect pain perception negatively and can worsen pain by influencing pain signal processing, pain threshold, inflammation, and disability.

Disrupted sleep may contribute directly to increased central pain processing, exacerbating daily pain, which creates a vicious cycle of perpetuated sleep disturbances and pain. While an association between pain and sleep problems has been established, this does not demonstrate causality; however, longitudinal studies conducted in both adolescent and adult pain populations have found sleep problems to be predictive of pain suggesting a unilateral relationship.

The sleep-pain relationship is multifactorial and therefore a multi-pronged approach should be taken when managing MSK pain. MSK conditions are typically managed by primary care and rehabilitation professionals such as general physicians, physiotherapists and chiropractors.

Evidence-based guidelines recommend that clinicians use a biopsychosocial approach to manage patients with MSK conditions, including screening for and addressing comorbidities and suboptimal lifestyle behaviours. Rehabilitation clinicians, however, typically do not comprehensively assess sleep problems or sleep outcomes [ 16 ], despite perceiving sleep as important for health and rehabilitative outcomes [ 17 ].

Given that sleep problems are strongly related to pain, and many patients have identified improved sleep as an important outcome for pain treatment this is one area deserving more attention in MSK pain populations.

Two systematic reviews and meta-analyses of randomized controlled trials RCT examined the effect of sleep interventions on improving sleep and pain [ 18 , 19 ].

Tang et al. Ho et al. These systematic reviews require updating, as their literature searches ended in and , respectively. Further, systematic reviews that seek to identify analytic observational studies i. To our knowledge, no recent systematic reviews have been conducted to assess the effectiveness of non-pharmacological interventions on sleep and health outcomes including pain defined by the World Health Organization WHO International Classification of Functioning, Disability and Health ICF framework in a population with MSK pain and comorbid sleep problems [ 20 ].

Therefore, we conducted a systematic review of the literature to synthesize the best evidence on the effectiveness of non-pharmacological interventions on sleep characteristics among adults with MSK pain and a comorbid sleep problem.

Our systematic review protocol was registered with the International Prospective Register of Systematic Reviews PROSPERO CRD We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statement to guide the conduct and reporting of this review [ 21 ].

Prior to the analyses, we amended our protocol to clarify that secondary or subsequent analyses of randomized trials were eligible to capture all relevant literature.

MSK pain involving the soft tissues of the muscles and joints including, but not limited to, non-specific neck, mid-back, low back pain with or without symptoms of radiculopathy, MSK chest pain, cervicogenic headache, tension-type headache, temporomandibular joint pain, MSK extremity pain, and osteoarthritis.

Excluded: MSK pain associated with major, structural, systemic pathology e. Excluded: all other diagnosed sleep disorders, including but not limited to, sleep-related breathing disorders sleep apnea, obstructive sleep apnea [OSA], obstructive breathing disorders , central disorders of hypersomnolence e.

Environmental e. Behavioral e. Physical therapy e. Multimodal interventions: sleep interventions combined with other interventions e. Examples of over-the-counter aids include diphenhydarmine i. Dietary sleep supplements include, but were not limited to, valerian, melatonin, chamomile, tryptophan, and kava.

Pharmacological interventions combined within a multimodal non-pharmacological approach were considered. We excluded any invasive interventions such as injections and surgeries. Other interventions including pharmacological interventions , placebo or sham interventions, wait list, or no intervention.

Sleep outcomes include: 1 sleep disturbances difficulty initiating or maintaining sleep, reduced sleep efficiency, altered sleep architecture ; 2 sleepiness difficulty remaining awake ; 3 sleep patterns; 4 sleep fragmentation sleep cycle unable to reach stage 4 non-rapid eye movement [NREM] and rapid eye movement [REM] due to waking up throughout sleep ; and 5 self-reported sleep quality tiredness upon waking, daytime tiredness, feelings of being rested and restored.

Common self-reported measures of sleep include the Pittsburgh Sleep Quality Index PSQI [ 22 ], and Insomnia Severity Index ISI [ 23 ]; objective measures include wrist actigraphy [ 24 ]. Health outcomes were classified according to the WHO International Classification of Functioning, Disability and Health ICF framework: 1 body function and structure e.

Common measures of pain include the visual analogue scale VAS , numerical rating scale NRS , and McGill Pain Questionnaire. We also included health-related quality of life e. Cohort and case-control studies with minimum participants per group at baseline c.

Excluded: cross-sectional studies, case reports, case series, pilot studies, study protocols, qualitative studies, non-systematic and systematic reviews, clinical practice guidelines, biomechanical studies, laboratory studies, cadaveric or animal studies, guidelines, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, guideline statements.

We developed our search strategy in consultation with a health sciences librarian, and a second librarian reviewed the search for completeness and accuracy using the Peer Review of Electronic Search Strategies PRESS Checklist [ 26 ].

We searched MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and PsycINFO from inception to April 2, The search strategy was first developed in MEDLINE and subsequently adapted to the other databases see supplementary material.

The search terms included subject headings specific to each database e. We used EndNote X9 software to create a database containing the search results. Pairs of trained, independent reviewers screened articles in two phases to determine eligibility.

In phase I, paired reviewers screened titles and abstracts to determine possibly relevant and irrelevant citations based on the outlined inclusion and exclusion criteria. In phase II, paired reviewers reviewed possibly relevant citations from the first phase using the full text article to determine eligibility.

Any disagreements during screening were resolved by discussion between the paired reviewers to reach consensus. If consensus could not be reached, a third reviewer independently appraised the citation and discussed with the other two reviewers to reach consensus.

Pairs of trained, independent reviewers critically appraised all relevant studies using the Scottish Intercollegiate Guidelines Network SIGN criteria for controlled trials, cohort studies, and case-control studies [ 27 ].

Consensus between reviewers was reached through discussion with the involvement of an independent third reviewer where necessary. We contacted authors when additional information was needed to complete the appraisal.

Pairs of independent reviewers extracted the data from each eligible study to create the evidence table Table 1. We extracted: 1 author, year and country; 2 MSK condition; 3 sleep problem criteria; 4 participant characteristics; 5 intervention arms; content; delivery, dosage and duration; 6 outcomes; and 7 key findings.

Where multiple outcome measures were used to assess each construct, we extracted data for all measures. We synthesized all eligible studies qualitatively using the Synthesis without Meta-analysis SWiM in systematic reviews reporting guideline [ 28 ].

A meta-analysis was not conducted due to the clinical, statistical, and methodological heterogeneity of the studies. We used minimal clinically important differences MCID to determine clinically important between-group effects. All data were analyzed using Microsoft Excel We categorized interventions as having a positive effect superior to comparison group , inconclusive effect some positive and some negative outcomes , no effect similar outcomes to comparison , or a negative effect inferior to comparison.

The effect estimates for positive or negative effects had to be statistically and clinically significant i. We screened citations Fig. Two RCTs reported in 6 articles; 3 articles for each RCT were eligible and critically appraised. We did not identify any eligible cohort or case-control studies.

Both RCTs were conducted in the U. and comprised of participants with OA pain and insomnia diagnosed according to DSM-IV-TR Table 1 [ 31 , 32 , 36 , 41 , 42 , 43 ].

Collectively, the studies analyzed participants. All arms received six weekly min group sessions delivered by mental health professionals. Group sizes ranged from five to 12 individuals. CBT-P included pain education, physical activation, goal setting, relaxation, activity pacing, guided imagery, and cognitive restructuring.

CBP-PI added standard components of CBT-I to CBT-P i. The EOC was designed as an attention control, and included educational content related to sleep and pain management; however, classes were facilitated in a nondirective, self-help format that did not include homework assignments, guided practice in CBT principles, or daily behavioral self-monitoring.

At baseline, all treatment arms had subthreshold levels of insomnia range Vitiello et al. then examined the relationship between short-term 2-month sleep improvement and long-term 9- and month sleep, pain, and fatigue outcomes [ 41 ].

The other RCT evaluated the efficacy of CBT for insomnia CBT-I vs. Both arms received eight weekly min individual sessions delivered by mental health professionals. CBT-I included sleep restriction therapy, stimulus control therapy, cognitive therapy for insomnia, and sleep hygiene education.

At baseline, participants had moderate severity insomnia 17 SD 5 ISI, 0—28 and pain 5 SD 2. Lerman at al. Both RCTs used appropriate randomization and blinding procedures of outcome assessors, used valid and reliable outcome measures, adjusted for differences in baseline characteristics between groups to achieve similarity at baseline, and performed intention-to-treat analyses Table 2 [ 31 , 32 , 36 , 41 , 42 , 43 ].

One weakness in both studies was that it was unclear if participants also received any interventions outside of the study. education only provided clinically important improvements in self-reported sleep measured by Insomnia Severity Index [ISI]; OR 2.

CBT-PI vs. CBT-P also provided clinically important improvements in self-reported sleep measured by ISI in all participants OR 2. CBT-P vs. education only provided clinically important improvements in sleep efficiency measured by wrist actigraphy in a subgroup of participants with severe pain at baseline mean difference 5.

Across all intervention arms, short-term 2-month clinically significant improvements in sleep were not associated with long-term 9- and month clinically significant improvements in any of the sleep outcomes ISI, SE, Pittsburgh Sleep Quality Index [PSQI], Dysfunction Beliefs and Attitudes About Sleep [DBAS] scale, Flinders Fatigue Scale [FFS] , Epworth Sleepiness Scale [ESS], Functional Outcomes of Sleep Questionnaire [FOSQ] or pain or health outcomes AIMS, GCPS, Pain Catastrophizing Scale [PCS], Tampa Scale for Kinesiophobia, Geriatric Depression Scale [GDS].

Smith et al. The intervention was no better than placebo for improving sleep onset latency SOL or pain outcomes VAS, Western Ontario and McMaster Universities Arthritis Index [WOMAC] pain subscale, Conditioned Pain Modulation, Temporal Summation at any time point.

In another secondary analysis, CBT-I was no better than placebo in reducing pain-catastrophizing Pain Catastrophizing Subscale [PCS] [ 43 ]. We identified two low risk of bias RCTs reported in 6 articles; 3 articles for each RCT assessing the effectiveness of CBT on sleep and pain outcomes in adults with OA and comorbid insomnia.

Both RCTs had similar findings. Intervention and comparison groups had similar effects on pain outcomes at all follow-up points. There was one inconsistent finding between the RCTs. Salwen et al. This inconsistency may be explained, in part, by differences in study population, interventions, comparisons and follow-up periods.

The participants in Smith et al. Trial authors discussed why CBT-I or CBT-PI may not have been shown to be superior to comparison groups at improving pain in people with comorbid insomnia. One potential reason is that a number of patients that entered the Lifestyles trial had subclinical levels of insomnia and pain, therefore reducing the potential for detecting improvement in these outcomes reaching MCID thresholds [ 31 , 41 , 42 ].

Baseline severity may need to be above some minimal threshold for reciprocal and durable effects of treating sleep and pain to be observed; for example, moderate insomnia ISI score: 15—21 [ 44 ] and moderate pain-related disability CPGS Grade III [ 45 ].

To better understand why interventions did or did not work or were delivered as intended, all interventions, comparison interventions including sham and control groups , and intervention components should be explicitly described. Using the template for intervention description and replication TIDieR checklist may facilitate this [ 46 ].

This is especially important for complex interventions consisting of various therapeutic components, such as CBT, which may be delivered in various ways and with various intensities.

Indeed, authors in both trials in our review explained that the comparison interventions may have also had effective components on pain i. A comprehensive description of the interventions may have facilitated that assessment. Our results are consistent with other systematic reviews reporting that non-pharmacological sleep interventions are promising for people with pain conditions; however, authors also suggested that further research is needed.

For example, Afolalu et al. Our review captured the same RCTs assessing individuals with OA; however, we did not identify information on low back pain because we excluded studies with small sample size and those assessing pharmacological interventions.

Conditions such as low back pain are self-limiting and often cyclical in nature compared to the exacerbating trajectory of OA [ 48 , 49 ]. The nature of the MSK condition should be considered when determining effect over a variety of follow-up times as this may impact the ability to recognize effect.

With respect to Ho et al. Finally, Tang et al. Strengths of our systematic review included a comprehensive literature search strategy that was peer-reviewed by a second health sciences librarian using the PRESS Checklist [ 26 ]. We conducted and reported our systematic review according to the PRISMA statement [ 21 ] and used explicit criteria for independent reviewers to conduct screening, critical appraisal, and data extraction.

We used MCID thresholds to determine clinically important between-group effects. MCIDs contribute to the interpretation of the outcomes indicating whether the effects of an intervention are clinically meaningful. Determining accurate MCIDs for specific populations is often challenging as the literature in this area is scarce.

While our aim was to determine the most suitable MCID for each outcome measure, population and context, it is possible that having selected alternate MCIDs may have led to varying results. However, we reported all the effect sizes and MCIDS; allowing readers to interpret the results and determine clinical importance.

This review has limitations. First, we only included studies published in English to increase feasibility, which may have excluded relevant studies published in other languages, however, this is an unlikely source of bias [ 50 , 51 , 52 , 53 , 54 ].

Second, we only included published peer-reviewed studies; therefore, we were unable to assess for potential publication bias. Third, studies had to include a sleep-related outcome as per the inclusion criteria to be considered relevant.

Therefore, we may have excluded studies that tested the effectiveness of interventions directed at sleep problems based on pain or other outcomes, but did not include a sleep-related outcome.

However, as our research question assesses the effectiveness of these interventions on sleep characteristics, these studies would be outside the scope of our review. Despite its high prevalence and burden, sleep problems apart from severe sleep disorders frequently requiring pharmacological or other medical treatment e.

Given the strong bi-directional relationship between sleep and pain [ 2 , 57 ], addressing sleep issues early on in the care plan and taking a more pro-active approach in sleep treatment may be beneficial for optimizing treatment outcomes in patients living with chronic MSK painful conditions and comorbid sleep problems.

While our review is limited in providing solutions long-term, clinical guidelines recommend screening and education as it is low-cost and non-invasive as it may provide benefit to patients while further research is conducted [ 58 ].

Only two RCTs were identified as relevant in our review. More high-quality research, particularly RCTs, are needed focusing on other non-pharmacological interventions in individuals with comorbid sleep problems and other MSK conditions, with varying degrees of pain, in addition to OA.

To determine the enduring effects of non-pharmacological treatments in improving both sleep and pain, future research may need to target individuals with more severe and persistent insomnia and pain symptoms.

Furthermore, the duration of the intervention should be consistent. In Vitiello et al. While CBT-I is well-established and it offers treatment components that are based on known physiological mechanisms underlying sleep, the mechanisms for chronic pain are not as well understood making this important to further explore.

In addition to sleep-related outcomes, investigators should select other outcomes important to individuals with painful MSK conditions, such as those related to improved function and participation in meaningful life activities. Future trials should assess the effectiveness of combining first line treatments for sleep problems e.

It is possible that this combination may augment their beneficial effects on sleep and pain. Our review demonstrated that CBT-I or CBT-PI provide some benefits to improving sleep outcomes, but not pain or other health outcomes, in adults with comorbid insomnia and osteoarthritis.

Further high-quality research is needed, particularly on other non-pharmacological interventions for comorbid sleep problems and a range of MSK conditions. In addition, further high-quality research is required to determine if sleep-focused treatments, such as CBT-I, targeted at people with comorbid sleep problems and other MSK conditions, is effective at improving their sleep and pain.

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