Pain Center, Department of Anesthesiology and Intensive Care Medicine, University Hospital Odense
Odense, 5000, Denmark
NCT Number: NCT06361914
Chronic pain constitutes an increasing health and social burden. More than 50% of patients with chronic pain report insomnia, and patients with comorbid insomnia often report stronger and widespread pain, compared to those who are sleeping well. Sleep disturbances are often considered a consequence to chronic pain. This means that insomnia is often overlooked or ineffectively managed with hypnotics or advice on sleep hygiene. Therefore, efficacious, easily accessible, and safe alternatives to the current pharmacological treatments for patients with chronic pain and insomnia are needed. Cognitive behavioral therapy for insomnia (CBT-I) is a cost-effective and safe treatment for insomnia and is recommended as first-line treatment. While highly efficacious, the challenge is to deliver CBT-I to those in need. The main barriers of face-to-face delivered CBT-I are availability of trained therapists, costs, as well as physical and geographical constraints.
The primary aim of this randomized controlled clinical superiority trial is to investigate whether digitally-delivered CBT-I has a greater effect on insomnia and pain than digitally-delivered sleep hygiene education in patients with chronic pain and comorbid insomnia.
Secondary objectives are to a) explore whether the pain-relieving effect is mediated by a change in physiological markers of sleep quality, b) whether health care cost and use of medications at 12 months are reduced after digital CBT-I, and c) to explore the effectiveness of digital CBT-I compared with sleep hygiene education on:
1. Physiological sleep metrics (recorded with ear EEG in subsample of 60 patients). 2. Self-reported sleep quality. 3. Quality of life. 4. Physical and mental health. 5. Thoughts and beliefs about sleep and pain.
This study is active but is not currently recruiting participants.
18 year and older
All sexes
Interventional
Not applicable
Odense, 5000, Denmark
This study aims to investigate the efficacy of digital CBT-I for improving sleep (i.e. reducing insomnia severity) and reducing pain intensity in patients with chronic pain and comorbid insomnia. To achieve this goal, the investigators will perform a randomized controlled single-blind clinical superiority trial. Participants will be randomized with an allocation 1:1 ratio into a digital CBT-I group and a sleep hygiene education group. Both groups will use the Hvil® app, but the amount of content will be different. Using a data manager not affiliated with the project through the Open Patients data Exploratory Network (OPEN) at Odense University Hospital, the randomization will be implemented in the program REDCap. The data manager will prepare the randomization list in REDCap. The computer algorithm will use permuted-block randomization of 2, 4 and 6 individuals. No stratifications will be applied to the randomization.
After inclusion, participants will receive an unique randomization key to impute in the Hvil® app according to the abovementioned procedure to receive either digital CBT-I or sleep hygiene education for 9 weeks. This Hvil® App platform is used for both treatments to ensure that only the contents is different, but the form of delivery is the same. All patient reported data will be filled in directly to the eCRF via an online questionnaire using REDCap. Statistical analyses will be blinded to treatment allocation.
Sample size estimation:
Minimal clinical important difference for insomnia severity is 5 point. With an estimated SD for change of 2 times the minimal clinical important difference (SD=10) for patients with chronic pain and insomnia, power of 80%, an alpha value of 0.05, a minimum of 63 participants in each group is required.
Minimal clinical important difference for pain intensity is 15% corresponding to a change of 1.0 points in this population. With a SD for change of 2.0 for patients with chronic pain and insomnia, power of 80%, an alpha value of 0.05, a minimum of 63 participants in each group is required.
With an expected drop-out of 30% the investigators plan to recruit 160 participants (80 for each group).
Stopping rules: This trial has two stopping rules. Inclusion will stop December 31st 2025. In the event that 130 patients have completed the 9 weeks follow-up before 160 patients have been recruited the investigators will stop recruitment of further participants.
All participants that are withdrawn from the study will be encouraged to complete all visits as scheduled. Participants that are withdrawn from the treatment will not be replaced and will be included in the intention-to-treat population. According to the sample size calculation, the investigators will include participants enough to tolerate a drop-out rate of up to 30%. Both intention-to-treat and per protocol analysis will be performed and compared to assess the robustness of the primary analysis.
Statistical methods:
Difference in change from baseline to 9 weeks in the two primary outcomes (ISI score or mean NRS pain in last 7 days, both being continuous variables) between the digital CBT-I group and the sleep hygiene education group will be estimated using a mixed linear model approach with ISI and NRS pain as outcomes, time, treatment arm (digital CBT-I or sleep hygiene education), and the interaction between time and treatment arm as fixed effects. Both participant specific intercept and slope will be considered as random effects. The model will be adjusted for ISI score or NRS pain at baseline, respectively. The error variance will be allowed to vary over time and across the two arms. Interactions will be parametrized as time dependent treatment effects such that the treatment effect at week 9 corresponds directly with the efficacy parameter of interest. The treatment effect will be expressed as the gain in reduction observed in the digital CBT-I arm, i.e. a positive number expresses a favoring of the intervention. The pre-specified effectiveness analyses will be based on the intention-to-treat (ITT) principle, which includes all participants that are assessed and randomized at baseline. In the case of missing data during the 9-week trial, repeated measures linear mixed models will take this into account automatically, under the assumption that data is missing at random.
For the statistical assessment of the two primary outcomes (ISI and pain intensity), the investigators will apply a sequential test procedure to compare the effect of the two treatments (CBT-I vs. sleep hygiene education) on ISI severity in the first step and the effect on pain intensity in the second step. This means that statistical significance in the second step will only be assessed if statistical significance has been reached in the first step . The investigators use this approach as it seems unlikely that these interventions has direct effect on pain, but rather work through improved sleep. The significance level is set to 5%.
In responder analysis, a responder is defined as a patient who report a more than 30% and 50% decrease in insomnia or pain after 9 weeks. Proportion of responders between treatment groups will be expressed by adjusted odds ratios. These will be based on a logistic regression model with treatment, baseline value of pain intensity and insomnia severity, and sex as covariates.
A detailed statistical analysis plan (SAP) will be made publicly available before the statistical analysis is initiated.
Healthy volunteers accepted: No
Only the study team can determine whether someone qualifies for participation.
Inclusion criteria
For a participant to be eligible, all inclusion criteria must be answered "yes":
Insomnia symptoms (Insomnia Severity Index (ISI) score > 10; moderate insomnia).
Exclusion criteria
For a participant to be eligible, all exclusion criteria must be answered "no":
For the EEG subgroup only (60 patients):
Sleep restriction includes behavioral instructions to limit the time spent in bed to increase sleep drive and further reduce time awake in bed.
Stimulus control therapy entails behavioral instructions to strengthen the association between bed and sleep and to eliminate conditioning of non-sleep behavior and bed.
Deactivation/relaxation training involves methods to reduce somatic tension and limit intrusive thought processes that interfere with sleep.
Cognitive therapy helps to identify, challenge, and modify dysfunctional beliefs about sleep.
Sleep hygiene education entails specific information relating to lifestyle and environmental factors that may interfere with or promote sound sleep. Sleep hygiene education also includes specific sleep facilitating recommendations, such as avoiding visual access to a clock in the bedroom, regular sleep scheduling, avoiding long daytime naps, and limiting alcohol, caffeine, and nicotine intake.
Sleep hygiene education entails specific information relating to lifestyle (diet, exercise, substance use) and environmental factors (light, noise, temperature) that may interfere with or promote sound sleep. Sleep hygiene education also includes specific sleep facilitating recommendations, such as avoiding visual access to a clock in the bedroom, regular sleep scheduling, avoiding long daytime naps, and limiting alcohol, caffeine, and nicotine intake.
Time frame: Difference in change between groups from baseline to 9 weeks.
Insomnia will be assessed with the Insomnia Severity Index (ISI), which is a brief 7 item patient-reported instrument with a score ranging from 0-28 (0=best;28=worst)
Time frame: Difference in change between groups from baseline to 9 weeks
Average pain intensity during last 7 days will be assessed on a 0-10 Numeric Rating Scale (NRS) (ranging from 'no pain to 'worst imaginable pain')
Time frame: Baseline, after 4 weeks, after 9 weeks
The trajectory of ISI scores from baseline, at 4 weeks and 9 weeks
Time frame: Change from baseline to 9 weeks
Difference in number of patients with more than 30% improvement in ISI severity score from baseline to 9 weeks
Time frame: Change from baseline to 9 weeks
Difference in number of patients with more than 50% improvement in ISI severity score from baseline to 9 weeks
Time frame: Weekly from baseline to 9 weeks
The trajectory of weekly NRS pain intensity scores from baseline to 9 weeks
Time frame: Change from baseline to 9 weeks
Difference in number of patients with more than 30% improvement in pain intensity from baseline to 9 weeks
Time frame: Change from baseline to 9 weeks
Difference in number of patients with more than 50% improvement in pain intensity from baseline to 9 weeks
Time frame: After 9 weeks
Assessment of overall change in insomnia from baseline to 9 weeks. Participants will be asked at 9 weeks: 'How is your insomnia now compared to when you entered this study', with 5 response options (much worse, worse, almost the same/unchanged, improved, much improved)
Time frame: After 9 weeks
Assessment of overall change in pain from baseline to 9 weeks. Participants will be asked at 9 weeks: 'How is your pain now compared to when you entered this study', with 5 response options (much worse, worse, almost the same/unchanged, improved, much improved)
Time frame: Baseline, after 4 weeks and after 9 weeks
Sleep quality will be assessed with the Pittsburgh Sleep Quality Index (PSQI), which is developed to provide a reliable, valid and standardized measure of sleep quality. The PSQI consists of 19 items with 15 multiple choice questions and 4 open-ended questions. The 19 items form the basis a global score. The seven components evaluated by the PSQI are: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications and daytime dysfunction. Each component has a score ranging from 0 to 3 yielding a total score of 21, with higher scores reflecting worse sleep difficulties
Time frame: Baseline and after 9 weeks
Physical and Mental Health will be assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS-10) Global Health questionnaire version 1.2. Difference in change in physical and mental health scores between treatment groups from baseline to 9 weeks. PROMIS-10 consist of 10 questions concerning different aspects of global health. The first 9 questions are score on a Likert scale with 5 response options, and the last question asks about pain using a 0-10 numeric rating scale
Time frame: Daily for 7 nights at baseline and after 9 weeks
Sleep diary (total sleep time and sleep efficiency) implemented in the Hvil® app.
Time frame: Baseline, after 4 weeks and after 9 weeks
Thoughts about sleep and pain via the Pain-Related Beliefs and Attitudes about Sleep (PBAS) questionnaire. PBAS consist of 10 items.
Time frame: Baseline, after 4 weeks and after 9 weeks
Thoughts about sleep via the Dysfunctional Beliefs and Attitudes About Sleep (DBAS) Questionnaire. DBAS consist of 16 questions.
Time frame: After 9 weeks
To explore compliance with the treatment arms the interaction with the Hvil App will be explored. This will be reported in terms of time/frequency of using with the app over the 9 weeks.
Time frame: Baseline and after 9 weeks
Measured by the European Quality of Life 5 Dimensions (EQ-5D) mobility domain; asking the participants to rate their mobility on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems
Time frame: Baseline and after 9 weeks
Measured by the European Quality of Life 5 Dimensions (EQ-5D) self care domain; asking the participants to rate their ability for self care on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: Baseline and after 9 weeks
Measured by the European Quality of Life 5 Dimensions (EQ-5D) usual activities domain; asking the participants to rate their ability to perform usual activities on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: Baseline and after 9 weeks
Measured by the European Quality of Life 5 Dimensions (EQ-5D) pain/discomfort domain; asking the participants to rate their level of pain or discomfort on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: Baseline and after 9 weeks
Measured by the European Quality of Life 5 Dimensions (EQ-5D) anxiety/depression domain; asking the participants to rate their level of anxiety or depression on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: Baseline and after 9 weeks
Measured by European Quality of Life Visual Analogue Scale (EQ-VAS), which asks the participant to rate their overall health 'today' on a 0-100 VAS. A higher score indicates a better quality of life.
Time frame: Baseline
The age of the participant will be calculated using the date of randomisation and the date of birth.
Time frame: Baseline
The sex of the participant assigned at birth (male or female)
Time frame: Baseline
Chronic pain will be assessed using the Graded Chronic Pain Scale Revised (GCPS-R) questionnaire. The GCPS-R is a brief, freely available questionnaire that assesses frequency and severity of pain and its impact. The GCPS-R uses 5 items to categorize pain into no chronic pain, mild chronic pain, bothersome chronic pain, and high-impact chronic pain
Time frame: Baseline
The categories for data on ethnicity are White, Asian, Black or African American, other
Time frame: Baseline
Self-reported in centimeter
Time frame: Baseline
Self-reported in kilograms
Time frame: Baseline
Self-reported marital status
Time frame: Baseline
The categories for level of education are compulsory education, upper secondary, bachelor degree, master degree, Phd degree
Time frame: Baseline
Using a pain drawing, patients will be classified into different pain groups at baseline: widespread pain, referred/radiating back pain patterns, regional and localized pain.
Time frame: Baseline
Self-reported medical history and concomitant illnesses relevant to the investigation will be recorded in the eCRF by a trained study nurse during the information visit. A clinically significant worsening of a concomitant illness will be reported as an AE
Time frame: Baseline
Self-reported concomitant medication will be recorded in the eCRF by a trained nurse during the information visit.
Time frame: After 12 months
Measured by the European Quality of Life 5 Dimensions (EQ-5D) mobility domain; asking the participants to rate their mobility on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: After 12 months
Measured by the European Quality of Life 5 Dimensions (EQ-5D) self care domain; asking the participants to rate their ability for self care on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: After 12 months
Measured by the European Quality of Life 5 Dimensions (EQ-5D) usual activities domain; asking the participants to rate their ability to perform usual activities on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: After 12 months
Measured by the European Quality of Life 5 Dimensions (EQ-5D) pain/discomfort domain; asking the participants to rate their level of pain or discomfort on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: After 12 months
Measured by the European Quality of Life 5 Dimensions (EQ-5D) anxiety/depression domain; asking the participants to rate their level of anxiety or depression on a 1-5 Verbal Rating Scale, a score of 1 indicating no problems, and a score of 5 indicating extreme problems.
Time frame: After 12 months
Measured by European Quality of Life Visual Analogue Scale (EQ-VAS), which asks the participant to rate their overall health 'today' on a 0-100 VAS. A higher score indicates a better quality of life.
Time frame: After 6 months
Insomnia will be assessed with the Insomnia Severity Index (ISI), which is a brief 7 item patient-reported instrument with a score ranging from 0-28 (0=best;28=worst)
Time frame: After 6 months
Average pain intensity during last 7 days will be assessed on a 0-10 Numeric Rating Scale (NRS) (ranging from 'no pain to 'worst imaginable pain')
Time frame: After 12 months
Proportion of participants using analgesics and sleep medication will be explored using data from the prescription database.
Time frame: after 12 months
The healthcare costs will be obtained from linking the trial data to Danish health registries. The healthcare costs of treatment will be reported in euro.
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM). SE is the ratio of TST to time in bed / 100%
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: Difference in change in sleep metric between treatment groups from baseline to 8 weeks.
Difference in change in sleep metric between treatment groups (digital CBT-I [n=30] vs.sleep hygiene education [n=30]) from baseline to 8 weeks. Sleep metrics will be derived from the EEG assessments as recommended by the American Academy of Sleep Medicine (AASM).
Time frame: 5 nights at baseline and 5 nights at week 8
Three 0-10 questions are used: 1) How did you experience falling asleep with the ear EEG device, 2) How did you experience sleeping with the ear EEG device?, 3) How would you rate your experience of soreness or discomfort in your ears after sleeping with the device? A lower sum score is worse.
Time frame: Baseline and 8 weeks
Any adverse device effect defined as an adverse effect related to the use of the ear EEG
Odense University Hospital
Other
Digital CBT-I for Patients With Chronic Pain and Insomnia (The Back2Sleep Trial). A Randomized Controlled Trial
Acronym: Back2Sleep
OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.
View the official ClinicalTrials.gov record (opens in a new tab)This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.
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