***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This article summarizes the literature on cognitive-behavioral therapy for insomnia ( CBT-I ) in patients with comorbid insomnia and chronic pain . An empirical rationale for the development of CBT-I in chronic pain is provided . The six r and omized controlled trials in this area are described and contrasted . The data suggest that CBT-I for patients with comorbid insomnia and chronic pain produces clinical ly meaningful improvements in sleep symptoms . Effects on pain are inconsistent , but tend to favor functional measures over pain severity . Hybrid interventions for insomnia and pain have demonstrated feasibility , but larger trials must be conducted to determine efficacy relative to CBT-I alone . Future efforts should employ more comprehensive assessment s of pain and psychosocial factors & NA ; This paper presents the results of a detailed study of the pain epidemiology and health related quality of life ( HRQL ) in 150 chronic non‐malignant pain patients consecutively referred to a Danish multidisciplinary pain center . Mean pain severity was 71.6 ( SD=18.5 ) on the VAS scale . Forty‐two percent reported poor quality of sleep . HRQL was evaluated with the Medical Outcome Study ‐Short Form ( SF‐36 ) , the Hospital Anxiety and Depression scale ( HAD ) and the Psychological General Well‐Being Scale ( PGWB ) . Compared with the normal population ( NP ) both SF‐36 scores and PGWB scores were significantly reduced ( P<0.001 ) indicating that physical , psychological and social well‐being were severely reduced . On the HAD scale 58 % were found to have a depressive or anxiety disorder . Statistically significant but modest correlations were found between pain severity and HRQL . Psychological and social well‐being was closely correlated . Sixty‐three percent of the referred patients had neurogenic pain conditions . Of these , only 25 % were treated with antidepressants or anticonvulsants at referral . Seventy‐three percent were treated with opioids at referral . Mean opioid consumption was 64 mg of morphine per day ( range 1–280 mg ) . Compared with the NP the chronic pain patients had used the health care system five times more often in the years prior to referral ( P<0.001 ) . The study confirms the severe multidimensional impact of chronic pain and demonstrates that HRQL of chronic non‐malignant pain patients is among the lowest observed for any medical condition Aims : Cognitive and behavioral treatments ( CBT ) for sleep problems and chronic pain have shown good results , although these results could improve . More recent developments based on the psychological flexibility model , the model underlying Acceptance and Commitment Therapy ( ACT ) may offer a useful addition to traditional CBT . The aim of this study was to examine whether an ACT-based treatment for chronic pain is associated with improved sleep . Secondly , we examined the associations between changes on measures of psychological flexibility and sleep-related outcomes . Methods : The study used an observational cohort methodology . Participants were 252 patients ( 73.8 % female ) attending a 4-week , interdisciplinary , pain management program in London , United Kingdom . Participants completed st and ard self-report measures of pain and functioning , sleep outcomes , and processes of psychological flexibility . Pre- to post-treatment , and pre-treatment to follow-up measures were examined for statistically significant differences using paired sample s t-tests . Secondarily , hierarchical multiple regression analyses were conducted to examine change in process measures in relation to change in treatment outcome . Results : Participants showed statistically significant improvements ( all p < 0.001 ) at post-treatment on measures of insomnia severity ( d = 0.45 ) , sleep interference ( d = 0.61 ) , and sleep efficiency ( d = 0.32 ) . Significant improvements in insomnia severity and sleep interference were also observed at 9-month follow up . Small to medium effect sizes were observed across the sleep outcomes . Statistically significant changes were also observed on measures of psychological flexibility , and these improvements were significantly associated with improvements on sleep-related outcomes , independently contributing up to 19 % of unique variance . Conclusion : This study supports the potential usefulness of ACT-based treatments for chronic pain for addressing co-occurring sleep difficulties . Further research is needed to determine how to improve the impact of this treatment for co-morbid pain and sleep difficulties , possibly using a r and omized-controlled trial design OBJECTIVE Exercise can improve sleep quality , but for whom and by what means remains unclear . We examined moderators and mediators of objective sleep improvements in a 12-month r and omized controlled trial among underactive midlife and older adults reporting mild/moderate sleep complaints . METHODS Participants ( N = 66 , 67 % women , 55 - 79 years ) were r and omized to moderate-intensity exercise or health education control .  Putative moderators were gender , age , physical function , self-reported global sleep quality , and physical activity levels . Putative mediators were changes in BMI , depressive symptoms , and physical function at 6 months . Objective sleep outcomes measured by in-home polysomnography were percent time in Stage I sleep , percent time in Stage II sleep , and number of awakenings during the first third of sleep at 12 months . RESULTS Baseline physical function and sleep quality moderated changes in Stage I sleep ; individuals with higher initial physical function ( p = .01 ) and poorer sleep quality ( p = .03 ) had greater improvements . Baseline physical activity level moderated changes in Stage II sleep ( p = .04 ) and number of awakenings ( p = .01 ) ; more sedentary individuals had greater improvements . Decreased depressive symptoms ( CI:-1.57 to -0.02 ) mediated change in Stage I sleep . Decreased depressive symptoms ( CI:-0.75 to -0.01 ) , decreased BMI ( CI:-1.08 to -0.06 ) , and increased physical function ( CI : 0.01 to 0.72 ) mediated change in number of awakenings . CONCLUSIONS Initially less active individuals with higher initial physical function and poorer sleep quality improved the most . Affective , functional , and metabolic mediators specific to sleep architecture parameters were suggested . These results indicate strategies to more efficiently treat poor sleep through exercise in older adults The aim of this study was to compare the effects of total sleep deprivation ( TSD ) , rapid eye movement ( REM ) sleep and slow wave sleep ( SWS ) interruption and sleep recovery on mechanical and thermal pain sensitivity in healthy adults . Nine healthy male volunteers ( age 26 - -43 years ) were r and omly assigned in this double blind and crossover study to undergo either REM sleep or SWS interruption . Periods of 6 consecutive laboratory nights separated by at least 2 weeks were design ed as follows : N1 Adaptation night ; N2 Baseline night ; N3 Total sleep deprivation ( 40 h ) ; N4 and N5 SWS or REM sleep interruption ; N6 Recovery . Sleep was recorded and scored using st and ard methods . Tolerance thresholds to mechanical and thermal pain were assessed using an electronic pressure dolorimeter and a thermode operating on a Peltier principle . Relative to baseline levels , TSD decreased significantly mechanical pain thresholds ( -8 % ) . Both REM sleep and SWS interruption tended to decrease mechanical pain thresholds . Recovery sleep , after SWS interruption produced a significant increase in mechanical pain thresholds ( + 15 % ) . Recovery sleep after REM sleep interruption did not significantly increase mechanical pain thresholds . No significant differences in thermal pain thresholds were detected between and within periods . In conclusion this experimental study in healthy adult volunteers has demonstrated an hyperalgesic effect related to 40 h TSD and an analgesic effect related to SWS recovery . The analgesic effect of SWS recovery is apparently greater than the analgesia induced by level I ( World Health Organization ) analgesic compounds in mechanical pain experiments in healthy volunteers In 52 studies , performance data were obtained the next day following bedtime ingestion of a sedative-hypnotic or a placebo . Only eight of these studies used insomniac patients . Most studies used young adult males .  Benzodiazepine hypnotics were most frequently administered and psychomotor performance was most often measured . Little consistent data are available on cognitive functioning and more complex behavior . Durg-related improvement in performance was not found , and , in comparing active drug to placebo , it is clear that all hypnotics , at some doses , produce decrements in performance the next day . Higher doses consistently showed a decrement , and this decrement was usually persistent over the entire day . Although long-acting drugs generally showed more performance decrement , half-life data were not consistent Background : Insomnia is a prevalent health complaint that is often difficult to evaluate reliably . There is an important need for brief and valid assessment tools to assist practitioners in the clinical evaluation of insomnia complaints . Objective : This paper reports on the clinical validation of the  Insomnia Severity Index ( ISI )  as a brief screening measure of insomnia and as an outcome measure in treatment research . The psychometric properties ( internal consistency , concurrent validity , factor structure ) of the ISI were evaluated in two sample s of insomnia patients . Methods : The first study examined the internal consistency and concurrent validity of the ISI  in 145 patients evaluated for insomnia at a sleep disorders clinic . Data from the ISI were compared to those of a sleep diary measure . In the second study , the concurrent validity of the  ISI  was evaluated in a sample of 78 older patients who participated in a r and omized-controlled trial of behavioral and pharmacological therapies for insomnia . Change scores on the  ISI  over time were compared with those obtained from sleep diaries and polysomnography .  Comparisons were also made between ISI scores obtained from patients , significant others , and clinicians . Results : The results of Study 1 showed that the  ISI  has adequate internal consistency and is a reliable self-report measure to evaluate perceived sleep difficulties . The results from Study 2 also indicated that the ISI is a valid and sensitive measure to detect changes in perceived sleep difficulties with treatment . In addition , there is a close convergence between scores obtained from the ISI patient 's version and those from the clinician 's and significant other 's versions . Conclusions : The present findings indicate that the ISI is a reliable and valid instrument to quantify perceived insomnia severity . The ISI is likely to be a clinical ly useful tool as a screening device or as an outcome measure in insomnia treatment research We examined individual responses to cognitive-behavior therapy for  insomnia in 51 persons with chronic pain to determine the rate of clinical ly significant change and to identify predictors of successful treatment response . Outcome measures consisted of the Pittsburgh Sleep Quality Index ( PSQI ) and diary measures of sleep latency and sleep continuity . Using reliable change indices , 57 % of participants were statistically improved on the PSQI after 7 weeks of treatment , but only 18 % were considered fully recovered from their sleep problems . No demographic variables predicted treatment response but persons who reliably improved on the PSQI had a lower sleep self-efficacy at baseline . Improvers showed a significant increase in sleep self-efficacy ratings and a decrease in self-reported levels of distress and pain-related disability . These results suggest that patients with insomnia secondary to chronic medical conditions can be helped with cognitive-behavior therapy , although most individuals continue to have mild or subthreshold sleep problems at posttreatment CONTEXT Sleep disturbances , pain , and inflammation co-occur in various medical conditions , but their interrelationships are poorly understood . OBJECTIVE We investigated the effects of reduced sleep duration ( by approximately 50 % ) to 4 h/night across 10 days , on peripherally circulating inflammatory mediators . In addition , we tested the prediction that degree of inflammation is quantitatively related to the extent to which pain is increased in response to prolonged sleep restriction . DESIGN R and omized , 16 day controlled in-laboratory study conducted in GCRC . METHODS Eighteen volunteers were r and omly assigned to either 12 days of sleeping 8 h/night or 4 h/night . Participants rated mood and pain symptoms throughout experimental days . Urine was collected and blood was drawn frequently on the baseline day and after the 10th experimental day for 25 hours . OUTCOME MEASURES Levels of plasma interleukin (IL)-6 , serum C-reactive protein ( CRP ) , plasma soluble tumor necrosis factor receptor p55 ( sTNF-R p55 ) , urinary levels of prostagl and in ( PG ) metabolites D2 and E2 , subjective assessment of pain and tiredness-fatigue . RESULTS IL-6 levels were elevated in the 4-h sleep condition over the 8-h sleep condition ( P < 0.05 ) . CRP levels showed the same trend as IL-6 , but did not differ significantly between groups ( P = 0.11 ) . Levels of sTNF-R p55 were unchanged in both groups . PG E2 and 11beta-F2alpha metabolite increased in 4-h sleepers , but did not differ significantly from the 8-h sleepers . Elevated IL-6 levels were strongly associated with increased pain ratings in response to sleep restriction ( r = 0.67 , P < 0.01 ) , and this association could not be explained by elevations in tiredness-fatigue . CONCLUSION Insufficient sleep quantity may facilitate and /or exacerbate pain through elevations of IL-6 . In disorders where sleep disturbances are common , insufficient sleep quantity itself may establish and maintain its co-occurrence with pain and increased inflammation OBJECTIVE Insomnia is a common complaint among cancer survivors . Fortunately , cognitive-behavioral therapy for insomnia ( CBT-I ) has been shown to be an effective treatment in this population . However , it is rarely implemented given its limited availability . To address this barrier , we examined the ability of an easily accessible online CBT-I program to improve insomnia symptoms in cancer survivors . METHODS Twenty-eight cancer survivors with insomnia were r and omly assigned to either an Internet insomnia intervention ( 
    Output:
    
Cognitive‐behavioral therapy  for insomnia can be efficacious for improvements in sleep initiation , sleep maintenance , perceived sleep quality , and pain interference with daily functioning in people with chronic pain .
A recent systematic review concluded that with additional training , physical therapist‐led cognitive‐behavioral interventions are efficacious for low back pain , allowing their implementation within the field .