Applying psychological interventions to the management of inflammatory arthritis and musculoskeletal pain IP90. Applying Cognitive Behavioural Therapy for Insomnia for Patients with Chronic Pain

The prevalence of sleep disturbance is high in a variety of chronic conditions where pain is a prominent symptom. For instance, at least 50% of patients with rheumatoid arthritis report difficulties with sleeping at night. Although pain is often the precipitating factor, cognitive behavioural theories suggest that persistent problems sleeping are maintained by a combination of physical and psychological factors, such as pain severity, lifestyle, rumination and beliefs about sleep. Recent trials have demonstrated that cognitive behavioural therapy for insomnia (CBT-I), which targets the perpetuating factors of sleep disturbance, can significantly improve sleep for individuals with chronic pain, including musculoskeletal pain, fibromyalgia and osteoarthritis. The aim of the workshop session will be to illustrate how CBT can be used to help individuals with chronic pain to better manage their sleeping difficulties. The ten-minute presentation will briefly introduce the conceptual framework for CBT-I and outline the core treatment components: stimulus control, sleep restriction, sleep hygiene, relaxation training and cognitive therapy. The group discussion that follows will provide the opportunity to elaborate upon the specific CBT-I components and to introduce useful therapeutic tools such as sleep and pain diary, questionnaires, and behavioural experiments. Disclosures: The authors have declared no conflicts of interest.

The prevalence of sleep disturbance is high in a variety of chronic conditions where pain is a prominent symptom. For instance, at least 50% of patients with rheumatoid arthritis report difficulties with sleeping at night. Although pain is often the precipitating factor, cognitive behavioural theories suggest that persistent problems sleeping are maintained by a combination of physical and psychological factors, such as pain severity, lifestyle, rumination and beliefs about sleep. Recent trials have demonstrated that cognitive behavioural therapy for insomnia (CBT-I), which targets the perpetuating factors of sleep disturbance, can significantly improve sleep for individuals with chronic pain, including musculoskeletal pain, fibromyalgia and osteoarthritis. The aim of the workshop session will be to illustrate how CBT can be used to help individuals with chronic pain to better manage their sleeping difficulties. The ten-minute presentation will briefly introduce the conceptual framework for CBT-I and outline the core treatment components: stimulus control, sleep restriction, sleep hygiene, relaxation training and cognitive therapy. The group discussion that follows will provide the opportunity to elaborate upon the specific CBT-I components and to introduce useful therapeutic tools such as sleep and pain diary, questionnaires, and behavioural experiments. Disclosures: The authors have declared no conflicts of interest.

IP91. APPLYING COGNITIVE BEHAVIOURAL APPROACHES IN A GROUP FOR THE SELF MANAGEMENT OF RA FATIGUE
Emma Dures 1 and Nicholas Ambler 2 1 Bristol Royal Infirmary, Bristol, United Kingdom; 2 Frenchay Hospital, North Bristol NHS Trust, Bristol, United Kingdom Background: In research on important outcomes from the patients' perspective, fatigue was raised as a major concern. Qualitative research reveals that patients consider it to be a symptom that is common, overwhelming, intrusive and unmanageable. Quantitative studies consistently show that significant fatigue occurs in up to 70% of RA patients (approximately 0.4 million people) and that it is as severe as RA pain. Fatigue both predicts and differentiates between different levels of quality of life in people with RA.
The literature suggests that RA fatigue is likely to be caused by varying combinations of clinical factors (inflammation, pain, disability) and psychosocial issues (coping, mood, illness beliefs). Rheumatology teams want to help patients manage their RA fatigue but there is limited evidence for interventions. Anti-tumour necrosis factor therapy might reduce fatigue in RA, but it is an expensive drug with potentially significant side-effects and in some areas access to the treatment is restricted. Glucocorticoids might also reduce fatigue in RA but efficacy can be short-lived and there are potentially serious side-effects with long-term use. Both these treatment options assume the driver of RA fatigue to be largely inflammatory, yet the literature has found no evidence of such as association.
However, there is growing evidence for the effectiveness of Cognitive Behavioural Therapy (CBT). CBT addresses the links between thoughts, feelings and behaviours and uses cognitive restructuring to help patients make changes in behaviour. Core selfmanagement skills such as problem-solving, goal-setting, practice and role models can work through enhancing self-efficacy (a belief that you can do something to make a difference). While CB therapists challenge core beliefs (e.g. self-esteem) and may use cognitive methods to manage depression, other health professionals might use CB approaches to explore simpler thoughts (e.g. illness beliefs) and apply these in goal-setting to help behaviour change. Many experienced rheumatology nurses and occupational therapists already use some CB skills and it has been shown that CB approaches delivered by experienced clinicians are effective when translated into rheumatology practice.
Our presentation will outline why the group modality offers unique therapeutic opportunities for the self management of fatigue. CB groups are more than techniques delivered 'simultaneously' to multiple patients and group processes are an important factor that aids learning and understanding of cognitive and behavioural strategies. In our workshop examples from a recent group programme using CB approaches to manage the impact of RA fatigue will highlight how group members can be a credible source of persuasion, validating and legitimising each other's experiences and why the group setting can be a safe place in which to pursue change. Methods: This first part of the workshop highlights the normality of patients' responses to the abnormal situation of rheumatic disease and chronic pain. Integrating theory and demonstration by role play, we will explore resistance to change behaviours that impede patients' attempts at effective self-management. We will consider the 'stages of change' model and concepts such as 'ambivalence' to change and 'resistance' to change. Through non-directive questoning we will demonstrate how a patient might explore their own motivations to change, or engage with, new behaviours. Results: Delegates will be able to understand some of the processes patients might go through in considering changing or acquiring new behaviours. Non-directive questioning will demonstrate how healthcare practitioners might help patients access and explore their personal motivations. Conclusions: The aim of the overall workshop will be to increase knowledge and understand some specific applications of cognitive behavioural therapy and motivational interviewing, to inflammatory conditions and musculoskeletal pain.
Delegates may wish to cross reference with the session: Diagnosing and treating systemic lupus erythematosus on 12th April commencing at 2.00. Disclosures: The authors have declared no conflicts of interest.