Clinical Sciences/Health Conditions
Bruno A. Bermudes, MD
PMR physician
Instituto de Medicina Fisica e Reabilitacao, Hospital das Clinicas HCFMUSP, Faculdade da Universidade de Sao Paulo, Sao Paulo, SP, BR.
São Paulo, Sao Paulo, Brazil
Kleber J. G. Chagas, MD
PMR physician
Instituto de Medicina Fisica e Reabilitacao, Hospital das Clinicas HCFMUSP, Faculdade da Universidade de Sao Paulo, Sao Paulo, SP, BR.
São Paulo, Sao Paulo, Brazil
Artur C. A. Santos, n/a
Researcher
Instituto de Medicina Fisica e Reabilitacao, Hospital das Clinicas HCFMUSP, Faculdade da Universidade de Sao Paulo, Sao Paulo, SP, BR.
São Paulo, Sao Paulo, Brazil
Felipe Fregni, MD
Professor of Physical Medicine and Rehabilitation
1. Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, United States 2. Harvard Medical School, Boston, MA, United States
Boston, Massachusetts, United States
Linamara R. Battistella, MD, PhD
Full Professor
Departamento de Medicina Legal, Bioética, Medicina do Trabalho e Medicina Física e Reabilitação, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR.
São Paulo, Sao Paulo, Brazil
Marta Imamura, MD, PhD (she/her/hers)
Associate Professor
Departamento de Medicina Legal, Bioética, Medicina do Trabalho e Medicina Física e Reabilitação, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR.
Sao Paulo / Sao Paulo, Sao Paulo, Brazil
Knee osteoarthritis (KOA) affects millions of older adults and frequently coexists with sleep disturbances, creating a bidirectional relationship that amplifies pain, reduces physical function, and diminishes quality of life. Despite advanced, multimodal pain-focused rehabilitation programs that significantly improve pain and mobility, sleep disturbances often persist, suggesting independent pathophysiological mechanisms and highlighting sleep as a neglected clinical outcome requiring systematic assessment and targeted intervention.
The objective of this study is to evaluate whether an advanced pain-focused rehabilitation program effectively improves sleep quality in patients with KOA and to examine the relationship between analgesic gains and sleep outcomes.
Design:
Ancillary analysis of a prospective cohort study (DEFINE KOA) was performed in a sample of 96 patients, predominantly female (84%), mean age 68.9±9.7 years, and mostly with bilateral KOA (94.8%). The majority had moderate-to-severe radiographic osteoarthritis per Kellgren-Lawrence grading: 1% grade 0, 29% grade I, 26% grade II, 16% grade III, and 28% grade IV. Baseline and post-treatment assessments measured pain (VAS, WOMAC), physical function (Timed Up & Go, 6-minute walk), and daytime sleepiness (Epworth Sleepiness Scale). Pain-centered rehabilitation alone is insufficient to address sleep problems in KOA. Comprehensive sleep assessment using validated tools (Pittsburgh Sleep Quality Index, Epworth, actigraphy, polysomnography for complex cases) and targeted interventions—such as cognitive-behavioral therapy for insomnia, appropriate pharmacologic management, and treatment of comorbid sleep disorders—are recommended for holistic care.
Results: Pain and function scores improved significantly after treatment; however, sleepiness scores remained unchanged (Epworth pre: 10.52±5.85; post: 10.17±5.52; p=0.351). No association was observed between changes in pain (VAS) and sleepiness (Epworth) (r²≈0, p=0.889), indicating that reductions in pain do not necessarily translate to sleep improvements. Persistent sleep disturbance despite substantial symptomatic and functional gains supports the existence of independent sleep-regulatory mechanisms, with sleep dysregulation potentially serving as a risk factor for pain recurrence.
Conclusion:
