What the head-to-head comparison actually shows
The clearest evidence comes from a randomized noninferiority trial that assigned adults with insomnia disorder to video telehealth CBT-I, in-person CBT-I, or a waitlist. Over 6–8 weekly sessions, insomnia severity fell by about 7.8 points with in-person treatment and 7.5 points with telehealth, versus 1.6 points on the waitlist. The difference between the two active formats was not statistically significant, and the trial was designed so that telehealth would count as noninferior only if its results stayed within a pre-set margin of in-person results; that condition was met [4].
That is a meaningful result for engagement in the sense that matters most clinically: people assigned to telehealth completed a course of treatment and improved about as much as those seen in person. The trial also found improvements on most secondary measures of functioning, with no differences between groups [4]. The catch is scope. These were adults with insomnia disorder, not adults with chronic pain, so the finding supports the idea that video delivery does not inherently weaken CBT-I, but it does not by itself prove the same equivalence in a pain population.
Why digital delivery is attractive for people with chronic pain
Chronic pain is common, and roughly half to four-fifths of adults with chronic pain also have clinically significant insomnia [1]. Behavioral sleep interventions such as CBT-I are attractive because they avoid the limitations and risks of sleep medication, and the evidence links sleep disruption to pain through a bidirectional relationship, with poor sleep contributing to central sensitization, a heightened sensitivity of the nervous system to pain [1]. If sleep is a modifiable target, then getting effective sleep treatment to more people with pain matters.
Digital delivery is one route to that. A review of behavioral sleep interventions in chronic pain notes that digital delivery options are promising but that barriers around access, cost, and routine insomnia screening persist [1]. Separately, a feasibility study of brief behavioral telehealth for sleep and pain in adults with chronic musculoskeletal orofacial pain points out that these interventions have historically been delivered in person, which is part of why testing them remotely is worth doing [2]. Neither study directly compares the two formats, so the case for digital delivery here rests on access and feasibility rather than on demonstrated superiority or equivalence in pain populations.
What people with pain say they want from a digital format
Engagement is not only about whether a program works on average; it is also about whether the format fits people's lives. In work informing an eHealth sleep intervention for adolescents with insomnia symptoms, including those with recurrent pain, the starting point was that in-person interventions are generally effective, while a digital program would be available on devices such as a smartphone app [3]. That framing treats digital delivery as a way to extend a proven approach rather than replace it, and it puts user perspectives at the center of designing the digital version.
This is a design and acceptability signal, not an outcome comparison. It suggests that people see value in a device-based format, but it does not tell us whether engagement or sleep outcomes would match in-person care. The honest summary is that the direct engagement comparison in chronic pain is still missing.
Where the evidence stands, and what to watch for
Putting the pieces together: the strongest direct comparison favors video CBT-I as noninferior to in-person CBT-I for insomnia severity, but in a general insomnia sample [4]. The chronic-pain evidence establishes that behavioral sleep interventions are clinically meaningful and that digital options are promising for access, without a head-to-head test in that group [1][2]. A digital pain-management intervention delivered by Zoom has been compared with in-person delivery in adults with chronic low back pain [5], but that intervention targets pain rather than sleep, so it cannot answer the sleep question.
For a reader deciding what to expect, the practical takeaway is that a video-based behavioral sleep program is a reasonable option with good evidence of comparable sleep outcomes in insomnia, and a plausible route to better access for people with chronic pain. What remains genuinely open is whether engagement and sleep outcomes in a chronic-pain population match in-person care, and that is the comparison the current evidence has not yet delivered.
Sources used in this answer
Behavioral Sleep Interventions for Chronic Pain: Mechanisms, Clinical Evidence, and Future Directions
A review of behavioral sleep interventions for chronic pain finds a bidirectional sleep–pain relationship, evidence that CBT-I can reduce pain-related neural activation and pain intensity, and notes digital delivery as promising while access, cost, and screening barriers persist; it does not compare digital with in-person delivery.
Feasibility of brief behavioral telehealth interventions for sleep and pain in adults with chronic musculoskeletal orofacial pain: an idiographic clinical trial
A feasibility trial examines brief behavioral telehealth interventions for sleep and pain in adults with chronic musculoskeletal orofacial pain, noting these interventions have historically been delivered in person, but it does not compare digital with in-person delivery.
… to inform user-centered development of an eHealth sleep intervention for adolescents: perspectives of youth with insomnia symptoms, with and without pain
Formative work for an eHealth sleep intervention for adolescents with insomnia symptoms, with and without recurrent pain, notes that in-person interventions are generally effective and that a digital program would be available on devices such as a smartphone app.
Randomized Noninferiority Trial of Telehealth Delivery of Cognitive Behavioral Treatment of Insomnia Compared to In-Person Care
In a randomized noninferiority trial of adults with insomnia disorder, telehealth CBT-I was noninferior to in-person CBT-I for insomnia severity, with mean improvements of 7.5 versus 7.8 points versus 1.6 on waitlist, and no group differences on most secondary outcomes.
Efficacy of a single-session “empowered relief” zoom-delivered group intervention for chronic pain: randomized controlled trial conducted during the COVID-19 …
A randomized trial compared a single-session Zoom-delivered group pain intervention with in-person delivery in adults with chronic low back pain, addressing delivery format but not a behavioral sleep intervention.