Massage Therapy Utilization in the Military Health System.

INTRODUCTION: Massage therapy is an evidence-based approach for pain management. Information regarding its utilization in the Military Health System (MHS) is lacking. The goal of this study is to evaluate massage therapy utilization patterns across the MHS to include who receives (patient characteristics and diagnoses) and provides (e.g., massage therapists) massage therapy and where (e.g., clinic type). MATERIALS AND METHODS: Medical record data of adult TRICARE Prime enrollees receiving outpatient massage therapy (Current Procedural Terminology codes: 97124 and 97140) from June 1, 2021, to May 31, 2023, were extracted from the MHS Data Repository. After identifying the index massage therapy visit, records for 6 months pre- and post-index were included. Descriptive statistics described massage therapy utilization patterns overall. Bivariate analysis compared patients who received massage therapy from massage therapists versus nonmassage therapist clinicians. RESULTS: Of patients who received massage therapy (n = 179,215), the median number of visits was 2 (interquartile range 1 to 4), the median age was 32 years (interquartile range 25 to 40), they were mostly assigned male (72%), White (53%), Senior Enlisted (51%), with a musculoskeletal diagnosis (90%), and recent non-steroidal anti-inflammatory drug (NSAID) prescription (58%). Massage therapy was primarily delivered by physical therapists (49%) in physical therapy clinics (74%). Massage therapists provided 0.2% of massage therapy. Patients who received massage therapy from massage therapists versus nonmassage therapists significantly varied across several patient and care characteristics. CONCLUSIONS: While massage therapy codes are documented frequently, massage therapists do not commonly provide massage therapy relative to nonmassage therapist providers. Access to massage therapists may be stymied by both lack of massage therapists and need for tertiary pain management referrals to access massage therapist-delivered care. Future research will leverage a health equity framework to (1) evaluate accessibility to massage therapy provided by massage therapists and (2) evaluate real-world evidence of massage therapy effectiveness.

Can a mathematical model predict an individual's trait-like response to both total and partial sleep loss?

Humans display a trait-like response to sleep loss. However, it is not known whether this trait-like response can be captured by a mathematical model from only one sleep-loss condition to facilitate neurobehavioural performance prediction of the same individual during a different sleep-loss condition. In this paper, we investigated the extent to which the recently developed unified mathematical model of performance (UMP) captured such trait-like features for different sleep-loss conditions. We used the UMP to develop two sets of individual-specific models for 15 healthy adults who underwent two different sleep-loss challenges (order counterbalanced; separated by 2-4 weeks): (i) 64 h of total sleep deprivation (TSD) and (ii) chronic sleep restriction (CSR) of 7 days of 3 h nightly time in bed. We then quantified the extent to which models developed using psychomotor vigilance task data under TSD predicted performance data under CSR, and vice versa. The results showed that the models customized to an individual under one sleep-loss condition accurately predicted performance of the same individual under the other condition, yielding, on average, up to 50% improvement over non-individualized, group-average model predictions. This finding supports the notion that the UMP captures an individual's trait-like response to different sleep-loss conditions.

A unified mathematical model to quantify performance impairment for both chronic sleep restriction and total sleep deprivation.

Performance prediction models based on the classical two-process model of sleep regulation are reasonably effective at predicting alertness and neurocognitive performance during total sleep deprivation (TSD). However, during sleep restriction (partial sleep loss) performance predictions based on such models have been found to be less accurate. Because most modern operational environments are predominantly characterized by chronic sleep restriction (CSR) rather than by episodic TSD, the practical utility of this class of models has been limited. To better quantify performance during both CSR and TSD, we developed a unified mathematical model that incorporates extant sleep debt as a function of a known sleep/wake history, with recent history exerting greater influence. This incorporation of sleep/wake history into the classical two-process model captures an individual's capacity to recover during sleep as a function of sleep debt and naturally bridges the continuum from CSR to TSD by reducing to the classical two-process model in the case of TSD. We validated the proposed unified model using psychomotor vigilance task data from three prior studies involving TSD, CSR, and sleep extension. We compared and contrasted the fits, within-study predictions, and across-study predictions from the unified model against predictions generated by two previously published models, and found that the unified model more accurately represented multiple experimental studies and consistently predicted sleep restriction scenarios better than the existing models. In addition, we found that the model parameters obtained by fitting TSD data could be used to predict performance in other sleep restriction scenarios for the same study populations, and vice versa. Furthermore, this model better accounted for the relatively slow recovery process that is known to characterize CSR, as well as the enhanced performance that has been shown to result from sleep banking.

Biphasic effects of alcohol as a function of circadian phase.

STUDY OBJECTIVES: To assess how alcohol affects multiple sleep latency tests (MSLT) and subjective measures of stimulation/sedation when alcohol is given at different circadian phases. PARTICIPANTS: Twenty-seven healthy young adults (age 21-26 yr) were studied. DESIGN: Double-blind placebo and alcohol (vodka tonic targeting 0.05 g% concentration) beverages were each administered three times during the 20-h forced desynchrony protocol. Sleep latency tests and Biphasic Effects of Alcohol Scale (BAES) were administered on each forced desynchrony day. The outcome variables for this study include sleep onset latency (SOL) and stimulation and sedation value (from the BAES). Each outcome variable was associated with the ascending or descending limb of the breath alcohol concentration (BrAC) curve and assigned a circadian phase within a 90° bin. MEASUREMENTS AND RESULTS: BrAC confirmed targeted maximal levels. Only outcome variables associated with the ascending and descending limb of the alcohol curve were analyzed for this article. Alcohol administered at a circadian time associated with greatest sleepiness showed longer SOL compared with placebo when measured on the ascending limb of the BrAC curve. We also found longer SOL with alcohol on the ascending limb of the BrAC curve in a circadian bin that favors greatest alertness. We observed shorter SOLs on the descending limb of the BrAC curve, but with no circadian phase interaction. The subjective data were partially consistent with the objective data. CONCLUSIONS: The physiologic findings in this study support the biphasic stimulating and sedating properties of alcohol, but limit the effect to specific circadian times.

PER3 and ADORA2A polymorphisms impact neurobehavioral performance during sleep restriction.

The objective of the study was to determine whether ADORA2A or PER3 polymorphisms contribute to individual responsivity to sleep restriction. Nineteen healthy adults (ages 18-39, 11 males, 8 females) underwent sleep restriction (SR) which consisted of seven nights of 3 h time in bed (TIB) (04:00-07:00). SR was preceded by seven in-laboratory nights of 10 h TIB (21:00-07:00) and followed by three nights of 8 h TIB (23:00-07:00). Volunteers underwent psychomotor vigilance, objective alertness, and subjective sleepiness assessments throughout. Volunteers were genotyped for the PER3 VNTR polymorphism (PER3(4/4) n = 7; PER3(4/5) n = 10; PER3(5/5) n = 2) and the ADORA2A c.1083T>C polymorphism, (ADORA2A(C) (/T) n = 9; ADORA2A(T) (/T) n = 9; ADORA2A(C) (/C) n = 1) using polymerase chain reaction (PCR). Separate mixed-model anovas were used to assess contributions of ADORA2A and PER3 polymorphisms. Results showed that PER3(4/4) and ADORA2A(C/T) individuals expressed greater behavioral resiliency to SR compared to PER(4/5) and ADORA2A(T/T) individuals. Our findings contrast with previously reported non-significant effects for the PER3 polymorphism under a less challenging sleep restriction regimen (4 h TIB per night for five nights). We conclude that PER3 and ADORA2A polymorphisms become more behaviorally salient with increasing severity and/or duration of sleep restriction (based on psychomotor vigilance). Given the small sample size these results are preliminary and require replication.

Trait-like vulnerability to total and partial sleep loss.

OBJECTIVE: To determine the extent to which individual differences in vulnerability to total sleep deprivation also reflect individual differences in vulnerability to multiple nights of sleep restriction. DESIGN: Two sleep loss conditions (order counterbalanced) separated by 2 to 4 weeks: (a) total sleep deprivation (TSD) of 2 nights (63 h continuous wakefulness); (b) sleep restriction (SR) of 7 nights of 3 h nightly time in bed (TIB). Both conditions were preceded by 7 in-laboratory nights with 10 h nightly TIB; and followed by 3 recovery nights with 8 h nightly TIB. Measures of cognitive performance (psychomotor vigilance, working memory [1-Back], and mathematical processing), objective alertness, subjective sleepiness, and mood were obtained at regular intervals under both conditions. Intra-class correlation coefficients (ICC) were computed using outcome metrics averaged over the last day (08:00-20:00) of TSD and SR. SETTING: Residential sleep/performance testing facility. PARTICIPANTS: Nineteen healthy adults (ages 18-39; 11 males, 8 females). INTERVENTIONS: 2 nights of TSD and 7 nights SR (3 h nightly TIB). RESULTS: volunteers who displayed greater vulnerability to TSD displayed greater vulnerability to SR on cognitive performance tasks (ICC: PVT lapses = 0.89; PVT speed = 0.86; 1-Back = 0.88; mathematical processing = 0.68, Ps < 0.05). In addition, trait-like responsivity to TSD/SR was found for mood variables vigor (ICC = 0.91), fatigue (ICC = 0.73), and happiness (ICC = 0.85) (all Ps < 0.05). CONCLUSION: Resilience to sleep loss is a trait-like characteristic that reflects an individual's ability to maintain performance during both types of sleep loss (SR and TSD). Whether the findings extend to sleep schedules other than those investigated here (63 h of TSD and 7 nights of 3 h nightly TIB) will be the focus of future studies.

Comparison of Motionlogger Watch and Actiwatch actigraphs to polysomnography for sleep/wake estimation in healthy young adults.

Sleep/wake identification and sleep parameter estimates from Motionlogger Watch and Actiwatch-64 actigraphs were compared to polysomnography (PSG). Following one night of baseline sleep, 29 volunteers remained awake for 36 h, followed by 11 h of recovery sleep in the laboratory. Two sets of analyses were performed: (1) epoch-by-epoch agreement and discriminability index (d') calculations, and (2) sleep parameter concordance with repeated measures ANOVAs. Sensitivity (sleep identification), specificity (wake detection), and overall agreement with PSG, as well as d', were higher for the Motionlogger than for Actiwatch. Relative to PSG, the Actiwatch-estimated total sleep time and sleep efficiency were underestimated and the number of awakenings was overestimated for baseline and recovery; sleep latency was underestimated on the baseline night. On the other hand, the Motionlogger-estimated total sleep time and sleep efficiency estimates were underestimated, and the sleep latency was overestimated on recovery, versus PSG. Despite these misestimations, it was concluded that the Motionlogger provided nominally better agreement with PSG, and that actigraphy generally constitutes a reasonably reliable tool for producing objective measurements of sleep/wake, but that users should remain mindful of its limitations.

Does timing of alcohol administration affect sleep?

STUDY OBJECTIVES: To explore the time of day effects of alcohol on sleep, we examined sleep following alcohol administered at four times of day and three homeostatic loads during a 20-hr forced desynchrony (FD) protocol. PARTICIPANTS: Twenty-six healthy young adults (21-25 yrs) were studied. DESIGN: Participants were dosed at 4 clock times: 0400 (n = 6; 2 females), 1600 (n = 7; 4 females), 1000 (n = 6; 1 female) or 2200 (n = 7; 2 females). Participants slept 2300 to 0800 for at least 12 nights before the in-lab FD study. Double blind placebo and alcohol (vodka tonic targeting 0.05g% concentration) beverages were each administered three times during FD at different homeostatic loads: low (4.25 or 2.24 hrs awake), medium (8.25 or 6.25 hrs awake), high (12.25 or 10.25 hrs awake) in the 0400 and 1600 or 1000 and 2200 groups, respectively. Sleep was staged and subjected to spectral analysis. MEASUREMENTS AND RESULTS: Breath Alcohol Concentration (BrAC) confirmed targeted maximal levels. At bedtime, BrAC was 0 in the low and medium homeostatic load conditions; however, at high homeostatic load, BrAC was still measurable. Spectral characteristics of sleep were unaffected with alcohol at any time of day. Few alcohol related changes were seen for sleep stages; however, with alcohol given at 0400 at a high homeostatic load there was an increase in wake. CONCLUSIONS: These data lend support to the idea that alcohol may be disruptive to sleep; however, our findings are inconsistent with the idea that a low dose of alcohol is a useful sleep aid when attempting to sleep at an adverse circadian phase.

Socializing by Day May Affect Performance by Night: Vulnerability to Sleep Deprivation is Differentially Mediated by Social Exposure in Extraverts vs Introverts.

STUDY OBJECTIVES: to examine the effects of socially enriched versus socially impoverished environments on performance and alertness decline during sleep deprivation in extraverts versus introverts. DESIGN: participants (n = 29 men, n = 19 women) were assigned to socially enriched (n = 24; 13 introverts, 11 extraverts) or socially impoverished (n = 24; 12 introverts, 12 extraverts) conditions (activities matched) for 12 hours (1000-2200) on Day 1 followed by 22 hours of sleep deprivation (2200-2000; 36 h awake total), monitored by actigraphy. The median split of volunteers' Eysenck Extraversion scores was used for extravert/introvert categorization. The Psychomotor Vigilance Task (PVT), modified Maintenance of Wakefulness Test (MWT), and Stanford Sleepiness Scale (SSS) were administered every 2 hours throughout. PVT speed, transformed lapses, modified MWT sleep-onset latency, and SSS were analyzed using mixed-model analyses of variance, with covariates of age and total actigraphic activity during enrichment or impoverishment. SETTING: residential sleep/performance testing facility. PARTICIPANTS: forty-eight healthy adults (aged 18-39). INTERVENTIONS: Twelve hours of socially enriched or isolated environments in extraverts and introverts prior to sleep deprivation. RESULTS: Social experience interacted with personality type to affect alertness and vigilance. Social enrichment, as compared with social impoverishment, was associated with more PVT lapses at 04:00 overall. Similarly, following social enrichment, PVT speed was significantly slower among extraverts than among introverts during sleep deprivation, but no personality-group differences emerged following social impoverishment. MWT sleep latency and SSS subjective sleepiness did not show significant personality or social-condition effects during sleep deprivation. CONCLUSIONS: the effect of social exposure on vulnerability or resiliency to sleep deprivation was modulated by introversion and extraversion. Extraverts exposed to social environments were more vulnerable to subsequent sleep deprivation than were introverts.

Sleep history affects task acquisition during subsequent sleep restriction and recovery.

The aim of the present study was to examine if sleep amount prior to sleep restriction mediated subsequent task acquisition on serial addition/subtraction and reaction time (RT) sub-tasks of the Automated Neuropsychological Assessment Metric. Eleven males and 13 females [mean (SD) age = 25 (6.5) years] were assigned to either an Extended [10 h time in bed (TIB)] (n = 12) or Habitual [Mean (SD) = 7.09 (0.7)] (n = 12) sleep group for 1 week followed by one baseline night, seven sleep restriction nights (3 h TIB) and five recovery nights (8 h TIB). Throughout baseline, restriction and recovery, mathematical and serial RT tasks were administered hourly each day (08:00-18:00 h). Math and serial RT throughput for each task (speed x accuracy product) was analysed using a mixed-model anova with fixed effects for sleep group, day and time-of-day followed by post hoc t-tests (Bonferroni correction). Math throughput improved for both groups during sleep restriction, but more so compared with baseline for the prior sleep Extended group versus the Habitual group during recovery. In sum, 1 week of sleep extension improved resilience during subsequent sleep restriction and facilitated task acquisition during recovery, demonstrating that nightly sleep duration exerts long-term (days, weeks) effects.

Oral appliance titration in patients with obstructive sleep apnea induces the appearance of periodic limb movements.

STUDY OBJECTIVES: Oral appliance (OA) therapy is considered a first line choice of therapy for some patients with mild or moderate obstructive sleep apnea (OSA) and an alternative form of treatment in those intolerant of continuous positive airway pressure (CPAP) use. According to several studies, periodic limb movements (PLM) appear during effective treatment of OSA with CPAP, but a similar phenomenon has not been described with the use of oral appliance. Herein, we describe the incidence of PLM in patients with OSA who underwent oral appliance therapy titration. DESIGN: This is a retrospective, [corrected] observational study set in a six-bed sleep center in an academic, military referral hospital. PATIENTS AND METHODS: Patients with OSA (n=21; 15 men and six women; mean age, 43 years; and age range, 25 to 53 years) treated with OA during a 1-year period were analyzed. [corrected] Patients were categorized according to the severity of sleep apnea and incidence of PLM on diagnostic polysomnography. Effective treatment of OSA and appearance or disappearance of PLM with arousal on subsequent oral appliance titration polysomnography were recorded and compared. RESULTS: Twenty-one patients were included in the analysis. [corrected] During baseline polysomnography, three of 21 (14%) patients had five or more PLM with arousal per hour while 11 of 21 (52%) patients had PLM with arousal during the oral appliance titration trial. CONCLUSION: Oral appliance therapy for obstructive sleep apnea is an effective treatment and ideal for use in military recruits. The appearance of periodic limb movements with arousal during oral appliance use should be considered as a cause of persistent daytime sleepiness despite effective treatment of obstructive sleep apnea in this subset of patients.

Banking sleep: realization of benefits during subsequent sleep restriction and recovery.

OBJECTIVE: Determine whether sleep extension (a) improves alertness and performance during subsequent sleep restriction and (b) impacts the rate at which alertness and performance are restored by post-restriction recovery sleep. DESIGN: Participants were randomly assigned to an Extended (10 h time in bed [TIB]) or Habitual TIB [mean (SD) hours = 7.09 (0.7)] sleep group for one week, followed by 1 Baseline (10 hours or habitual TIB), 7 Sleep Restriction (3 h TIB), and 5 Recovery Sleep nights (8 h TIB). Performance and alertness tests were administered hourly between 08:00-18:00 during all in-laboratory phases of the study. SETTING: Residential sleep/performance testing facility. PARTICIPANTS: Twenty-four healthy adults (ages 18-39) participated in the study. INTERVENTIONS: Extended vs. habitual sleep durations prior to sleep restriction. RESULTS: Psychomotor vigilance task (PVT) lapses were more frequent and modified maintenance of wakefulness (MWT) sleep latency was shorter in the Habitual group than in the Extended group across the sleep restriction phase. During the Recovery phase, PVT speed rebounded faster (and PVT lapsing recovered significantly after the first night of recovery sleep) in the Extended group. No group differences in subjective sleepiness were evident during any phase of the study. CONCLUSION: The extent to which sleep restriction impairs objectively measured alertness and performance, and the rate at which these impairments are subsequently reversed by recovery sleep, varies as a function of the amount of nightly sleep obtained prior to the sleep restriction period. This suggests that the physiological mechanism(s) underlying chronic sleep debt undergo long-term (days/weeks) accommodative/adaptive changes.

Effects of dextroamphetamine, caffeine and modafinil on psychomotor vigilance test performance after 44 h of continuous wakefulness.

Prolonged sleep loss impairs alertness, vigilance and some higher-order cognitive and affective capacities. Some deficits can be temporarily reversed by stimulant medications including caffeine, dextroamphetamine, and modafinil. To date, only one study has directly compared the effectiveness of these three compounds and specified the doses at which all were equally effective in restoring alertness and vigilance following 64 h of wakefulness. The present study compared the effectiveness of these same three stimulants/doses following a less extreme period of sleep loss (i.e., 44 h). Fifty-three healthy adults received a single dose of modafinil 400 mg (n = 11), dextroamphetamine 20 mg (n = 16), caffeine 600 mg (n = 12), or placebo (n = 14) after 44 h of continuous wakefulness. After 61 h of being awake, participants obtained 12 h of recovery sleep. Psychomotor vigilance was assessed bi-hourly during waking and following recovery sleep. Relative to placebo, all three stimulants were equally effective in restoring psychomotor vigilance test speed and reducing lapses, although the duration of action was shortest for caffeine and longest for dextroamphetamine. At these doses, caffeine was associated with the highest percentage of subjectively reported side-effects while modafinil did not differ significantly from placebo. Subsequent recovery sleep was adversely affected in the dextroamphetamine group, but none of the stimulants had deleterious effects on postrecovery performance. Decisions regarding stimulant selection should be made with consideration of how factors such as duration of action, potential side-effects, and subsequent disruption of recovery sleep may interact with the demands of a particular operational environment.

Evening alcohol suppresses salivary melatonin in young adults.

The study objective was to determine the acute effects of a moderate evening dose of alcohol on salivary melatonin levels in humans with stable prior sleep-wake histories and in a controlled environment. Twenty-nine adults (nine males) ages 21 to 25 (M=22.6, SD=1.2) yrs adhered to a 10-day at-home stabilized sleep schedule followed by three in-lab adaptation, placebo, and alcohol (order counterbalanced) study nights. Alcohol (vodka: 0.54 g/kg for men and 0.49 g/kg for women) or placebo beverage was consumed over 30 min, ending 1 h before stabilized bedtime. At 140 and 190 min after alcohol administration, melatonin level was reduced by 15% and 19%, respectively, in comparison to placebo. The findings indicate that a moderate dose of alcohol in the evening suppressed melatonin in young adults.

Effects of a moderate evening alcohol dose. I: sleepiness.

BACKGROUND: Few studies examining alcohol's effects consider prior sleep/wake history and circadian timing. We examined introspective and physiological sleepiness on nights with and without moderate alcohol consumption in well-rested young adults at a known circadian phase. METHODS: Twenty-nine adults (males=9), ages 21 to 25 years (M=22.6, SD=1.2), spent 1 week on an at-home stabilized sleep schedule (8.5 or 9 hours), followed by 3 in-lab nights: adaptation, placebo, and alcohol. Alcohol (vodka; 0.54 g/kg for men; 0.49 g/kg for women) or placebo beverage was consumed over 30 minutes ending 1 hour before stabilized bedtime. In addition to baseline, 3 sleep latency tests (SLTs) occurred after alcohol/placebo ingestion (15, 16.5, and 18 hours after waking). Stanford Sleepiness Scales (SSS) and Visual Analog Scales (VAS) of sleepiness were completed before each SLT and approximately every 30 minutes. The Biphasic Alcohol Effects Scale (BAES) was administered a total of 4 times (baseline, 5, 60, and 90 minutes postalcohol/placebo). Subjects' circadian phase was determined from melatonin levels in saliva samples taken at approximately 30-minute intervals. RESULTS: All sleepiness and sedation measures increased with time awake. Only SSS and BAES sedation measures showed higher levels of sleepiness and sedation after alcohol compared with placebo. The mean circadian phase was the same for assessments at both conditions. CONCLUSIONS: Alcohol did not increase physiological sleepiness compared with placebo nor was residual sedation evident under these conditions. We conclude that the effects on sleepiness of a moderate dose of alcohol are masked when sleep-wake homeostatic and circadian timing influences promote high levels of sleepiness.

Effects of a moderate evening alcohol dose. II: performance.

BACKGROUND: This second of a pair of papers investigates the effects of a moderate dose of alcohol and staying up late on driving simulation performance and simple visual reaction time (RT) at a known circadian phase in well-rested young adults. METHODS: Twenty-nine adults (9 males), ages 21 to 25 years, spent 1 week on an at-home stabilization schedule of 8.5 to 9 hours, followed by 3 nonconsecutive nights in-lab: adaptation, placebo, and alcohol. Performance task practice occurred on 3 occasions before the study. Alcohol (vodka; 0.54 g/kg men; 0.49 g/kg women mixed with tonic) was consumed over 30 minutes ending 1 hour before normal bedtime; the same quantity of beverage was given on placebo. Driving simulation (with drive-only and dual-task drive and subtract components) and psychomotor vigilance task (PVT) testing occurred before and after alcohol/placebo ingestion. Breath alcohol concentration (BrAC) readings were taken before all test sessions. Saliva samples were taken approximately every 30 minutes to determine circadian phase. RESULTS: Driving simulation and PVT variables significantly deteriorated with increasing time awake. Driving simulator lane variability was worse with alcohol compared with placebo at 15.5 hours awake. No PVT variable showed an effect of alcohol. CONCLUSIONS: Driving simulation performance deteriorated with extended waking and with alcohol; driving was most impaired at the peak alcohol level. The PVT, less complex than the driving simulation, did not show effects of alcohol, a finding consistent with previous literature that disruptive effects of low alcohol concentrations increase with task complexity. Overall, simulated driving performance is significantly impaired late at night when even a moderate dose of alcohol is consumed.