Restful Rehabilitation: Sleep's Essential Role in Occupational Therapy Education, Intervention, and Research.

All humans have the occupational right to sleep; therefore, occupational therapy practitioners must prioritize sleep with their clients. In this column, we identify ways to incorporate sleep health into the education and training of occupational therapy practitioners. This starts with identifying entry-level and continuing education opportunities to proclaim sleep as an occupation and a basic biological need. Current practitioners must recognize that sleep health is multidisciplinary, and existing interventions can help clients achieve good sleep health throughout their lifespan. Given the paucity of sleep research in occupational therapy, the potential exists to investigate new, occupation-based assessments and interventions. We provide specific approaches to expand sleep and sleep health knowledge in occupational therapy education, practice, and research.

Weighted Blankets as a Sleep Intervention: A Scoping Review.

IMPORTANCE: Sleep disorders are associated with a range of health conditions, with poor sleep often further exacerbating individuals' health, well-being, and ability to participate in daily occupations. Weighted blankets offer a potentially simple nonpharmacological sleep intervention option. OBJECTIVE: To summarize available literature on instrumentation and outcomes associated with overnight use of weighted blankets for therapeutic purpose. EVIDENCE REVIEW: A scoping review following the PRISMA review guidelines was conducted. Sources included MEDLINE, Cochrane Library, CINAHL, PsycINFO, Scopus, Embase, and Google. Included studies reported on overnight use of weighted blankets. Critical appraisal of studies was conducted with standardized tools. FINDINGS: Eighteen studies met the inclusion criteria. Positive outcomes were reported for adults, including improved sleep, reduction in medication use, and improved mood. Sleep outcomes were mixed for children and adolescents but included improved occupational performance. Methodological quality of included studies regarding effectiveness was variable. Ten studies included details of the intervention, whereas only one study reported on implementation. No specific guidelines for use were included. CONCLUSIONS AND RELEVANCE: Weighted blankets are used as a sleep intervention for individuals across the life span experiencing a range of health conditions. Currently, there is more evidence of effectiveness with adults, although parents are favorable regarding weighted blanket use for children. Implementation and recommendation of weighted blankets are typically led by occupational therapists, with knowledge of the intervention facilitating use. This review provides information to inform occupational therapists' clinical decision-making and continued implementation of weighted blankets for individuals with sleep problems. Plain-Language Summary: This scoping review summarizes what is known about the use of weighted blankets as a sleep intervention for people of all ages. There is more evidence for overnight use of weighted blankets for adults, with improvements reported in sleep, mood, medication use, and pain. Although there is little evidence of improvement in sleep for children, some children show improvement in everyday functioning, and parents report positive outcomes from overnight use of weighted blankets. These findings suggest that occupational therapists should consider offering or recommending weighted blankets as a sleep intervention option for people of all ages, alongside consideration of individuals' preferences. Development of practice guidelines that incorporate current research findings is urgently needed to support occupational therapists' use of weighted blankets.

Effect of exercise on sleep and cardiopulmonary parameters in patients with pulmonary artery hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) is considered to be a rare progressive disease resulting from restricted flow through the pulmonary arterial circulation resulting ultimately in right-sided heart failure. Most patients with PAH suffer from sleep disorders, reduced aerobic fitness, and mortality risk despite optimized medical treatment. This study investigated the effect of 12 weeks of aerobic training on sleep quality, sleep efficiency, right ventricular systolic pressure (RVSP), and aerobic fitness in patients with PAH. METHODS: Thirty patients with PAH were randomized to two equal groups, training group (A) and control group (B). The Pittsburg sleep quality index (PSQI) questionnaire and a wrist-worn actigraph were used for the assessment of sleep quality and sleep efficiency respectively. RVSP was measured using echocardiography. Cardiopulmonary exercise testing (CPET) assessed maximal heart rate and VO2max. All were measured before and after the study period for both groups. Exercise training was conducted on a bicycle ergometer as an individually-tailored moderate-intensity aerobic training session (60 to 70% of the maximal heart rate reached during the initial exercise test) for 30 to 45 min/day, 3 sessions/week for 12 weeks (36 sessions). RESULTS: Sleep scores and RVSP showed significant reductions and VO2max-representing the aerobic fitness-showed a significant increase in the group (A) compared with group (B). CONCLUSION: These results suggest that aerobic training has a positive effect on three risk factors for mortality in patients with PAH, namely sleep quality, decline in exercise capacity, and right ventricular remodeling. CLINICAL TRIALS REGISTRATION: Clinical trial registered in ClinicalTrials.gov , ID: NCT04337671.

Effects of a community-based exercise program on mobility, balance, cognition, sleep, activities of daily living, and quality of life in PD: a pilot study.

Aim: The primary objective of the study was to evaluate the effects of a community-based exercise program for adults with Parkinson's disease (PD). Patients & methods: This one-group pretest and post-test design involved 22 participants with PD who participated in two to three exercise sessions per week for 8 weeks. Outcomes assessed for statistical significance included balance, mobility, cognition, activities of daily living, sleep and quality of life. Results: Although exercise is positively correlated with improvements in function, this short-duration study did not demonstrate this. Qualitative themes revealed an increase in self-perceived socialization, coordination and motivation to continue exercise. Conclusion: This community-based exercise study showed improvements in socialization, self-reported coordination and motivation to exercise. Further research is needed to assess community exercise interventions for PD.

Optimized Sleep After Brain Injury (OSABI): A Pilot Study of a Sleep Hygiene Intervention for Individuals With Moderate to Severe Traumatic Brain Injury.

Background. Disrupted sleep is common after traumatic brain injury (TBI) particularly in the inpatient rehabilitation setting where it may affect participation in therapy and outcomes. Treatment of sleep disruption in this setting is varied and largely unexamined. Objective. To study the feasibility of instituting a sleep hygiene intervention on a rehabilitation unit. Methods. Twenty-two individuals admitted to a brain injury unit were enrolled and allocated, using minimization, to either a sleep hygiene protocol (SHP) or standard of care (SOC). All participants wore actigraphs, underwent serial cognitive testing, and had light monitors placed in their hospital rooms for 4 weeks. Additionally, participants in the SHP received 30 minutes of blue-light therapy each morning, had restricted caffeine intake after noon, and were limited to 30-minute naps during the day. SHP participants had their lights out time set according to preinjury sleep time preference. Both groups were treated with the same restricted formulary of centrally acting medications. Results. Of 258 patients screened, 27 met all study inclusion criteria of whom 22 were enrolled. Nine participants in each group who had at least 21 days of treatment were retained for analysis. The protocol was rated favorably by participants, families, and staff. Actigraph sleep metrics improved in both groups during the 4-week intervention; however, only in the SHP was the change significant. Conclusions. Sleep hygiene is a feasible, nonpharmacologic intervention to treat disrupted sleep in a TBI inpatient rehabilitation setting. A larger study is warranted to examine treatment efficacy. ClinicalTrials.gov Identifier: NCT02838082.

Effects of speed of processing training and transcranial direct current stimulation on global sleep quality and speed of processing in older adults with and without HIV: A pilot study.

Some older adults with human immunodeficiency virus (HIV) experience poor sleep which can worsen cognition. Transcranial direct current stimulation (tDCS) and cognitive training have improved sleep and cognition in studies of older adults; yet, their combined influence is unknown in adults with HIV. Older adults with HIV (n = 33) and without HIV (n = 33) were randomized to receive 10 one-hour sessions of speed of processing (SOP) training with tDCS or sham tDCS over approximately 5 weeks. tDCS with SOP training did not improve sleep. Omitting correction of multiple comparisons for this exploratory pilot study, main effects for HIV (F[1, 59] = 5.26, p = .03, ηp2 = .082) and tDCS (F[1, 59] = 5.16, p = .03, ηp2 = .080) on the Digit Copy Test were detected. A HIV × tDCS interaction was detected on the Letter Comparison Test (F[1, 59] = 5.50, p = .02, ηp2 = .085). Useful Field of View scores improved across all four groups (F[1, 59] = 64.76, p < .001, ηp2 = .523). No significant effects for HIV (F[1, 59] = 1.82, p = .18) and tDCS (F[1, 59] = .01, p = .94) were detected on the Useful Field of View test. While the current study did not show effects of combined tDCS and SOP training on sleep quality, future studies are needed to examine the effects of such interventions on sleep-related cognitive functions among cognitively impaired adults with HIV.

Meta-analysis: Exercise intervention for sleep problems in cancer patients.

BACKGROUND: Sleep problems cause physical and mental distress and may influence the survival of cancer patients. OBJECTIVES: This study aimed to explore the efficacy of exercise intervention to improve sleep in cancer patients. METHODS: Published papers from 1980 to 2018 were searched. RESULTS: The major findings included (a) exercise intervention had small positive effects on enhancing total subjective sleep quality (TSSQ; g = 0.38, 95% CI = 0.21-0.54) and objective sleep onset latency (g = 0.21, 95% CI = 0.01-0.41). (b) The characteristics in subgroups in regarding the small to large effects of an exercise programme on sleep were identified. First, the groups of a home-based exercise and a supervised exercise combined with a home-based exercise had a medium effect on TSSQ than the usual group. Second, interventions with aerobic exercise, especially the 4- to 8-week programmes and those with weekly volume of 80-149 min per week for cancer patients with ongoing or completed treatment also had a medium to large positive effect on TSSQ. Finally, patients with breast cancer and haematologic malignancies contributed a small effect in this meta-analysis. CONCLUSIONS: Maintaining regular aerobic exercises, even of different durations and weekly volumes, benefits patient sleep quality.

Cognitive behavioural therapy for post-stroke fatigue and sleep disturbance: a pilot randomised controlled trial with blind assessment.

The objective of this study was to evaluate the effectiveness of individual cognitive behavioural therapy (CBT) for post-stroke fatigue and sleep disturbance compared to treatment as usual (TAU). In a parallel two-group pilot randomised controlled trial of 15 participants, nine were allocated to eight weekly sessions of adapted CBT and six continued usual care rehabilitation. The primary outcome was the Fatigue Severity Scale (FSS-7) at two and four months from baseline. Secondary outcomes included measures of sleep, mood and quality of life. Outcomes were assessed by a rater who was blind to group membership. At the four-month endpoint, the CBT group demonstrated significantly reduced fatigue relative to TAU (FSS-7 mean difference: 1.92, 95% CI: 0.24 to 3.60). Significant group differences also emerged for sleep quality and depression, favouring the CBT group. Insomnia and physical quality of life improved immediately post-therapy but were no longer superior to TAU at follow-up. Overall, CBT is a promising treatment for improving post-stroke fatigue, sleep quality and depression. Gains were maintained for two months after therapy cessation and represented large treatment effects. These findings highlight the feasibility of the intervention and warrant extension to a phase III clinical trial.

Sleep and fatigue after TBI.

BACKGROUND: Whilst post traumatic brain injury fatigue (PTBIF) and sleep disturbance are common sequelae following brain injury, underlying mechanisms, and the potential for targeted interventions remain unclear. OBJECTIVE: To present a review of recent studies exploring the epidemiology of PTBIF and sleep disturbance, the relationship and neuropsychological correlates of these issues, potential approaches to intervention, and implications for neurorehabilitation. METHODS: A review of relevant literature was undertaken, with a focus on PTBIF relating to sleep disturbance, the neuropsychological correlates of these issues and implications for neurorehabilitation. This paper does not set out to provide a systematic review. RESULTS: Multidimensional approaches to assessment and treatment of sleep disturbance and PTBIF are required. CONCLUSIONS: There is a need for more robust findings in determining the complex nature of relationships between PTBIF, sleep disturbance, and correlates. Longitudinal prospective data is required to increase our understanding of the nature and course of PTBIF and sleep disturbance post TBI. Large scale clinical trials are required in evaluating the potential benefits of interventions.

Association of sleep with neurobehavioral impairments during inpatient rehabilitation after traumatic brain injury.

BACKGROUND: Sleep disturbance is a common sequela after traumatic brain injury (TBI). Many of the impairments following TBI may be exacerbated by impaired sleep-wake cycle regulation. OBJECTIVES: To investigate the relationship between total sleep time (TST), measured by wrist actigraphy and observational sleep logs, and neurobehavioral impairments during inpatient rehabilitation after TBI. METHODS: Twenty-five subjects undergoing inpatient rehabilitation for traumatic brain injury were included. TST was measured using wrist actigraphy and observational sleep logs. Neurobehavioral impairments were assessed using the Neurobehavioral Rating Scale-Revised (NRS-R), a multidimensional clinician-based assessment. RESULTS: Of 25 subjects enrolled, 23 subjects completed the study. A significant negative correlation was found between total NRS-R and TST calculated by observational sleep logs (r = -0.28, p = 0.007). The association between total NRS-R and TST, as calculated by actigraphy, was not significantly correlated (R = -0.01, p = 0.921). CONCLUSIONS: Sleep disturbance during inpatient rehabilitation is associated with neurobehavioral impairments after TBI. TST measured by actigraphy may be limited by sleep detection algorithms that have not been validated in certain patient populations. Considerations should be made regarding the feasibility of using wearable sensors in patients with cognitive and behavioral impairments. Challenges regarding actigraphy for sleep monitoring in the brain injury population are discussed.

Objective measures of sleep and wakefulness in patients with moderate to severe brain injury on an inpatient rehabilitation unit. Pearls and pitfalls of actigraph monitoring.

BACKGROUND: As awareness of disrupted sleep in patients with traumatic brain injury (TBI) increases so does interest in finding objective measures of sleep. As a result, many clinicians are turning to actigraphs to monitor sleep in patients with altered consciousness. Actigraphs are accelerometers which have been used in sleep research for over four decades. OBJECTIVE: The purpose of the present study was to determine the best method for scoring actigraphs in a TBI population and to describe the benefits and pitfalls of using actigraphs with patients on a brain injury rehabilitation unit. METHODS: A retrospective chart review of 43 patients compared three different ways of scoring night time rest periods: autoscoring, manual scoring, and set interval scoring for the sleep parameters of sleep efficiency, wakefulness after sleep onset, and total sleep time. Nursing compliance with using the event marker on the device to set rest period was also analyzed. RESULTS: The autoscoring method of determining the rest interval showed an inflation of sleep efficiency. For each sleep parameter compared, the strongest correlations were observed between the manual and set interval scoring methods. Compliance using event markers to set rest interval was low (16.7%). CONCLUSIONS: Set interval scoring is the most efficient method to determine the rest interval in TBI patients. The use of event markers was an unreliable method to determine rest period.

Occupational Therapy Interventions Addressing Sleep for Community-Dwelling Older Adults: A Systematic Review.

Because of age-related changes in sleep patterns, older adults may get less sleep than the recommended amount and experience decreased performance in daytime activities as a result. This article examines the evidence for the effectiveness of interventions within the scope of occupational therapy addressing sleep. Thirteen Level I studies met inclusion criteria and were categorized into three themes: (1) one-to-one single-component interventions, (2) one-to-one multicomponent interventions, and (3) group multicomponent interventions. Strong evidence supports cognitive-behavioral intervention strategies for older adults that include relaxation, sleep hygiene education, problem solving, and physical exercise, among others, delivered one to one or in a group. Routine use of these interventions is recommended.

A Survey of Practicing Sleep Coaches.

BACKGROUND: Sleep coaches are individuals of various backgrounds who offer services to families struggling with behavioral childhood sleep problems. We conducted a survey of coaches to further elucidate scope of practice, practice patterns, geographic distribution, education, training, and beliefs regarding qualification requirements. METHODS: A Web-based survey was completed by 142 individuals who identified as a sleep coach. RESULTS: Coaches were distributed across 17 countries and 5 continents. Overall, 65% of coaches served clients in countries beyond their home country. Within the United States, coaches were generally located in more affluent and well-educated zip codes near large metropolitan centers, 91% served clients beyond their home state, and 56% served clients internationally. Educational background varied across coaches (12% high school degree, 51% bachelor's degree, 32% master's degree, 2% doctoral degree, 1.5% JD degree). Few coaches (20%) were or had been licensed health care providers or carried malpractice insurance (38%). Coaches usually provided services for children < 4 months of age to about 6 years of age, and were much less likely to provide services for children with comorbid neurodevelopmental (32%) or significant medical disorders (19%). Coaches reported an average of 3 new and 6 total clients per week and working 20 hr per week on average. Most coaches (76%) felt that a formal sleep coach training program was the most important qualification for practice. CONCLUSIONS: These results highlight a diversity of background, training, and geographical distribution of sleep coaches, and may help inform discussions regarding guidelines for training and credentialing of sleep coaches.

Randomized trial of Tibetan yoga in patients with breast cancer undergoing chemotherapy.

BACKGROUND: The current randomized trial examined the effects of a Tibetan yoga program (TYP) versus a stretching program (STP) and usual care (UC) on sleep and fatigue in women with breast cancer who were undergoing chemotherapy. METHODS: Women with stage (American Joint Committee on Cancer (AJCC) TNM) I to III breast cancer who were undergoing chemotherapy were randomized to TYP (74 women), STP (68 women), or UC (85 women). Participants in the TYP and STP groups participated in 4 sessions during chemotherapy, followed by 3 booster sessions over the subsequent 6 months, and were encouraged to practice at home. Self-report measures of sleep disturbances (Pittsburgh Sleep Quality Index), fatigue (Brief Fatigue Inventory), and actigraphy were collected at baseline; 1 week after treatment; and at 3, 6, and 12 months. RESULTS: There were no group differences noted in total sleep disturbances or fatigue levels over time. However, patients in the TYP group reported fewer daily disturbances 1 week after treatment compared with those in the STP (difference, -0.43; 95% confidence interval [95% CI], -0.82 to -0.04 [P = .03]) and UC (difference, -0.41; 95% CI, -0.77 to -0.05 [P = .02]) groups. Group differences at the other time points were maintained for TYP versus STP. Actigraphy data revealed greater minutes awake after sleep onset for patients in the STP group 1 week after treatment versus those in the TYP (difference, 15.36; 95% CI, 7.25-23.48 [P = .0003]) and UC (difference, 14.48; 95% CI, 7.09-21.87 [P = .0002]) groups. Patients in the TYP group who practiced at least 2 times a week during follow-up reported better Pittsburgh Sleep Quality Index and actigraphy outcomes at 3 months and 6 months after treatment compared with those who did not and better outcomes compared with those in the UC group. CONCLUSIONS: Participating in TYP during chemotherapy resulted in modest short-term benefits in sleep quality, with long-term benefits emerging over time for those who practiced TYP at least 2 times a week. Cancer 2018;124:36-45. © 2017 American Cancer Society.

Hábitos de sueño en lactantes y preescolares / Sleep habits in infants and preschoolers

Objetivo: conocer los hábitos de sueño en lactantes y preescolares, identificar los hábitos incorrectos y el insomnio infantil por hábitos incorrectos (IIHI), y valorar si la puesta en marcha de determinadas estrategias mejoraba el insomnio infantil. Métodos: estudio analítico longitudinal, llevado a cabo en el Servicio de Pediatría de dos centros de Atención Primaria, de abril de 2006 a febrero de 2007. La población de estudio fueron niños de edades comprendidas entre los 8 meses y los 3 años. Se trataba de entrevistar a los padres durante las visitas de revisión de los niños, sobre hábitos del sueño de sus hijos, presencia y características del sueño diurno, lugar, hora y forma de dormir por la noche, existencia de despertares nocturnos habituales, etc. Si se detectaban alteraciones del sueño se les proponía una intervención educativa que debían aplicar para que sus hijos mejoraran la alteración del sueño. Se llevó a cabo un análisis descriptivo y analítico. Resultados: se obtuvo información de 315 menores, 57,2% niños y 42,8% niñas. Por edades: el 22% tenía 8 meses, el 22% 12 meses, el 17% 18 meses, el 20% 2 años y el 19% 3 años. El 84% se iba a dormir antes de las diez de la noche. El 56% iniciaba el sueño en su habitación. El 61% inicia el sueño solo en su cama o cuna. Entre los niños de 3 años de edad, un 10% dormía en la cama con los padres. El 84% tardaba menos de 30 minutos en dormirse y el 4% más de una hora. El 44% presentaba despertares nocturnos habituales. El 85% de los padres considera que su hijo no tiene problemas con el sueño y el 87% no ha consultado nunca por un problema de sueño. Respecto a los hábitos de sueño, el 48% tenía hábitos correctos, el 38% fue incorrecto y un 14% presentaba IIHI. Se interviene en la alteración del sueño de 164 niños, al mes un 12% lo había resuelto y a los tres meses el 18%. Conclusiones: más de la mitad de los lactantes y preescolares presentaba hábitos de sueño incorrectos. La prevalencia de IIHI fue relevante. La puesta en marcha de una intervención educativa hacia los padres que debían aplicar para mejorar los hábitos de sueño de los niños, consiguió resolver el problema en un bajo porcentaje de los casos (AU)

Objectives: to understand the sleep patterns in infants and preschoolers, to identify incorrect habits and childhood insomnia due to disorderly habits (CIDH), and to assess if the implementation of certain strategies leads to an improvement in childhood insomnia. Methods: a longitudinal analytic study, conducted in the Paediatric Units of two Primary Care Centres, from April, 2006 to February, 2007. The study population consisted in 8-month to 3-year-old children. Parents were interviewed during their children’s follow-up visits, regarding their sleep habits, presence and characteristics of daytime sleep, place, time and manner of night sleep, existence of habitual nocturnal wakening, etc. If any sleep alterations were detected, an educational intervention was proposed, that they should apply in order to improve their children’s sleep alteration. A descriptive and analytic study was conducted. Results: information was obtained about 315 children: 57.2% were boys and 42.8% girls. By ages, 22% were 8-month old, 22% were 12-month-old, 17% were 18-month old, 20% were 2-year-old and 19% were 3-year old. Of these, 84% went to bed before 10 p.m.; 56% initiated sleep in their room; 61% initiated sleep alone in their bed or cot. Among 3-year-old children, 10% slept in bed with their parents. An 84% of children took less than 30 minutes in falling sleep, and 4% over an hour; 44% presented habitual nocturnal wakening. Regarding parents, 85% considered that their child had no sleep problems, and 87% had never consulted for a sleep problem. In terms of sleep patterns, 48% had correct habits, 38% were incorrect, and 14% presented CIDH. There was an intervention in the sleep disorders of 164 children; at least 12% had solved them at one month, and 18% at 3 months. Conclusions: over half of infants and preschoolers presented incorrect sleep habits. The prevalence of CIDH was relevant. The implementation of an educational intervention targeted to parents, which they should apply in order to improve their children’s sleep habits, led to solving the problem in a low proportion of cases (AU)

Sleep Health Promotion: Practical Information for Physical Therapists.

Sleep disturbances occur in one third of the US population, and the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control has deemed insufficient sleep to be a public health problem. Knowledge about sleep and skills to screen sleep disorders and to promote sleep health have been recommended for physical therapists. Furthermore, in survey studies, physical therapists overwhelmingly agree that sleep is important for health and poor sleep impairs function. Sleep is critical for the proper functioning of the body, including immune function, tissue healing, pain modulation, cardiovascular health, cognitive function, and learning and memory. Sleep disruptions occur across the life span and in individuals with various conditions that are typically treated by physical therapists. Therefore, the purpose of this perspective paper is to (1) discuss the relevance of sleep to physical therapist practice, (2) recommend tools to screen for the 3 most common sleep disorders, and (3) provide suggestions for how therapists can integrate sleep health in prevention, health promotion, and wellness interventions.