Restoring effective sleep tranquility (REST): A feasibility and pilot study

A randomized clinical trial for a self-guided sleep intervention following moderate-severe traumatic brain injury: Study protocol

BACKGROUND

Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI.

METHODS

This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention.

CONCLUSION

This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI.

Cognitive Behavioral Therapy for Insomnia Improves Sleep Outcomes in Individuals With Concussion: A Preliminary Randomized Wait-List Control Study

OBJECTIVE

Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard treatment for insomnia, but there is limited evidence on the treatment effect of CBT-I in individuals after a concussion. Therefore, the main purpose of this study was to evaluate the treatment effect of CBT-I on sleep outcomes and postconcussion symptoms.

SETTING

This study was conducted at an academic institution. The CBT-I sessions were conducted using a teleconferencing system (Zoom).

PARTICIPANTS

Participants were eligible to participate if they were at least 4 weeks post- concussion, aged 18 to 64 years, and scored 10 or more on the Insomnia Severity Index. A total of 40 people were enrolled; 32 participants were included in analyses.

DESIGN

This was a randomized controlled wait-list study. Participants were randomized into starting the CBT-I intervention immediately after the baseline assessment or into the wait-list group for 6 weeks before starting CBT-I. Assessments were performed at baseline, 6, 12, and 18 weeks.

MAIN MEASURES

The primary outcome was the Insomnia Severity Index. Secondary measures included the Pittsburg Sleep Quality Index, Post-Concussion Symptom Scale, and Beck Depression and Anxiety Inventories. Statistical analyses included a repeated-measures analysis of variance, t tests, and mixed linear regression modeling.

RESULTS

There was a group-by-time interaction for the sleep outcomes but not for the concussion or mood outcomes. Differences were seen between groups on sleep outcomes, symptom severity, and depression. The treatment effect was maintained following CBT-I for all outcomes. Improvement in sleep outcomes was predictive of improvement in postconcussion symptom severity and number of symptoms.

CONCLUSIONS

CBT-I reduces insomnia in individuals with concussions, and improved sleep was associated with lower postconcussion and mood symptoms. These effects were maintained 6 to 12 weeks following the intervention.

The Impact of Weighted Blanket Use on Adults with Sensory Sensitivity and Insomnia

Purpose

This study's purpose was to determine the impact of weighted blanket use on moderate to severe insomnia in adults with sensory sensitivity greater than the average population.

Methods

For this study, a four-week, single-case, multiple-participant ABA study design was used. Through convenience sampling, four participants scoring 15 or greater on the Insomnia Severity Index (ISI), which categorizes them as having moderate to severe insomnia, and much more than most people in sensory sensitivity on the Adolescent/Adult Sensory Profile were recruited. First, seven-day baseline sleep data was gathered, followed by two weeks of weighted blanket use, concluding with a seven-day withdrawal phase. Additional outcome measures included: Tuck and Snooze Survey, Consensus Sleep Diary Morning, and Additional Sleep Diary Questions. Data analysis included visual analysis, mean comparisons, Tau-U calculations, and pre- to post-ISI category comparisons.

Results

All participants' ISI scores were categorized as one level less severe postintervention. All participants demonstrated increased sleep quality, and three participants showed an increase in sleep duration based on individual mean comparisons between baseline and intervention phases.

Conclusion

Weighted blankets appear beneficial in reducing insomnia severity in adults with much more than the average population sensory sensitivity. In addition, those with self-reported anxiety may have increased benefit from this intervention.

Psychosocial treatments for nightmares in adults and children: a systematic review

BACKGROUND

As nightmares may be a risk factor for, or symptom of, multiple psychological disorders, some researchers suggest that nightmares should be screened, diagnosed, and treated. Treatments for nightmares include trauma-focused Cognitive Behavioural Therapy and Image Rehearsal Therapy, and pharmacological interventions such as prazosin and nitrazepam. As recent research has put into question our current understanding of treatment efficacy, there is a need to systematically review findings related to the effectiveness of nightmare treatments to inform best practice. The current review assessed the efficacy of psychosocial treatments of nightmare in all cohorts.

METHODS

A systematic search of four databases for peer reviewed journal articles from 2000 onwards produced 69 (35 RCTs, 34 non-RCTs) eligible articles that underwent narrative synthesis.

RESULTS

The results provide strong evidence for exposure and image rehearsal treatments for the reduction of nightmare frequency, severity, and distress, in civilian, military, idiopathic, and posttraumatic stress disorder (PTSD) cohorts. There is emerging evidence that self-guided and brief treatment modalities offer efficient and effective treatment options. There is an urgent need for clinical trials of treatment effectiveness in children.

CONCLUSIONS

The results suggest that treatments for nightmares are most effective when they facilitate a sense of control or mastery by directly targeting the nightmare content and/or the client's emotional responses to the nightmare content.

TRIAL REGISTRATION

A review protocol was registered with PROSPERO (CRD42020204861).

How Occupational Therapists Assess and Address the Occupational Domain of Sleep: A Survey Study

IMPORTANCE

Sleep is a foundational occupation in the Occupational Therapy Practice Framework: Domain and Process (2nd ed.), yet little is known about how occupational therapists assess and address sleep in practice.

OBJECTIVE

To survey practicing occupational therapists' comfort with their level of knowledge about sleep, how they are assessing and addressing sleep in clinical practice, and the amount of sleep-related education they have received.

DESIGN

Cross-sectional survey study.

SETTING

Electronic survey.

PARTICIPANTS

Practicing occupational therapists were invited to participate in November 2020. Survey invitations were sent via email targeting occupational therapists serving as clinical instructors.

OUTCOMES AND MEASURES

The survey consisted of 41 items assessing comfort with sleep knowledge, occupation of sleep, and sleep education received. This survey was modified from a previous survey and tailored to the occupational therapy profession.

RESULTS

A total of 169 occupational therapists completed the survey. Most (87%) agreed that sleep was an occupation, but only 44% evaluated their clients' sleep, and 30% established treatment goals pertaining to sleep. In addition, 66% reported not receiving education about sleep in their entry-level occupational therapy program, and 78% reported receiving no continuing education about sleep in the past 2 yr. Most (92%) reported that occupational therapists should be better prepared to evaluate and treat sleep after graduation.

CONCLUSIONS AND RELEVANCE

Most occupational therapists identified sleep as an area of occupation but had limited knowledge of how to assess and address sleep in practice. Entry-level occupational therapy education programs must enhance sleep-related curricula, and continuing education programs tailored to sleep issues within occupational therapists' practice are needed. What This Article Adds: The results of this study indicate gaps in occupational therapists' knowledge regarding how best to assess and treat sleep problems. We offer next steps to improve the profession's capacity to address the occupation of sleep.

Evaluation of an occupation-based sleep program for people with Insomnia

Background

Sleep problems are a health issue worldwide. Based on the Person-Environment-Occupation-Performance model, we developed an occupation-based sleep programme to promote awareness of sleep hygiene factors, promote an environment conductive to sleep, and restructure participation in daytime activities with a focus on occupational balance.

Method

This study uses a non-equivalent group design to evaluate the effectiveness of an occupation-based sleep intervention among community-dwelling adults with insomnia, when compared with a treatment-as-usual (TAU) group which focused on sleep hygiene, and relaxation.

Results

When compared with the TAU group ( n = 20), the intervention group ( n = 22) had significant improvement in sleep duration, occupational balance, and reduction in mood symptoms at both post treatment and 1-month follow up.

Conclusion

The results demonstrated that an occupation-based programme is an effective treatment for insomnia disorder and demonstrated the role which occupational therapy could play in primary health care service.

Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury

Background

Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.

Materials and Methods

This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).

Results

87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).

Discussion

Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.

Participation Mediates the Relationship Between Postconcussive Symptoms and Suicidal Ideation Among Veterans

IMPORTANCE

Veterans with mild traumatic brain injury (mTBI) and associated symptoms are at risk for suicide. Postconcussive symptoms (PCS) may heighten risk for suicidal thoughts by limiting veterans' participation.

OBJECTIVE

To investigate whether participation mediates the relationship between PCS and suicidal ideation.

DESIGN

Cross-sectional, exploratory design. Structural equation models were used to investigate whether participation mediated the relationship between PCS and suicidal ideation.

SETTING

Community.

PARTICIPANTS

Veterans with mTBI (N = 145).

OUTCOMES AND MEASURES

The Ohio State University TBI Identification Method was used to establish mTBI diagnosis. We identified latent variables for PCS and participation using the Neurobehavioral Symptom Inventory and select domains of the Medical Outcomes Study Short Form-36, respectively. We used the Beck Scale for Suicide Ideation to measure the presence of suicidal ideation.

RESULTS

Participation mediated the relationship between PCS and the presence of suicidal ideation (odds ratio [OR] = 1.09, p = .011). More severe PCS were associated with lesser participation (β = -.86, p < .001); greater participation was associated with lower odds of suicidal ideation (OR = 0.92, p = .007).

CONCLUSIONS AND RELEVANCE

PCS may heighten risk for suicidal thoughts among veterans by limiting successful participation, a primary target of occupational therapy intervention. Thus, the results suggest that occupational therapy practitioners can play a substantial role in suicide prevention services for veterans with mTBI. Preventive services could mitigate suicide risk among veterans with mTBI by enabling sustained engagement in meaningful and health-promoting activity (e.g., reasons for living) and targeting PCS. What This Article Adds: Researchers have proposed that occupational therapy practitioners can help prevent veteran suicide by supporting their engagement in meaningful, health-promoting activity and by targeting suicide risk factors within their scope of practice. To the best of our knowledge, this is the first study to offer empirical support for such proposed suicide prevention efforts. Although additional research is needed, these results are promising and highlight a distinct role for occupational therapy in suicide prevention.

Follow-Up Analyses From a Wait-List Controlled Trial of Occupational Therapist-Delivered Cognitive-Behavioral Therapy for Insomnia Among Veterans With Chronic Insomnia

IMPORTANCE

Veterans often experience chronic insomnia, and professionals capable of delivering effective interventions to address this problem are lacking.

OBJECTIVE

To evaluate the efficacy of the Restoring Effective Sleep Tranquility (REST) program, an occupational therapist-led cognitive-behavioral therapy for insomnia (CBT-I) intervention to treat sleep problems among post- 9/11 veterans.

DESIGN

Wait-list controlled trial with 3-mo follow-up.

SETTING

Community-based veteran support program in a Mountain West university.

PARTICIPANTS

Fifteen post-9/11 veterans with sleep disturbances who were assigned to either the REST intervention or a wait-list control group. Outcomes and Measures: Sleep-related, health-related, and participation-related patient-reported outcomes (PROs) and daily sleep diary variables.

RESULTS

Wait-list controlled trial benefits included improved sleep-related (e.g., sleep disturbance), health-related (e.g., depression), and participation-related (e.g., meaningful activity) PROs. Findings were confirmed after participants in both the intervention and the control groups (n = 13) received the REST intervention, including improved daily sleep diary outcomes (e.g., sleep efficiency). All gains were maintained at 3 mo.

CONCLUSIONS AND RELEVANCE

Occupational therapy practitioners with advanced training in CBT-I have the potential to safely deliver an effective CBT-I intervention to veterans with sleep disturbances in a community-based setting. What This Article Adds: Occupational therapy practitioners with sleep-related education and training can positively affect the well-being of their clients through improving sleep participation.

The influence of sleep disturbances and sleep disorders on pain outcomes among veterans: A systematic scoping review

Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management.

Association of Sleep and Hand Function in People With Carpal Tunnel Syndrome

This study examined whether sleep quality is associated with hand function above and beyond what can be explained by the effect of pain and carpal tunnel syndrome (CTS) severity on hand function in clients with CTS. The sample included 53 adults ages 30-86 yr. The Manual Ability Measure-20, Pittsburgh Sleep Quality Index, visual analog scale for pain, and electromyography for CTS diagnosis and severity level were used to measure outcomes. Sleep quality was significantly associated with manual ability after controlling for CTS severity and pain. In CTS care, attention to sleep is significant because it may promote hand function.

Occupational therapy and posttraumatic stress disorder: A scoping review

Background.

People who are diagnosed with posttraumatic stress disorder (PTSD) can experience disruptions in their daily occupations. Occupational therapists may assist clients with PTSD to reengage in meaningful occupations.

Purpose.

This scoping review aims to identify and describe the ways occupational therapy addresses PTSD in clinical practice.

Method.

Scholarly databases were searched for documents relating to occupational therapy and PTSD. Two reviewers independently applied selection criteria and systematically extracted information. Data were extracted and synthesized in a narrative format.

Findings.

Fifty sources met inclusion criteria and three major themes were identified: recognizing trauma within specific populations, PTSD’s impact on a range of occupations, and occupational therapy’s response to PTSD.

Implications.

Occupational therapists are working in multidisciplinary teams to reduce the impact of PTSD on the daily occupations of their clients. More effectiveness studies are required to understand the outcomes of occupational therapy interventions for clients with PTSD.

Military Service Member Perspectives About Occupational Therapy Treatment in a Military Concussion Clinic

The purpose of this study is to describe important features of occupational therapy practice for treatment of military service members with chronic symptoms and a history of mild traumatic brain injury (mTBI) in a military concussion care clinic from service members' perspectives with support from occupational therapy practitioners. Two series of focus groups were conducted with service members with chronic mTBI-related symptoms (n = 6) and practitioners (n = 5). Data were analyzed concurrently with collection. We identified five main themes: therapeutic relationship, consistent inclusion of family members, combat versus noncombat injuries, loss of military identity, and assessment against population norms. The findings of this study suggest that service members' evaluations of occupational therapy are based on the overall experience of the encounter, centered by the therapeutic relationship, rather than specific intervention strategies or technology.

Occupational Therapy Practice in Sleep Management: A Review of Conceptual Models and Research Evidence

The effectiveness of sleep intervention developed by occupational therapists was reviewed, and a conceptual framework for organizing the developing practice of sleep management in occupational therapy was proposed in this paper. Evidence-based articles on sleep management practice in occupational therapy from 2007 to 2017 were retrieved. Four types of effective sleep management intervention were identified from the literature, including the use of assistive devices/equipment, activities, cognitive behavioral therapy for insomnia, and lifestyle intervention, and the use of assistive device was the most popular intervention. Applying the Person-Environment-Occupation Performance (PEOP) framework, we developed a conceptual framework for organizing occupational therapy practice in sleep management. The future development of occupation-based sleep intervention could focus on strategies to (1) minimize the influence of bodily function on sleep, (2) promote environment conducive to sleep, and (3) restructure daytime activity with a focus on occupational balance.

Sleep disorder prevalence in at-risk adolescents and potential effects of nightmare triad syndrome

Objective At-risk high school students, those considered to have a higher probability for academic failure or dropping out, were assessed for various sleep disorders. Effects were compared between students with and without the nightmare triad syndrome (NTS+), the sleep disorders' cluster of frequent nightmares, insomnia disorder and suspected sleep-disordered breathing (SDB). Methods Data were gathered at a charter school for at-risk youth using: computer based surveys, physical airway exams, and mental health interviews by school social worker. Ninety-two students were enrolled, and 70 completed all study components. Results Students were teenaged [17.10 (1.50) years], male (52.2%) slightly overweight [BMI 25.50 (6.41)] Hispanics (87.0%); two-thirds (65 of 92) subjectively reported a sleep problem. Frequent nightmares (39.1%), insomnia (ISI ≥ 12, 41.3%), and SDB risk (79.3%) were common. Several presumptive sleep disorders (insomnia, SDB risk, parasomnia, or nightmares) were associated with worse sleep quality and lower quality of life. Nineteen students met criteria for NTS. Compared to NTS-, NTS+ showed significantly lower quality of life (p < 0.003, g = 0.84). Regression analyses revealed higher levels of depression and anxiety symptoms in NTS+ students. NTS was associated with reduced quality of life independent of anxiety symptoms. Conclusion Prevalence of presumptive sleep disorders was high with a tendency for clusters of sleep disorders in the same individual. Students with NTS+ showed worse outcomes and reduced quality of life, mediated partially by depression and anxiety. To examine relationships between sleep disorders and mental health in at-risk adolescents, research investigations must include both subjective and objective measurements of sleep.