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And so to bed

Matthew Limb discovers how physiotherapists are moving into a new area with notable success.

For many people, a good night’s sleep comes as easily as one sheep, two sheep, three but for others there is no such luxury.

Physiotherapists are helping to bring relief to patients with sleep disorders and some practitioners see this an area of growing opportunity for the profession. Their skills could be in demand as obesity levels linked to certain sleep disorders rise and treatment at an increasing number of centres gains a higher profile.

Lisa Plummer, a lecturer at Oxford Brookes University, says: ‘We have more sleep units emerging in the UK now and people are becoming more aware of the condition.’ Fiona Schreuder, who worked with Ms Plummer at the respected sleep disorder centre at Sydney’s Royal Prince Albert hospital, agrees: ‘Sleep studies haven’t been very accessible for patients, but I think that’s changing. I think people are becoming more aware of sleep and breathing during sleep.’

Consultant physiotherapist Denise Daley set up a sleep clinic at the Royal Surrey County hospital, Guildford, where she works alongside chest physicians (see panel: The sleep clinic). She says: ‘In the past funding was a problem. Many patients had to travel long distances to a large centre. Now many district general hospitals and smaller centres have begun to develop sleep clinics.’

It is not known how many physiotherapists are working in the field of sleep disorders but their contributions are already significant. Michelle Chatwin, who has the rare title of consultant physiotherapist in sleep and ventilation at the Royal Brompton hospital, London, explains: ‘It could be that physios are getting involved because they are looking after patients with non-invasive ventilation, and initiation quite often happens within the same department.’

Ms Plummer, who trained as a respiratory physio and worked in critical care, sees physiotherapy as the ideal profession to be working in sleep disorders, ‘without taking away the role that other professionals have.’ And Mrs Daley believes physios can have a major leadership or strategic role in setting up services in this area, raising their profile and reinforcing their skills.

‘Sleep has not traditionally been an area for physiotherapy,’ she says. ‘But as physios we have a good understanding of ventilation and all the mechanics of breathing.’ Dr Chatwin agrees: ‘I think physios add to the role because we have good assessment skills and we’re used to problem-solving.’

The most common sleep disorder is obstructive sleep apnoea. This is a respiratory condition caused by closure of the upper airway during sleep. (The term ‘obstructive’ is used to distinguish OSA from rarer forms of sleep apnoea, such as central sleep apnoea, which is when the brain ‘forgets’ to breathe during sleep). The blocked airway interrupts breathing, leading to falls in oxygen levels in the blood and potential build-up of carbon dioxide levels. ‘Basically your body says this isn’t normal and you come out of deep sleep,’ says Dr Chatwin.

Some people go into a lighter stage of sleep or a brief period of wakefulness in order to restore their normal breathing. However further episodes of apnoea can occur, which can mean hundreds of subtle micro-arousals a night that the individual might not even be aware of. In more severe cases, says Dr Chatwin, people feel that they are choking and so wake up, bolt upright, gasping.

OSA can have serious consequences. The resulting poor sleep can harm people’s lives in a variety of ways, causing daytime sleepiness and poor concentration, affecting performance at work and relationships. People with sleep apnoea are seven to 12 times more likely to have a road accident. According to the British Thoracic Society, sleep apnoea is a contributory factor in the development of hypertension, heart disease and stroke.

Dr Chatwin describes the typical patient with sleep apnoea as male, middle aged and overweight. Typically, during the restorative phase of sleep known as rapid eye movement sleep, the only muscles kept working are the eyes and diaphragm.

In larger men, the weight of floppy muscles in the neck can obstruct the airway. Dr Chatwin expains: ‘The degree of sleep apnoea severity is related to your size – the bigger you are, the bigger your neck.’ Snoring is a common symptom of sleep apnoea and many patients seek treatment following complaints from their partners. If there is suspicion of sleep apnoea patients are referred for a sleep study.

Dr Chatwin says: ‘Quite a lot of hospitals now have the facility to do studies on respiratory channel monitoring, looking at nasal airflow and oxygen saturations, which will pick up if someone has sleep apnoea.’ People are also given a subjective ‘sleepiness score’. ‘Usually patients underestimate their sleepiness, you can see patients falling asleep in the waiting room while you’re waiting to see them.’

The gold standard treatment for OSA is continuous positive airways pressure therapy, which was formally approved last year by the National Institute for Health and Clinical Excellence. Patients wear a nasal or face mask attached to a small pump that generates a flow of air. Breathing out against the resistance means that the upper airway is kept open and does not keep closing during sleep, explains Dr Chatwin.

Physiotherapist Lisa Emmett, who works with the sleep and home ventilation service at St James hospital, Leeds, says CPAP has an excellent success rate. ’About 90-95 per cent of people who try the machine do want to carry on with it on a long-term basis. The CPAP machine also eliminates snoring so most partners are very impressed.’ St James puts 400 to 450 patients a year on to CPAP.

‘We can’t keep up with the waiting list,’ Ms Emmett says. ‘There has been a lot of information in the media recently highlighting OSA and it seems to have opened the floodgates. And as a population, we’re getting larger.’

She says administering CPAP doesn’t particularly require physiotherapy skills: ‘I don’t think it’s a physio tool, but equally I think we’re very capable of doing the job. Obviously if somebody asks for advice on losing weight then as well as referring to a dietician it’s nice to be able to encourage them with specific exercises.’

Ms Emmett works with two clinical nurse specialists and a specialist sleep and ventilation consultant. She suspects there are few physios working in this field.

‘I’d worked on the respiratory ward for a while and had a good understanding of ventilation,’ she says. ‘I was brought in, not just to cover OSA but because of the number of patients with neuromuscular conditions, such as motor neurone disease or muscular dystrophy, who obviously had problems with secretion clearance and difficulty coughing.’

Playing catch up

Despite efforts by physiotherapists and others in this area, the UK still appears to have a lot of catching up to do. Lisa Plummer, who is thought to be the first UK physio to receive a masters degree in sleep medicine from Sydney University, says: ‘It’s fair to say we’re still behind Australia and the US in our approach and ability to offer services to patients with sleep disorders.’

Ms Plummer believes there are a lot of people who may have a sleep disorder and this is not being picked up. She says: ‘I think it’s good to remember there can be a large proportion of inpatients, not just respiratory patients, who may be suffering sleep problems.’

Fiona Schreuder, who lectures at the University of Hertfordshire, which runs a non-invasive ventilation masters module, would like physiotherapists working in NIV to be aware that there is an extended role open to them. ‘A lot of physios are dealing with the equipment anyway, in the acute setting, so there’s no reason this couldn’t be transferred into a long-term setting, a domicillary setting.’

For physiotherapists hoping to work in sleep disorders, Ms Daley says: ‘It very much depends on how the sleep service is set up in hospitals. If it is linked to the medical respiratory service, then the NIV service physios are in a good position to become involved. If the sleep clinics are run by ENT or sit outside respiratory medicine, however, then physio involvement is less likely. Physiotherapists interested in NIV and CPAP should look to work in a hospital where the physios play a big part. In our hospital it is the physios who lead the NIV service.

‘I advocate more physios being involved,’ she adds. ‘They should not be afraid to push the boundaries and push themselves forward.’ FL

Obstructive sleep apnoea syndrome

Associated health risks

  • hypertension
  • ischaemic heart disease
  • stroke
  • cardiac arrhythmias
  • decreased cognition
  • diabetes
  • depression
  • lack of interest in sex
  • impotence
  • road traffic accidents
  • premature death

Social consequences

  • falling asleep in meetings and underperformance
  • snoring leading to complaints from partners
  • notifiable condition to the Driver and Vehicle Licensing Agency
  • decreased academic performance in children
  • hyperactivity in children

The sleep clinic

Denise Daley set up a sleep clinic at the Royal Surrey County hospital, Guildford.

As a consultant physiotherapist she has a strategic role, overseeing all chronic respiratory services and saw the clinic as a vital precursor to offering a home non-invasive ventilation service for people with chronic respiratory disease.

She says: ‘Although patients with sleep apnoea differ from those with chronic respiratory disease and hypoventilation, it is vital to be able to differentiate between the two.

‘We felt in our trust a local sleep service would not only benefit sleep patients, but would also link very well with our long-standing acute NIV service and the subsequent development of a home NIV service.’

Ms Daley runs the sleep clinic working alongside chest physicians. They see patients suspected of having sleep apnoea, many of whom present with daytime fatigue. Part of the assessment is a sleep study.

She explains: ‘Patients attend clinic where they are set up with simple equipment for a home sleep study, which is a cost-effective way of testing them for sleep apnoea. They prefer not to be admitted to hospital for their tests – it is important to rule out any other potential causes of their symptoms. Once we have a diagnosis of sleep apnoea, we provide a CPAP machine for a trial.’

Following publication of NICE’s technical appraisal last year, primary care trusts are obliged to supply CPAP machines for patients diagnosed with moderate to severe sleep apnoea or people with mild sleep apnoea who have symptoms of daytime sleepiness. Ms Daley says: ‘Many physiotherapists are involved in NIV and CPAP acutely.

They are also becoming more involved in NIV in the community setting.

‘Physiotherapists have the skills required for respiratory assessment, understanding of the mechanics of ventilation, mask fitting, problem solving and ventilatory support,’ she says. ‘Where these services are combined in hospitals, I think it is a natural step for physiotherapists to be included in teams providing a sleep service.’

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