A brief view on insomnia assessment and non-pharmacological management.
Insomnia is a heterogeneous disorder involving difficulty in initiating sleep, the inability to fall asleep once awake, being awake during normal bedtime hours, sleep dissatisfaction and associated daytime impairment like sleepiness and fatigue. It is important that physiotherapists show an awareness of specific physiological sleep disorders such as sleep apnoea, restless leg syndrome, and substance abuse, to guide them to appropriate services. Medication like bronchodilators and steroid is also known to disrupt sleep.
The cognitive behavioural model of insomnia proposed by Harvey (2002) incorporates an individual’s daytime and night-time situations, and emphasises several cognitive, emotional and belief factors, which play a role in maintaining insomnia.
The psychophysiological insomniacs report intrusive thoughts and inability to seize the mind during the sleep initiation period and attempting to suppress these thoughts. There are also daytime consequences of poor sleep, such as fatigue or a belief that they need to avoid activities or rest excessively during the day, which further fuel insomnia.
Meta-analysis reports have shown improvement in sleep quality with nonpharmacological treatments. A sedative medication does not address the distress or root cause of insomnia. Opiates for controlling pain are known to disrupt REM sleep and have significant side effects. Therefore nonpharmacological management may be useful in certain groups of patients.
Cognitive Behavioural Therapy (CBT)
CBT for insomnia incorporates relaxation, stimulus control, sleep restriction, promoting sleep hygiene and cognitive restructuring therapy aimed at targeting the factors that perpetuate insomnia (Siebern et al., 2012). CBT alone has produced long term benefits on insomnia compared to pharmacological intervention or a combination of CBT and pharmacological intervention (Jacobs et al., 2004).
The most common forms of relaxation are image guided relaxation and progressive muscle relaxation. It is a known fact that relaxation reduces the effect of anxiety and muscle tension, which can be helpful in initiating sleep.
This approach attempts to change patients’ lifestyles and sleep environment by improving the sleep-wake schedules, including improving healthy habits such as avoiding stimulants like caffeine and tobacco in order to optimise sleep quality. The use of sleep hygiene education is associated with initially improved sleep continuity, depth and improved mood on morning awakening in healthy elderly subjects (Hoch et al., 2001). Stimulus control is also part of sleep hygiene and is one of the most effective behavioural interventions (Morin et al., 1994) aimed at helping the patient associate rapid sleep onset with the bed and the bedroom.
A meta-analysis by Dolezal et al (2017) and Yang et al (2012) on the effects of exercise on sleep problems concluded that exercise reduced insomnia regardless of the mode, duration and intensity, especially in populations suffering from disease. A decrease in both sleep latency (time taken to get to sleep) and the use of sleep medication is noted. Wiklund et al’s (2018) study concluded that significant beneficial effects on insomnia along with some reduction in pain intensity were confirmed in the exercise group.
Key points for clinical practice
- During clinical assessment therapists can explore the nature of sleep disturbance such as difficulties in falling asleep, frequent wakening, duration of sleep, sleep environment and day time consequence of poor sleep
- Physiotherapists will benefit from enhancing their knowledge on nonpharmacological management of sleep to implement in clinical practice promoting lifestyle with CBT, sleep hygiene and exercises prescription
Mind-body exercisers showed significantly better mood, mental health, and sleep compared to aerobic exercisers. Tai Chi and Yoga are known to improve sleep quality by reducing sympathetic tone, reducing the effect of anxiety (Sidharth et al 2014). From a clinical prospective, it is important to note occupational physical activity didn’t derive the benefits that we expect from leisurely exercises. Exercises in the night prevent initiation of sleep as moderate levels of exercise is associated with increase in adrenaline and noradrenaline. Therefore a structured programme of graded exercises for patients with multiple comorbidities and complex needs may help improve their sleep and thereby their general health and well being.
- Narender Nalajala is consultant physiotherapist;
- Laura Gutting is advance practice physiotherapist at Ashford and St Peter’s Hospital NHS Trust
The Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM 5), is commonly used as diagnostic criteria:
A Predominant complaint of dissatisfaction with sleep quantity and quality associated with one (or more) of the following symptoms:
- Difficulty initiating sleep (in children this may manifest as difficulty initiating sleep without caregivers’ intervention).
- Difficulty maintaining sleep. Characterised by frequent awakenings and problems returning to sleep after awakenings (in children, this may manifest as difficulty returning to sleep without caregivers intervention).
- Early morning awakening with inability to return to sleep.
B The sleep disturbance causes clinically significant distress or impairment in social occupational, educational, academic, behavioural or other important areas of functioning.
C The sleep difficulty occurs at least three nights per week.
D The sleep difficulty is present for at least three months.
E The sleep difficulty occurs despite adequate opportunity for sleep.
F The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (eg narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G The insomnia is not attributed to the physiological effects of substance (eg drug abuse, medication).
H Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
- With non-sleep disorder mental comorbidity, including substance use disorders
- With other medial comorbidity
- With other sleep disorders
- Episodic: symptoms last at least one month but less than three months
- Persistent: symptoms last three months or longer
- Recurrent: two (or more) episodes within the space of a year
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Hoch CC, Reynolds III CH, Buysse DJ et al. Protecting sleep quality in later life: a pilot study of bed restriction and sleep hygiene. J Gerontol Psychol Sci 2001; 56: 52–59.
Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behaviour therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med . 2004: 164(17): 1888-96.
Morin CM, Culbert JP, Schwartz SM. Nonpharmacological Interventions for Insomnia: A Meta-Analysis of Treatment Efficacy. 1994 Aug; 151(8):1172-80. Am J Psychiatry 1994:151(8): 1172-80
Siddarth D, Siddarth P, and Lavretsky H. “An observational study of the health benefits of yoga or Tai Chi compared with aerobic exercise in community-dwelling middle-aged and older adults,” American Journal of Geriatric Psychiatry, vol. 22, no. 3, pp. 272–273, 2014.
Siebern AT, Suh S, Nowakowski S. Non-pharmacological treatment of insomnia. Neurotherapeutics. 2012 Oct;9(4):717-27
Wiklund T, Linton SJ, Alföldi P, Gerdle B. Is sleep disturbance in patients with chronic pain affected by physical exercise or ACT-based stress management? - A randomized controlled study. BMC Musculoskelet Disord. 2018 Apr 10; 19(1):111.
Yang PY, Ho KH, Chen HC, Chien MY. Exercise training improves sleep quality in middle-aged and older adults with sleep problems: a systematic review. J Physiother. 2012;58(3):157-63.
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