Mechanisms by which sleep disturbance contributes to osteoarthritis pain: A conceptual model

Sleep disturbance is prevalent in aging and painful rheumatologic populations, but it has largely been a neglected dimension of the routine clinical care of arthritis patients. Pain associated with osteoarthritis (OA) is a leading cause of disability worldwide, and factors that contribute to pain in OA are poorly understood. Sleep disturbance is not only a consequence of pain, it is also likely to play an integral role in pain expression. Emerging research suggests that many patients with OA demonstrate signs of generalized hyperalgesia and faulty central pain modulatory processing similar to other idiopathic pain disorders, such as fibromyalgia. Sleep disruption is increasingly recognized as a direct contributor to both hyperalgesia and impaired endogenous pain modulation. This article reviews the extant literature on sleep disturbance and hyperalgesia in patients with OA. We propose a conceptual working model describing pathways by which sleep disturbance interacts directly with central pain processing mechanisms and inflammatory processes, and indirectly with mood and physical functioning to augment clinical OA pain. The clinical and research implications of the model are discussed.     

Evidenced-based hypnotherapy for the management of sleep disorders

There is a plethora of research suggesting that combining cognitive-behavioral therapy with hypnosis is effective for a variety of psychological, behavioral, and medical disorders. Yet, very little empirical research exists pertaining to the use of hypnotherapy as either a single or multitreatment modality for the management of sleep disorders. The existing literature is limited to a small subset of nonbiologic sleep disorders. The objectives of this paper are: to provide a review of the most common sleep disorders, with emphasis on insomnia disorders; discuss the cognitive-behavioral approaches to insomnia; and review the existing empirical literature on applications of hypnotherapy in the treatment of sleep disturbance. The overreaching goal is to educate clinicians on how to incorporate sleep therapy with hypnotherapy. There is an immediate need for research evaluating the efficacy of hypnotherapy in the management of sleep disturbance.     

Sleep disturbance in patients with advanced cancer

Sleep is a complex process, acknowledged to be essential for health and wellbeing. Sleep disturbance is reported to be a significant problem for patients across the cancer care trajectory, including those in the palliative phase of illness. This paper reviews the literature specific to sleep disturbance in patients with advanced cancer. The Human Response to Illness model, which is consistent with the central tenets of palliative care philosophy, provides a valuable framework to examine and organize the current knowledge related to sleep disturbance. The four perspectives of this biopsychosocial nursing model--physiology, pathophysiology, behavioural and experiential, as well as the personal and environmental factors--offer a broad perspective to better understand this multidimensional symptom and create a strong foundation for nursing care and future research directions.     

Sleep disturbances and fatigue in critically ill patients

Sleep disturbances and fatigue are significant problems for critically ill patients. Existing sleep disorders, underlying medical/surgical conditions, environmental factors, stress, medications, and other treatments all contribute to a patient's inability to sleep. Sleep disturbance and debilitating fatigue that originate during acute illness may continue months after discharge from intensive care units (ICUs). If these issues are unrecognized, lack of treatment may contribute to chronic sleep problems, impaired quality of life, and incomplete rehabilitation. A multidisciplinary approach that incorporates assessment of sleep disturbances and fatigue, environmental controls, appropriate pharmacologic management, and educational and behavioral interventions is necessary to reduce the impact of sleep disturbances and fatigue in ICU patients. Nurses are well positioned to identify issues in their own units that prevent effective patient sleep. This article will discuss the literature related to the occurrence, etiology, and risk factors of sleep disturbance and fatigue and describe assessment and management options in critically ill adults.     

Chronic headache and sleep disturbance

Headache and sleep disturbance are common health complaints. Both complaints often co-exist in the same patient, leading some to suspect a causal relationship or common underlying pathology. However, the empirical literature in this area is limited. Some attempts have been made to explore the relationship between headache and sleep disturbance, but few consistencies have emerged in the literature. There is no accepted model for understanding the link between headache and sleep disturbance. This paper reviews the available literature concerning comorbid headache and sleep disturbance and offers some preliminary suggestions based on the available literature to guide their evaluation and management. Information specific to the relationship between sleep disturbance and chronic daily headache, where available, is highlighted.     

Sleep assessment of hospitalised patients: A literature review

Background

Sleep is a dynamic and essential part of human life and health. In healthcare settings, nurses are strategically placed to promote sleep and sleep health. In this regard, nursing actions should be based upon effective methods of assessment of patient sleep. Standardised sleep assessment does not currently occur in the care of acute hospitalised patients. Use of an appropriate measurement tool would help evaluate inpatient sleep. An effective, efficient sleep assessment tool is needed to aid clinicians. Such assessment would enable specific nursing intervention to be tailored to individual patients.

Objective

The objective of this paper was to examine the literature on sleep measurement to identify subjective sleep assessment tools that may be suitable for routine use with hospitalised patients, and to evaluate their reliability and validity.

Method

A review of existing literature was undertaken to identify and evaluate subjective sleep measurement tools.

Results

The initial literature searches identified 402 articles, of which ten met the criteria for review. These reported on three subjective sleep measurement scales: the Richards-Campbell Sleep Questionnaire; the St Mary's Hospital Sleep Questionnaire; and the Verran Snyder-Halpern Sleep Scale. The Richards-Campbell Sleep Questionnaire is brief and easy to use. In specific samples, its items correlate with domains reflecting sleep quality and has shown excellent internal consistency. Equivocal results and scoring challenges were found with the St Mary's Hospital Sleep Questionnaire. The Verran Snyder-Halpern Sleep Scale captured sleep disturbance and total sleep time, but time-to-complete is more burdensome than the Richards-Campbell Sleep Questionnaire.

Conclusions

The current use of sleep assessment instruments in the acute hospital setting is restricted mainly to research activities. Of the three tools identified that could be used clinically to measure inpatient sleep, and although it was developed for use in the intensive care setting, the Richards-Campbell Sleep Questionnaire held greatest potential due to its ease and rapidity of use. However, it has yet to be validated for use with general hospital inpatients, and further research is required in this area.     

Sleep in Patients with Chronic Migraine

Purpose of Review

The biological and pathophysiological interaction between sleep and chronic migraine (CM) remains to be fully elucidated. In this article, we provide a narrative review of the literature on sleep disturbance and CM, highlighting recent advances in sleep research and insights into mechanisms that could mediate a role of sleep disturbances in migraine chronification. We discuss the potential for cognitive-behavioral insomnia therapy (CBTi) as an intervention for CM with comorbid insomnia. Finally, we propose a model of the mechanisms underlying the interactions among sleep physiology, maladaptive migraine-coping behaviors, and coexisting factors which contribute to sleep disturbances in CM based on conceptual models used in sleep research.

Recent Findings

Insomnia is the most common sleep complaint among patients with CM. CM patients experience more frequent and severe insomnia symptoms than patients with episodic migraine (EM). It has been suggested that sleep disturbances may predispose individuals to migraine attacks, which may affect the pain-processing trigeminovascular system and thus play a role in migraine progression. Encouraging but limited evidence suggests that management of insomnia via behavioral sleep therapy may reverse CM to EM and possibly prevent migraine chronification.

Summary

Migraine has a complex relationship with sleep. The use of objective sleep study such as polysomnographic microstructural sleep analysis and actigraphy could help connect sleep disturbances and processes related to CM. Future longitudinal studies should examine whether effective behavioral treatments such as CBTi can reverse migraine chronification.

     

Clinical management of poor sleep quality in patients with chronic obstruction pulmonary disease

Sleep disturbance is the most common clinical problem for patients with chronic obstruction pulmonary disease (COPD). Potentially the result of changes in patient breathing patterns, symptoms of the disease, or pharmacological side effects, sleep disturbance can negatively affect COPD patients both physiologically and psychologically. It is therefore important for the medical community to acknowledge the problem through clear observation and suitable application of assessment tools in order to recommend therapies able to promote sleep quality. The article reviews the literature and analyzes clinical cases to discuss the effects of chronic obstruction pulmonary disease on sleep and potential management strategies. I hope this article will be a useful resource for the medical community to improve clinical nursing quality.     

Understanding the sleep needs of older hospitalized patients: a review of the literature

Previous studies have demonstrated a high prevalence of sleep disturbance among elderly people which can exacerbate during a period of hospitalization. Whilst studies on patients' sleep experiences have largely been conducted in acute care settings, relatively little is known about the sleep experiences of elderly patients hospitalized in extended care settings. This paper aims to provide a literature review on the sleep experiences of older patients admitted into hospitals, with reference also made to studies conducted in the community in order to substantiate the existence of sleep disruptions before elderly people are admitted into hospitals. Electronic databases and specific search terms from 1980 to 2004 were used to conduct the literature search. Nurses play a crucial role in ensuring that patients get a good night's sleep and will need an in-depth understanding of older patients' sleep experiences to effectively manage different sleeping patterns and sleep needs in the clinical areas.     

Mind-Body Treatments for the Pain-Fatigue-Sleep Disturbance Symptom Cluster in Persons with Cancer

ContextCo-occurring pain, fatigue, and sleep disturbance comprise a common symptom cluster in patients with cancer. Treatment approaches that target the cluster of symptoms rather than just a single symptom need to be identified and tested.ObjectivesTo synthesize evidence regarding mind-body interventions that have shown efficacy in treating two or more symptoms in the pain-fatigue-sleep disturbance cancer symptom cluster.MethodsA literature search was conducted using CINAHL, Medline, and PsychInfo databases through March 2009. Studies were categorized based on the type of mind-body intervention (relaxation, imagery/hypnosis, cognitive-behavioral therapy/coping skills training [CBT/CST], meditation, music, and virtual reality), and a preliminary review was conducted with respect to efficacy for pain, fatigue, and sleep disturbance. Mind-body interventions were selected for review if there was evidence of efficacy for at least two of the three symptoms. Forty-three studies addressing five types of mind-body interventions met criteria and are summarized in this review.ResultsImagery/hypnosis and CBT/CST interventions have produced improvement in all the three cancer-related symptoms individually: pain, fatigue, and sleep disturbance. Relaxation has resulted in improvements in pain and sleep disturbance. Meditation interventions have demonstrated beneficial effects on fatigue and sleep disturbance. Music interventions have demonstrated efficacy for pain and fatigue. No trials were found that tested the mind-body interventions specifically for the pain-fatigue-sleep disturbance symptom cluster.ConclusionEfficacy studies are needed to test the impact of relaxation, imagery/hypnosis, CBT/CST, meditation, and music interventions in persons with cancer experiencing concurrent pain, fatigue, and sleep disturbance. These mind-body interventions could help patients manage all the symptoms in the cluster with a single treatment strategy.     

Using alternative therapies in treating sleep disturbance

Sleep disturbance is a common health problem among adults, and enhancing sleep quality is an issue of significant importance to healthcare providers. As sleep quality worsens into insomnia, individuals may seek assistance from medication. However, sedative hypnotic drugs pose potentially adverse effects. Also, most medical treatments (e.g., positive pressure assistant ventilators) represent invasive interventions that must be prescribed by physicians. Non-pharmacological alternative therapies are commonly recommended and adopted by community nurses. Alternative therapies for sleep disturbance included exercise, cognitive behavior therapy, multiple strategies, music, and acupressure. In general, moderately intensive walking exercise is the intervention most recommended by professionals to help patients deal with sleep disturbance. Therefore, it is suggested that future researchers devise sleep quality promotion strategies that are suitable for home practice in order to apply the findings and spirit of research already done in this area.     

Sleep disorders of patients in intensive care

The objective of this article is to present a literature review of German and English literature concerning sleep disturbances of critically ill adults in intensive care units. It represents mainly nursing research-based studies which focused on characteristics and possible causes of sleep disturbances. The literature revealed that patients suffer from moderate to severe sleep deprivation characterized by a decrease of total sleep length and quality, and by sleep fragmentation. The causes are multifactorial. Nurses have an important role to play in recognizing and assessing factors that contribute to sleep deprivation and in intervening to reduce the effects of sleep deprivation. The research studies in this review represent the positivistic scientific perspective where sleep deprivation research has been objectified and controlled. A broader, more indepth understanding is needed, however, so that the subjective view of critically ill persons can be represented.     

恶性骨肿瘤患者化疗间歇期睡眠障碍与生活质量的相关性研究

目的了解恶性骨肿瘤患者化疗间歇期的睡眠障碍和生活质量情况,以及睡眠障碍与生活质量的相关关系。方法使用匹兹堡睡眠质量指数,欧洲癌症研究与治疗组织生活质量核心问卷对120例在广州市某三级甲等医院进行化疗的骨肿瘤患者进行问卷调查。结果恶性骨肿瘤患者化疗间歇期睡眠障碍评分(8.44±3.67)分,有55.8%的患者存在睡眠障碍。患者生活质量明显低于常模,除认知功能、气促、便秘和腹泻4个条目外,其余两组比较差异有统计学意义(P0.05),但总体生活质量优于住院患者,除社会功能、便秘和腹泻3个条目外,其余两组比较差异有统计学意义(P0.05)。生活质量的各功能维度得分与睡眠障碍得分呈负相关(P0.01),症状维度中,除恶心与呕吐和腹泻外,其余各症状得分与生活质量呈正相关(P0.01)。结论骨肿瘤患者化疗间歇期生活质量较差,且普遍存在睡眠障碍症状,睡眠障碍越严重,患者生活质量越差。因此提示医护人员要关注患者的睡眠质量,分析导致睡眠障碍的原因,提出干预措施,从而提高化疗患者的生活质量。     

Headache and sleep: examination of sleep patterns and complaints in a large clinical sample of migraineurs

OBJECTIVES: This study characterized sleep parameters and complaints in a large clinical sample of migraineurs and examined sleep complaints in relation to headache frequency and severity. BACKGROUND: The relationship between headache and sleep has been documented at least anecdotally in medical literature for well over a century and clinical texts allude to the importance of sleep as a headache precipitant. A small number of empirical studies have emerged, but the precise nature and magnitude of the headache/sleep association and underlying mechanisms remain poorly understood. METHODS: In this investigation, 1283 migraineurs were drawn from 1480 consecutive headache sufferers presenting for evaluation to a tertiary headache clinic. Patients underwent a physical examination and structured interview assessing a variety of sleep, headache, and demographic variables. Migraine was diagnosed according the IHS criteria (1.1 to 1.6 diagnostic codes). Migraineurs were 84% female, with a mean age of 37.4 years. Groups were formed based on patient's average nocturnal sleep patterns, including short, normal, and long sleep groups, and were compared on headache variables. RESULTS: Sleep complaints were common and associated with headache in a sizeable proportion of patients. Over half of migraineurs reported difficulty initiating and maintaining sleep at least occasionally. Many in this sample reported chronically shortened sleep patterns similar to that observed in persons with insomnia, with 38% of patients sleeping on average 6 hours per night. Migraines were triggered by sleep disturbance in 50% of patients. "Awakening headaches" or headaches awakening them from sleep were reported by 71% of patients. Interestingly, sleep was also a common palliative agent for headache; 85% of migraineurs indicated that they chose to sleep or rest because of headache and 75% were forced to sleep or rest because of headache. Patients with chronic migraine reported shorter nightly sleep times than those with episodic migraine, and were more likely to exhibit trouble falling asleep, staying asleep, sleep triggering headache, and choosing to sleep because of headache. Short sleepers (ie, average sleep period 6 hours) exhibited significantly more frequent and more severe headaches than individuals who slept longer and were more likely to exhibit morning headaches on awakening. CONCLUSIONS: These data support earlier research and anecdotal observations of a substantial sleep/migraine relationship, and implicate sleep disturbance in specific headache patterns and severity. The short sleep group, who routinely slept 6 hours per night, exhibited the more severe headache patterns and more sleep-related headache. Sleep complaints occurred with greater frequency among chronic than episodic migraineurs. Future research may identify possible mediating factors such as primary sleep and mood disorders. Prospective studies are needed to determine if normalizing sleep times in the short sleeps would impact headache threshold.     

The Association of Sleep and Pain: An Update and a Path Forward

Ample evidence suggests that sleep and pain are related. However, many questions remain about the direction of causality in their association, as well as mechanisms that may account for their association. The prevailing view has generally been that they are reciprocally related. The present review critically examines the recent prospective and experimental literature (2005–present) in an attempt to update the field on emergent themes pertaining to the directionality and mechanisms of the association of sleep and pain. A key trend emerging from population-based longitudinal studies is that sleep impairments reliably predict new incidents and exacerbations of chronic pain. Microlongitudinal studies employing deep subjective and objective assessments of pain and sleep support the notion that sleep impairments are a stronger, more reliable predictor of pain than pain is of sleep impairments. Recent experimental studies suggest that sleep disturbance may impair key processes that contribute to the development and maintenance of chronic pain, including endogenous pain inhibition and joint pain. Several biopsychosocial targets for future mechanistic research on sleep and pain are discussed, including dopamine and opioid systems, positive and negative affect, and sociodemographic factors.     

Sleep and quality of life in breast cancer patients

This study described sleep in a heterogeneous sample of breast cancer patients using the Pittsburgh Sleep Quality Index (PSQI) and examined the relation between sleep disturbance and health-related quality of life as measured by the Rand 36-Item Health Survey. Chemotherapy and radiation therapy were explored as predictors of sleep disturbance in breast cancer patients, and the sleep characteristics of breast cancer patients were compared to the sleep characteristics of a sample of medical patients with general medical conditions. Results showed that 61% of breast cancer patients had significant sleep problems. Sleep was characterized by reduced total sleep time with sleep frequently being disturbed by pain, nocturia, feeling too hot, and coughing or snoring loudly. Despite the frequency of significant sleep disturbance, pharmacological and cognitive-behavioral treatments of sleep problems were observed to be inadequate. Limited evidence was found for the role of chemotherapy and radiation therapy in the sleep disturbance of breast cancer patients, and the general pattern of sleep disturbance in breast cancer patients was not significantly different than that observed in medical patients with general medical conditions. Breast cancer patients having significant sleep problems had greater deficits in many areas of health-related quality of life. The implications of the findings and study limitations are discussed.     

Sleep and trauma: an overview

Sleep disturbance is common after traumatic events of various types, such as combat, physical trauma, and sexual abuse, and closely intertwined with Posttraumatic Stress Disorder (PTSD), a common outcome of severe and prolonged trauma. This paper reviews the current literature on the significance and characteristics of sleep disturbance occurring in the context of trauma, examines the relationship between sleep disturbance and PTSD, identifies gaps in knowledge relative to the role of sleep disturbance in trauma and PTSD, and discusses the implications of this body of knowledge for clinical practice.     

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Abstract

Aim

This study investigated 10 cancer patients’ experiences of a relaxation programme run by the Occupational Therapy Department in a specialist cancer centre.

Background

Anxiety, sleep disturbance, and fatigue are highly prevalent in patients with cancer. The relaxation training programme has been helpful in reducing these symptoms.

Design

A retrospective, hermeneutic phenomenology approach was used.

Method

The study sampling consisted of 10 individuals who met the inclusion criteria. Semi-structured interviews were carried out. In keeping with the principles of hermeneutic research, interview data were analysed and key themes were derived over time as a result of fusion of the researcher's own interpretations with those of the interviewees.

Results

The four themes were the patients’ beliefs in helping oneself during the healing process, using coping mechanisms, being able to set priorities, and being able to take back control. Although each of the themes was interlinked, they are presented individually and discussed in the light of relevant literature.

Conclusion

The main conclusion was that patients were not just attending relaxation for their anxiety, but also held strong beliefs that the relaxation helped them cope with symptoms and other issues arising from their cancer experiences.

Relevance to clinical practice

The occupational therapy-led relaxation programme can help symptoms of anxiety and sleep disturbance in cancer patients. This implies further scope for researching how the relaxation helps them in different ways and whether there is any particular time during the treatment trajectory when the relaxation programme would be of optimum benefit.