Opinion
Time to wake up: bridging the gap between theory and practice for sleep in occupational therapy Christina Fung,1 Catherine Wiseman-Hakes,2 Mary Stergiou-Kita,3 Michelle Nguyen4 and Angela Colantonio 5 Key words: Sleep, activities of daily living, occupational performance, assessment.
Sleep plays an essential role in physical, cognitive and emotional functioning, and in occupational performance and participation; it is now considered within the scope of occupational therapy practice. However, since sleep is not routinely assessed and addressed in standard practice, a practice gap exists. Interventions are available to optimize sleep and cope with the consequences of sleep disorders, but occupational therapists may overlook the effect of sleep on function, so missing opportunities to provide relevant management strategies. This opinon piece argues the benefits of including sleep within occupational therapy practice and provides suggestions to facilitate its inclusion within practice, education and research.
1 Medical student, University of Toronto, Faculty
of Medicine, Toronto, Ontario, Canada. of Toronto, Department of Rehabilitation Science, Toronto, Ontario, Canada and Post Doctoral Fellow, Hôpital du Sacré-Cœur de Montréal, Departement de Psychiatrie, Faculté du Médecine, Université de Montréal, Montreal, Quebec, Canada. 3 Scientist, Toronto Rehabilitation Institute, University Health Network (UHN) and Assistant Professor, University of Toronto, Department of Occupational Science and Occupational Therapy, Toronto, Ontario, Canada. 4 Occupational Therapist, University of Toronto, Department of Occupational Science and Occupational Therapy, Toronto, Ontario, Canada. 5 Professor, University of Toronto, Department of Occupational Science and Occupational Therapy and Senior Scientist, Toronto Rehabilitation Institute, University Health Network (UHN), Toronto, Ontario, Canada. 2 Lecturer, University
Corresponding author: Catherine Wiseman-Hakes, Lecturer, Department of Rehabilitation Science, 160-500 University Avenue, Toronto M5G 1V7, Ontario, Canada. Email:
[email protected] Reference: Fung C, Wiseman-Hakes C, Stergiou-Kita M, Nguyen M, Colantonio A (2013) Time to wake up: bridging the gap between theory and practice for sleep in occupational therapy. British Journal of Occupational Therapy, 76(8), 384–386.
Introduction Sleep is a complex, vital, and active process that is critical in maintaining human health. It is essential in immune and endocrine function, modulation of emotion and mood, neuroplasticity, cognition, learning, functional abilities (communication, cognition and emotional) and occupational performance (Wiseman-Hakes et al 2009). Problems with sleep or sleep and wake disorders such as insomnia, excessive daytime sleepiness, hypersomnia and circadian rhythm disorders are prevalent across neurological disorders (for example, traumatic brain injury and Parkinson’s disease), physical disorders (for example, chronic pain and rheumatoid arthritis) and psychological challenges (for example, anxiety and depression) (Ancoli-Israel and Ayalon 2006, Garcia-Borreguero et al 2003, Hammond and Jefferson 2002, Sayer et al 2002, Wiseman-Hakes et al 2009). Utilizing the International Classification of Functioning, Disability, and Health (World Health Organization [WHO] 2010), researchers have revealed that sleep disorders can have a significant impact on a person’s functioning at various levels, including body functions (such as energy and drive or attention), activities and participation (as in recreation and leisure or in carrying out daily routines) and environmental factors (for example, arising from immediate family and health-care systems and policies) (Gradinger et al 2011). Finally, emerging research has demonstrated that interventions can improve sleep, wakefulness and daytime functioning in cognitive, communication and mood domains in individuals with traumatic brain injuries (Wiseman-Hakes et al 2011), contributing to mounting evidence that sleep plays a crucial role in optimizing physical, cognitive and emotional functioning, and that interventions can be utilized to optimize sleep and enhance functional and occupational performance.
DOI: 10.4276/030802213X13757040168432 © The College of Occupational Therapists Ltd. Submitted: 29 May 2012. Accepted: 15 January 2013.
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Assessing sleep We propose that sleep (and wakefulness) should be routinely assessed and addressed as part of standard occupational therapy practice, given the multitude
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Christina Fung, Catherine Wiseman-Hakes, Mary Stergiou-Kita, Michelle Nguyen and Angela Colantonio
of functional and occupational performance issues that arise from sleep problems amongst the populations that occupational therapists serve. The inclusion of sleep is already supported in existing guidelines and research evidence. The American Occupational Therapy Association’s revised Occupational therapy practice framework: domain and process (2008) identified sleep as an area of occupation that requires assessment in relationship to adequacy of rest and sleep, sleep preparation and sleep participation. Within the literature, there are various discussions of occupational therapists’ involvement in sleep across the lifespan. For example, Fjeldsted and Hanlon-Dearman (2009) discussed the use of sleep questionnaires and logs to assess sleep patterns and difficulties in children with fetal alcohol spectrum disorders and sensory processing challenges. Garms-Homolovà et al (2010) demonstrated the benefits of daily occupational therapy for elderly nursing home residents who experienced non-restful sleep and morning fatigue. Sleep apnea is being recognized as a new area whereby occupational therapists can use their knowledge and expertise to assist individuals in improving their sleep and engagement in daily occupations (Opp Hofmann 2008). Despite support from existing guidelines and the research evidence, there is currently a lack of occupational therapy representation at national and international sleep conferences and few, if any, occupational therapists are working in formal sleep clinics. We argue that there appears to be a gap, whereby occupational therapists are not routinely assessing sleep, recognizing sleep as a significant issue or making recommendations to their clients. Given their skills in relation to the assessment of the personal and environmental issues influencing sleep, occupational therapists are well positioned to enhance their roles in the area of sleep and sleep problems. In the remainder of this opinion piece, therefore, we offer suggestions as to how the profession should increase its profile in sleep within clinical practice, education, and research domains.
Occupational therapy assessment of sleep While occupational therapists are not in a position to diagnose sleep disorders, they are able to make an assessment of sleep problems and their effect on occupational performance and participation, and identify when a referral to a sleep clinic is warranted. This should involve three key processes: (1) a routine exploration of an individual’s selfreported quantity and quality of sleep, how he or she feels in the morning and in terms of wakefulness, energy levels, and the need for naps during the day; (2) the identification of life conditions (for example, anxiety, stress, caregiver and /or work responsibilities), behaviors (for example, diet, exercise and caffeine intake) and environmental factors (for example, light or noise) that can either facilitate or hinder sleep and (3) an understanding of the impact of sleep and sleep problems on an individual’s functional abilities and daily occupational performance.
Both (1) and (2) can be completed through an interview, with the use of standardized questionnaires such as the BEARS Sleep Screening Assessment (Owens and Dalzell 2005) for children, the Pittsburgh Sleep Quality Index (Buysse et al 1989), the Epworth Sleepiness Scale (Johns 1991), the Insomnia Severity Index (Morin 1993) or the Diagnostic Interview for Insomnia (Morin 1993) for adults. Furthermore, 115 health measure instruments that relate to sleep disorders have been identified, including generic or condition-specific instruments (for example, for insomnia, narcolepsy, sleep apnea or restless legs syndrome) that focus on different areas, such as diagnosis, understanding beliefs and attitudes about sleep, sleep quality, snoring, symptoms (for example, decreased alertness or daytime sleepiness), movement or breathing issues (as reported by bed partners), or quality of life (Gradinger et al 2011). The Functional Outcome of Sleep Questionnaire (Weaver et al 1997) is well suited to meet the need to understand the impact of sleep and sleep problems on an individual’s functional abilities and daily occupational performance — as identified in (3), above. Additionally, the Daily CognitiveCommunication and Sleep Profile (Wiseman-Hakes et al 2011) is an example of a self-reporting instrument that investigates sleep-wake disturbances in relation to cognition, communication and mood.
Occupational therapy interventions for sleep problems Upon completion of the assessment, occupational therapists can provide education and interventions to individuals and their significant others, to promote optimal sleep performance. In terms of an individual’s personal perspective, occupational therapists can teach people not only how to be aware of their pain, energy levels, sleepiness and fatigue but also how to manage their time and stress levels (for example, through time management and cognitive behavioural techniques) (Ponsford et al 2012). A person can be taught how to modify behaviors to optimize sleep (for example, through diet, exercise, instituting regular sleep and wake times) (AOTA 2008). From the environmental perspective, occupational therapists can recommend changes to the environment (for example, levels of noise or light) and the use of light therapy to facilitate the timing of activities or increase wakefulness during the day (Ponsford et al 2012). Further, to manage the consequences of poor sleep, occupational therapists can provide individuals with strategies such as pacing activities, planning rest breaks and organizing daily schedules according to peak energy levels. In conjunction with sleep medicine specialists, occupational therapists can provide the non-pharmacological intervention strategies, described above, to contribute positively to restful sleep patterns.
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Time to wake up: bridging the gap between theory and practice for sleep in occupational therapy
Recommendations for enhancing the role of occupational therapy in sleep While there is evidence to support the role of occupational therapists in addressing sleep problems, sleep continues to have a limited profile within occupational therapy and occupational science. Thus, in order to advance this issue, we recommend the following to enhance occupational therapy’s profile in this area. Educational sessions regarding sleep and wakefulness should be integrated into the existing occupational therapy curriculum so that students develop the knowledge, skills, and competencies to address sleep and wakefulness issues. Lectures and group teaching should include education regarding sleep as an occupation, sleep assessment, critical appraisal and application of standardized tools, and best practice interventions. Occupational therapists should increase their practice knowledge by attending professional development workshops that address interventions for optimizing sleep and daytime wakefulness, led by colleagues or researchers in the field of sleep and rehabilitation. In addition, provincial, national, and international professional organizations should develop accreditation standards based on existing guidelines that address the assessment and interventions of sleep within occupational therapy practice. Subsequently, these accreditation standards should be employed to accredit educational and professional development programs. To promote understanding of the importance of sleep and its relationship to function, the University of Alberta, Faculty of Rehabilitation Medicine has formed a ‘Sleep and Function Interdisciplinary Group’, led by a researcher from the Department of Occupational Therapy. This group has made several significant contributions to the sleep literature, including critical reviews of the evidence for non-pharmacological sleep interventions for individuals with dementia (Brown et al 2013). We recommend further evaluations of the effectiveness of occupational therapy educational, cognitive-behavioural and environmental interventions to enhance both sleep quantity and quality and daily occupational performance. These would provide a larger evidence base to inform occupational therapy practice. To enhance the implementation of sleep within occupational therapy practice, we also recommend further development of occupational therapy models that could guide therapists in identifying the possible impact of sleep quality and quantity, and sleep disorders, on occupational performance. In conclusion, adequate sleep quality and duration, and associated daytime wakefulness, are critical for physical, emotional, cognitive and communication performance in daily occupations. As sleep underlies key aspects of health across the lifespan, we argue that occupational therapists should be equipped with a subset of skills to assess and address sleep in practice. We provide recommendations above to improve the awareness of sleep in occupational therapy practice.
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Acknowledgements The preparation of this article was supported by a grant from the Canadian Institutes of Health Research. Other support came from the Toronto Rehabilitation Institute, which receives funding through the Ontario Ministry of Long Term Care. Dr. Colantonio received support from the Saunderson Family Chair in Acquired Brain Injury Research and a CIHR Research Chair in Gender, Work and Health (#126580). Dr Wiseman-Hakes received support through a Fellowship in Clinical Research from the Canadian Institutes of Health Research. References American Occupational Therapy Association (2008) Occupational therapy practice framework: domain and process. 2nd ed. American Journal of Occupational Therapy, 62(6), 625-83. Ancoli-Israel S, Ayalon L (2006) The diagnosis and treatment of sleep disorders in older adults. American Journal of Geriatric Psychiatry, 14(2), 95-103. Brown CA, Berry R, Tan MC, Khoshia A, Turlapati L, Swedlove F (2013) A critique of the evidence base for non-pharmacological sleep interventions for persons with dementia. Dementia, 12(2), 210-37. Buysse DJ, Reynolds III CF, Monk TH, Berman SR, Kupfer DJ (1989) The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193-213. Fjeldsted B, Hanlon-Dearman A (2009) Sensory processing and sleep challenges in children with fetal alcohol spectrum disorder. Occupational Therapy Now, 11(5), 26-28. Garcia-Borreguero D, Larrosa O, Bravo M (2003) Parkinson’s disease and sleep. Sleep Medicine Reviews, 7(2), 115-29. Garms-Homolovà V, Flick U, Rohnsch G (2010) Sleep disorders and activities in long term care facilities – a vicious cycle? Journal of Health Psychology, 15(5), 744-54. Gradinger F, Glässel A, Bentley A, Stucki A (2011) Content comparison of 115 health status measures in sleep medicine using the ICF as a reference. Sleep Medicine Reviews, 15(1), 33-40. Hammond A, Jeffreson P (2002) Rheumatoid arthritis. In: A Turner, M Foster, SE Johnson, eds. Occupational therapy and physical dysfunction: principles, skills and practice. 5th ed. Edinburgh: Churchill Livingstone. Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep, 14(6), 540-45. Morin CM (1993) Insomnia: psychological assessment and management. New York: Guilford Press. Opp Hofmann A (2008) Waking up to new practice areas: sleep apnea and OT. American Occupational Therapy Association Inc. Available at: http://www. aota.org/News/Centennial/40313/Wellness/Apnea.aspx Accessed 13.07.12. Owens JA, Dalzell V (2005) Use of the ‘BEARS’ sleep screening tool in a pediatric residents’ continuity clinic: a pilot study. Sleep Medicine, 6(1), 63-69. Ponsford JL, Ziino C, Parcell D, Shekleton JA, Roper M, Redman JR, Rajaratnam SMW (2012) Fatigue and sleep disturbance following traumatic brain injury: their nature, causes and potential treatments. Journal of Head Trauma Rehabilitation, 27(3), 224-33. Sayar K, Arikan M, Yontem T (2002) Sleep quality in chronic pain patients. Canadian Journal of Psychiatry, 47(9), 844-48. Weaver TE, Laizner AM, Evans LK, Maislin G, Chugh DK, Lyon K, Smith PL, Schwartz AR, Redline S, Pack AI, Dinges DF (1997) An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep, 20(10), 835-43. Wiseman-Hakes C, Colantonio A, Gargaro J (2009) Sleep and wake disorders following traumatic brain injury: a critical review of the literature. Critical Reviews in Physical and Rehabilitation Medicine, 21(3-4), 317-14. Wiseman-Hakes C, Victor JC, Brandys C, Murray B (2011) Impact of post traumatic hypersomnia on functional recovery of cognition and communication. Brain Injury, 25(12), 1256-65. World Health Organization (2010) International classification of functioning, disability, and health. Available at: http://www.who.int/classifications/icf/en/ Accessed 07.07.13.
