1. Occupational Therapy and Sleep in the Army CDR Laura M. Grogan, OTR/L May 25, 2010

2. A period of mind body rest during which volition and consciousness are temporarily inactive and bodily functions are partially suspended; a behavioral state that is reversible to external stimuli; a multi-dimensional construct that includes how long it takes to fall asleep, the duration and quality of sleep, and the perceived restoration achieved during sleep; a naturally occurring process

3. Fatigue A chronic state of exhaustion Can be experienced both physically and mentally Can impact the ability to efficiently and effectively perform daily tasks and responsibilities Problems with fatigue and sleep typically benefit from medical management, which includes comprehensive assessment and OT intervention

4. Comorbidity of Symptoms mTBI/Concussion Insomnia Impaired Memory Poor concentration Depression Anxiety Irritability Stress symptoms Emotional numbing Avoidance Intrusive symptoms Insomnia Impaired Memory Poor concentration Depression Anxiety Irritability Headache Dizziness Fatigue Noise/Light intolerance PTSD/ASR

5. Sleep Disorders Sleep disorders involve any difficulties related to sleeping, including difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep Insomnia- Problems falling or staying asleep Illness, depression, anxiety, poor hygiene, medication, pain Hypersomnia- Excessive sleepiness, inability to be alert or awake Narcolepsy, sleep apnea, RLS, idiopathic hypersomnia, PLM movement disorder Sleep Rhythm Problems- Diff. sticking to a regular sleep schedule Jet lag, shift work, new parents Sleep Disruptive Behaviors- Unusual behaviors during sleep Sleep terrors, sleep walking, REM sleep behavior disorder Sleep Apnea- Pauses in breathing during sleep. Pauses last long enough that one or more breaths are missed, and such episodes occur repeatedly during sleep

6. Causes for Insomnia Insomnia is like a barometer of your emotional well- being, it can occur because: You suffered a loss, are under stress or are worried, or have a medical condition that interrupts your sleep Insomnia can occur if you are experiencing: Anxiety, Depression, Mania, Nightmares/PTSD Insomnia can occur before symptoms of depression and can be a sign that you may need to seek help from a health care provider. It can also occur as a result of depression

7. Cyclic Behavior When you feel depressed or anxious, you have difficulties sleeping. When you have difficulties sleeping, you are more likely to feel depressed or anxious. This is called THE SLEEP MISERY CYCLE SLEEP MISERY CYCLE Poor Sleep Daytime: Fatigue Low Energy Difficulties Coping with Stress Anxiety Depression Irritability

8. Impact of Insomnia Cognitive symptoms: Attention Concentration Memory Judgment Visual perceptual skills Physical symptoms: Headaches Insomnia Fatigue Blurred vision Slowed reaction time Behavioral changes: Irritability Depression Anxiety Sleep disturbances Problems with emotional control Inadequate sleep can also depress the immune system & accelerate the aging process!

9. Sleep / Fatigue Measurement The Epworth Sleepiness Scale (ESS) is a self administered 8-item questionnaire to measure daytime sleepiness in adults. It provides an estimate of a person’s level of sleepiness in daily life but does not specify what factors contribute to sleepiness or diagnose specific conditions. It measures one aspect of a person’s sleep- wake health status and can be used as a baseline measure of sleep-wake health status (Johns, 1992) http://epworthsleepinessscale.com/about-epworth- sleepiness/

11. Sleep / Fatigue Measurement The Fatigue Severity Scale (FSS) can be used when fatigue is a barrier to performance of everyday tasks. The FSS is a short questionnaire of 9 self rating questions (Krupp, LaRocca, Muir-Nash, & Steinberg, 989) A systematic review of fatigue measures suggested that the FSS demonstrated good psychometric properties & has the ability to detect change over time (Whitehead, 2009) The FSS total score can help a therapist determine when a physician referral is indicated for further evaluation http://www.healthywomen.org/content/article/fatigue-severity-scale-fss

12. FSS Questionnaire During the past week, I have found that: Disagree  ----------  Agree My motivation is lower when I am fatigued. 1234567 Exercise brings on my fatigue.1234567 I am easily fatigued.1234567 Fatigue interferes with my physical functioning. 1234567 Fatigue causes frequent problems for me. 1234567 My fatigue prevents sustained physical functioning. 1234567 Fatigue interferes with carrying out certain duties and responsibilities. 1234567 Fatigue is among my three most disabling symptoms. 1234567 Fatigue interferes with my work, family, or social life. 1234567 Total Score:

13. Treatment of Fatigue Sleep Hygiene- addresses behavioral and environmental factors that precede sleep & may interfere with sleep Nutrition & Hydration- required for optimal healing, recovery & energy Regular Exercise/Activity- builds brain function & activity tolerance Energy Conservation- pacing/scheduling tasks & breaks Stress Reduction- diaphragmatic breathing, muscle relaxation, meditation, yoga, guided imagery Referrals- Pain Mgmt., BH, Nutritionist, Acupuncturist, Substance abuse/ETOH program recommendation, sleep study recommendation

14. Treatment of Sleep Medication- prescribed by a Doctor (Ambien, Lunesta, Minipress, Restoril, Sertraline, Trazodone, Prazosin) Cognitive and Behavioral Therapy- Sleep Gym Rescripting/Image Rehearsal Therapy (IRT)- Sleep Gym Hygiene Therapy- Sleep Gym CPAP Machine- blows air to keep airway open Complimentary/Alternative Therapy- Aromatherapy & essential oils- lavender, rose, jasmine Herbal remedies (in forms of teas or tinctures) chamomile, hops, catnip, valerian, St. John’s wart, peppermint, passion flower Yoga- attitude adjustment, squeeze out tension, calming Meditation

15. Treatment of Sleep Medication- prescribed by a Doctor (Ambien, Lunesta, Minipress, Restoril, Sertraline, Trazodone, Prazosin) Cognitive and Behavioral Therapy- Sleep Gym Rescripting/Image Rehearsal Therapy (IRT)- Sleep Gym Hygiene Therapy- Sleep Gym CPAP Machine- blows air to keep airway open Referrals- See previous slide Complimentary/Alternative Therapy- Aromatherapy & essential oils- lavender, rose, jasmine Herbal remedies (in forms of teas or tinctures) chamomile, hops, catnip, valerian, St. John’s wart, peppermint, passion flower Yoga- attitude adjustment, squeeze out tension, calming Meditation

16. Medication Pitfalls Drug tolerance- More sleep aid is required to work Drug dependence- Medication reliance to sleep Withdrawal symptoms- Stopping a medication abruptly can cause withdrawal symptoms Side effects- Drowsiness the next day, confusion, dry mouth, forgetfulness, decreased safety, cognitive changes Drug interactions- Other medications can interact with sleep med’s Rebound insomnia- Insomnia can become even worse than before Masking an underlying problem- Medical, mental disorder, or even a sleep disorder could be present. Proper treated could provide relief from insomnia

17. Medication Pitfalls for SM’s Only take a sleeping aid when you can obtain a full night of sleep (7 to 8 hours) Some medications cause withdrawal side effects when stopped abruptly Never drink alcohol (or take illegal drugs) near the time when you take a sleeping pill Never drive a car or operate machinery after taking a sleeping pill Contraindications may apply with use of other medication

18. CBT-I Treatment Behavioral: Sleep Restriction, Stimulus Control, Relaxation Therapy Excessive time in bed, irregular sleep schedules, incompatible sleep activities, hyper arousal, sleep avoidance, safety behaviors Cognitive: Counseling Unrealistic sleep expectations, sleep misconceptions, anticipatory anxiety, poor coping skills, fear of sleep, nocturnal vigilance, worry about post-trauma related issues, intrusive memories, distress, and physical reactions while in bed

19. CBT-I Treatment Continued Educational: Sleep Hygiene, Support Groups, Links of Interest Targeting the SM’s current knowledge and improving upon it Support: Follow up and care

20. Treatment Interventions Mind Body Relationship The Law of Effect- Behaviors can be learned and triggered Leave the bed and bedroom when you are unable to fall asleep after about 15-20 minutes. Return to bed only when you feel sleepy again Repeat this as many times as needed. This will strengthen the association between sleep and bed (versus insomnia and bed) A key to success is doing anything that is not mentally or physically activating in a quiet and dimly lit space

21. Treatment Interventions Image Rehearsal Therapy Train the brain to encounter a positive desired outcome in a wake and sleep state Guided imagery using a relaxing scene or series of experiences to change nightmares into non-disturbing dreams by composing new dreams while awake. Write down your new dreams and rehearse them using your imagination. Rehearse your new dreams several times during the day and just before you go to bed Can also be used to train your mind, body & spirit for success!

22. Treatment Interventions Train Your Brain Train the brain to efficiently and effectively become quiet before you go to bed Schedule worry or excessive thoughts: Schedule time to worry, or excessively think during the day. This is when you are most likely able to create solutions, develop a good plan or have the energy to prepare for the next day or week Train your brain to effectively worry and develop solutions during the day with consistency Talk back to your thoughts in a healthy way Dispute or change the thought, focus on sounds

23. www.dvbic.org *A TBI OT Tool Kit is expected to be released early this year and will address fatigue. CLINICAL PRACTICE GUIDANCE: OCCUPATIONAL THERAPY AND PHYSICAL THERAPY FOR MILD TRAUMATIC BRAIN INJURY Office of the Surgeon General Proponency Office for Rehabilitation and Reintegration

24. “The best cure for insomnia is to get a lot of sleep.” – W.C. Fields Questions?