Keywords

This book comprises a collection of case studies of patients with sleep complaints resulting from various pathologies and causes. It describes the physical therapy management to remediate disordered sleep in each case, with the ultimate goal of maximizing the patient’s functional capacity and overall health and well-being.

Sleep is recognized as a complex process impacted not only by a primary disorder or pathology but also by confounding lifestyle practices and attributes [1]. The extent to which lifestyle practices and attributes contribute either primarily or secondarily to a patient’s sleep disturbance is established through detailed assessment by the physical therapist. Findings are used to identify behavior change goals and strategies, which are discussed and agreed with the patient. Such an evidence-informed health and lifestyle framework [2, 3] is consistent with physical therapy practice in the twenty-first century [4,5,6,7], and the International Classification of Functioning, Disability and Health (ICF) (Fig. 1.1) [8], that has been long endorsed by World Physiotherapy [9].

Fig. 1.1
A classification chart classifies the health condition into body functions and structures, activity, and participation. Environmental factors and personal factors are classified under activity.

International classification of functioning, disability, and health from the World Health Organization. ([8]; This figure has been modified and reprinted with permission of the World Health Organization (WHO), and all rights are reserved by the Organization)

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Contemporary physical therapy is committed to the overall health of the patient [10]. Lifestyle-related non-communicable diseases (NCDs) are the leading causes of disability and premature death in high-income countries and increasingly in middle- and low-income countries [11]. Several NCDs, for example, cardiovascular disease, respiratory disease, stroke, obesity, and cancer, can disrupt sleep [12]. Thus, irrespective of a patient’s presenting complaints, contemporary physical therapy practice includes assessment of smoking, alcohol use, nutritional status, body mass, stress, and sleep, as well as sedentary behavior, inactivity, and structured exercise [4]. Healthy nutrition and exercise, in particular, go hand-in-hand [13].

Given that the relationship between sleep disorders and lifestyle practices and attributes is bidirectional, this chapter focuses on the literature related to the impact on sleep of lifestyle practices and attributes that also largely underlie NCDs. An established tool for assessing indexes and lifestyle behaviors, the modified Health Improvement Card (mHIC), is also described.

Chapter 2 outlines the literature specifically related to the contextual factors of the ICF, namely, environmental and personal factors that influence a night’s sleep in an individual. Behavioral interventions that can be used by the physical therapist to modify one or more lifestyle practices or attributes to reverse adverse practices which compromise an individual’s sleep and to promote healthy practices to maximize it are also described in that chapter and elsewhere [14,15,16].

Sleep Deprivation, Health, and Function

The health consequences of sleep deprivation have been well documented in the companion textbook [17] and other established evidence syntheses [18]. Comparable to other lifestyle factors, sleep deprivation is a metabolic oxidative stressor associated with chronic low-grade systemic inflammation (CLGSI), the common pathway for many chronic conditions [19]. Besides the traditional assessment of underlying pathophysiology associated with conditions and/or diseases contributing to sleep impairment, the physical therapist needs also to assess lifestyle practices and attributes. Lifestyle factors impact sleep independently, as well as in combination with underlying pathophysiology. Behavioral interventions can then be prescribed to maximize sleep quality and quantity. Adequate metabolic reserves and being well rested and restored are necessary conditions to maximize the benefits of exercise and minimize potential adverse effects in the sleep deprived individual.

Sleep is essential for health and for physiologic healing and repair [1, 20]. Sleep deprivation, on the other hand, is associated with various pathological, functional, and behavioral consequences [21] including high blood pressure, increased stress hormones, and lower immune function. Functional performance and capacity are reduced, along with impaired hand–eye coordination and reaction times. Sleep deprivation leads to daytime sleepiness, including the tendency to fall asleep during activities such as driving. All these contribute to making patients unsafe when navigating their environments. Sleep deprived individuals are more likely to be lethargic, mentally depressed, and disinterested in being active or exercising, which correspondingly compromises health and well-being. Even in the short term, sleep deprivation can increase susceptibility to viral infection and contribute to weight gain, heart disease, and diabetes [12]. Mortality risk increases with severity and duration of sleep deprivation [22].

Optimal Sleep Quantity and Quality

Generally, 7–9 h of uninterrupted sleep to enable a person to go through the sleep cycles is recommended for health and well-being in adults [23]. Young people and older adults require more or less sleep, respectively. Importantly, the clinician needs to appreciate that sleep is a behavior that is under stimulus control of the environment as well as a physiologic function. It needs to be regular and habitual to manifest its maximal benefits. The behavior of sleep is maximized by attention to sleeping hygiene practices and the environment where an individual sleeps [16]. These aspects and their assessments are detailed in the companion text [17].

Lifestyle Practices and Attributes That Impact Sleep

Targeted attention to patients’ lifestyle practices and attributes within the health and lifestyle framework underpins physical therapy clinical practice guidelines, in general [2]. This section briefly reviews the impact of lifestyle practices and attributes on sleep specifically, and the need for the physical therapist to assess sleep and intervene by addressing not only the underlying pathology wherever possible but also those lifestyle practices and attributes factors that compromise sleep. By addressing these factors, sleep can be improved. Adverse lifestyle practices and attributes, along with sleep pathologies, are pro-inflammatory and have been well documented to contribute to CLGSI [24, 25]. CLGSI can be ameliorated with behavior change toward anti-inflammatory lifestyle practices. Topics include smoking, alcohol use, nutrition, body weight, and stress, as well as the level of conditioning including sedentariness, inactivity, and inadequate structured exercise.

Smoking

Because nicotine, a major constituent of tobacco, is a central nervous system stimulant, smoking contributes to insomnia [26]. Smokers often have problems falling and staying asleep and are more likely to develop breathing issues and experience restless leg syndrome, both of which interrupt sleep [27]. Smoking disturbs sleep cycles and leads to difficulty getting up in the morning and decreases alertness. Half of the people who smoke wake during the night with a nicotine craving [28]. Of some 1100 smokers surveyed in one study, 17% slept less than 6 h a night and 28% reported “disturbed” sleep quality [29]. Although exercise may offset the adverse effects of smoking on sleep, smoking cessation is the priority [30].

Alcohol Use

Alcohol depresses the central nervous system. It suppresses the all-important rapid eye movement sleep cycle, which is essential for physical and mental restoration and repair following sleep [31]. Alcohol reduces sleep latency onset, although alcohol may enable healthy people to fall asleep sooner and briefly sleep more deeply [32]. These findings have been supported in a questionnaire study in which men reported impaired sleep quality and duration, and general sleep disturbances, after consuming alcohol [33].

Nutritional Status

When it comes to health and the role of nutrition, an editorial published in the British Journal of Sports Medicine pitted exercise against diet; it summed it up—‘You cannot outrun a bad diet’ [34]. Nutritional quality impacts sleep, in turn, exercise capacity. For example, deficiency of key nutrients such as calcium, magnesium, and vitamins A, C, D, E, and K has each been associated with short sleep, differentially between men and women, likely mediated through the disruption of hormonal pathways [35]. Elements of the western-style diet have been reported to be deleterious to sleep. Low fiber and saturated fat are associated with lighter, less restorative sleep with more sleep arousals [36].

A healthy whole food plant-based Mediterranean diet (high in legumes, vegetables, fruit; and low in animal sourced foods, fat, sugar and salt, and processed foods) has been the most studied diet in the world, and has been reported to be among the healthiest [37, 38]. Its benefits have been attributed to the fact that a whole food plant-based diet is anti-inflammatory, whereas the standard western-style diet is pro-inflammatory contributing to NCDs [39]. Adherents to this diet have less disrupted nocturnal sleep compared with others [38,39,40]. They also have reported less anxiety and depression, conditions well known to disturb sleep [41]. Compared with the traditional western-style diet, the Mediterranean diet is higher in omega-3 fatty acids, which independently reduce symptoms of depression, and improve sleep and protect against cognitive deficits associated with sleep loss. This diet is also high in tryptophan, melatonin, magnesium, B vitamins and vitamin D; nutrients associated with several parameters linked with sound sleep [37].

Further, based on a sophisticated crossover design, the low-fat vegan diet was recently reported to surpass the Mediterranean diet in terms of general healthfulness and reduced disease risk [42]. The vegan diet was superior with respect to participants’ body weight, lipid levels, and insulin sensitivity. Blood pressure decreased on both diets, but more so on the Mediterranean diet. These findings are consistent with the conclusions of the EAT Lancet Commission that the planet needs to shift to a whole food plant-based diet for individual, national, and planetary health [43]. Whether the consumption of a low-fat vegan diet specifically improves sleep beyond that reported with a Mediterranean diet when it is compared with other dietary regimes remains to be established.

That humans are vegan-by-design has been unequivocally supported by a detailed comparative analysis of the anatomy, physiology, and digestive/metabolism of carnivores, omnivores, and herbivores [44]. Not only have humans been shown to be dedicated herbivores, but there was no resemblance to omnivores—both plant and meat eaters—which is commonly believed by the public, health professionals, and dedicated so-called disease organizations. Substantial evidence has now been mounted that the cultural eating patterns of people in western countries, that include animal-sourced foods including meat, eggs, and dairy, are associated with many NCDs. These include chronic cardiovascular, respiratory, and metabolic diseases that are pandemic today [45] and frequently associated with breathing and sleep disorders [1].

In western countries, gastrointestinal dysfunction including gastroesophageal reflux disease (GERD) and ‘heart burn’ are also prevalent [46]. These often manifest when a person reclines, thus interfere with sleep. Such conditions are associated with a person’s lifestyle practices and attributes including excess body weight, moderate/high alcohol consumption, smoking, and postprandial heavy exercise as well as lack of regular physical activity [47]. Eating habits such as consuming diets with heavy acid loads, irregular meal patterns, large volume of meals, and eating meals just before bedtime also contribute. Elements of the western-style diet have also been implicated, namely, fatty, fried food/products, acidic foods, coffee/tea, and carbonated beverages are triggers for GERD symptoms [47, 48]. The whole food plant-based diet because it is lean, green, and largely alkaline can offset gastroesophageal reflux, regurgitation, and heart burn [49].

Coffee, tea, and many soda drinks are caffeinated. Caffeine being a central nervous system stimulant can directly interfere with sleep induction [50]. Depending on the patient’s sensitivity, caffeinated foods and beverages should be avoided several hours before bed. In addition, soda drinks typically have high content of sugar, an established energizer and stimulant, thus are best avoided before bed, or avoided altogether. Sugar is an oxidative stressor, pro-inflammatory, and increases C-reactive protein in an index of CLGSI [51].

Body Mass

Increased body mass is a major contributor to obstructive sleep apnea and related problems [52]. Fat deposits are commonly found in the tongue and around the neck and throat, as well as the waist and hips, and around internal organs. Reduced body mass can reduce these fat deposits, thus is recommended to reduce the severity of the apneic and hypopneic events [53, 54].

Insufficient sleep has been associated with obesity and increased waist circumference [55, 56]. In particular, increased waist circumference [56] is an indicator of numerous cardiovascular problems which, as they become more severe, compromise breathing and sleep.

Impaired sleep is associated with hypertension, potentially mediated through its association with increased body mass and associated hypoventilation during recumbency and rest [57, 58].

Stress

Western-style living is associated with high stress levels and sleep disturbance not only in adults but also in children [59]. The association of sleep and mental health can be bidirectional or a combination of both directions. Sleep can be disrupted by mental health issues most commonly anxiety and depression [60]; in turn, sleep deprivation can lead to anxiety and depression [60, 61]. A detailed assessment enables the physical therapist to establish the association between sleep and mental health in a given patient; which, in turn, informs targeted lifestyle behavior change interventions.

Sedentary Behavior, Inactivity, and Lack of Exercise

Traditionally, physical therapists have focused on sedentarism and inactivity as the basis for prescription of structured exercise in order to maximize the functional capacity of patients. With the adoption of the ICF however, physical therapists have recognized that functional capacity reflects other lifestyle practices and attributes including sleep, and underlying pathologies, and the reverse. Unless judiciously prescribed however, imposing exercise stress on a patient who is sleep deprived may not only exacerbate their symptoms but also further compromise their immune status by increasing a CLGSI response.

People with disrupted sleep are more likely to sit more and be less active, or not undertake regular structured exercise [1]. All three categories need to be assessed clinically in patients with sleep disorders. Imposing increased exercise load on sleep deprived individuals with the intent of improving exercise capacity is not likely to be effective and could be unsafe. First, the underlying causes of and contributors to disrupted sleep need to be identified and mitigated or largely reversed to prepare the patient physiologically for increased exercise stress.

Assessment of Lifestyle Practices and Attributes That Impact Sleep

This section highlights tools to assess sleep and describes the modified Health Improvement Card (mHIC) (Figs. 1.2a, b) [62]. The mHIC is a user-friendly tool for assessing basic lifestyle practices and attributes and serves as a basis for targeting and tailoring lifestyle behavior change programs.

Fig. 1.2
A 2-part illustration. A, A set of formulas for health improvement card and illustration for biometrics scorecard and health improvement action plan. B, It has texts and illustrations titled lifestyle scorecard and health improvement action plan.figure 2

(a, b) Modified health improvement card. ([62]; Modified and reprinted with permission World Health Professions Alliance

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Tools to Assess Sleep

There are several established tools for assessing and evaluating sleep quality and quantity objectively and subjectively which have been described in this text’s companion volume [63, 64]. In addition, the Pittsburgh Sleep Quality Index [65, 66] is one of the most used tools for the subjective assessment of sleep quality, and is considered valid and reliable [67]. It is publicly accessible and can be completed online or on paper. The findings can then serve as a basis for behavioral change interventions which have been well described elsewhere [7,8,9,10,11,12,13,14,15,16].

The ICF check list provides a comprehensive framework for assessing functional health of individuals with sleep disorders in a clinical setting [68]. It enables the clinician to identify how various factors impact that individual’s sleep and also provide an informed basis for targeted intervention.

The Modified Health Improvement Card

A useful easily administered assessment/evaluation tool for major lifestyle behaviors and attributes is the mHIC (Fig. 1.2). It provides a basis for targeting and tailoring education and interventions to effect positive lifestyle behavior change. The original HIC [69, 70] was developed by the World Health Professions Alliance which consists of the world’s five leading established health professions including nurses, physicians, and physical therapists. It has been modified to update its criteria for healthy and unhealthy lifestyle practices and attributes based on current evidence. The mHIC is designed to complement the assessment findings from dedicated sleep assessment tools.

The mHIC has three sections: patient’s information, biometrics, and key lifestyle-related behaviors. Lifestyle behaviors and recommendations are rated based on degree of risk, that is, on a color-coded traffic light system of green (meeting the criteria for health for each behavior and associated with low NCD risk), amber (cautionary NCD disease risk), and red (unhealthy and associated with high NCD disease risk). The mHIC serves as a basis for patient education in that it clearly identifies targets for the patient’s behavioral change of lifestyle practice and attributes.

Summary and Conclusion

Lifestyle practices and attributes can interfere with a patient’s sleep independently, as well as when they are superimposed on various conditions and diseases affecting sleep. Conversely, pathophysiological conditions can impact lifestyle practices and attributes, thereby further compromising sleep. Thus, the physical therapist’s assessment necessarily includes assessment of lifestyle practices and attributes, which impact sleep independently, in addition to the conventional assessment of the underlying pathophysiological conditions. To complement the findings from sleep assessment tools, the mHIC is an easy-to-use clinical tool for assessing lifestyle practices and attributes, as well as providing a basis for patient education and targeting specific health behavior changes. Behavior change interventions are prescribed by the physical therapist to maximize the patient’s sleep, in turn, functional capacity and overall health. Alternatively, referral by physical therapists to other health professionals may be warranted. In this case, physical therapists have a responsibility to support those health behavior change initiatives instituted by other health professionals.

This chapter highlights the use of the health and lifestyle framework in the physical therapists’ clinical practice guidelines, with special reference to individuals with sleep problems. It summarized the literature related to the impact on sleep of lifestyle practices and attributes, that also largely underlie NCDs, namely: smoking; alcohol use; nutritional status; body mass; and stress; as well as sedentary behavior, inactivity, and lack of structured exercise. Contemporary physical therapy practice warrants going beyond the traditional biomedical model and ‘exercise as medicine’ mantra, to maximizing functional capacity and performance through maximizing lifestyle attributes and practices including sleep. Physical therapy management of sleep disorders, based on the evidence-informed health and lifestyle framework that is consistent with twenty-first century physical therapy practice, can maximize several inter-related outcomes for patients with sleep disorders, that is, health-related, preventive, disease-specific, and functional.