Sick and Tired: Understanding and Managing Sleep Difficulties in ...

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Discussion This study explored the effects of a brief mindfulness body scan intervention on sleep quality in people with FMS in comparison to a PMR control group. There was a significant interaction effect on the sleep fragmentation index as measured by actigraphy for group and time. There were no other significant differences between the groups at baseline or follow up, although positive trends were observed in the mindfulness groups for overall perceived sleep quality (PSQI global score). Positive improvements were also observed in both groups in perceived sleep efficiency, pain, fatigue, although the magnitude of the improvements appeared to be larger in the mindfulness group. The significant intervention between group and time for sleep fragmentation appeared to be due to increased sleep fragmentation in the PMR group, rather than improvements in the mindfulness group, suggesting that the PMR intervention may have been disruptive to sleep quality while participants were completing the intervention. Indeed, three participants who completed the PMR intervention provided informal feedback to the team that the intervention had aggravated their symptoms. As a result participants reported that they had discontinued the intervention for the remainder of the week or did not carry it out every day. Previous research has revealed that PMR has been shown to be particularly effective for those experiencing chronic pain with high levels of arousal (Friedberg & Jason, 2001). However, Friedberg (2001) noted that this type of relaxation may lead to an initial increase in fatigue or pain (Friedberg & Jason, 2001). This study has highlighted that PMR may also lead to an increase in fragmented sleep. It appears that the increase in sleep fragmentation, decreased after discontinuation of the intervention (in week three), although as the intervention was only completed for the period of one week, it is unclear if this increase would have decreased over time naturally as the previous findings suggest. This study revealed that participants underestimated their total sleep time and sleep efficiency, and overestimated the amount of time it took for them to fall asleep (sleep onset latency) when compared to the objective actigraphy findings. This supports the findings of previous research using subjective and objective measures of sleep quality in 145
people with FMS (Perlis, Giles, Mendelson et al., 1997). This highlights the importance of the role of beliefs and expectations about sleep and people‟s perceptions of sleep quality (Morin & Espie, 2003). It also suggests that these perceptions need to be addressed in interventions to improve sleep quality in this population. However, there was objective evidence of the poor sleep quality experienced by people with FMS in the actigraphy findings suggesting that the sleep disturbance experienced is unlikely to be a sleep state misperception disorder. There is emerging evidence that non- pharmacological interventions focusing on addressing dysfunctional beliefs, re- establishing a consistent sleep pattern and improving coping may improve sleep difficulties and other health outcomes in FMS (Edinger et al., 2005). Although the observed positive trends in perceived sleep efficiency, pain and fatigue did not reach significance, the findings do suggest that further investigation of the effects of a brief mindfulness intervention is warranted. The magnitude of the findings may have been reduced as measures were not taken in week two when the greatest impact of the intervention was likely to be observed (rather than taken on week three after participants had been asked to stop completing the intervention). Therefore any benefits of the intervention may have been weakened. Questionnaire assessments at week two would have also enabled better comparison with the actigraphy measures taken across the three weeks. It has also been suggested that a three point difference in SF-36 scores may be a clinically significant change (although this may not reach statistical significance) (Samsa et al., 1999). Previous research has also revealed positive trends in mindfulness based interventions that have not reached significance, due to comparable improvements in the control group who were offered an education intervention (Astin et al., 2003). This suggests that people with FMS may benefit from increased education about their condition, time with a supportive therapist or the observed improvements may be due to an expectancy effect and therefore a usual care control would strengthen studies exploring mindfulness in FMS. Strengths and Limitations The effect of the mindfulness intervention on health outcomes in FMS may have been limited, as improvements were observed in sleep efficiency, pain and fatigue in both groups. Although the PMR intervention was used to control for the effects of relaxation 146
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Sick and Tired: Understanding and M
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Chapter Four. The Nature and Effect
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References ........................
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List of Tables Table 1. Participant
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Co-authored Works Although the stud
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Acknowledgments This thesis would n
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Intellectual Property Rights There
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Confidential Material No participan
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The role of sleep in FMS appears to
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little information was available as
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Psychophysiologic insomnia which is
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and are less able to inhibit the pa
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widely applied in clinical practice
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of fewer tender points; usually bet
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Current Management Strategies The t
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also likely to depend on a number o
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deep sleep (stages three and four)
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Although sleep moves through the sl
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Figure 3. The Integrative Model of
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However, conducting a blood test is
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As sleep is a complex process invol
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Sleep Diaries Sleep diaries are a k
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pain). Lentz et al (1999) revealed
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These results have also been suppor
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(McCracken & Iverson, 2002) which s
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Figure 4. Conceptual model of the d
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Clinical Implications Despite the p
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Chapter Three. Sleep in FMS As high
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& Penzien, 2003), although alpha wa
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pauses in breathing indicative of s
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Relationships between Sleep and Pai
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Managing Sleep Disturbance in FMS D
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may be possible to help patients im
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person to initiate an action (such
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and Nicassio et al (1995) only expl
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1) Poor sleep quality, defined by t
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elow 0.7 are acceptable. Therefore
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heart disease (Epstein et al., 1999
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In order to explore the links betwe
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questionnaire 78 (77.2%) of the par
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efficiency, suggesting that partici
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Older age and longer length of illn
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Table 2. Correlations between demog
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Logistic Regression As 97% of the s
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in bed, participants may have devel
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Relationship between Negative Affec
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participants, who may be less likel
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emotional problems, increased pain
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eactions are most likely to be detr
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It has been suggested that the auto
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For both groups, participants were
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with and without chronic medical co
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As previously described on page 61,
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Figure 7. Scree plot for the explor
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Figure 8. Scree plot for the explor
Page 111 and 112: Table 6. Participant characteristic
Page 113 and 114: Table 7. Measures of central tenden
Page 115 and 116: CON = DBAS-10 Dysfunctional beliefs
Page 117 and 118: The Exp (B) values revealed that hi
Page 119 and 120: has explored the use of napping on
Page 121 and 122: It became clear, through the analys
Page 123 and 124: interventions. With this in mind, t
Page 125 and 126: The philosophy of phenomenology was
Page 127 and 128: Methods Participants were given a w
Page 129 and 130: Table 11. Interview schedule for th
Page 131 and 132: Rigour The interview transcripts we
Page 133 and 134: “The main symptom is this overwhe
Page 135 and 136: Theme Two. Inter-relationship betwe
Page 137 and 138: where I live, so I don‟t know, I
Page 139 and 140: Participants also described how the
Page 141 and 142: “XXXX (name of person) planned a
Page 143 and 144: A strong theme that emerged in this
Page 145 and 146: conducted at several time points, w
Page 147 and 148: Chapter Seven. Investigating the Ef
Page 149 and 150: activities because they no longer f
Page 151 and 152: Therefore as this was a feasibility
Page 153 and 154: Self-reported sleep quality was ass
Page 155 and 156: The progressive muscle relaxation (
Page 157 and 158: Exploring the baseline data, there
Page 159 and 160: Consequently, univariate analysis w
Page 161: There was no significant correlatio
Page 165 and 166: The aim of this study was to explor
Page 167 and 168: observed in perceived overall sleep
Page 169 and 170: elaborated on in Chapter Six, which
Page 171 and 172: Four) revealed that global sleep qu
Page 173 and 174: Modifications to the Call-Schmidt a
Page 175 and 176: MBSR programme in people with FMS (
Page 177 and 178: diagnostic criteria for these sleep
Page 179 and 180: comprehensive measures to look at t
Page 181 and 182: References Abad, V. C., Sarinas, P.
Page 183 and 184: Brand, S., Gerber, M., Beck, J., Ha
Page 185 and 186: Crofford, L. J., & Demitrack, M. A.
Page 187 and 188: Goldenberg, D. L., Kaplan, K. H., N
Page 189 and 190: Johns, M. W. (2002). Sleep propensi
Page 191 and 192: Leung, Y. Y., Ho, K. W., Zhu, T. Y.
Page 193 and 194: Mease, P. J. (2005). Fibromyalgia s
Page 195 and 196: symptoms in healthy subjects; Corre
Page 197 and 198: approach with illustration to the h
Page 199 and 200: Thomas, E. N., & Blotman, F. (2010)
Page 201 and 202: Yunus, M. B., Masi, A. T., & Aldag,
Page 203 and 204: Appendices Appendix A: Search Strat
Page 205 and 206: Sleep and Fibromyalgia Syndrome Con
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Page 209 and 210: The following questions relate to y
Page 211 and 212: There are lots of ways to try to de
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42. I try hard to prevent other thi
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During the past month have you had
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Appendix E: Published paper of Stud
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Sleep and Fibromyalgia Syndrome Con
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Appendix H: Participant Questionnai
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Below are 10 statements reflecting
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The questions in this scale ask you
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Appendix I. Published Paper for Stu
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Appendix K. Information Sheet and C
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Sleep in Fibromyalgia Syndrome Cons
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Appendix L: Letter of Ethical Appro
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Appendix M. Letter to GPs for Study
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What are the side effects of any tr
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Appendix O: Poster Advertising Stud
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Appendix Q: Participant Questionnai
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HAD Scale Read each item and place
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During the past month have you had
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Appendix R. Letter from Dr Mark Cro
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PUBLICATIONS Peer Reviewed Journal
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and panic-like episodes, Faculty of
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