PHYSIOTHRAPY IN SLEEP

DISORDERS
CONTENTS
• Sleep ( Stages, Cycle , Neurophysiology)
• International Classification Of Sleep Disorders
• Types Of Sleep Disorders
• Assessment Of Sleep Disorders
• Physiotherapy In Sleep Disorders
• Electrotherapy
• Exercises Training
• Psychotherapies
• Recent Advances
DEFINATION
• Sleep defined as natural periodic state of rest for mind and body with
closed eyes characterized by partial or complete loss of
consciousness.
• Infant 66% of day, adult 33% of the day
• 33% to 50% of the adult population (Insomnia)
Stages of Sleep
• Sleep usually occurs in 2 phases
• 1. REM (Paradoxical Sleep, 20 -30%, imp. For memory consolidation,
dreams present, Low volt high freq desynchronised waves are present
as wakefulness.)
• 2. N-REM Sleep- divided into 4 stages (Stage I, II, III, IV), 70-80%, slow
wave sleep, no dreaming
N- REM
• Stage I (Stage of drowsiness) - wave with infrequent
between being awake & falling asleep.

• Stage II (Stage of Light Sleep) – Superimposed low volt waves Freq 14

per sec
disengaged of surroundings,
 body temp., regular RR & HR.
• Stage III (Medium Sleep) - Freq of wave1-2 per sec with amp. 100 v.

• Stage IV (Deep Sleep) – prominent with low Freq & high amp.

• Stage III + IV= N3 deepest & more restorative sleep, BP, RR, Msls
relaxed, energy restored, release of hormones like – GH, increased
tissue repair& growth
REM
• After falling asleep & recurs every 90 min.
• Provides energy to brain & body
• Supports daytime performances
• Dreaming with active brain
• Rapid Eye movement. with sleep paralysis
Neurophysiology of Sleep
• Sleep and the circadian rhythm of sleep depend on complex neural
mechanisms which are not entirely known.
• Different neurotransmitter systems, which include acetylcholine,
norepinephrine, serotonin, dopamine, histamine and orexin, regulate
cortical arousal by afferents from the basal nucleus of Meynert,
brainstem and hypothalamic nuclei.
Neuro Modulators
Sleep Disorders
• Alterations in the quality, quantity and pattern of sleep result in sleep
disorders. Persistent and repeated interruption of sleep affects the
health of an individual.
• Sleep disturbances are commonly observed in the general population
and in individuals with psychiatric illness.
• Highly prevalent in psychiatric disorders.
Epidemiology
• In Western populations 0.047% to 50.5%.
• Most prevalent disorder insomnia followed by sleep disordered
breathing, restless leg syndrome, nightmares, sleep talking, sleep
walking and narcolepsy
SLEEP DISOREDERS PREVALANCE RATE
Narcolepsy 12.5%

Sleep Breathing disorders 14.5%

RLS / PLMS (periodic limb movement disorders) 14.8%

Circadian rhythm disorder 4.5%

Parasomnia 13.8%
International classification of sleep disorders
Sleep related
Insomnia Hypersomnolence
breathing disorders

Chronic Narcolepsy
OSA disorders
insomnia type 1/2

Short term Central sleep apnoea Idiopathic

insomnia syndrome hypersomnia

Other insomnia Hyperventilation

Kleine-Levin syndrome
disorders

Hypoxemia disorders Hypersomnia due to

medical/psychiatric disorders
and medication

Insufficient sleep syndrome

 Sleep related
Circadian rhythm Parasomnia
movement
disorders s
disorders
Delayed/advanced NREM related Restless leg syndroms
phase disorders parasomnias
Periodic limb movement
REM related disorder
Irregular/24 hours rhythm parasomnias
disorders
Leg cramps, bruxism,
others rhythmic movement disorder
Shift work disorders
Myoclonus disorders

Jet lag

Others
Insomnia
• Subjective perception of difficulty with sleep initiation, duration,
consolidation, or quality that occurs despite adequate opportunity for
sleep, and that results in some form of daytime impairment.
• 18 hrs absent sleep reduces reaction time Approx 50%
• Aetiology
Primary insomnia-
1. Genetic and cultural factors
2. Personality Characteristics
3. Personal History
4. Assorted Habits And Routines
Comorbid insomnia-
1. Psychiatric disorders
2. Medical conditions
3. Neurological diseases
4. Chronic pain
5. Other sleep disorders
Sleep related breathing disorders
• Obstructive Sleep Apnoea’s (OSA)
- Signs and Symptoms
- Usually associated with other medical or psychiatric disorders
- Coupled with 5 or more obstructive respiratory events
- Frequency of obstructive respiratory events >15/h
- AHI Grading of apneas
- Treatment of OSA
• Central sleep apnoea
- Definition
- Factors for diagnosis

• Obesity related hypoventilation

- BMI > 30
- Elevation in day time PaCO2
Central disorder of hyper-somnolence
• Definition
Excessive sleeping during daytime
• Not attributed any other sleep related disorders
• Causes
CNS abnormalities
• Multiple sleep latency test
• Types
- Narcolepsy
- Idiopathic hypersomnia
Circadian rhythm sleep wake disorders
• Definition
• Subtypes
- Delayed sleep wake phase
- Advanced sleep wake phase
- Irregular sleep wake phase
- Non 24 hrs sleep wake phase
- Jet lag disorders
Parasomnias
• NREM disorders
Definition
Confusional arousal , sleep walking, sleep terrors, sleep eating
Criteria to diagnose

• REM disorders
Definition
Nightmare disorder, sleep paralysis
Sleep related movement disorders
• Urge to move body parts
• Criteria to diagnose
• Periodic limb movement disorder
Assessment Of Sleep Disorders
• It mainly depends on specific outcome measures like
• Insomnia Severity Index
• Pittsburgh sleep quality index
• Investigations
1. EEG
2. Polysomnography
3. Actigraphy
4. Others (Blood Analysis, Radiography only if indicated)
EEG
• Electrical activity of large num of neurons in brain recorded with
electrodes place on the scalp.
• Brain waves
• Relation of brain waves with cortical activity
Polysomnography
• It is specialized investigation, used to detect only if there is a H/o or
suspicion of OSA/ Movement Disorder / uncertain diagnosis/ arousal /
violent / Injurious behavior or no response to initial therapy is
achieved.
Actigraphy
• It is used to assess characteristics circadian rhythm patterns / sleep
disturbances with insomnia or insomnia with depression
Physiotherapy in sleep disorders
Practical information for physiotherapy
• Assess overall sleep health & screen for sleep disorders esp. Insomnia,
OSA & RLS.
• Refer for further assessment. if risk is found.
• Provide sleep hygiene education to pt.
• Provide appropriate ex programme.
• Consider positioning to promote sleep quality.
• Address bed mobility issue
Physiotherapeutic approach
• CES
• T-DSC
Electrotherapy • r-TMS
• TEN

• RELAXATION,
Physical activities POSITIONING
• PRE/PA
• YOGA

• SLEEP HYGINE
• MBSR
Advanced psychotherapeutics • BIOFEEDBACK
• MEDITATION
• BBAT
Cranial electrotherapeutic stimulation
• Introduction
• Application
• Classes
- Class 1
- Class 2
- Class 3
• Working
Title Aim Methodology Conclusion

The effect of cranial To study the effect of CES A randomized, controlled Study found influence on
electrotherapy stimulation on sleep efficiency on clinical study on 40 sleep parameters. Cranial
on sleep in healthy women young healthy women females without sleep electrotherapy stimulation
Boris Wagenseil et, al disorders (age: 18-35 is a highly promising
2018 years) was conducted. technique for therapy of
Each subject underwent insomnia. It has now been
two nights of evidenced that the pulse
polysomnography in a waves also penetrate
sleep center. During the through the cranium.
second night, we applied
CES with a commercial
device (Alpha-Stim 100)
using either active or sham
stimulation (double-
blinded). Sleep was
evaluated with respect to
differences between the
active and sham modes.
Sleep EEG analysis was
applied to determine
frequency changes.
Title
Efficacy of cranial electric
stimulation for the
treatment of insomnia: A
randomized pilot study
R. Gregory Lande et al
(2013)
Aim
This pilot study examined
the potential efficacy of
cranial electric stimulation
for the treatment of
insomnia
Methodology Conclusion
Researchers approached Study concluded that
eligible subjects who scored immediately after these
21 or above on the five days, male subjects on
Pittsburgh Insomnia Rating the average reported that
Scale. The researchers then they had slept better.
randomly assigned the
subjects to receive either an
active or sham device. Each
study subject received 60
min of active or sham
treatment for five days.
Following each intervention
the subjects completed a
sleep log, as well as three
and ten days later.
the study was conducted
among active duty service
members receiving mental
health care on the
Psychiatry Continuity
Service (PCS)
Trans cranial direct current stimulation
• Introduction
• Mechanism of action
Title
Modulation of Total Sleep
Time by Transcranial Direct
Current Stimulation
Lukas Frase et al
2016
Aim
The study tested that total
sleep time (TST) in humans
can be modulated by the
non-invasive brain
stimulation technique
transcranial direct current
stimulation (tDCS).
Methodology Conclusion
Nineteen healthy The study provides proof-
participants were included of-concept that TST can be
in the analysis. All decreased in healthy
participants underwent an humans by non-invasive
extensive screening to rule bifrontal anodal tDCS.
out any sleep disorder. All
participants provided
written informed consent
before the study. All
participants underwent a
within-subject, repeated
measures protocol for 5
nights in sleep lab.tDCS
was applied between 2200
and 2246 h before sleep
according to the
experimental protocol.
Transdermal electrical neuromodulation
• Introduction
• Application
• Parameters
• Mechanism of action
Title Aim Methodology
Transdermal electrical To test hypotheses that The study was conducted
neuromodulation of the modulation of the TSNC three studies designed to
trigeminal sensory nuclear can improve sleep quality test hypotheses, with total
complex improves sleep and mood in healthy number of participants
quality and mood. individuals. were 99. Total of 1,386
Alyssa M. Boasso days were monitored. TEN
(2016) modulation of trigeminal
and cervical nerves prior
to sleep onset was
administered. overnight
actigraph and heart rate
recordings, and
biochemical analyses
compared to baseline or
sham controls was done.
Conclusion
TEN modulation of
trigeminal and cervical
nerves prior to sleep onset
produced significant
improvements in sleep
quality.
we observed some
frequency dependence in
that TEN delivered at
lower frequencies (0.50 –
0.75 kHz) was significantly
more effective at
improving sleep quality
and reducing anxiety than
higher frequency TEN
waveforms.
Study concluded that
electrically modulating
TSNC activity through its
afferent inputs improves
sleep quality and reduces
anxiety
Exercise training
• Promising non pharmacological treatment to improve sleep
• Exercise training may include
- Aerobic exercises
- Progressive resistance exercises
• Physiological effect
- Body temperature
- Muscular relaxation
- Sympathetic tone
• Intensity and volume of exercises
Title Aim Methodology Conclusion

Effect of Acute Physical To assess and to compare Forty-eight insomnia Acute moderate-intensity
Exercise on Patients with the acute effects of three patients, 38 female (mean aerobic exercise appears
Chronic Primary Insomnia different modalities of age 44.4 ± 8 y) were to reduce pre-sleep
Giselle S. Passos et al physical exercise on sleep randomly assigned to 4 anxiety and improve sleep
(2019) pattern of patients with groups: control (CTR, n = in patients with chronic
chronic primary insomnia. 12), moderate-intensity primary insomnia.
aerobic exercise (MAE, n =
12), high-intensity aerobic
exercise (HAE, n = 12), and
moderate-intensity
resistance exercise (MRE, n
= 12). The patients were
assessed on sleep pattern
(by polysomnogram and
daily sleep log) and anxiety
(STAI) before and after the
acute exercise
Title Aim Methodology Conclusion

A Randomized Controlled To test that if exercise A 10-week randomized Study concluded that
Trial of the Effect of would improve subjective controlled trial was utilized. weight lifting exercise was
Exercise on Sleep sleep quality and activity Participants of aged >60 effective in improving
Nalin A. Singh et al in depressed elders with a diagnosis of major or subjective sleep quality,
(2002) minor depression.A total of depression, strength, and
32 subjects.Intervention quality of life without
consisted of a supervised significantly changing
weight-training program habitual activity.
three times a week or an
attention-control group.
Main outcome measures
were Pittsburgh Subjective
Sleep Quality Index ,Likert
Scale of Subjective Sleep
Quality and Quantity,
Paffenbarger Activity Index,
Geriatric Depression
Scale,Beck Depression
Inventory, Hamilton Rating
Scale of Depression,and the
Medical Outcomes Survey
Short Form 36
Title Aim Methodology Conclusion

Effects of resistance Aim of the Study was to The study design included 5 Study concluded that
exercise timing on sleep investigate the acute visits and lasted engaging in RE at any time
architecture and nocturnal effects of timing of approximately 2 weeks. of the day may improve
blood pressure Resistance exercises on ages of 18 and 25 years quality of sleep as
JESSICA R. ALLEY et al sleep architecture and were recruited from the compared with no RE.
(2016) nocturnal blood pressure. student population. Resistance exercise may
Twenty-four participants offer additional benefits
completed the study (n = 12 regarding the ability to fall
men). asleep and stay asleep to
populations with
osteoporosis, sarcopenia,
anxiety, or depression.
Title Aim Methodology Conclusion

The Effect of Resistance Determine the acute and Thirteen studies were In conclusion, acute
Exercise on Sleep: A chronic effects of included. exercise, and the effect of
Systematic Review of resistance exercise on Intervention: Any form of adding resistance to
Randomized Controlled sleep quantity and quality. resistance exercise consistent aerobic exercise, studies of
Trials with the definition of the chronic resistance exercise
American College of Sports
Ana Kovacevic et al Medicine (ACSM).Both acute in isolation suggest
(2019) exposure and studies of significant improvements
chronic exercise were in subjective sleep quality.
included. Interventions were However, given the small
considered chronic if they number of studies,
consisted of at least four heterogeneity in clinical
bouts of exercise. cohorts, and the lack of
Interventions involving less
than four exercise bouts were objective sleep measures,
classified as acute. No conclusions about the
limitations were imposed efficacy of chronic
based on intensity, volume, resistance training, and
frequency, duration, type of the cohorts that may
equipment.Isotonic, isometric, benefit the most are still
and isokinetic interventions premature.
were eligible, Multi-
component interventions
were potentially eligible.
Title
Surveying the effects of an
exercise program on the
sleep quality of elderly
males
Aim
To examine the
effectiveness of an
exercise program on the
sleep quality of the elderly.
Methodology Conclusion
A semi-experimental study The study showed
was carried out on the effectiveness of scheduled
elderly males referred to exercising on the quality of
the Shahid Yari Elderly sleep of the elderly. It is
Center, Kermanshah, Iran. recommended, therefore,
The sample group to add an exercise
comprised of 46 program to the daily
participants: 23 in the program of the elderly.
experimental group and 23
in the control group. The
study was carried out for a
period of 2 months and
follow-up was conducted
every week. To improve
the quality of sleep of the
participants, a four-stage
exercise program was
implemented and the
collected data were
analyzed by SPSS version
20
Management of sleep apnoea
• Oral Appliance (Mandibular Repositioning appliance, tongue
refraining device etc.)
• Implantable Stimulating devices (HGNS, Submental TNS, Direct Fine
wire stim., direct hypoglossal stim.)
• Physiotherapy (Tongue brushing, tongue slide, tongue forces, tongue
press
• Surgery (MMA, uvulopalato pharyngoplasty)
Cognitive behavioural therapy
• Cognitive behavioural therapies comprised of
1. Sleep restriction therapy
2. Stimulus control therapy
3. Sleep hygiene
4. Paradoxical intention therapy
5. Relaxation
Sleep Restriction Therapy
• Limiting the time spent in bed leads to more efficient sleep that is
both consolidated and more regular and predictable. Time in bed is
allowed to increase as the patient demonstrates a continuing ability
to sleep.
• This treatment plan consists of limiting time in bed to the patient's
estimated total sleep time (not less than 5 hours)- Increasing 15-30
min. /week if SE (Sleep Efficieny) >85%, same if SE B/w 80-85%
Stimulus Control therapy
• There are essentially three steps
to the process-
1. Introduce the exercise
2. Detail the stimulus control
instructions
3. Make a plan for what to do during the
night.
Paradoxical intention Therapy
• Paradoxical intention therapy attempts to replace 'trying to fall asleep'
with 'trying to stay awake’.
• The aim of the technique is to get you to take a more passive role
towards sleep by deliberately preventing your attempts to fall asleep.
• Instructions to give patients -
1. When you are in bed lie in a comfortable position and put the lights
out.
2. In the darkened room, keep your eyes open
3. As time goes by, try to stay awake but relaxed.
4. Remind yourself not to try to sleep but to let sleep overtake you, as
you gently try to resist it.
5. Keep this mind-set going as long as you can, and if you get worried at
staying awake remind yourself that is the general idea, so you are
succeeding.
6. Don't actively prevent sleep by trying to rouse yourself.
Biofeedback therapies
• biofeedback therapy is a method that one can use to gain control over
involuntary processes in your body.
• Types of Biofeedback
1. Electroencephalography (EEG)
2. Respiratory Biofeedback
3. Heart Rate Variability Biofeedback
4. Electromyography (EMG)
• Biofeedback devices
• Biofeedback Techniques
1. Deep Breathing
2. Progressive Muscle Relaxation
3. Guided Imagery
4. Mindfulness Meditation
Recent advances
Title Aim Methodology Conclusion

Effect of hydrotherapy on To evaluate the effect of Practice of hydrotherapy is

sleep deficiency among hydrotherapy on sleep effective in reducing sleep
older people (2019) deprivation in older adults deficiency and hence can
be considered as effective
method of intervention
Title Aim Methodology Conclusion

The effects of a sleep To determine if sleep robot This study is a randomized The sleep robot is a novel
robot intervention on intervention helps to waitlist-controlled trial method and a potential
sleep, depression and reduce sleep deprivation, with a recruitment target treatment option for
anxiety in adults with depression and anxity. of a minimum of 44 adults people with insomnia,
insomnia – Study protocol with insomnia and sleep when the recommended
of a randomized waitlist- disturbing arousal. first-line treatments of
controlled trial (2021) Participants will complete Cognitive Behavioral
pre-, mid- and post- Therapy and
intervention assessments, pharmaceuticals are
in addition to a 1-month inaccessible or
follow-up. The primary undesirable.
outcome measure is the
Insomnia Severity Index.
Secondary sleep outcome
measures are the Pre-
Sleep Arousal Scale, a
sleep diary and actigraphy.
A secondary comorbid
symptoms outcome
measure is the Hospital
Anxiety and Depression
Scale.
Title Aim
VIRTUAL REALITY GUIDED To evaluate effect of brief
IMAGERY FOR INSOMNIA virtual reality guided
(IVR) (2023) imagery for insomnia (iVR)
in adults with chronic
insomnia
Methodology Conclusion
12 adults (Mage=38.2 This pilot findings suggest
years, SD=20.7, 50% iVR is feasible and
female) with chronic promising treatment for
insomnia completed 4- chronic insomnia. Because
weeks of iVR delivered via the intervention can be
Oculus Go headsets pre-installed, iVR may be
equipped with blue light particularly useful for
blocking lenses and pre- individuals with limited
loaded with a guided internet access
relaxation application,
sleep hygiene instructions,
and modified stimulus
control instructions.
Participants completed a
Satisfaction Survey at post-
treatment.
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