Have you ever heard of a Korean Stone Bed? I never had until I visited the home of one of my patients who was from South Korea.
She had been referred to me for severe and chronic back pain following a recent history of multiple spinal fusions. This condition caused her to have a reduced ability to perform activities of daily living (ADLs) and reduced walking and standing tolerance. She had a futon alongside the stone bed. Between the two large surfaces, there was not much floor space left over to move about within her small apartment.
As observed during her evaluation, it seemed she would transfer slowly and painfully between her stone bed and her futon to take meals or phone calls during the day. When I first saw the ornate wood and tiled bed in the middle of her apartment, it seemed obvious that this was an important cultural relic, one that seemed particularly meaningful to my patient.
Incredibly curious about this seemingly odd choice for a sleeping arrangement considering the patient’s medical condition, I went home and researched it. I didn’t find a lot of information or scientific evidence, but I read a few online personal opinions about how some Koreans embraced the idea of stone beds for healing benefits. I learned that many of these beds come with warming mechanisms that heat up the jade, stone, or in my patient’s case, ceramic tiles upon which a person sleeps. I suppose the rationale behind this is much like the beneficial claims of the trendy “hot stone massage”.
This was certainly a unique perspective. The discussion and intervention of bed mobility, sleep positioning, and quality of sleep, which I would have with any of my patients who have chronic back pain was, in this situation, most definitely one of communication, collaboration, cultural understanding, and a lot of compromises. I did my very best to explain the importance of maintaining hip alignment and joint positioning during sleep, rest, and bed mobility and transfers, as well as to offer examples of supports and props that my patient could utilize to minimize joint pressures and strain. We discussed the beneficial use of heat as well as the risk of increasing joint inflammation if heat is overused. In the end, I remained unconvinced that this stone bed was helping my patient’s goal of pain reduction, but ultimately I knew that the decision to change her sleeping arrangement would have to come from her.
Sleep and Rest Within Occupational Therapy
As we all know, sleep preferences are personal, deeply ingrained, and can be incredibly difficult to change or alter. However, sleep disorders and an inability to get a sufficient amount of quality sleep is a common refrain in patients as well as the general population. Lack of sleep can affect a patient’s ability to heal, decreases pain tolerance, increases stress response, and can lead to increased length of time spent in bed, causing risk for pressure sores and poor outcomes.
When populations with decreased access to natural sunlight, limited physical activity, increased comorbidities and polypharmacy use are factored in, the effects are even more of a concern. Thus, when working with a geriatric population, there’s a good chance that occupational therapists (OTs) will encounter patients whose lives are affected by sleep disturbances and physical ramifications as a consequence of a poor night’s sleep.
Listed as occupations, sleep and rest within occupational therapy practice framework [i] are important, but often overlooked aspects of our patients’ lives that we must strive to address.
Sleeping Within an SNF Environment: Complications and Interventions
Besides the usual factors complicating sleep quality such as age, medical condition, pain, and anxiety, other factors inherent to a hospital or skilled nursing facility (SNF) can also affect patients’ sleep. A 2017 article in Nursing Review [ii] discussed the quality of patients’ sleep within such facilities. Factors affecting patients’ sleep included:
- the experience of sleeping in a new and different bed
- the presence of others in multiple beds within a room
- frequent interruptions for medical and medication needs
- indwelling devices such as catheters and IVs
- various lights and mechanical sounds that are not conducive to a restful sleep
The article stated that healthcare providers’ perceptions of patients’ quality of sleep can be unreliable. The authors suggested the use of standardized sleep assessments such as the Richards-Campbell Sleep Questionnaire, which uses patients’ self-reports to measure sleep depth, quality, and latency, awakenings, and the act of returning to sleep.
Once assessed, the article suggested adaptive approaches for the staff to consider in order to improve patients’ sleeping experience. As environmental factors are part of an occupational therapist’s domain, this provides OTs with another opportunity to problem-solve patient-centered obstacles to quality care. Establishing quiet times when activities and interventions are reduced to a minimum, monitoring and limiting sounds and lights within the corridors and rooms, and establishing a night-time routine were some of the adaptations the article suggested.
Homecare: Lifestyle Modifications For Healthier Sleep Habits
For patients living at home, lifestyle choices can affect a healthy balance of wake, sleep, and rest. Patients may often report fatigue during the day and a desire to nap midday, which can throw off nighttime sleep schedules. Numerous studies have addressed the health benefits of sleep cycle completion and sleep consolidation. Some of these studies have considered the restriction of daytime napping in order to increase the amount of nighttime sleep, with the aim of increasing the opportunity for sleep cycle completion and sleep consolidation.
A 2016 study in the American Journal of Occupational Therapy [iii] considered the effects of six months of occupation-based lifestyle intervention on the sleep and napping habits of community-living seniors. The intervention methods for the study group included two-hour weekly group sessions that included:
- a didactic presentation
- peer exchange
- participation in activities
- personal reflection relating to the topics of healthy lifestyle behaviors, including sleep
Participants also received ten individualized one-hour sessions within their home or community, as a supplement to the group sessions for the adoption and maintenance of the desired lifestyle behavioral changes. These interventions included modification of sleep schedules and sleep environments, as well as the consideration and modification of daily habits, roles, and routines that would encourage the patient to participate in daily activities such as exercise and socialization.
While the participants in this study were not encouraged one way or the other regarding napping, some reported via a survey that they had stopped napping over the course of the six-month period. Perhaps, the most significant result of this study was that, among the participants who had stopped napping, those participating in the lifestyle redesign program actually increased their total net consolidated sleep time as compared to the control group that did not receive OT intervention.
The control group had stopped napping, but without the modifications and activity interventions, their total amount of sleep time actually decreased. This supports the perspective that the combination of lifestyle modifications, daytime activities, and daytime sleep restriction can result in a longer, more consolidated, and thus healthier nighttime sleep.
Night Time Positioning Equipment
Often we may find ourselves working with patients who are unable to reposition themselves or who have painful joint contractures and physical needs that can interrupt a restful night’s sleep. For these patients, we address goals such as increased participation in bed mobility, increased joint mobilization, and range of motion to decrease muscular contractions. Also included is the education of a patient’s caregivers as to the level of support needed for repositioning the patient as well as repositioning schedules to minimize the risk of pressure sores.
However, another possible consideration to aid these patients is night time positioning equipment (NTPE). NTPE can assist with positioning a patient into symmetrical alignment, decrease the risk of pressure sores and muscle spasms, and decrease the need for waking up to reposition. This can result in a more restful night’s sleep, improved posture during daily activities, and decreased burden of care.
In 2014, the New Zealand Journal of Occupational Therapy [iv] published the findings from a survey of 16 patients, varying in ages from childhood to over 65-years on their opinions regarding their NTPE over a two-year period. The respondents included a combination of those living in both homes and residential facilities. Their feedback was consistent with the benefit claims for NTPE, namely increasing the ability to lie straight, reduce muscle spasms and pressure, and about half of them reported a decreased need for nighttime repositioning. However, this survey also addressed ease of use and the ability to transport and clean the NTPE.
These factors are especially relevant to those residing in residences such as SNFs, and more research is needed regarding the practicality of providing NTPE for this population. The survey also considered patients’ reasons for abandonment of the equipment, namely:
- inability to regulate body temperature
- changing physical needs (growth, or post-surgery, etc.)
When implementing a plan to address the occupation of sleep with your patients, consider browsing through the online website called SleepOT.org [v], which is an international network of OTs providing resources regarding sleep. Links to useful resources are downloadable and include sleep diaries, assessments, and outcome measures for use with various populations including those with insomnia and sleep apnea. There is also a bedroom environment screening tool, and intervention suggestions, among them, how to assist patients to adjust to using their continuous positive airway pressure (CPAP) device, assessing and educating patients regarding sleep-disordered breathing (SDB), and ideas for cognitive interventions to address insomnia.
Learn more about improving sleep quality in our previous post, “8 Ways Scientifically Proven to Improve Your Sleep Quality.”
[i] Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014).
[ii]Batten, Lesley and Claire Minton. “‘Appeared to Sleep Well’: How Much Sleep Has Your Patient Had and Why Does It Matter?.” Nursing Review (1173-8014), vol. 17, no. 4, Aug/Sep2017, pp. 15-18. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=125017175&site=eds-live.
[iii] Leland, Natalie E., et al. “Napping and Nighttime Sleep: Findings from an Occupation-Based Intervention.” American Journal of Occupational Therapy, vol. 70, no. 4, Jul/Aug2016, pp. p1-p7. EBSCOhost, doi:10.5014/ajot.2016.017657.
[iv]Innocente, Rachel. “Night-Time Positioning Equipment: A Review of Practices.” New Zealand Journal of Occupational Therapy, vol. 61, no. 1, Apr. 2014, pp. 13-19. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=107846326&site=eds-live.
[v] Sleep OT, 2016, sleepot.org/