Review Article

Occupational Therapy Practice in Sleep Management: A Review of Conceptual Models and Research Evidence

Table 3

Characteristics of included studies.

Author, year, countrySetting subjectSample size (), age, sex (M/F)Level of evidence/clinical study design, inclusion/exclusion criteria (IC/EC)Type of interventionOutcome measureResults

Eakman et al., 2016, USAVarious university campuses, 911 US Military veterans, age 35.6 ± 7.4, sex 8/0Level III
Single-arm feasibility pilot study
IC: post 911 military veteran attending college, service-connected injury, reported sleep difficulties, willing to complete daily diaries
EC: diagnosis of epilepsy or bipolar disorder
Two months of sleep intervention: restoring effective sleep tranquility
(REST) program
7 group sessions
8 individual sessions
(i) Sleep restriction
(ii) Stimulus control
Sleep hygiene
(i) Sleep problems index II of the medical outcomes study sleep measure (MOS-sleep)
(ii) Patient-reported outcomes measurement information system-sleep disturbance (PROMIS-SD)
(iii) Pittsburgh Sleep Quality Index (PSQI)
(iv) Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS)
(v) Patient-reported outcomes measurement information system-ability to participate in social roles and activities (PROMIS-AP)
(vi) Patient-reported outcomes measurement information system-satisfaction with participation in social roles (PROMIS-SP)
(vii) Patient-reported outcomes measurement information system-pain interference (PROMIS-PI)
(viii) Canadian Occupational Performance Measure (COPM)
(i) Reduced sleep difficulties (, )
(ii) Reduced nightmares (, )
(iii) Fewer dysfunctional sleep-related beliefs (, )
(iv) Greater ability to participate in social roles (, )
Trends toward improved satisfaction with participation and reduced pain interference

Farrehi et al., 2016, USA [21]Hospital, aged 18–75,
age 56.22 ± 11.41
Level I
(i) Intervention group: occupational therapy sleep tool intervention (eye mask, ear plugs, and white noise machine) sleep education on environment control
(ii) Control group: sleep education
(i) COPM
(ii) FIM
(iii) Patient-Reported Outcome Measurement Information System Survey: fatigue, physical functioning, sleep disturbance, wake disturbance
(iv) Brief Pain Inventory (short form)
(v) Pain reduction associated with sleep deprivation
(i) Significant reduction of fatigue scores over 3 days, compared with controls ()
(ii) Trend toward improvement in sleep disturbance, sleep-related impairment, physical functioning, pain severity, or paint interference (p>0.1)
(iii) No difference in length of stay () or use of opioids ()

Gee et al., 2017, USA [22]Autism spectrum disorder,
age 3–6 years old
Level V
An ABA single-subject design
IC: children had a diagnosis of ASD, present with sleep problem, sensory over responsibility
Use of weighted blankets(i) Sleep quality
(ii) Time to fall asleep
(iii) Sleep duration
(iv) Behavioral ratings on waking
(i) Moderate improvement of the measured constructs related to sleep quality
(ii) Increased in total amount of sleep per night
(iii) Decrease in time to fall asleep
(iv) Sleep between 1 and 3 hours a night more as a result of the weighted blanket

Gutman et al., 2016, USA [23]Community living, adults aged 25–65,
age 43.2 ± 12.2, sex 9/20
Level I
IC: poor sleep for 2 months, agreed to follow sleep hygiene for 3 weeks
EC: taking sleeping pills, suffered from pain, medical diagnosis causing sleep disruption, pets or family members causing sleep disruption, pregnant or smokers
Three weeks of sleep intervention of the following:
(i) Dreampad pillow
(ii) iRest meditation
(iii) Sleep hygiene
(i) General Sleep Disturbance Scale
(ii) Pittsburgh Sleep Quality Index
(iii) Actigraph accelerometer
(iv) Sleep diary
(i) iRest meditation group experienced statistically more time asleep than both the Dreampad pillow () and sleep hygiene groups ()
(ii) Dreampad pillow group experienced statistically fewer nighttime awakenings than iRest meditation () and sleep hygiene groups ()
(iii) No difference was found between groups in perceived sleep quality, length of time needed to fall asleep, or next-day fatigue level

Heidt et al., 2016, USA [24]Hospital, aged 18–75,
age 57.5 ± 9.9, sex 29/23
Level III
Experimental study design with single sample and pre-post testing
(i) Simple sleep-enhancing education
(ii) Sleep-enhancingtools
(i) Patient-Reported Outcome Measurement Information System Survey: fatigue, physical functioning, sleep disturbance, wake disturbance(i) Significant improvement in fatigue (, ), sleep disturbance (, ), and wake disturbance (, )
(ii) No significant improvement in the physical function aspect ()

Jarus et al., 2011, Canada [25]Meir Medical Center, preterm infants,
postmenstrual age (days) 30.37 ± 2.57, sex 12/20
Level II
IC: birth weight less than 1750 g, stable in room air
EC: major congenital anomalies or major neurological illness, using medication affects the infant’s sleep-wake cycle
(i) Alternate position every 3-4 hours after feedings(i) Actigraph measurement
(ii) Naturalistic observations of newborn behavior (NONB)
(i) In the prone position, there were more approach reactions than withdrawal reactions () while in the supine position
(ii) In the prone position, more patterns were observed as opposed to more awake patterns

Leland et al., 2016, USA [26]Various elderly community centers, age > 65,
age 74.2 ± 7.7, sex 65/141
Level I
(i) Occupation-basedintervention(i) SF 36
(ii) Center for Epidemiologic Studies Depression Scale-Revised
(iii) Sleep time
(iv) Napping time
(i) The average time sleeping was 8.2 hours daily with SD 1.7
(ii) 29% of participants reported daytime napping at baseline, 36% of whom no longer napped at follow-up
Among participants who stopped napping, those who received an occupation-based intervention replaced napping time with nighttime sleep, and those who did not receive an intervention experienced a net loss of total sleep ()

Schoen et al., 2017, USA [27]South Shore Therapies and Knippenberg, Patterson, Langley, & Associates, children with autism spectrum disorderLevel III
A quasi-experimental, single-group, pretest/posttest design
IC: parents reported moderate to severe sleep disturbance
EC: had stressful life circumstance that could account for new onset sleep difficulties, medical or psychiatric illness, medication known to cause insomnia or sedation, receiving medication or CBT for sleep disorder, could not comply with sleep diary or use of pillow
(i) iLs Dreampad pillow(i) A sleep diary documented average sleep duration and average time to fall asleep during the preintervention phase and the last 2 weeks of the treatment phase
(ii) The Children’s Sleep Habits Questionnaire (CSHQ)
(iii) The Pediatric Quality of Life Inventory (PedQL)
(iv) The Parental Concerns Questionnaire (PCQ)
(v) The Swanson, Nolan, and Pelham (SNAP-IV)
(i) Procedures were acceptable and feasible for families. All measures were sensitive to change. Children with ASD demonstrated significant change in sleep duration (, ) and time needed to fall asleep (, ) from pretest to intervention
(ii) Improvements were noted in autism-related behaviors, attention (, ), and quality of life (, ), SNAP-IV (, ); parent satisfaction was high

Wen et al., 2017, USA [28]Traumatic brain injury,
age 31
Level IV
Mixed-methods pilot study
IC: diagnosis of chronic TBI (6-month postinjury), ability to stand/move, ability to follow a 3-step command, ability to read/speak English
EC: neurological conditions like bipolar disorder and attention deficit hyperactive disorder
(i) Yoga
(ii) Breathing exercise
(i) Pittsburgh Sleep Quality Index
(ii) Neuropathy Pain Scale
(iii) Behavior Rating Inventory of Executive Function
(iv) Beck Depression Inventory
(i) One participant showed 25% reduction in depressive symptoms, and other improvements were found in the inhibition and emotional control scales of the BRIEF

Wolfhope et al., 2016, USA [29]Saint Francis University, autism spectrum disorder,
age 3–6
Level IV
A preexperimental single-case design and followed the OXO research design
(i) iLs Dreampad mini(i) Self-created questionnaire
(ii) FitBit Flex
(i) Increase in the number of hours of sleep received per night
(ii) Increase in observed attention and focus
(iii) Decrease in meltdowns

Wooster et al., 2015, USA [30]Various community settings, children with autism spectrum disorderLevel III
A pretest-posttest, one group design
(i) Occupational therapy-basedparent educational program
(ii) Sensory calming strategies, sleep hygiene xroutines, sleep schedules, bedtime routines, environmental modification, faded bedtime practices, and bedtime pass techniques
(i) Knowledge-basedpretest-posttest was designed and administered before and after the educational program
(ii) Children’s Sleep Habits Questionnaire (CSHQ): bedtime resistance, sleep anxiety, sleep onset delay, sleep duration, night waking, daytime sleepiness, sleep-disordered breathing, and parasomnias
(i) Significant increase in parental knowledge () on the basis of the occupational therapy educational program provided