Hindawi

Occupational erapy International

Volume 2018, Article ID 8637498, 12 pages
https://doi.org/10.1155/2018/8637498

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

Eris C. M. Ho1 and Andrew M. H. Siu 2

1
Occupational Therapy Department, Queen Elizabeth Hospital, Hospital Authority, Kowloon, Hong Kong
2
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong

Correspondence should be addressed to Andrew M. H. Siu; a.siu@polyu.edu.hk

Received 21 March 2018; Revised 4 June 2018; Accepted 25 June 2018; Published 29 July 2018

Academic Editor: Claudia Hilton

Copyright © 2018 Eris C. M. Ho and Andrew M. H. Siu. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.

The effectiveness of sleep intervention developed by occupational therapists was reviewed, and a conceptual framework for
organizing the developing practice of sleep management in occupational therapy was proposed in this paper. Evidence-based
articles on sleep management practice in occupational therapy from 2007 to 2017 were retrieved. Four types of effective sleep
management intervention were identified from the literature, including the use of assistive devices/equipment, activities,
cognitive behavioral therapy for insomnia, and lifestyle intervention, and the use of assistive device was the most popular
intervention. Applying the Person-Environment-Occupation Performance (PEOP) framework, we developed a conceptual
framework for organizing occupational therapy practice in sleep management. The future development of occupation-based
sleep intervention could focus on strategies to (1) minimize the influence of bodily function on sleep, (2) promote environment
conducive to sleep, and (3) restructure daytime activity with a focus on occupational balance.

1. Introduction the addictive and side effects may pose significant threats
to health and well-being in the long run. In general, health
Sleep problem is the difficulty in initiating or maintaining care management of sleep problems involves pharmacolog-
sleep or suffering from nonrestorative sleep accompanied ical and/or nonpharmacological interventions [9]. Pharma-
by daytime functional impairment [1]. Sleep problems are a cological intervention should be monitored by physicians,
worldwide health issue, with an average prevalence rate rang- and medication is usually prescribed on a short-term basis,
ing from 10% to 30% in developed countries [2, 3]. Hong given the concerns of potential dependence and the side
Kong, a fast-paced city, has a relatively high prevalence effects of medication on cognitive performance. Nonphar-
(39.4%) of sleep problems [4]. Sleep is important for health macological sleep interventions often include sleep hygiene
and well-being. People with sleep problems are prone to suf- education, relaxation [10, 11], and cognitive-behavioral
fer from serious medical conditions, such as obesity, heart treatment for insomnia which targets the modification of
disease, high blood pressure, and diabetes [5]. Sleep problems maladaptive thoughts that perpetuate insomnia [12].
also affect cognitive performance, including alertness, reac- In occupational therapy theories, sleep is conceptualized
tion, memory, and learning [6]. Very often, sleep problems as a restorative occupation with the goal of rest and recuper-
could impact on daily occupations such as work, daily activ- ation, and good sleep and rest could support the formation of
ities, social performance, and well-being. the occupation mix of self-care, work, and leisure during the
It is uncommon for people to seek help for insomnia [7, 8]. day [13–15]. The concepts of occupational balance focus on
Instead of consulting health care professionals, many people time use and suggest that the balance between rest/sleep
use over-the-counter sleeping pills or use alcohol or substances and daytime activity is important in promoting function
to cope with sleep problems. Both methods can offer only a and well-being [13, 16–18]. Sleep has a significant impact
temporary or limited improvement of sleep quality, and on functional performance in self-care, work, and leisure.
2 Occupational Therapy International

Thus, sleep and daytime functioning are closely interrelated, on the research design. Eight out of the eleven articles were
and excessive or insufficient sleep or daytime activities will categorized as level III or above in terms of evidence, which
contribute to occupational imbalance. indicates well-conducted studies with strong evidence
As a member of the primary care team, there is clearly a including consistent results (Table 1). Three articles involved
growing need for occupational therapists to provide inter- randomized controlled trials (RCT). Based on the Cochrane
ventions for patients with sleep problems and related mental Handbook of Reviews of Effectiveness of Interventions, we
health issues. To facilitate the development of sleep manage- evaluated the risk of bias in the three RCT studies
ment practice in occupational therapy, there is a need to fur- (Table 2). The result showed that allocation sequence gener-
ther conceptualize on how sleep and occupation are linked ation, concealment, and blinding were adequately performed
and identify evidence-based occupational-based interven- in two out of the three studies. However, there are variations
tions that could be used in clinical practice. in detection and attrition bias among them. The design of the
In sum, only a few conceptual models or frameworks, like RCT studies are quite different: (1) there is broad variation in
the PEOP model or the concept of occupational balance, have the duration of intervention (varied from three days to six
attempted to discuss how sleep is related to occupation, and months); (2) study samples include both adults and elderly;
how it could fit into occupational therapy practice. While and (3) there is a lack of detail on the research methodology,
some evidence-based studies have been published on sleep for example, regarding randomization, baseline measure-
interventions in occupational therapy practice, there appears ments, and blinding procedures. As the number of studies
to be great diversity in the target groups, objectives, and com- is small and there is inadequate information to conduct
ponents of programs, and/or in methodology. There has been a formal meta-analysis of the interventions, a descriptive
no formal review or analysis of the characteristics of inter- approach was used in the review of the research evidence.
vention programs or their findings. This article aims to con- Mixed Methods Appraisal Tool (MMAT) 2001 version
duct a systematic review of the literature on occupational [32] is adopted for quality assessment. This is a five-item
therapy theories and practice for patients with sleep prob- checklist, designed for assessing the quality of the articles in
lems and the research evidence published in the past ten relation to different types of research designs. Four areas
years. The objectives are to (1) identify the key intervention focus on the methodology, outcomes, statistical process,
approaches and the components of sleep management and result interruption. Each item scored 0 or 1 and yield a
administered by occupational therapists, (2) examine the maximum of 4 points (100%). The quality of 11 articles was
research evidence on the effectiveness of occupational ther- examined, and the results are shown in Table 1. Overall
apy interventions for people with sleep problems, and (3) for- speaking, 55% of the articles demonstrate satisfactory quality
mulate a conceptual framework for sleep management in with rating 3/4 (75%) in MMAT and all level I and level II
occupational therapy. studies achieved satisfactory rating.

2. Review of Research Evidence 3. Analysis of Research Evidence

2.1. Literature Search. A literature search was performed On the whole, occupational therapy-based sleep intervention
according to the 2009 PRISMA Statement for systematic was found to be effective in improving patients’ sleep to dif-
reviews [19]. Two researchers performed the review using ferent extents. Coverage of existing services and types of
the OneSearch search engine of the Hong Kong Polytechnic intervention were reviewed systematically to build up knowl-
University, which integrated a number of research databases. edge for further discussion. Three of the studies were level I
The inclusion criteria were (1) sleep intervention developed RCTs [21, 23, 26], one was a level II nonrandomized study
by an occupational therapist, (2) sleep as primary outcome, [25], three were level III one-group nonrandomized pretest
(3) peer-reviewed articles, and (4) written in English. Papers and posttest studies (Eakman et al. 2016; [24, 30]), two were
only describing the role of occupational therapists in sleep level IV descriptive studies that included analysis of out-
management, theoretical papers, books, and editorial were comes (case series) [28, 29], and one was a level V case study
excluded. The search included papers published between [22]. Ten studies were from the United States, and one from
October 1, 2007, and October 1, 2017 (the previous ten Canada; no study on sleep intervention was published in an
years to the review). To ensure a comprehensive coverage Asian country during the review period.
of the literature, the search terms included “sleep,” “rest,”
or “insomnia” and “occupational therapy,” “occupational 3.1. Characteristics of Target Population. To conduct an anal-
therapist,” or “occupational therapy intervention.” Keyword ysis of the articles, we summarized the study background
searches were performed in five key databases: Scopus (Else- (author, year of publication, and country), format (design
vier), MEDLINE/PubMed, Science Citation Index (SCI), and sample size), patients’ characteristics (age range, sex, set-
OneFile (GALE), and ScienceDirect. 256 articles were ting, and type of disease), and type of occupational therapy
included, and after applying inclusion and exclusion criteria, outcome and intervention (Table 3).
11 articles were retained for data synthesis [20–30]. Figure 1 Sample size varies from two [28, 30] to 217 [26], and par-
shows the systematic search and review process. ticipants’ age ranges from 30 days to 82 years old. The influ-
ence of participant group in sleep management is diverse.
2.2. Risk of Bias. Two assessors conducted the quality assess- The diagnoses of participants include people with an autistic
ment of the articles. Level of evidence [31] was graded based spectrum disorder (ASD) [22, 27, 29, 30], traumatic brain
Occupational Therapy International 3

Objective
(i) Occupational therapy for patients with sleep
problems

Study selection
Identification

(i) All types of journal article

(ii) Full text published in English from Oct 1, 2007 to Oct 1, 2017
(iii) Sleep intervention led by occupational therapist
(iv) Study population not limited

Keywords
(i) “Sleep” OR “Insomnia” OR “Rest” AND
(ii) “Occupational Therapy” OR “Occupational Therapist” OR “Occupational Therapy
Intervention”

Data sources (n = 256)

(i) Scopus (Elsevier)
Screening

(ii) MEDLINE/PubMed
(iii) Science Citation Index (SCI)
(iv) OneFile (GALE)
(v) ScienceDirect

Exclude (n = 245)
(i) Not related to sleep intervention (n = 119)
(ii) Not led by occupational therapist (n = 88)
Eligibility

(iii) Combination
(iv) Duplication (n = 22)

Include (n = 11)
(i) Articles fulfilling the selection criteria (n = 11)
Included

Articles Articles Articles Articles

Articles
discussing discussing use discussing comparing
discussing
lifestyle of activity assistive interventions
CBTi
n=1 n=1 equipment n=1
n=2
n=6

Figure 1: Flowchart of the literature search and selection process.

injury (TBI) [28], and posttraumatic stress disorder (PTSD) et al. [23] compared the effectiveness of three different inter-
(Eakman et al. 2016). Other study participants include ventions: sleep aids, meditation activity, and sleep hygiene.
community-dwelling elderly, adults with sleep problems
[23, 26], and in-patients [21, 24, 25]. Two studies focus on
people with primary insomnia who had no medical or psy- 3.2.1. Use of Assistive Device/Equipment. Environment can
chiatric problems, and whose insomnia was likely related to significantly affect one’s sleep, and a key occupational ther-
lifestyle and aging issues [23, 26]. apy intervention is the use of assistive aids or positioning to
facilitate sleep onset. The six articles that used sleep aids eval-
uated the effectiveness of the Dreampad pillow, weighted
3.2. Key Types of Sleep Intervention and Effectiveness. Four blankets, and sleep tools including eye masks, earplugs, and
types of sleep intervention were identified: (1) use of assistive white noise machines. The Dreampad pillow is a patented
devices/equipment [21, 22, 24, 25, 27, 29]; (2) use of activities technology which conducts soothing music in the pillow that
[28]; (3) cognitive behavioral therapy for insomnia (Eakman relaxes the body and mind, and it is supported with a music
et al. 2016; [30]); and (4) lifestyle intervention [26]. Gutman app of library of research-backed sleep-inducing music. The
4 Occupational Therapy International

Table 1: Quality assessment by Mixed Methods Appraisal Tool (MMAT) 2001 version.

Level of evidence Quality appraisal

Author, year Research design Type
(LoE) (MMAT)
Single-arm feasibility
Eakman et al., 2016 Quantitative descriptive Level III 3/4
pilot study
Quantitative randomization
Farrehi et al., 2016 [21] RCT Level I 3/4
controlled (trials)
An ABA single-
Gee et al., 2017 [22] Qualitative Level V 1/4
subject design
Quantitative randomization
Gutman et al., 2016 [23] RCT Level I 3/4
controlled (trials)
Experimental study
Heidt et al., 2016 [24] Quantitative descriptive Level III 4/4
design
Quantitative nonrandomization
Jarus et al., 2011 [25] Waitlist control trials Level II 3/4
controlled
Quantitative randomization
Leland et al., 2016 [26] RCT Level I 3/4
controlled (trials)
A quasi-experimental,
Schoen et al., 2017 [27] single-group, pretest/ Quantitative descriptive Level III 2/4
posttest design
Wen et al., 2017 [28] Mixed-methods pilot study Mixed methods Level IV 1/4
Wolfhope et al., 2016 Mixed-methods pilot study Mixed methods Level IV 2/4
A pretest-posttest,
Wooster et al., 2015 [30] Quantitative descriptive Level III 2/4
one group design

Table 2: Risk of bias table for the RCTs.

Author, year Selection bias Performance bias Detection bias Attrition bias Reporting bias
Random sequence Allocation Blinding of Patient-reported All-cause Selective
Short-term Long-term
generation concealment participants outcomes mortality reporting
Farrehi et al.,
+ + + + ? ? ? +
2016 [21]
Gutman et al.,
? ? ? ? ? + ? +
2016 [23]
Leland et al.,
+ + + ? ? + + +
2016 [26]
Note. Categories for risk of bias are as follows: +: low risk; ?: unclear risk; −: high risk.

studies on the Dreampad pillow show that it could signifi- 3.2.2. Use of Activities. Two studies use mind-body activities
cantly improve sleep duration and latency [27, 29], improve to promote sleep, including iRest meditation, yoga, and
sleep quality, and reduce nighttime awakenings [23]. It also breathing [23, 28]. It is generally believed that calming or
helps to improve secondary outcomes, including autism- mindful activity can improve sleep quality at night, but effec-
related behaviors and attention [27, 29] and quality of life tiveness varies in the articles reviewed. The use of meditation
and parent satisfaction (Schoen et al. 2016). Gee and col- activity was found to result in statistically longer sleep time
leagues (2007) found that the weighted blanket, a sleep aid than sleep hygiene education alone [23]. Yoga and breathing
developed for patients with ASD, could increase sleep dura- techniques were not found to increase sleep duration, but
tion and shorten latency. could reduce depressive symptoms [28].
Overall, there is much evidence supporting the effective-
ness of sleep aids in promoting patients’ sleep and reducing 3.2.3. Cognitive Behavioral Therapy for Insomnia (CBTi). In
sleep disturbance during hospital stays [24] or reducing recent years, increasing numbers of occupational therapists
physical symptoms like pain [21] and fatigue [24]. Other have undergone training in how to conduct CBTi for patients
than prescribing aids, there are also studies on how position- with sleep problems. CBTi is a structured program which
ing could promote sleep in preterm babies. Jarus and col- aims to improve sleep by identifying and changing the nega-
leagues [25] found that prone position showed more sleep tive thoughts and behaviors related to it, such as cognitive
pattern and less awake patterns than supine position. traps and beliefs concerning sleep restriction [10, 12]. CBTi
 Table 3: Characteristics of included studies.

Level of evidence/clinical
Author, year, Sample size (n),
Setting subject study design, inclusion/ Type of intervention Outcome measure Results
country age, sex (M/F)
exclusion criteria (IC/EC)
(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
(i) Reduced sleep difficulties
Occupational Therapy International

Index (PSQI)
(t = 3 29, p = 0 02)
Level III (iv) Dysfunctional Beliefs and
Two months of sleep (ii) Reduced nightmares
Single-arm feasibility Attitudes about
intervention: restoring (t = 2 79, p = 0 03)
pilot study Sleep Scale (DBAS)
effective sleep tranquility (iii) Fewer dysfunctional
IC: post 911 military (v) Patient-reported outcomes
Various university (REST) program sleep-related beliefs
n = 8, veteran attending college, measurement information
Eakman et al., campuses, 911 7 group sessions (t = 3 63, p = 0 01)
age 35.6 ± 7.4, service-connected injury, system-ability to participate
2016, USA US Military 8 individual sessions (iv) Greater ability to
sex 8/0 reported sleep difficulties, in social roles and activities
veterans CBTi participate in social
willing to complete daily (PROMIS-AP)
(i) Sleep restriction roles (t = −2 86, p = 03)
diaries (vi) Patient-reported outcomes
(ii) Stimulus control Trends toward improved
EC: diagnosis of epilepsy measurement information
Sleep hygiene satisfaction with
or bipolar disorder system-satisfaction with
participation and reduced
participation in social roles
pain interference
(PROMIS-SP)
(vii) Patient-reported outcomes
measurement information
system-pain interference
(PROMIS-PI)
(viii) Canadian Occupational
Performance Measure
(COPM)
(i) Significant reduction of
(i) COPM fatigue scores over 3 days,
(i) Intervention group:
(ii) FIM compared with controls
occupational therapy
(iii) Patient-Reported Outcome (p = 0 02)
sleep tool intervention
Measurement Information (ii) Trend toward improvement
(eye mask, ear plugs,
Farrehi et al., n = 120, System Survey: fatigue, in sleep disturbance, sleep-
Hospital, Level I and white noise
2016, USA age 56.22 physical functioning, sleep related impairment,
aged 18–75 RCT machine) sleep
[21] ± 11.41 disturbance, wake disturbance physical functioning, pain
education on
(iv) Brief Pain Inventory severity, or paint
environment control
(short form) interference (p>0.1)
(ii) Control group: sleep
(v) Pain reduction associated (iii) No difference in length of
education
with sleep deprivation stay (p = 0 9) or use of
opioids (p = 0 7)
5
 Table 3: Continued.
6

Level of evidence/clinical
Author, year, Sample size (n),
Setting subject study design, inclusion/ Type of intervention Outcome measure Results
country age, sex (M/F)
exclusion criteria (IC/EC)
(i) Moderate improvement of
the measured constructs
Level V related to sleep quality
An ABA single-subject (i) Sleep quality (ii) Increased in total amount
Gee et al., Autism n = 4, design (ii) Time to fall asleep of sleep per night
Use of weighted
2017, USA spectrum age 3–6 IC: children had a (iii) Sleep duration (iii) Decrease in time to fall
blankets
[22] disorder years old diagnosis of ASD, present (iv) Behavioral ratings on asleep
with sleep problem, sensory waking (iv) Sleep between 1 and 3
over responsibility hours a night more as a
result of the weighted
blanket
(i) iRest meditation group
experienced statistically
more time asleep than both
Level I the Dreampad pillow
RCT (p < 0 006) and sleep
IC: poor sleep for 2 months, hygiene groups (p < 0 03)
agreed to follow sleep Three weeks of sleep (i) General Sleep Disturbance (ii) Dreampad pillow group
hygiene for 3 weeks intervention of the Scale experienced statistically
Gutman et al., Community n = 29,
EC: taking sleeping pills, following: (ii) Pittsburgh Sleep Quality fewer nighttime
2016, USA living, adults age 43.2 ± 12.2,
suffered from pain, medical (i) Dreampad pillow Index awakenings than iRest
[23] aged 25–65 sex 9/20
diagnosis causing sleep (ii) iRest meditation (iii) Actigraph accelerometer meditation (p < 0 04) and
disruption, pets or family (iii) Sleep hygiene (iv) Sleep diary sleep hygiene groups
members causing sleep (p < 0 004)
disruption, pregnant or (iii) No difference was found
smokers between groups in perceived
sleep quality, length of time
needed to fall asleep, or
next-day fatigue level
(i) Significant improvement in
fatigue (t = 5 5, p < 0 001),
(i) Patient-Reported Outcome
sleep disturbance (t = 3 9,
Level III (i) Simple sleep- Measurement Information
Heidt et al., n = 52, p < 0 001), and wake
Hospital, Experimental study enhancing education System Survey: fatigue,
2016, USA age 57.5 ± 9.9, disturbance (t = 3 8,
aged 18–75 design with single sample (ii) Sleep-enhancing physical functioning, sleep
[24] sex 29/23 p < 0 001)
and pre-post testing tools disturbance, wake
(ii) No significant improvement
disturbance
in the physical function
aspect (p = 0 1)
Occupational Therapy International
 Table 3: Continued.

Level of evidence/clinical
Author, year, Sample size (n),
Setting subject study design, inclusion/ Type of intervention Outcome measure Results
country age, sex (M/F)
exclusion criteria (IC/EC)
Level II (i) In the prone position, there
RCT were more approach
n = 32, IC: birth weight less than reactions than withdrawal
(i) Actigraph measurement
Jarus et al., Meir Medical postmenstrual 1750 g, stable in room air (i) Alternate position reactions (p < 0 001) while in
(ii) Naturalistic observations
2011, Canada Center, preterm age (days) EC: major congenital every 3-4 hours the supine position
of newborn behavior
[25] infants 30.37 ± 2.57, anomalies or major after feedings (ii) In the prone position, more
(NONB)
sex 12/20 neurological illness, patterns were observed as
using medication affects the opposed to more awake
Occupational Therapy International

infant’s sleep-wake cycle patterns

(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
(i) SF 36
napped at follow-up
Various elderly (ii) Center for Epidemiologic
Leland et al., n = 217, Among participants who
community Level I (i) Occupation-based Studies Depression Scale-
2016, USA age 74.2 ± 7.7, stopped napping, those who
centers, RCT intervention Revised
[26] sex 65/141 received an occupation-based
age > 65 (iii) Sleep time
intervention replaced
(iv) Napping time
napping time with nighttime
sleep, and those who did not
receive an intervention
experienced a net loss of total
sleep (p < 0 05)
Level III
(i) Procedures were acceptable
A quasi-experimental,
(i) A sleep diary documented and feasible for families. All
single-group, pretest/
average sleep duration and measures were sensitive to
posttest design
average time to fall asleep change. Children with ASD
IC: parents reported
during the preintervention demonstrated significant
moderate to severe sleep
South Shore phase and the last 2 weeks change in sleep duration
disturbance
Therapies and of the treatment phase (t = −3 01, p < 0 003) and
EC: had stressful life
Schoen et al., Knippenberg, (ii) The Children’s Sleep time needed to fall asleep
circumstance that could (i) iLs Dreampad
2017, USA Patterson, Langley, n = 15 Habits Questionnaire (t = −2 83, p < 0 005) from
account for new onset pillow
[27] & Associates, (CSHQ) pretest to intervention
sleep difficulties, medical or
children with autism (iii) The Pediatric Quality of (ii) Improvements were noted
psychiatric illness,
spectrum disorder Life Inventory (PedQL) in autism-related behaviors,
medication known to cause
(iv) The Parental Concerns attention (t = −2 63,
insomnia or sedation,
Questionnaire (PCQ) p < 0 009), and quality of life
receiving medication or
(v) The Swanson, Nolan, and (t = −2 94, p < 0 003), SNAP-
CBT for sleep disorder,
Pelham (SNAP-IV) IV (t = −2 44, p < 0 015);
could not comply with sleep
parent satisfaction was high
7

diary or use of pillow

 8

Table 3: Continued.

Level of evidence/clinical
Author, year, Sample size (n),
Setting subject study design, inclusion/ Type of intervention Outcome measure Results
country age, sex (M/F)
exclusion criteria (IC/EC)
Level IV
Mixed-methods pilot
study
IC: diagnosis of chronic
(i) Pittsburgh Sleep Quality (i) One participant showed 25%
TBI (6-month postinjury),
Index reduction in depressive
Wen et al., ability to stand/move, ability (i) Yoga
Traumatic n = 2, (ii) Neuropathy Pain Scale symptoms, and other
2017, USA to follow a 3-step (ii) Breathing
brain injury age 31 (iii) Behavior Rating Inventory improvements were found in
[28] command, ability to read/ exercise
of Executive Function the inhibition and emotional
speak English
(iv) Beck Depression Inventory control scales of the BRIEF
EC: neurological conditions
like bipolar disorder and
attention deficit
hyperactive disorder
(i) Increase in the number of
Level IV hours of sleep received per
Wolfhope Saint Francis
n = 2, A preexperimental single- (i) iLs Dreampad (i) Self-created questionnaire night
et al., 2016, University, autism
age 3–6 case design and followed mini (ii) FitBit Flex (ii) Increase in observed
USA [29] spectrum disorder
the OXO research design attention and focus
(iii) Decrease in meltdowns
(i) Occupational
(i) Knowledge-basedpretest-
therapy-based
posttest was designed and
parent educational
administered before and
program
after the educational
(ii) Sensory calming (i) Significant increase in
program
Various community strategies, sleep parental knowledge
Wooster Level III (ii) Children’s Sleep Habits
settings, children hygiene xroutines, (p = 0 003) on the basis of
et al., 2015, A pretest-posttest, one Questionnaire (CSHQ):
with autism sleep schedules, the occupational therapy
USA [30] group design bedtime resistance, sleep
spectrum disorder bedtime routines, educational program
anxiety, sleep onset delay,
environmental provided
sleep duration, night
modification, faded
waking, daytime sleepiness,
bedtime practices,
sleep-disordered breathing,
and bedtime pass
and parasomnias
techniques
Occupational Therapy International
Occupational Therapy International 9

Environment Person Environmental modification

Environment Bodily function
(i) Physical/social/cultural (i) Physiological/psychological/cognitive
Environmental modification Use of activity

Lifes
Work /

Activit

Habi
Daily
education CBTi

tyle
t
y
Sleep
Decrease Leisure/ Promote
ADL/IADL
function social function &
Occupational
onall imbalance
patio Occupational
Occupation
nal balance
b
bala well-being

Time use Characteristic

CBTi
(i) Time used in different (i) Values and meaning/social
Lifestyle intervention occupation or alone/active or
sedentary Use of activity
Participation
(i) Pattern of occupation mixed
Environmental modification
Subjective choice of occupation

Figure 2: Occupational therapy on sleep management.

is usually conducted on a weekly basis and monitored via dif- guiding practice (Eakman et al. 2016; Wooster et al. 2016),
ferent assessments, like a sleep diary. Two of the studies while another refers to daytime engagement and how it is
adopted CBTi as the core of their sleep management pro- related to sleep based on a lifestyle redesign program [26].
gram. They found that CBTi could significantly improve In this part of the review, we would like to propose a concep-
the ability to handle sleep issues in patients with PTSD tual model for organizing sleep interventions and occupa-
[30], reduce their sleeping difficulties and nightmares, reduce tional therapy practice based on the PEOP framework
dysfunctional sleep beliefs, and improve their ability to par- (Christiansen et al. 2011). Figure 2 shows how we could inte-
ticipate in social roles (Eakman et al. 2016). grate the theory and practice of occupational therapy based
on current research evidence and explains the unique role
3.2.4. Lifestyle Intervention. Among the selected articles, of occupational therapy in sleep management.
there is one large-scale RCT that focuses on lifestyle interven- Based on the PEOP framework, occupation-based sleep
tion to promote sleep among community-dwelling elderly management can focus on three levels: (1) person: minimiz-
[26]. The lifestyle intervention emphasizes the promotion ing the influence of bodily function on sleep (Eakman et al.
of healthy sleep habits and activity rescheduling and facili- 2016; [22, 25, 28, 30]); (2) environment: promoting environ-
tates role transition in aging through education, experience ment conducive to sleep [21, 24, 27, 29]; and (3) occupation:
sharing, and goal setting. Too much or too little daytime restructuring daytime activity [26].
activity is highly related to sleep pattern at night; reschedul- First, the “person” level relates to bodily function, which
ing of daytime activity helps one in achieving a balanced life- includes physiological, psychological, and cognition perfor-
style to facilitate sleep during night time. The program mance. Bodily function can affect one’s sleep. People suffer-
demonstrates positive changes in sleep behaviors, including ing from depression and pain and the elderly very often
increased sleeping hours, reduced sleep difficulties, and have sleep problems (Foley et al. 2004). Sleep interventions
reduced nightmares [26]. Clients also reduced daytime nap- targeting bodily function could include the use of activity to
ping and increased daytime engagement, especially social promote calming effects on the body to shorten sleep latency
activities. This study suggests that sleep management does [23, 28]; CBTi could be applied to manage the cognitive traps
not only just concern sleep but also daytime functioning. in PTSD (Eakman et al. 2016; [30]); or a weighted blanket
could be used to address the overresponsivity of children
4. Conceptual Framework for Occupational with ASD [22] or to position a preterm baby [25]. Although
Therapy Practice in Sleep Management bodily function cannot be improved quickly and is not totally
reversible, this factor should also be considered with the aim
Few of the 11 articles explicitly mention the conceptual or of maximizing functioning.
theoretical framework used. Only two studies mention the Second, occupational therapists could use environmental
use of cognitive behavioral therapy as a framework for interventions in the physical, social, or cultural domains to
10 Occupational Therapy International

address sleep problems. This review shows that the control of balance, and it can be applied to assess the occupational
environmental factors plays a significant role in sleep man- balance of both patients and healthy individuals. More
agement [21, 24, 27, 29]. Examples of such an intervention comprehensive occupation-based assessment will definitely
include the use of the newly designed Dreampad pillow, advance the development of sleep management in occupa-
weighted blankets, and sleep tools; controlling light, temper- tional therapy.
ature, and humidity levels; and the use of body positions to
tackle sleep problems caused by specific diseases. In Hong
Kong, a densely populated city, living environment may cre- 6. Limitations
ate sleep barriers for patients. Circumstances permitting the
There are two key limitations of this study. First, only eleven
use of sleep tools to reduce environmental stimuli may facil-
studies were identified by the review. Although this reflects
itate sleep. Besides physical environment, social environmen-
the lack of evidence-based studies of sleep intervention in
tal factors, such as sleep partner (both human and pets), also
occupational therapy, we may consider expanding the search
affect sleep and should be considered in an intervention.
and be more inclusive in the review. One such possibility is to
Third, the subjective choice of daily activities is the most
widen the search criteria and include papers studying multi-
important area in future service development for sleep man-
disciplinary sleep intervention programs in which the occu-
agement. Everyone has the right to determine the combina-
pational therapists participate as a team member. The
tion of daily occupations to achieve occupational balance
second limitation of this study is that it could not provide
even when suffering from illness. However, one’s daytime
estimates on effect sizes of occupational therapy interven-
activity can clearly have an impact on one’s sleep [26]. In
tions in sleep management. Only three studies are level I clin-
sleep management programs, it is important for therapists
ical trials which could be used for meta-analysis. We decided
to guide clients to choose daily activities and develop occupa-
not to proceed with meta-analysis based on a small number
tional balance (Figure 1), including how to organize daytime
of studies, which are implemented using different interven-
occupations (activity of daily living/household, work/educa-
tion methods for different clients.
tion, and leisure/social), how to allocate time to daily occupa-
While studies on sleep in occupational therapy have
tions, and how to restructure activity patterns according to
become increasingly conspicuous, the number of relevant lit-
the meaning and purpose of activities.
erature remains limited. It is necessary to extend the scope of
The above analysis shows that occupational therapists
research by including patients from different disease groups
provide sleep management guidance to patients from diverse
and types and patients with reported history of sleep prob-
disease groups in all age groups. Most of the programs pre-
lems. There is a great diversity in the methodologies adopted
sented in the literature were developed for a specific disease
by the selected articles, including case-control trial, RCT, and
group, such as children with ASD ([22, 27, 29]; Wooster
case series. If only RCTs were to be reviewed here, only three
et al. 2016) or traumatic brain injury [28]. Although sleep is
articles would have been included, which would have limited
highly correlated with mental condition, the development
the analysis. The heterogeneity of study designs may also
of sleep programs in mental healthcare is relatively limited.
have affected the analysis. Moreover, specific database in
Only one study among the 11 reviewed articles focuses on
occupational therapy may be considered to include for
this (Eakman et al. 2016). The role of occupational therapists
revealing more related articles in occupational therapy such
in sleep management in mental health settings has been
as OTseeker and OTsearch.
explored over a long time (Faulkner et al. 2015), but the effec-
tiveness of the proposed intervention has not been evaluated
scientifically. A huge number of people suffering from 7. Conclusion
insomnia in Hong Kong present with initial mood distur-
bance; early intervention plays an important role to prevent Sleep is a restorative occupation from the occupational ther-
long-term healthcare burden. apy perspective. Its main function is to help us recover from
daytime occupations, to build up energy to move forward.
5. Occupational Therapy-Based Sleep/Daytime The selected literature provides an overview of the scope
Functional Assessment and types of sleep intervention. The findings, along with
the rising incidence of sleep problems, indicate a need for fur-
This review has shown that occupational therapists should ther exploration in this topic. Occupational therapists could
assess the occupational balance between daytime activities address the needs of people with insomnia, by developing
and sleep. Limited information on occupational therapy- sleep management programs using environmental interven-
related assessment was found in the literature. The Canadian tion, assistive devices/equipment, the use of activity, CBTi,
Occupational Performance Measurement (COPM) (Eakman and lifestyle interventions. Based on the PEOP framework,
et al. 2016; [21]) and the Functional Independent Measure occupation-based sleep interventions can aim to (1) mini-
(FIM) [21] have been used in some sleep management mize the influence of bodily function on sleep; (2) promote
studies to investigate daytime functioning. FIM focuses environment conducive to sleep; and (3) restructure daytime
on one’s functioning while COPM focuses on occupational activity with a focus on occupational balance. Further devel-
performance and satisfaction, without fully exploring life- opment of sleep management from an occupational therapy
style. Dür et al. [33] developed an occupational balance perspective will strengthen the role of sleep within clinical
questionnaire (OB-Quest) to further explore occupational practice, education, and research domains.
Occupational Therapy International 11

Conflicts of Interest being,” Canadian Journal of Occupational Therapy, vol. 71,

no. 4, pp. 202–209, 2004.
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