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A Wake-up Call to Better Sleep, Part 2

If, as sleep experts suggest, health professionals should be monitoring sleep with the same vigilance as blood pressure, diet and exercise, this has significance for massage therapy practice. Part 1 of this article looked at the health risks associated with sleep deprivation; this second instalment will consider the compenents of good quality sleep and a sampling of the volume of current research to discover what it tells us about massage therapy’s role in helping our clients achieve it.

WHAT IS HEALTHY SLEEP?
There are three main aspects of healthy sleep, which, when they occur together, constitute a high-quality sleep pattern. They are: sufficient sleep, restorative sleep and efficient sleep.

SUFFICIENT SLEEP
While it is an overlysimplistic marker of sleep quality, sleep duration is an important bottom line. In the first half of this article, we saw the guidelines for average hours of sleep needed per age group and heard that our emerging cultural trend is to denigrate the value of sleep for work-age adults, by equating sleeping less with being more productive or having a stronger character. Experts are also expressing concern about the declining average sleep durations of toddlers, teenagers and seniors because of the negative impact on their particular physical and mental health requirements.

Just being able to get enough sleep is a big challenge for many who are ill or in pain. Insufficient sleep is a well-established component of conditions ranging from fibromyalgia to emphysema to multiple sclerosis. In individuals with cancer it is estimated that “co-morbid insomnia” incidence is 30 to 50 per cent (Theopold, 2004; reported in Berger et al., 2006). Poor sleep duration is also associated with life-change situations such as pregnancy, menopause, major surgery and terminal illness.

One aspect of massage therapy efficacy appears to be helping people get to sleep and sleep longer. An interesting study in the cancer literature (Smith et al., 2002) involved  hospital in-patients who were receiving intensive radiation or chemotherapy protocols. The intervention group (MT) received a minimum of three massages during their one-week stay as compared to a group who spent similar time in conversation with a supportive nurse (NI). Sleep was essentially maintained in the MT group but worsened significantly for the NI group. This is a substantial result for massage therapy, as anyone who has been in hospital can attest. Another study (Mok & Woo, 2004), which evaluated massage for anxiety and shoulder pain in elderly stroke patients, found that when questioned about their reactions to the massage treatments, many focused on how it benefitted their sleep, saying variations of, “I finally slept.” In a sleep assessment (Richards, 1994) involving a comparison of back massage versus standard nursing care only in patients in private rooms in a critical care unit, the massaged subjects slept more than an hour longer than the control group.

Generally speaking, these types of studies involve short, simple massage therapy protocols such as a gentle back treatment with a soothing, nurturing intention. Individuals in an acute or persistent sympathetic state are neurochemically impaired from falling asleep or sustaining sleep. Such massage-related findings point out the usefulness of massage in stimulating the elemental sense of relaxation, normalcy and safety that has soothed infants and those under duress over the course of human evolution.

Not everyone who sleeps as much (or more) as the averages suggest is getting a good night’s sleep, however. Individuals with sleep apnea often complain of waking up “exhausted” despite having slept as much as 10-11 hours. This can also happen in certain types of depressive illness. Some circadian sleep disturbances also involve  normal sleep duration. This is where the other aspects of sleep quality must be considered.

RESTORATIVE SLEEP
Healthy sleep patterns must meet the criteria encompassed in the word “restorative.” In order to be restorative, a major sleep must:

• include the correct NREM/REM cycling;
• complete several full sets of sleep cycles;
• include sufficient time in each phase to match the individual’s current requirements, including homeostatic “catch-up” as needed, or additional time in the correct specific sleep segments if the person has particular needs such as healing tissues, learning a new skill or restoring emotional balance;
• occur at the right circadian time, in that maximum melatonin concentration and minimum body temperature must both occur after the mid-point of sleep but before waking.

With respect to the last point, current thinking is that the human body cannot evolve a response to sleep deprivation nor to altered light/dark signals. Individuals who work at night and sleep during the day tend to have lighter, shorter and less restorative sleeps, and people who live nearer the poles have higher incidences of sleep-related physical and mental health problems.

In the massage client population, there are numerous factors such as stress, pain and physical impairments that reduce the restorative qualities of their sleep. When there are bodily issues such as apnea/dyspnea, pain, mobility challenges, digestive or urinary hyperactivity, heart rate irregularities, and so on, the brain will not allow itself to sink into deeper sleep modes, maintaining a more vigilant and less restorative light sleep pattern. Stress and worry tend to have similar effects. Deep sleep and REM sleep are the most easily lost or impaired, and as we discussed in Part 1 these are the sleep stages where restorative needs are mostly fulfilled.

Sleep will not be restorative without deep sleep processes that ensure function and balancing of neurochemicals, hormones, enzymes, metabolic rates and the like, and REM procedures that include thought, learning and emotion processing. All of these are essential to the physiological and psychological elements of restoration during sleep.

In a nursing article (Davis, 2003) about sleep and pain from arthritis and fibromyalgia, the author considers that the traditional concept of sleep loss as secondary to factors like pain is being replaced by a much more chicken-and-egg view of interlaced causation. As an example, she reports on a study where it was observed that simply improving sleep reduces pain levels and pain distress in arthritis sufferers. This can be accomplished in the first instance via sleep medication, but with limited efficacy because, although sleeping pills can get the person to sleep and sustain sleep duration, none have yet been created that can impel normal sleep stage cycling. Any strategy beyond an initial one of re-establishing sleep duration must involve more viable longer-term methods, and massage therapy is on the short list of those found to be most effective. She also points out that people become accustomed to the idea that good sleep is not possible, and that long-term strategies must be effective in demonstrating that consistent sleep improvement is possible – they must restore sleep confidence, if you will.

Massage therapy seems to be remarkably effective in promoting restorative sleep even in difficult circumstances. There are numerous in-hospital studies that show massage therapy has major measurable effects, usually on pain and anxiety, following the promotion of a restorative sleep. In a Mayo Clinic instructional article (Anderson & Cutshall, 2007) that talks about the benefits of massage therapy in cardiac intensive care, a specific patient anecdote is recounted in which a surgical patient was so physically uncomfortable on Day 2 post-op that he could not co-operate with normal recovery protocols. After a 20-minute session with the staff massage therapist, he “reported [the next day] that he no longer had pain in his neck and shoulders and was finally able to have a good night’s sleep. In addition he was able to walk round the unit several times and was able to use his incentive spirometer without difficulty. The numbness in his left arm and fingers went away.”

This patient had no prior experience with massage and had been initially skeptical.

Another aspect of massage effectiveness in such cases (Mitchinson et al., 2007) is a reduced need for strong analgesics, which has many health and recovery benefits. These types of results speak to the capacity of massage to help restore neurochemical availability and re-establish more normal neuromodulation. In addition to pain and anxiety, factors such as nausea, blood pressure and dyspnea often show improvement with massage, especially if there is substantial symptom distress. While most of these studies consider acute symptoms, others have found beneficial effects for chronic conditions such as fibromyalgia, migraine and low back pain. In some studies, the sleep effect is well documented and in others the reader is left to infer the degree to which sleep promotion played a role in the massage therapy results. A well-known meta-analysis (Moyer et al., 2003) suggests that promoting restorative sleep, especially deep sleep, is a likely mechanism for massage’s effects on chronic pain conditions.

Several studies have also considered the effects of massage on stress, appetite and growth in infants. One (Kelmanson & Adulas, 2006) observed sleep as a major focus, showing that their massaged low birth weight infants had significantly better quality sleep and gained more weight compared to the control group infants.

There is also an interesting small study (Ferber et al., 2002) that examines massage and circadian rhythm adjustment in newborns. Mothers in the intervention group massaged their infants at a set evening time for 14 days in a row during the first month of life. The control group mothers followed an alternate consistent bedtime routine. By eight weeks of age the massaged infants were showing better light/dark cycle adaptation than the control group babies, and at 12 weeks were producing more melatonin. This is a single study, but raises some interesting questions about whether future research might support the use of massage therapy for people with circadian sleep disorders.

EFFICIENT SLEEP
Sleep quality is also measured in terms of the Sleep Efficiency Index (SEI), which is a simple calculation of the amount of time spent asleep versus the amount of time in bed aspiring to be asleep. Normal sleep efficiency for a child or teenager is around 95 per cent, for a healthy adult, about 85 per cent, and for an 80-year-old, 75-80 per cent. In contrast to the myth that seniors need less sleep, since they have less efficiency they actually need to spend more time in bed in order to achieve restorative sleep. People who are ill, injured, in pain, stressed, depressed or anxious have substantial declines in sleep efficiency.

Sleep efficiency is notoriously bad in intensive care units, often falling under 50 per cent at a time when the need for restorative sleep is especially high. In the Richards study mentioned earlier, the massaged patients had a 20-point jump in SEI as well as substantial improvements in sleep staging. Another interesting study (Field et al., 1992), involving adolescent in-patients in a psychiatric facility, focused on massage’s capacity to reduce anxiety and negative behaviours. The study involved back massages on five consecutive afternoons. The researchers included an observation of the subjects’ night-time sleep – the average SEI was 79.7 on the first day and 91.3 on the fifth.

FOOD FOR THOUGHT
One of the issues sleep specialists have begun to tackle is that most doctors, having themselves been educated within a sleep deprivation value system, tend to have blind spots when it comes to sleep and health. A thought-provoking study (reported in Cole & Richards, 2007) created a situation where seniors who went to their doctors for a check-up were debriefed by social workers following the medical appointment. It was found that while 70 per cent reported having at least one sleep quality complaint and 45 per cent  reported substantial difficulty, few received any advice or treatment and only 17 per cent of the doctors recorded the information in the patient’s file. It is incumbent on us as massage therapists to consider whether we are doing much better.

While we assume that there is more interesting research and analysis yet to come, the volume and range of the current literature suggest massage therapy is very effective in all aspects of sleep quality promotion. We need to be monitoring our clients’ sleep information and considering its relevance in each symptom picture – in many instances sleep restoration will be the cornerstone to achieving the other treatment goals. As well, the evidence to date, suggests that powerful results often come from shorter, lighter treatment approaches that focus on soothing and nurturance. There are times when this is the most suitable and effective treatment plan, especially until restorative sleep is re-established and more tissue-challenging work becomes appropriate. Massage therapy’s effectiveness in this realm points to our need to re-think assumptions about how much of our work actually is accomplished via direct manipulation of tissue and how much through influencing factors such as metabolism, hormone production and brain chemistry.

Debra Curties is a graduate of Sutherland-Chan School & Teaching Clinic in Toronto and presently works there as executive director and longtime instructor of pathology and clinical theory. She has been involved in multiple professional organizations in Canada and the U.S. and is a recipient of the Ontario Massage Therapy Association’s Meritorious Service Award and the AMTA COS Meritorious Service Award. A co-founder of Curties-Overzet Publications, Debra is the author of Breast Massage and Massage Therapy and Cancer. She also travels extensively teaching continuing education courses for massage practitioners.