Interventions to Improve Sleep for People Living With or Beyond Cancer (2018–2022)

Abstract

Systematic review briefs provide a summary of the findings from systematic reviews evaluated in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings related to physical activity interventions and cognitive behavioral therapy-insomnia to improve sleep for people living with and beyond cancer.

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation for adults living with and beyond cancer?”

Current Theme Reported

The main theme of this systematic review is to focus on physical activity interventions and cognitive behavioral therapy-insomnia (CBT-I) to improve sleep.

Clinical Scenario

Sleep is essential to all aspects of health. Cancer patients frequently complain about sleep disturbances (Voiss et al., 2019). Researchers have found that breast cancer survivors, up to 10 yr posttreatment, can still report sleep problems and that poor sleep quality can result in low quality of life and increased pain, fatigue, anxiety, and depression (Lowery-Allison et al., 2018). Physical activity can help manage sleep problems and reduce the mortality risk for breast cancer (Palesh et al., 2018). Researchers report reduced fatigue in cancer survivors after high-, moderate-, and low-level physical activity (Kampshoff et al., 2015). Sleep medication is the most commonly prescribed intervention for cancer patients with sleep disturbances; however, evidence shows that nonpharmacological treatments may be more beneficial (Ancoli-Israel, 2015). Specifically, CBT-I has been demonstrated to be an effective treatment to address sleep disturbance for adults living with and beyond cancer (Suh et al., 2021). It is important for occupational therapy practitioners (OTPs) to support clients living with and beyond cancer by incorporating physical activity into their daily routines for the management of sleep disturbances.

Summary of Key Findings

Two Level 1a systematic reviews provided strong strength of evidence supporting physical and mind–body exercises to improve sleep. One Level 1a systematic review provided moderate strength of evidence supporting CBT-I to improve sleep (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Table 1.

Evidence Table for Interventions to Improve Sleep

Author, Year Level of Evidence (types of study designs) Risk of Bias (RoB)Setting	Systematic Review Details	Findings From Reviews
Subtheme: Physical Activity Interventions to Improve Sleep Two Level 1a systematic reviews provided strong strength of evidence supporting the use of moderate-intensity walking or mind–body exercise interventions to improve sleep for people with cancer (majority breast cancer).
Tang et al. (2019) Level 1a—SR and meta-analysis (comparing walking to yoga) RoB Low Setting Community or home	Participants N = 1,918, majority breast cancer patients, mean age: 55, 86% women. Majority (77% yoga and 50% walking) were people with breast cancer (Stages I–III) Number of Articles 25 RCTs (24 English and 1 published in Chinese); 13 studies yoga (n = 1,227), 12 studies walking (n = 691). Databases Searched PubMed, EMBASE, CINAHL, Cochrane Library, CNKI, and Airiti Library Outcome(s) of Interest Sleep Intervention(s) of Interest Moderate-intensity walking compared with yoga Delivery Methods Group or individual Dose Ranges Mean intervention duration, 3×/wk over 8.4 wks. Majority of yoga interventions 1× wk, 70–120 min, 4–12 wk; walking 2–7×/wk for 4 wk.	Moderate-intensity walking interventions had a statistically significant improvement in sleep disturbance and were significantly better than yoga interventions. There was a significantly better adherence in the walking interventions than in the yoga interventions. Yoga did improve sleep so client preference should decide which to use.
Kreutz et al. (2019) Level 1a—SR and meta-analysis RoB Moderate Setting Community or home	Participants N = 2,107, 100% women with breast cancer, during and after treatment, mean age 53 yrs. Number of Articles 22 RCTs Databases Searched PubMed, Web of Science, and Cochrane databases and by checking the references in the published studies, SRs, and meta-analyses Outcome(s) of Interest Objective and self-reported sleep outcomes Intervention(s) of Interest Physical (walking, aerobic, resistance, or combination) and mind–body exercise (yoga, tai chi, qigong) Delivery Methods Majority in person/supervised Dose Ranges 20–90 min (majority 60), 1–7×/wk, 4–24 wk	Both the physical and mind–body activity interventions had significant improvement in self-reported sleep outcomes for those during and after treatment. No significant improvement shown in objective outcomes.
Subtheme: CBT-I to improve sleep One Level 1a systematic review provided moderate strength of evidence supporting the use of CBT-I to improve sleep for people with cancer.
Squires et al. (2022) Level 1a—SR and meta-analysis RoB Low Setting Community or home	Participants N = 1,461; seven articles included exclusively women with breast cancer; the remainder included mixed cancers and stages; mean age and % female not reported Number of Articles 22 RCTs Databases Searched PubMed, EMBase, PsycINFO, clinicaltrials.gov, World Health Organization’s (WHO) international clinical trials registry platform via Cochrane central register of randomized controlled trials (CENTRAL), and ProQuest searched for gray literature Outcome(s) of Interest Primary outcome: insomnia severity Secondary sleep and symptom outcomes: sleep diary and wrist actigraphy-measured sleep parameters—SOL, WASO, SE, TST, and subjective sleep quality Intervention(s) of Interest CBT-I Delivery Methods Varied—individual and group, in-person, internet, and video-based Dose Ranges Duration ranged from 6 to 12 wk, generally with one 30–120 min session per week	CBT-I significantly improved insomnia severity with benefits at 3- and 6-mo follow-up (large effect size). CBT-I resulted in large effects for sleep quality, small to large effects for diary-measured sleep efficiency, WASO, TST, and SOL. No significant difference between in-person and remote CBT-I was found.

Note. CBT-I = cognitive behavioral therapy-insomnia; CINAHL = Cumulative Index to Nursing and Allied Health Literature; CNKI = China National Knowledge Infrastructure; RCT = randomized controlled trial; RoB = risk of bias; SE = sleep efficiency; SOL = sleep onset latency; SR = systematic review; TST = total sleep time; WASO = wake after sleep onset.

Bottom Line for Occupational Therapy Practice

OTPs should consider providing interventions to reduce sleep disturbances, including sleep efficiency and latency in adults with various cancer types and stages. Although practitioners can consider using both physical and mind–body exercise interventions aimed at reducing sleep problems, it is recommended that physical exercise interventions such as moderate-intensity walking, aerobic exercise, resistance exercise, or a combination of aerobic and resistance are prioritized, as they are more effective than mind–body exercises such as yoga, tai chi, and qigong. However, if a patient prefers yoga or another mind–body exercise over walking, this patient preference should be encouraged.

When using moderate-intensity walking interventions for sleep disturbances, OTPs can recommend these as independent interventions or combine them with other forms of exercise. They should consider a frequency of at least 3×/wk for ≥8 wk and closely monitor and supervise exercise sessions for high-risk patients with cardiac or pulmonary comorbidities. Monitoring the intensity of intervention through the percentage of target heart rate or perceived exertion is essential for the best outcomes. In addition, OTPs should consider CBT-I to improve sleep in adults with various cancer types and stages. Environmental interventions including eye masks and earplugs to address light and noise disturbances have been studied, especially to decrease awakenings in the hospital. Occupational therapists can play an integral role in helping individuals in establishing a regular sleep schedule with consideration to an individual’s routines, habits and contexts such as fluid intake and bathroom routines, avoiding stimulants, and exposure to daylight time (Zhao et al., 2022). It can be delivered in various ways such as individual, group, online, and telephone (Ma et al., 2021).