Improving sleep quality for cancer patients: benefits of a home-based exercise intervention

Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer

PURPOSE

This study aims to provide recommendations on the optimal strategies and interventions for the prevention, screening, assessment, and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) in adult cancer populations.

METHODS

A systematic search of the published health literature was conducted to identify randomized controlled trials, clinical practice guidelines, systematic reviews, and other guidance documents. The Sleep Disturbance Expert Panel [comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers, and guideline methodologists] reviewed, discussed, and approved the final version of the guideline. Health care professionals across Canada were asked to provide feedback through an external review process.

RESULTS

Three clinical practice guidelines and 12 randomized controlled trials were identified as the evidence base. Overall, despite the paucity of evidence, the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using standardized screening tools on a routine basis. While prevention of sleep disturbance is the desired objective, cognitive behavioral therapies are effective in improving sleep outcomes. As part of the external review with 16 health care providers, 81 % indicated that they agreed with the recommendations as written.

CONCLUSIONS

Sleep difficulty is a prevalent problem in cancer populations that needs greater recognition by health professionals. Prevention, screening, assessment, and treatment strategies supported by the best available evidence are critical. Recommendations and care path algorithms for practice are offered.

Elevated peri-transplant distress in caregivers of allogeneic blood or marrow transplant patients

PURPOSE

A full-time 24/7 caregiver is required for 100 days or longer following an allogeneic blood or marrow transplant during which time caregivers have multiple demands. Although distress in caregivers is documented, generalization is limited by small sample sizes, restricted range of assessments, and lack of information as to which caregivers may be more vulnerable to distress. The purpose of this study was to describe the peri-transplant psychological status of a sample of caregivers of allogeneic transplant patients.

METHODS

We assessed caregiver mood, stress, burden, and sleep using valid self-report measures in 109 caregivers of allogeneic transplant patients prior to stem cell transplantation. Caregivers' scores were compared with norms or established cutoff scores for behavioral measures. Additionally, demographic characteristics such as age and sex were tested as predictors of distress.

RESULTS

Caregivers showed significant levels of anxiety, stress, intrusion and avoidance behaviors, and poor sleep at the start of transplant compared with established norms. Younger caregivers were more distressed than older caregivers. There were no differences in levels of distress between male and female caregivers.

CONCLUSION

The peri-transplant period is a time of heightened anxiety and distress for caregivers of allogeneic transplant patients. This study indicates that caregivers would benefit from support programs in the peri-transplant period. Recommendations for types of support that may be helpful to caregivers are provided, but additional research is needed to validate that these programs would help caregivers providing care to patients receiving an allogeneic transplant in the peri-transplant period.

A mixed exercise training programme is feasible and safe and may improve quality of life and muscle strength in multiple myeloma survivors

Background

Exercise programmes are beneficial for cancer patients however evidence is limited in patients with multiple myeloma (MM), a cancer that is characterised by osteolytic bone disease, giving rise to high levels of bone morbidity including fractures and bone pain.

Methods

We conducted a single arm phase 2 study of an exercise programme (EP) as rehabilitation for treated MM patients, to evaluate feasibility, effects on QOL and physiological parameters. Patients were given individualised programmes, comprising stretching, aerobic and resistance exercises, carried out under supervision for 3 months then at home for a further 3 months.

Results

Study uptake was high, 60 of 75 (80%) patients approached consented to the study. Screen failures (11, due to fracture risk and disease relapse) and patient withdrawals (12) resulted in a final 37 patients enrolling on the programme. These 37 patients demonstrated high attendance rates in the supervised classes (87%), and high levels of adherence in home exercising (73%). Patients reported better QOL following the EP, with improvement in FACT-G and Fatigue scores over time from baseline (p<0.01 for both, one-way repeated measures ANOVA) to 6 months. Upper and lower limb strength also improved on the EP, from baseline to 6 months (p<0.01 for both). There were no adverse reactions.

Conclusions

An EP in MM patients is feasible and safe, with high attendance and adherence. Benefits in QOL, fatigue and muscle strength await confirmation in randomized studies, prompting urgent evaluation of the benefits of EP in the rehabilitation of MM patients.

Prevalence, putative mechanisms, and current management of sleep problems during chemotherapy for cancer

Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.

A Mechanism-Based Approach to Prevention of and Therapy for Fibromyalgia

Fibromyalgia syndrome (FMS) is characterized by pain referred to deep tissues. Diagnosis and treatment of FMS are complicated by a variable coexistence with regional pain, fatigue, sleep disruption, difficulty with mentation, and depression. The widespread, deep pain of FMS can be a consequence of chronic psychological stress with autonomic dysregulation. Stress acts centrally to facilitate pain and acts peripherally, via sympathetic vasoconstriction, to establish painful muscular ischemia. FMS pain, with or without a coexistent regional pain condition, is stressful, setting up a vicious circle of reciprocal interaction. Also, stress interacts reciprocally with systems of control over depression, mentation, and sleep, establishing FMS as a multiple-system disorder. Thus, stress and the ischemic pain it generates are fundamental to the multiple disorders of FMS, and a therapeutic procedure that attenuates stress and peripheral vasoconstriction should be highly beneficial for FMS. Physical exercise has been shown to counteract peripheral vasoconstriction and to attenuate stress, depression, and fatigue and improve mentation and sleep quality. Thus, exercise can interrupt the reciprocal interactions between psychological stress and each of the multiple-system disorders of FMS. The large literature supporting these conclusions indicates that exercise should be considered strongly as a first-line approach to FMS therapy.

Exercise interventions on health-related quality of life for cancer survivors

BACKGROUND

Cancer survivors experience numerous disease and treatment-related adverse outcomes and poorer health-related quality of life (HRQoL). Exercise interventions are hypothesized to alleviate these adverse outcomes. HRQoL and its domains are important measures for cancer survivorship.

OBJECTIVES

To evaluate the effectiveness of exercise on overall HRQoL and HRQoL domains among adult post-treatment cancer survivors.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, PEDRO, LILACS, SIGLE, SportDiscus, OTSeeker, and Sociological Abstracts from inception to October 2011 with no language or date restrictions. We also searched citations through Web of Science and Scopus, PubMed's related article feature, and several websites. We reviewed reference lists of included trials and other reviews in the field.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing exercise interventions with usual care or other nonexercise intervention to assess overall HRQoL or at least one HRQoL domain in adults. Included trials tested exercise interventions that were initiated after completion of active cancer treatment. We excluded trials including people who were terminally ill, or receiving hospice care, or both, and where the majority of trial participants were undergoing active treatment for either the primary or recurrent cancer.

DATA COLLECTION AND ANALYSIS

Five paired review authors independently extracted information on characteristics of included trials, data on effects of the intervention, and assessed risk of bias based on predefined criteria. Where possible, meta-analyses results were performed for HRQoL and HRQoL domains for the reported difference between baseline values and follow-up values using standardized mean differences (SMD) and a random-effects model by length of follow-up. We also reported the SMDs between mean follow-up values of exercise and control group. Because investigators used many different HRQoL and HRQoL domain instruments and often more than one for the same domain, we selected the more commonly used instrument to include in the SMD meta-analyses. We also report the mean difference for each type of instrument separately.

MAIN RESULTS

We included 40 trials with 3694 participants randomized to an exercise (n = 1927) or comparison (n = 1764) group. Cancer diagnoses in study participants included breast, colorectal, head and neck, lymphoma, and other. Thirty trials were conducted among participants who had completed active treatment for their primary or recurrent cancer and 10 trials included participants both during and post cancer treatment. Mode of the exercise intervention included strength training, resistance training, walking, cycling, yoga, Qigong, or Tai Chi. HRQoL and its domains were measured using a wide range of measures.The results suggested that exercise compared with control has a positive impact on HRQoL and certain HRQoL domains. Exercise resulted in improvement in: global HRQoL at 12 weeks' (SMD 0.48; 95% confidence interval (CI) 0.16 to 0.81) and 6 months' (0.46; 95% CI 0.09 to 0.84) follow-up, breast cancer concerns between 12 weeks' and 6 months' follow-up (SMD 0.99; 95% CI 0.41 to 1.57), body image/self-esteem when assessed using the Rosenberg Self-Esteem scale at 12 weeks (MD 4.50; 95% CI 3.40 to 5.60) and between 12 weeks' and 6 months' (mean difference (MD) 2.70; 95% CI 0.73 to 4.67) follow-up, emotional well-being at 12 weeks' follow-up (SMD 0.33; 95% CI 0.05 to 0.61), sexuality at 6 months' follow-up (SMD 0.40; 95% CI 0.11 to 0.68), sleep disturbance when comparing follow-up values by comparison group at 12 weeks' follow-up (SMD -0.46; 95% CI -0.72 to -0.20), and social functioning at 12 weeks' (SMD 0.45; 95% CI 0.02 to 0.87) and 6 months' (SMD 0.49; 95% CI 0.11 to 0.87) follow-up. Further, exercise interventions resulted in decreased anxiety at 12 weeks' follow-up (SMD -0.26; 95% CI -0.07 to -0.44), fatigue at 12 weeks' (SMD -0.82; 95% CI -1.50 to -0.14) and between 12 weeks' and 6 months' (SMD -0.42; 95% CI -0.02 to -0.83) follow-up, and pain at 12 weeks' follow-up (SMD -0.29; 95% CI -0.55 to -0.04) when comparing follow-up values by comparison group.Positive trends and impact of exercise intervention existed for depression and body image (when analyzing combined instruments); however, because few studies measured these outcomes the robustness of findings is uncertain.No conclusions can be drawn regarding the effects of exercise interventions on HRQoL domains of cognitive function, physical functioning, general health perspective, role function, and spirituality.Results of the review need to be interpreted cautiously owing to the risk of bias. All the trials reviewed were at high risk for performance bias. In addition, the majority of trials were at high risk for detection, attrition, and selection bias.

AUTHORS' CONCLUSIONS

This systematic review indicates that exercise may have beneficial effects on HRQoL and certain HRQoL domains including cancer-specific concerns (e.g. breast cancer), body image/self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue, and pain at varying follow-up periods. The positive results must be interpreted cautiously due to the heterogeneity of exercise programs tested and measures used to assess HRQoL and HRQoL domains, and the risk of bias in many trials. Further research is required to investigate how to sustain positive effects of exercise over time and to determine essential attributes of exercise (mode, intensity, frequency, duration, timing) by cancer type and cancer treatment for optimal effects on HRQoL and its domains.

Exercise interventions on health-related quality of life for people with cancer during active treatment

BACKGROUND

People with cancer undergoing active treatment experience numerous disease- and treatment-related adverse outcomes and poorer health-related quality of life (HRQoL). Exercise interventions are hypothesized to alleviate these adverse outcomes. HRQoL and its domains are important measures of cancer survivorship, both during and after the end of active treatment for cancer.

OBJECTIVES

To evaluate the effectiveness of exercise on overall HRQoL outcomes and specific HRQoL domains among adults with cancer during active treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed MEDLINE, EMBASE, CINAHL, PsycINFO, PEDRO, LILACS, SIGLE, SportDiscus, OTSeeker, Sociological Abstracts from inception to November 2011 with no language or date restrictions. We also searched citations through Web of Science and Scopus, PubMed's related article feature, and several websites. We reviewed reference lists of included trials and other reviews in the field.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and quasi-randomized controlled clinical trials (CCTs) comparing exercise interventions with usual care or other type of non-exercise comparison intervention to maintain or enhance, or both, overall HRQoL or at least one distinct domain of HRQoL. Included trials tested exercise interventions that were initiated when adults with cancer were undergoing active cancer treatment or were scheduled to initiate treatment.

DATA COLLECTION AND ANALYSIS

Five paired review authors independently extracted information on characteristics of included trials, data on effects of the intervention, and assessed risk of bias based on predefined criteria. Where possible, we performed meta-analyses for HRQoL and HRQoL domains for the reported difference between baseline values and follow-up values using standardized mean differences (SMDs) and a random-effects model by length of follow-up. We also reported the SMD at follow-up between the exercise and control groups. Because investigators used many different HRQoL and HRQoL domain instruments and often more than one for the same domain, we selected the more commonly used instrument to include in the SMD meta-analyses. We also report the mean difference for each type of instrument separately.

MAIN RESULTS

We included 56 trials with 4826 participants randomized to an exercise (n = 2286) or comparison (n = 1985) group. Cancer diagnoses in trial participants included breast, prostate, gynecologic, hematologic, and other. Thirty-six trials were conducted among participants who were currently undergoing active treatment for their cancer, 10 trials were conducted among participants both during and post active cancer treatment, and the remaining 10 trials were conducted among participants scheduled for active cancer treatment. Mode of exercise intervention differed across trials and included walking by itself or in combination with cycling, resistance training, or strength training; resistance training; strength training; cycling; yoga; or Qigong. HRQoL and its domains were assessed using a wide range of measures.The results suggest that exercise interventions compared with control interventions have a positive impact on overall HRQoL and certain HRQoL domains. Exercise interventions resulted in improvements in: HRQoL from baseline to 12 weeks' follow-up (SMD 0.33; 95% CI 0.12 to 0.55) or when comparing difference in follow-up scores at 12 weeks (SMD 0.47; 95% CI 0.16 to 0.79); physical functioning from baseline to 12 weeks' follow-up (SMD 0.69; 95% CI 0.16 to 1.22) or 6 months (SMD 0.28; 95% CI 0.00 to 0.55); or when comparing differences in follow-up scores at 12 weeks (SMD 0.28; 95% CI 0.11 to 0.45) or 6 months (SMD 0.29; 95% CI 0.07 to 0.50); role function from baseline to 12 weeks' follow-up (SMD 0.48; 95% CI 0.07 to 0.90) or when comparing differences in follow-up scores at 12 weeks (SMD 0.17; 95% CI 0.00 to 0.34) or 6 months (SMD 0.32; 95% CI 0.03 to 0.61); and, in social functioning at 12 weeks' follow-up (SMD 0.54; 95% CI 0.03 to 1.05) or when comparing differences in follow-up scores at both 12 weeks (SMD 0.16; 95% CI 0.04 to 0.27) and 6 months (SMD 0.24; 95% CI 0.03 to 0.44). Further, exercise interventions resulted in a decrease in fatigue from baseline to 12 weeks' follow-up (SMD -0.38; 95% CI -0.57 to -0.18) or when comparing difference in follow-up scores at follow-up of 12 weeks (SMD -0.73; 95% CI -1.14 to -0.31). Since there is consistency of findings on both types of measures (change scores and difference in follow-up scores) there is greater confidence in the robustness of these findings.When examining exercise effects by subgroups, exercise interventions had significantly greater reduction in anxiety for survivors with breast cancer than those with other types of cancer. Further, there was greater reduction in depression, fatigue, and sleep disturbances, and improvement in HRQoL, emotional wellbeing (EWB), physical functioning, and role function for cancer survivors diagnosed with cancers other than breast cancer but not for breast cancer. There were also greater improvements in HRQoL and physical functioning, and reduction in anxiety, fatigue, and sleep disturbances when prescribed a moderate or vigorous versus a mild exercise program.Results of the review need to be interpreted cautiously owing to the risk of bias. All the trials reviewed were at high risk for performance bias. In addition, the majority of trials were at high risk for detection, attrition, and selection bias.

AUTHORS' CONCLUSIONS

This systematic review indicates that exercise may have beneficial effects at varying follow-up periods on HRQoL and certain HRQoL domains including physical functioning, role function, social functioning, and fatigue. Positive effects of exercise interventions are more pronounced with moderate- or vigorous-intensity versus mild-intensity exercise programs. The positive results must be interpreted cautiously because of the heterogeneity of exercise programs tested and measures used to assess HRQoL and HRQoL domains, and the risk of bias in many trials. Further research is required to investigate how to sustain positive effects of exercise over time and to determine essential attributes of exercise (mode, intensity, frequency, duration, timing) by cancer type and cancer treatment for optimal effects on HRQoL and its domains.

A randomized trial of aerobic exercise and sleep quality in lymphoma patients receiving chemotherapy or no treatments

BACKGROUND

Patients with lymphoma experience sleep problems that may be managed with aerobic exercise but no previous study has examined this issue.

METHODS

We randomized 122 patients with lymphoma to usual care (n = 62) or 12 weeks of supervised aerobic exercise training (AET; n = 60). Our primary sleep endpoint was global sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI). Secondary endpoints were the PSQI component scores. Planned subgroup analyses were also conducted.

RESULTS

Intention-to-treat analyses indicated that AET resulted in a nonsignificant (P = 0.16) improvement in global sleep quality compared with usual care [mean group difference = -0.64; 95% confidence interval (CI), -1.56 to +0.27]. In planned subgroup analyses, statistically significant or borderline significant interactions were identified for type of lymphoma (P(interaction) = 0.006), current treatment status (P(interaction) = 0.036), time since diagnosis (P(interaction) = 0.010), body mass index (P(interaction) = 0.075), and baseline sleep quality (P(interaction) = 0.041). Specifically, AET improved global sleep quality in patients with lymphoma who had indolent non-Hodgkin lymphoma (P = 0.001), were receiving chemotherapy (P = 0.013), were <2 years post-diagnosis (P = 0.005), were obese (P = 0.025), and were poor sleepers at baseline (P = 0.007).

CONCLUSIONS

AET did not significantly improve sleep quality in this heterogeneous sample of patients with lymphoma; however, clinically identifiable subgroups appeared to benefit. Future exercise trials targeting these responsive subgroups are needed to confirm these findings.

IMPACT

If replicated in larger and more focused trials, aerobic exercise may be an attractive option to manage sleep dysfunction in patients with cancer because of its favorable safety profile and other documented health benefits.

Sleep disturbance interventions in oncology patients and family caregivers: a comprehensive review and meta-analysis

Sleep disturbance is a significant problem for both oncology patients and family caregivers (FCs), and is associated with poorer functional status, quality of life, and potentially disease progression. This review describes a comprehensive literature search and meta-analysis of the efficacy of interventions for sleep disturbance in oncology patients and their FCs. This search revealed 47 studies that evaluated the effects of a number of interventions on sleep disturbance/sleep quality, as a primary or secondary outcome in oncology patients. The primary purposes of the review were to synthesize findings from intervention studies for sleep disturbance in oncology patients and their FCs; to evaluate the efficacy of these interventions; to identify gaps in the literature; and to provide directions for future research. In addition, all 47 intervention studies were evaluated in terms of key intervention and study characteristics. Both strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the efficacy of interventions, and may collectively guide future research. Finally, the importance of including the FC in sleep disturbance interventions is discussed. In light of the detrimental effects that sleep disturbance has on both the patient and the FC, this systematic review may better inform essential future intervention efforts.

Reporting characteristics of cancer pain: a systematic review and quantitative analysis of research publications in palliative care journals

Objective:

A common disorder requiring symptom palliation in palliative and end-of-life care is cancer. Cancer pain is recognized as a global health burden. This paper sought to systematically examine the extent to which there is an adequate scientific research base on cancer pain and its reporting characteristics in the palliative care journal literature.

Materials and Methods:

Search conducted in MEDLINE and CINAHL sought to locate all studies published in 19 palliative/ hospice/ supportive/ end-of-life care journals from 2009 to 2010. The journals included were: American Journal of Hospice and Palliative Care, BMC Palliative Care, Current Opinion in Supportive and Palliative Care, End of Life Care Journal, European Journal of Palliative Care, Hospice Management Advisor, Indian Journal of Palliative Care, International Journal of Palliative Nursing, Internet Journal of Pain Symptom Control and Palliative Care, Journal of Pain and Palliative Care Pharmacotherapy, Journal of Palliative Care, Journal of Palliative Medicine, Journal of Social Work in End-of-life and Palliative Care, Journal of Supportive Oncology, Palliative Medicine, Palliative and Supportive Care, and Supportive Care in Cancer. Journal contents were searched to identify studies that included cancer pain in abstract.

Results:

During the years 2009 and 2010, of the selected 1,569 articles published in the journals reviewed, only 5.86% (92 articles) were on cancer pain.

Conclusion:

While researchers in the field of palliative care have studied cancer pain, the total percentage for studies is still a low 5.86%. To move the field of palliative care forward so that appropriate guidelines for cancer pain management can be developed, it is critical that more research be reported upon which to base cancer pain therapy in an evidence-based palliative care model.

Validation of the Taiwanese version of the Athens Insomnia Scale and assessment of insomnia in Taiwanese cancer patients

CONTEXT

It is well known that insomnia is highly prevalent in cancer patients. Although various studies have used the Athens Insomnia Scale (AIS) for insomnia assessment, it has never been applied to cancer patients with insomnia.

OBJECTIVES

The purpose of this study was to establish the reliability and validity of the Taiwanese AIS version (AIS-T) and evaluate the severity of insomnia among cancer patients in Taiwan.

METHODS

Using a cross-sectional research design, 195 cancer patients (n=195) were recruited from outpatient oncology clinics.

RESULTS

Cronbach's alpha for internal consistency was 0.83, and the test-retest reliability was 0.94 over an interval of three days, based on a sample of 30 patients. Moreover, concurrent validity could be evaluated by significant correlations of the AIS-T with the Pittsburgh Sleep Quality Index-Taiwan form (PSQI-T) (r=0.82, P<0.001) and sleep efficiency measured by Actiwatch parameters (r=-0.54, P<0.001). Construct validity could be established by the Brief Fatigue Inventory-Taiwan form (r=0.56, P<0.001) and Medical Outcomes Study Short Form-36-Taiwanese version (physical component summary: r=-0.52, P<0.001; mental component summary: r=-0.53, P<0.001). The AIS-T could detect significant known-group validity from sleep quality (PSQI-T ≥ 5 or <5, respectively). The Actiwatch parameters are consistent with the results of the AIS-T, and both data sets indicate that patients experienced sleep disturbances. The prevalence of insomnia, as defined by the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th ed., was 22.56%; 49.2% subjects had significant insomnia at the score ≥ 6 at AIS-T.

CONCLUSION

This study concludes that the AIS-T is a reliable and valid instrument for assessing insomnia among cancer patients in Taiwan.

Physical activity within a CBT intervention improves coping with pain in traumatized refugees: results of a randomized controlled design

OBJECTIVE

Many traumatized refugees experience both posttraumatic stress disorder and chronic pain. Based on Mutual Maintenance Theory and the Perpetual Avoidance Model, this study examined the additional effect of physical activity within a biofeedback-based cognitive behavioral therapy (CBT-BF) for traumatized refugees.

DESIGN

In a controlled design, 36 patients were randomized into one of three conditions (CBT-BF, CBT-BF with physical activity [CBT-BF+active], and a waiting list control group [WL]). Thirty patients (n=10 in each group) completed the treatment and a follow-up assessment 3 months later. Participants' coping strategies, pain and mental health status, and physiological reactivity were assessed before and after the intervention and at 3-month follow-up. Treatment effects were analyzed using analyses of variance with baseline scores as covariates (ANCOVAs) and the Reliable Change Index.

RESULTS

The CBT-BF and CBT-BF+active groups showed improvements in all outcome measures relative to the WL group. The effect sizes for the main outcome measures were higher in the CBT-BF+active group than in the CBT-BF group. Repeated measures analyses of covariance showed significant group effects for coping strategies--in particular, for the "cognitive restructuring" and "counter-activities" subscales as well as a marginally significant group effect for "perceived self-competence"--with the CBT-BF+active group showing more favorable outcomes than the CBT-BF group. Moreover, 60% of participants in the CBT-BF+active group showed clinically reliable intraindividual change in at least one subscale of the pain coping strategies questionnaire, compared with just 30% of participants in the CBT-BF group.

CONCLUSION

Findings of improved coping strategies, larger effect sizes, and higher rates of clinical improvement in the CBT-BF+active group suggest that physical activity adds value to pain management interventions for traumatized refugees. Given the small sample size, however, these preliminary results need replication in a larger trial.

Exercise, sleep quality, and mediators of sleep in breast and prostate cancer patients receiving radiation therapy

Cancer patients often report impaired sleep quality. Impaired sleep quality may be due to increased levels of sleep-mediating cytokines resulting from cancer treatment. Exercise may have a positive influence on sleep-mediating cytokines, such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and soluble tumor necrosis factor-alpha receptor (sTNF-R), which may improve sleep quality. This two-arm pilot study compared the influence of a home-based exercise intervention with standard care/control on sleep quality and mediators of sleep. Breast and prostate cancer patients (n = 38) beginning radiation therapy were randomized to a 4-week exercise program or no exercise arm. Global sleep quality, subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction were assessed with the Pittsburgh Sleep Quality Index. IL-6, TNF-α, and sTNF-R were measured before and after intervention. There was a greater improvement in sleep quality in the exercise group from pre- to postintervention, although the difference was not significant. Additionally, there were associations between IL-6 and sleep efficiency and duration, suggesting that regulation of sleep-mediating cytokines by exercise may mediate improvements in sleep-quality components.