Evaluating the Success of Perioperative Self-Guided Meditation in Reducing Sleep Disturbance After Total Knee Arthroplasty

Evaluating the effect of preoperative interventions on sleep health in the perioperative period: a systematic review

Surgery and general anaesthesia have deleterious effects on sleep and disrupted perioperative sleep health is a risk factor for poor surgical outcomes. The objective of this systematic review was to summarise preoperative interventions that report sleep outcomes. Studies that delivered an intervention initiated >24 h prior to surgery among an adult sample without a diagnosed sleep disorder were included. Studies were excluded if they were preclinical or were not published in English. MEDLINE, MEDLINE ePubs Ahead of Print and In-process Citations, Embase, Cochrane Central Register of Controlled Trials, APA PsycINFO, CINAHL, and the Web of Science were searched on February 2, 2023. This review was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and was registered with the International Prospective Register of Systematic Reviews (identifier: CRD42021260578). Risk of bias was assessed using the Cochrane Risk-of Bias 2 tool for randomised trials and the Risk Of Bias In Non-randomised Studies - of Interventions for non-randomised trials. Certainty of findings were assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. The searching yielded 10,938 total citations, and after screening resulted in 28 randomised and 19 non-randomised trials (47 total) with 4937 participants. Sleep was a primary outcome in 16 trials; a sleep outcome was significantly improved relative to comparator in 23 trials. This review demonstrates that preoperative sleep is modifiable via a variety of interventions, including pharmacological, non-pharmacological, and nursing interventions delivered preoperatively or perioperatively. Our results should be considered with caution due to an overall intermediate to high risk of bias in the included trials, and low to very low certainty of evidence. This review supports the modifiability of sleep health among surgical patients and provides the groundwork for preoperative sleep optimisation research.

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Mind-Body Therapies in the Management of Otolaryngologic Disease: A State-of-the-Art Review of Randomized Controlled Trials

OBJECTIVE

To review and assess the peer-reviewed literature on the utility of mind-body therapy (MBT) as an adjunct treatment in the management of otolaryngologic disease.

DATA SOURCES

PubMed, Embase, and Cochrane.

REVIEW METHODS

Randomized control trials (RCTs) of MBTs in the management of otolaryngologic disease from 2002 to 2022 were identified and included according to predefined criteria. Interventions requiring expensive equipment were excluded because the goal of MBT is to be cost-conscious. All studies were subjected to a two-stage blinded screening, extraction, and appraisal process. The outcomes of the intervention and control groups were compared.

CONCLUSION

RCTs of MBTs, including breathing exercises (4), aromatherapy (2), biofeedback (2), meditation, (2), and yoga (2), have been studied in several otolaryngologic conditions, including septoplasty/rhinoplasty (3), head and neck cancer (2), facial palsy (2), and tinnitus (2). Most studies were of moderate risk of bias on appraisal, and each MBT studied was found to significantly reduce subjective and objective distress associated with the otolaryngologic condition in question.

IMPLICATIONS FOR PRACTICE

Despite a paucity of strong evidence supporting the universal use of MBTs, our review suggests that MBTs are cost-effective and easily deployable complementary tools in the management of otolaryngologic disease. Future large, methodologically rigorous RCTs are needed to address the limitations of the included studies, such as improper blinding and inappropriate statistical analysis. As MBTs are studied further, a case for their current use can be made because of their low cost and minimal risk to patients.

Interaction between functional capability and sleep quality at midterm after total knee arthroplasty: a Japanese retrospective cohort study

No report has clarified the frequency and interacting factors affecting sleep disturbance among Asian patients at midterm after total knee arthroplasty (TKA). This study aimed to evaluate the frequency of sleep disturbance at midterm after TKA in a Japanese cohort and to identify intervening factors for sleep. We hypothesized that residual knee pain and decreased functional capability negatively interact with sleep quality after TKA. A total of 209 Japanese participants (average age: 77.1 ± 8.3 years; postoperative follow-up period: 4.5 ± 1.9 years) who underwent primary TKA for knee osteoarthritis were included in this study. Sleep quality, satisfaction, pain, functional capability, joint awareness, and mental condition were evaluated using the Pittsburgh Sleep Quality Index (PSQI), Knee Society Score (KSS) 2011, Forgotten Joint Score (FJS)-12, and 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS). Multivariable analysis was performed to determine the influencing factors on PSQI. The scores for the PSQI, satisfaction with pain level while lying in bed, pain during level walking, functional activity category in the KSS 2011, awareness of the artificial joint in bed at night in the FJS-12, and SF-12 MCS were 6.7 ± 3.0, 5.8 ± 1.8, 1.6 ± 2.3, 62 ± 22, 1.5 ± 1.4, and 56 ± 9.3 on average, respectively. Sleep disturbance (PSQI ≥ 5.5) occurred in 54% of the Japanese participants. Multivariable analysis revealed that high functional capability was a significant factor associated with sleep quality improvement (p < 0.05). Decreased functional capability, not residual knee pain, negatively interacted with sleep quality. The sleep disturbance rate was high during the middle postoperative period after TKA in the Japanese cohort.

[Postoperative Sleep Disturbance in Patients Undergoing Arthroplasty: Risk Prediction Modeling Based on Logistic Regression]

Objective

To construct a risk predictive model for postoperative sleep disturbance (PSD) in patients undergoing arthroplasty by using logistic regression.

Methods

We retrospectively collected the data of 4286 patients who underwent joint replacement surgeries at a tertiary-care hospital in Chengdu, China between January 1, 2017 and September 30, 2021. With 3001 cases in the training set and 1285 cases in the test set, we constructed the model by using a logistic regression algorithm to screen for predictors in Matlab, displaying the predicted risks of postoperative sleep disturbance with nomographs. The performance of the model was assessed by the area under the curve ( AUC) of the receiver operating characteristic curve, accuracy, precision, recall, F1 value, and calibration curve.

Results

A total of 9 predictors, including post-admission preoperative sleep disturbance, ward type, body mass index, smoking status, range of diseases, joint mobility (flexion), joint mobility (extension), preoperative last hemoglobin, and type of surgery, were eventually included in the study for predictive modeling . The performance assessment findings of the predictive model were as follows, AUC value, 0.708 (95% confidence interval: 0.677-0.740), accuracy, 75.20%, precision, 65.80%, recall, 43.70%, and F1 value, 0.525. The calibration curve showed good agreement between the predicted probabilities and the actual data.

Conclusion

The model constructed in the study has good predictive efficacy and the nomographs are simple and easy to use. With this model, health workers can make preoperative prediction of the risk of PSD in arthroplasty patients based on the predictors, which facilitates early prevention and reduces the risk of postoperative sleep disturbance in patients.

Sleep Disturbances and Disorders in Patients with Knee Osteoarthritis and Total Knee Arthroplasty

➤

There is increasing evidence that patient-reported outcomes following total knee arthroplasty (TKA) are associated with psychosocial factors and pain catastrophizing. Sleep disturbance, pain, and mental health have a complex interaction, which, if unrecognized, can be associated with impaired patient-reported outcomes and dissatisfaction following TKA.

➤

The gold standard of objective sleep assessment is polysomnography, which is not feasible to use routinely for TKA patients. Wearable devices are a validated and less costly alternative.

➤

Subjective sleep measures, such as the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, or Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive test sleep domains, are simple to administer and provide additional insight into sleep disturbance. Although objective and subjective measures do not correlate precisely, they can be informative together.

➤

Sleep disturbances in the elderly population are common and multifactorial in etiology, stemming from the interplay of sleep disorders, medication side effects, and pain. Commonly prescribed medications following TKA as well as postoperative pain can exacerbate underlying sleep disturbances.

➤

Obstructive sleep apnea (OSA) is prevalent in patients seeking TKA. In the setting of OSA, postoperative opioids can cause respiratory depression, resulting in consequences as severe as death. A standardized multimodal pain protocol including anti-inflammatories and gamma-aminobutyric acid (GABA) analogues may allow for decreased reliance on opioids for pain control.

➤

Surgeons should reassure patients that postoperative sleep disturbance is common and transient, collaborate with the patient's primary care doctor to address sleep disturbance, and avoid prescription of pharmaceutical sleep aids.

Temporal changes in sleep quality and knee function following primary total knee arthroplasty: a prospective study

PURPOSE

Several patient-reported outcome measures (PROMs) have been used to assess improvement in the quality of life following total knee arthroplasty (TKA). However, there is paucity of studies evaluating the sleep quality and knee function following TKA. The primary aim of our study was to evaluate the sleep quality and knee function in primary TKA patients using the Pittsburgh Sleep Quality Index (PSQI) and Knee Society Score (KSS), respectively. The secondary aim was to assess the correlation between the two outcome measures over the course of first post-operative year following TKA.

METHODS

One hundred sixty-eight patients (female-140/male-28) with mean age of 64.63 years (± 7.50) who underwent 168 primary unilateral TKA using a cemented posterior-stabilised implant without patella resurfacing between June 2018 and October 2018 were included in the study. Global PSQI and KSS were recorded pre-operatively and post-operatively weekly up to six weeks and at one year. Body mass index (BMI) and Charlson comorbidity index (CCI) were recorded during pre-operative assessment.

RESULTS

Mean(± SD) BMI and CCI were 28.45(± 4.64) and 2.48(± 0.93), respectively. Pre-operative global PSQI of 1.98(± 0.97) increased to 13.48(± 3.36) in the first post-operative week (p < 0.001) and remained high during all the six weeks following TKA (p < 0.001), whereas at the first post-operative year, it reduced to 2.10(± 1.15) (p = 0.15). Pre-operative KSS of 52.00(± 9.98) increased to 71.67(± 6.58) and 85.49(± 4.67) at 6 weeks and the first post-operative year respectively (p < 0.001). Pre-operative global PSQI had moderate correlation with pre-operative KSS (r = 0.39) (p < 0.001). Strong correlation was noted between pre-operative global PSQI and six week post-operative KSS (r = 0.47) (p < 0.001). Low correlation was noted between pre-operative global PSQI and KSS at the first post-operative year (r = 0.10, p = 0.19) following TKA. Multiple regression analysis revealed age, CCI, and pre-operative range of motion as independent predictors of global PSQI.

CONCLUSIONS

Patients undergoing TKA experience changes in sleep quality but report an overall improvement in knee function during the first post-operative year. Sleep quality has moderate to strong correlation with knee function in the early post-operative period beyond which there is a low correlation with knee function thereby suggesting a transient phenomenon. Hence patients undergoing TKA can be appropriately counselled regarding the variation in sleep quality in the post-operative period and reassured accordingly.