Rehabilitation: The Critical Role of Sleep Hygiene

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August 3, 2022|Craig H. Lichtblau, M.D., P.A. International Journal of Physical Medicine and Rehabilitation|

Craig H. Lichtblau1,2,3*, Christopher Warburton4, Gabrielle Meli4, Allyson Gorman5

1Medical Director of The Osseointegration Program at The Paley Orthopedic and Spine Institute at St. ,West Palm Beach, FL, USA; 2Physical Medicine and Rehabilitation Consultant to The Paley Orthopedic and Spine Institute, St. Mary’s Medical Center, West Palm Beach, Florida, USA; 3Consultant to Children’s Medical Services for The State of Florida, District 9, St. Mary’s Medical Center, West Palm Beach, Florida 33407, United States; 4University of Miami Miller School of Medicine, Miami, FL, USA; 5Medical College of Wisconsin, Wauwatosa, Wisconsin, USA

ABSTRACT
Sleep is vital to life, and poor sleep hygiene is associated with an array of health deficits. Through its physiological impact, inadequate sleep undermines the rehabilitation process, preventing optimal recovery. Without proper sleep, patients experience fatigue, are at increased risk for psychiatric illness, and tend to have a lower threshold for pain. Each of these consequences of insufficient sleep is associated with poorer rehabilitation outcomes. To ensure that rehabilitation is successful, physicians must evaluate, monitor, and address potential sleep disturbances as well as their sequelae in relevant patients. Referral to mental health professionals, such as psychiatrists and psychologists, may be warranted to restore healthy sleep cycles.

Keywords: Rehabilitation; Sleep; Sleep hygiene; Anxiety; Depression; Fatigue

INTRODUCTION

Sleep is critical for human life, facilitating key biological functions [1-3]. As such, inadequate sleep leads to adverse effects, which may impact cognition, emotion, immunity, metabolism, and other bodily systems [4]. Despite its importance, sleep is often deprioritized or overlooked as integral to health, and a large proportion of the population does not get enough of it [5]. According to the U.S. Centers of Disease Control and Prevention (CDC), 1 out of every 3 adults suffers from insufficient sleep [6]. Between 50 million and 70 million adults face sleep disorders in the U.S. alone [7,8].

While sleep habits are linked to a variety of diseases, including cardiovascular disease, stroke, neurodegenerative disease, migraine, and type 2 diabetes, they also play a critical role in rehabilitation processes and are therefore vital for recovery [9- 23]. Sleep dysfunction has been shown to be associated with reduced health-related quality of life with respect to both physical and mental health during rehabilitation as well as negative rehabilitation outcomes [22-24].

Critically, good sleep hygiene involves not only getting enough hours of sleep but ensuring that sleep is restful. Such restful sleep requires a balance of the sleep stages; particularly Slow-Wave Sleep (SWS) and Rapid Eye Movement (REM) sleep [25]. When sleep is disturbed, the progression through the sleep stages is interrupted. It is essential that those undergoing rehabilitation get the guidance they need to restore their sleep cycles to ensure the volume and quality of sleep required for successful rehabilitation [24].

LITERATURE REVIEW

Poor sleep leads to fatigue, which undermines the rehabilitation process

Physical and mental fatigue has been identified as barriers to rehabilitation and patient recovery and must therefore be addressed as a prerequisite for optimal rehabilitation outcomes [26]. Though disease and long-term stress have often been pointed to as the culprits of fatigue, there is increasing evidence that disturbed sleep may be a more important contributor [27]. Most experts agree that without proper sleep, physiological resources are not adequately restored, which leads to fatigue.

Not only does fatigue frequently occur in those with disordered sleep, but it is the most common complaint associated with insomnia [28,29]. Research into the link between sleep and fatigue has revealed that fatigue is driven more by poor sleep quality than by other sleep factors and that it contributes to mental fatigue more than other potential contributors such as workload or lack of exercise [27,30].

Correspondence to: Dr. Craig H. Lichtblau, Physical Medicine and Rehabilitation Consultant to the Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, Florida, USA, E-mail: [email protected]

Received: 12-Sep-2022, Manuscript No. JPMR-22-18897;

Editor assigned: 16-Sep-2022, PreQC No. JPMR-22-18897 (PQ);

Reviewed: 06-Oct-2022, QC No. JPMR-22-18897;

Revised: 12-Oct-2022, Manuscript No. JPMR-22-18897 (R);

Published: 21-Oct-2022, DOI: 10.35248/2329-9096.22.S18.002.

Citation: Lichtblau CH, Warburton C, Meli G, Gorman A (2022) Rehabilitation: The Critical Role of Sleep Hygiene. Int J Phys Med Rehabil. S18:002. Copyright: © 2022 Lichtblau CH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

While the detriment of physical fatigue in rehabilitation is clear, the mental fatigue resulting from lack of sleep may also be quite pernicious with respect to recovery because of its profound impact on patients’ attention and task performance [31,32]. The influence of sleep on task performance has indeed been widely demonstrated. Even young healthy subjects who learn new motor skills are more likely to display performance improvements following sleep compared to an equivalent duration of wakefulness [33-35]. These effects of sleep on motor performance are likely mediated by the memory consolidation process that occurs only during sleep [36].

Luckily, fatigue can be overcome with improvements to sleep hygiene [30,37]. Research has shown that fatigue can be reversed even in those who change their sleep habits by taking only a 20-minute nap each day [38]. Given the importance of avoiding fatigue during the rehabilitation process, strategies aimed at reducing fatigue by enhancing the duration or quality of sleep should be considered in the relevant patient population.

Successful rehabilitation relies on mental health, which is disrupted by poor sleep habits

Psychiatric disorders are associated with limitations in physical functioning, and those with such disorders are less likely to achieve successful medical rehabilitation results [39,40]. In the context of rehabilitation, psychiatric disorders are not only detrimental due to their effects on physical functioning but also due to their behavioral consequences, such as their tendency to reduce therapy adherence [40]. To ensure optimal rehabilitation results, it is therefore critical to prevent or treat psychiatric illness in rehabilitation patients.

Addressing sleep cycle disturbances offers one key strategy for boosting mental health in rehabilitation patients. Poor sleep is known to contribute to psychiatric illnesses, including anxiety, anxiety-related disorders, depression, and other mood disorders [4,41-45] While disturbed sleep is often considered a symptom of psychiatric disorders, data suggest that poor sleep is also a causal factor contributing to these disorders [5,46-48]. A classic example is the increased risk of developing depression amongst those with chronic fatigue [49,50].

In addition to increasing the risk for mental health disturbances, poor sleep hygiene also exacerbates preexisting psychiatric conditions [51]. Given that those undergoing rehabilitation often face psychological challenges that may induce psychiatric symptoms, it is important these patients achieve good sleep hygiene to avoid developing or exacerbating such symptoms. Without proper management of sleep and mental health, the rehabilitation process is likely to be significantly jeopardized. In many cases, referring patients to psychiatrists and psychologists may offer the dual benefit of helping to restore healthy sleep cycles while also addressing co-morbid mental health issues.

Poor sleep hygiene promotes pain, which hinders the rehabilitation process

While it is intuitive that pain interferes with rehabilitation, appreciating the critical role of sleep in minimizing that pain is less intuitive. However, sleep disruption prevents optimal rehabilitation by reducing pain tolerance, which enhances the risk for new pain as well as for exacerbation of exiting pain [52- 60].

Preclinical research has also shown that injuries preceded by acute sleep loss, result in greater pain than injuries preceded by adequate sleep [7]. Interestingly, sleep deprivation for just one night has been shown to impair descending pain pathways, leading to sensitization in peripheral pain pathways and enhanced spinal excitability [61]. Similarly, heightened pain sensitivity has been observed in certain patients following just one night of sleep problems [25,62].

Several chemicals and brain systems are implicated in the effects of sleep deficiency on pain, including dopamine, serotonin, melatonin, adenosine, nitric oxide, and the opioid and orexinergic systems [25,63,64]. For instance, sleep deprivation leads to the downregulation of certain dopamine receptors, which may alter the experience of pain, such that those with poor sleep hygiene suffer from hyperalgesia [55,65].

In those undergoing rehabilitation, sleep disturbances may also contribute to pain by adversely affecting the immune system, leading to inflammation, and potentially exacerbating the conditions for which rehabilitation is intended [25,66]. Importantly, pain in these patients can be reduced when disordered sleep is effectively managed [53]. Accordingly, effective pain management improves functional recovery during rehabilitation across several contexts [67-69].

Restore sleep cycle to support successful rehabilitation

Physicians who are managing rehabilitation need to address interrupted sleep cycles to prevent or overcome fatigue, psychiatric symptoms, and pain that can disrupt the rehabilitation process and lead to suboptimal outcomes. There are a variety of ways to promote healthy sleep. The most frequently used non-prescription sleep aid is melatonin, which has been shown to promote total sleep time, reduce the time required to fall asleep, and enhance sleep efficiency [70,71].

In addition to melatonin, prescription sleep drugs like Ambien-a sedative that works by modulating GABA receptor as well as other drugs such as antidepressants, benzodiazepines, and antihistamines may improve sleep cycle [72-75]. For example, low dose sedative antidepressants such as amitriptyline or nortriptyline are often prescribed in those with comorbid mental health disturbances and difficulty with sleep [76].

Nonpharmacological interventions can also support healthy sleep. These approaches include Cognitive Behavioral Therapy (CBT) and relaxation techniques, such as yoga and meditation [77,78]. There is some evidence that acupuncture can also improve sleep hygiene [79].

CONCLUSION

Regardless of the specific approach to restore healthy sleep cycles, referral to mental health professionals like psychiatrists or psychologists may be warranted. While the best approach to ensuring proper sleep is likely to be patient-dependent, it is vital to address and monitor sleep and the symptoms of inadequate sleep in those undergoing rehabilitation.

REFERENCES

  1. Xie L, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013; 342(6156):373-7.
  1. Siegel JM. Sleep viewed as a state of adaptive inactivity. Nat Rev Neurosci. 2009;10(10):747-753.
  2. Benington JH, Craig Heller H. Restoration of brain energy metabolism as the function of sleep. Prog Neurobiol. 1995;45(4):347- 360.
  3. Richards A, Kanady JC, Neylan TC. Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms. Neuropsychopharmacology. 2020;45(1):55-73.
  4. Freeman D, Sheaves B, Waite F, Harvey AG, Harrison PJ. Sleep disturbance and psychiatric disorders. Lancet Psychiatry. 2020;7(7):628-637.
  5. 1 in 3 adults don’t get enough sleep. CDC. 2022.
  6. Vanini G. Sleep Deprivation and Recovery Sleep Prior to a Noxious Inflammatory Insult Influence Characteristics and Duration of Pain. Sleep. 2016;39(1):133.
  7. Altevogt BM, Colten HR, Boat TF, Mignot E, Litt IF, et al. Sleep disorders and sleep deprivation: an unmet public health problem.
  8. Nagai M, Hoshide S, Kario K. Sleep duration as a risk factor for cardiovascular disease- a review of the recent literature. Curr Cardiol Rev. 2010;6(1):54-61.
  9. Lao XQ, Liu X, Deng HB, Chan TC, Ho KF, Wang F, et al. Sleep Quality, Sleep Duration, and the Risk of Coronary Heart Disease: A Prospective Cohort Study With 60,586 Adults. J Clin Sleep Med. 2018;14(1):109-117.
  10. Koo DL, Nam H, Thomas RJ, Yun CH. Sleep Disturbances as a Risk Factor for Stroke. J Stroke. 2018;20(1):12-32.
  11. Grandner MA, Jackson NJ, Pak VM, Gehrman PR. Sleep disturbance is associated with cardiovascular and metabolic disorders. J Sleep Res. 2012; 21(4):427-433.
  12. Patyar S, Patyar RR. Correlation between Sleep Duration and Risk of Stroke. J Stroke Cerebrovasc Dis. 2015;24(5):905-911. doi:10.1016/J. JSTROKECEREBROVASDIS.2014.12.038
  13. Ma C, Pavlova M, Liu Y, Liu Y, Huangfu C, Wu S, et al. Probable REM sleep behavior disorder and risk of stroke: A prospective study. Neurology. 2017;88(19):1849-1855.
  14. Ooms S, Overeem S, Besse K, Rikkert MO, Verbeek M, Claassen JAHR. Effect of 1 night of total sleep deprivation on cerebrospinal fluid β-amyloid 42 in healthy middle-aged men: A randomized clinical trial. JAMA Neurol. 2014;71(8):971-977.
  15. Tarasoff-Conway JM, Carare RO, Osorio RS, Glodzik L, Butler T, Fieremans E, et al. Clearance systems in the brain-implications for Alzheimer disease. Nat Rev Neurol. 2015;11(8):457-470.
  16. Glaser N, Styne D. Weighing the causal evidence that associates short sleep duration with obesity. Pediatrics. 2017;140(3).
  17. Shan Z, Ma H, Xie M, Yan P, Guo Y, Bao W, et al. Sleep duration and risk of type 2 diabetes: a meta-analysis of prospective studies. Diabetes Care. 2015;38(3):529-537.
  18. Kelman L, Rains JC. Headache and sleep: Examination of sleep patterns and complaints in a large clinical sample of migraineurs. Headache. 2005;45(7):904-910.
  19. Sahota P. Morning headaches in patients with sleep disorders. Sleep Med. 2003;4(5):377.
  20. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993;53(1):65-72.
  21. Kim WH, Jung HY, Choi HY, Park CH, Kim ES, Lee SJ, et al. The associations between insomnia and health-related quality of life in rehabilitation units at 1month after stroke. J Psychosom Res. 2017;96:10-14.
  22. Iddagoda MT, Inderjeeth CA, Chan K, Raymond WD. Post-stroke sleep disturbances and rehabilitation outcomes: a prospective cohort study. Intern Med J. 2020;50(2):208-213.
  23. Laver KE, Spargo C, Saggese A, Ong V, Crotty M, Lovato N, et al. Sleep disturbance and disorders within adult inpatient rehabilitation settings: A systematic review to identify both the prevalence of disorders and the efficacy of existing interventions. J Am Med Dir Assoc. 2020;21(12):1824-1832.e2.
  24. Yang CP, Wang SJ. Sleep in patients with chronic migraine. Current Pain Headache Rep. 2017;21(9):1-7.
  25. Chestnut TJ. Fatigue in stroke rehabilitation patients: A pilot study. Physiother Res Int. 2011;16(3):151-158.
  26. Åkerstedt T, Knutsson A, Westerholm P, Theorell T, Alfredsson L, Kecklund G. Mental fatigue, work and sleep. J Psychosom Res. 2004;57(5):427-433. (All versions)
  27. Fortier-Brochu É, Beaulieu-Bonneau S, Ivers H, Morin CM. Relations between sleep, fatigue, and health-related quality of life in individuals with insomnia. J Psychosom Res. 2010;69(5):475-483.
  28. Riedel BW, Lichstein KL. Insomnia and daytime functioning. Sleep Med Rev. 2000;4(3):277-298.
  29. Lavidor M, Weller A, Babkoff H. How sleep is related to fatigue. Br J Health Psychol. 2003;8(Pt 1):95-105.
  30. Yang C, Lin Y, Cai MY, Qian ZQ, Kivol J, Zhang WJ. Cognitive fatigue effect on rehabilitation task performance in a haptic virtual environment system. J Rehabil Assist Technol Eng. 2017;4:2055668317738197.
  31. Hvolby A. Associations of sleep disturbance with ADHD: Implications for treatment. Atten Defic Hyperact Disord. 2015;7(1):1-18.
  32. Gudberg C, Wulff K, Johansen-Berg H. Sleep-dependent motor memory consolidation in older adults depends on task demands. Neurobiol Aging. 2015;36(3):1409-1416.
  33. Robertson EM, Pascual-Leone A, Press DZ. Awareness modifies the skill-learning benefits of sleep. Curr Biol. 2004;14(3):208-212.
  34. Doyon J, Bellec P, Amsel R, Penhune V, Monchi O, Carrier J, et al. Contributions of the basal ganglia and functionally related brain structures to motor learning. Behavioural brain research. 2009;199(1):61-75.
  35. Gudberg C, Johansen-Berg H. Sleep and Motor Learning: Implications for Physical Rehabilitation After Stroke. Front Neurol. 2015;6.
  36. Cooke KM, Kreydatus MA, Atherton A, Thoman EB. The effects of evening light exposure on the sleep of elderly women expressing sleep complaints. J Behav Med. 1998;21(1):103-114.
  37. Hayashi M, Watanabe M, Hori T. The effects of a 20 min nap in the mid-afternoon on mood, performance and EEG activity. Clin Neurophysiol. 1999;110(2):272-279.
  38. Wells KB, Golding JM, Burnam MA. Psychiatric disorder and limitations in physical functioning in a sample of the Los Angeles general population. Am J Psychiatry. 1988;145(6):712-717.
  1. Harter M, Reuter K, Weisser B, Schretzmann B, Aschenbrenner A, Bengel J. A descriptive study of psychiatric disorders and psychosocial burden in rehabilitation patients with musculoskeletal diseases. Arch Phys Med Rehabil. 2002;83(4):461-468.
  2. Cox RC, Olatunji BO. Sleep in the anxiety-related disorders: A meta-analysis of subjective and objective research. Sleep Med Rev. 2020;51.
  3. Riemann D, Krone LB, Wulff K, Nissen C. Sleep, insomnia, and depression. Neuropsychopharmacology. 2020;45(1):74-89.
  4. Li M, Cui J, Xu B, Wei Y, Fu C, Lv X, et al. Sleep disturbances and depression are co-morbid conditions: insights from animal models, especially non-human primate model. Front Psychiatry. 2021;12:827541.
  5. Steiger A, Pawlowski M. Depression and Sleep. Int J Mol Sci. 2019;20(3).
  6. Thase ME. Depression and sleep: Pathophysiology and treatment. Dialogues Clin Neurosci. 2006;8(2):217.
  7. Adrien J. Neurobiological bases for the relation between sleep and depression. Sleep Med Rev. 2002;6(5):341-351.
  8. Ng TH, Chung KF, Ho FYY, Yeung WF, Yung KP, Lam TH. Sleep-wake disturbance in interepisode bipolar disorder and high-risk individuals: A systematic review and meta-analysis. Sleep Med Rev. 2015;20:46-58.
  9. Krystal AD. Psychiatric disorders and sleep. Neurol Clin. 2012;30(4):1389-1413.
  10. Perils ML, Giles DE, Buysse DJ, Tu X, Kupfer DJ. Self-reported sleep disturbance as a prodromal symptom in recurrent depression. J Affect Disord. 1997;42(2-3):209-212. [Google Scholar]
  11. Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biol Psychiatry. 1996;39(6):411-418.
  12. Mellman TA. Sleep and anxiety disorders. Psychiatr Clin North Am. 2006;29(4):1047-58.
  13. Sivertsen B, Lallukka T, Petrie KJ, Steingrimsdottir OA, Stubhaug A, Nielsen CS. Sleep and pain sensitivity in adults. Pain. 2015;156(8):1433-1439.
  14. Moldofsky H. Sleep and pain. Sleep Med Rev. 2001;5(5):385-396.
  15. Sipilä RM, Kalso EA. Sleep Well and Recover Faster with Less Pain: A Narrative Review on Sleep in the Perioperative Period. J Clin Med. 2021;10(9).
  16. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552.
  17. Afolalu EF, Ramlee F, Tang NKY. Effects of sleep changes on pain-related health outcomes in the general population: A systematic review of longitudinal studies with exploratory meta-analysis. Sleep Med Rev. 2018;39:82-97.
  18. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survey. Eur J Epidemiol. 2005;20(3):243-249.
  19. Ødegård SS, Sand T, Engstrøm M, Stovner LJ, Zwart JA, Hagen K. The long-term effect of insomnia on primary headaches: a prospective population-based cohort study (HUNT-2 and HUNT-3). Headache. 2011;51(4):570-580.
  20. Sivertsen B, Lallukka T, Salo P, Pallesen S, Hysing M, Krokstad S, et al. Insomnia as a risk factor for ill health: results from the large population-based prospective HUNT Study in Norway. J Sleep Res. 2014;23(2):124-132.
  21. Boardman HF, Thomas E, Millson DS, Croft PR. The natural history of headache: predictors of onset and recovery. Cephalalgia. 2006;26(9):1080-1088.
  22. Staffe AT, Bech MW, Clemmensen SLK, Nielsen HT, Larsen DB, Petersen KK. Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants. PLoS One. 2019;14(12).
  23. Tang NKY, Goodchild CE, Sanborn AN, Howard J, Salkovskis PM. Deciphering the Temporal Link between Pain and Sleep in a Heterogeneous Chronic Pain Patient Sample: A Multilevel Daily Process Study. Sleep. 2012;35(5):675-687.
  24. Haack M, Simpson N, Sethna N, Kaur S, Mullington J. Sleep deficiency and chronic pain: Potential underlying mechanisms and clinical implications. Neuropsychopharmacology. 2020;45(1):205- 216.
  25. Hicks RA, Moore JD, Findley P, Hirshfield C, Humphrey V. REM sleep deprivation and pain thresholds in rats. Percept Mot Skills. 1978;47(3 Pt 1):848-850.
  26. Volkow ND, Tomasi D, Wang GJ, Telang F, Fowler JS, Logan J, et al. Evidence that sleep deprivation downregulates dopamine D2R in ventral striatum in the human brain. J Neurosci. 2012;32(19):6711- 6717.
  27. Nijs J, Mairesse O, Neu D, Leysen L, Danneels L, Cagnie B, et al. Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Phys Ther. 2018;98(5):325- 335.
  28. de Luca ML, Ciccarello M, Martorana M, Infantino D, Mauro GL, Bonarelli S, et al. Pain monitoring and management in a rehabilitation setting after total joint replacement. Medicine. 2018;97(40).
  29. Silver J, Mayer RS. Barriers to pain management in the rehabilitation of the surgical oncology patient. J Surg Oncol. 2007;95(5):427-435.
  30. Cheville AL, Smith SR, Basford JR. Rehabilitation Medicine Approaches to Pain Management. Hematol Oncol Clin North Am. 2018;32(3):469-482.
  31. Brzezinski A, Vangel MG, Wurtman RJ, Norrie G, Zhdanova I, Ben-Shushan A, et al. Effects of exogenous melatonin on sleep: A meta-analysis. Sleep Med Rev. 2005;9(1):41-50.
  32. Pevet P, Challet E. Melatonin: Both master clock output and internal time-giver in the circadian clocks network. J Physiol Paris. 2011;105(4- 6):170-182.
  33. Everitt H, Baldwin DS, Stuart B, Lipinska G, Mayers A, Malizia AL, et al. Antidepressants for insomnia in adults. Cochrane Database Syst Rev. 2018;5(5).
  34. Lu XM, Zhu JP, Zhou XM. The effect of benzodiazepines on insomnia in patients with chronic obstructive pulmonary disease: a meta-analysis of treatment efficacy and safety. Int J Chron Obstruct Pulmon Dis. 2016;11(1):675-685.
  35. Lie JD, Tu KN, Shen DD, Wong BM. Pharmacological treatment of insomnia. P T. 2015;40(11):759.
  36. Harrison TS, Keating GM. Zolpidem: a review of its use in the management of insomnia. CNS Drugs. 2005;19(1):65-89.
  1. CLARK MS, SMITH PO, JAMIESON B. Antidepressants for the Treatment of Insomnia in Patients with Depression. Am Fam Physician. 2011;84(9).
  2. Trauer JM, Qian MY, Doyle JS, Rajaratnam SMW, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(3):191-204.
  3. Zhou ES, Gardiner P, Bertisch SM. Integrative Medicine for Insomnia. Med Clin North Am. 2017;101(5):865-879.
  4. Cheuk DK, Yeung WF, Chung K, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev. 2012;(9).