Sleep Fact Sheet

Introduction to Sleep


Poor sleep can be very frustrating and disruptive, often presenting with difficulty falling asleep or waking up during the night. This can often result in you feeling tired and unrested the following day. A study by Ohayon (2002) revealed that 8% to 18% of the population has dissatisfaction with sleep quality and quantity.

Most people will experience sleep problems during their lives, with episodes of insomnia thought to affect 1/3 of the UK population (NHS-Choices).

Insomnia is defined by difficulty falling or staying asleep, early awakening, or a sensation of unrefreshing sleep (Merk, 2014). It is not a disease and can have many different causes ranging from short term emotional stressors such as worry with work or changing of jobs or environment; physical disorders such as pain conditions like arthritis, cancers, discs etc, to mental health conditions such as depression or anxiety.

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How is our sleep regulated?


The control of sleep and wakefulness is not entirely understood, however scientists have identified many areas of the brain involved in regulating the sleep process.

Circadian_rhythm_labeledOne process, which is perhaps more commonly known, is how light affects our sleeping pattern.

During the day, light stimulates special receptors (photosensitive cells) within our eyes. This enables sensory information to be carried to special bundles of cells in the hypothalamus (called the suprachiasmatic nuclei).

On receiving this information inhibitory signals reduce the release of melatonin from the pituitory gland in the centre of our brain. Melatonin has the affect of causing drowsiness.

Consequently, as daylight diminishes towards the end of the day, there is an increase in melatonin contributing to sleepiness.

How to Manage sleep


Management of insomnia according to NICE guidelines (2015) may include:

Identify the causes of insomnia if possible.
Advise no driving if you’re feeling sleepy.
Provide advice on good sleep hygiene.
Hypnotic drugs may be prescribed short term depending on individual cases with further review.
Referral to psychological services or for cognitive therapy.

What can we do to help?


Below are a list of services we offer that may be able to help you with supported evidence.

Acupuncture Evidence

Papers are consistent in showing that most trials have found acupuncture to be significantly more effective than hypnotic drugs, no treatment, or sham acupuncture. However recommendations should be cautious as many papers exhibit poor methodological quality.

More investment and research is therefore warranted in this area

Research Conclusion
Clinical Trials
Curative effect of acupuncture and moxibustion on insomnia: a randomized clinical trial.

Gao et al 2013
J Tradit Chin Med.

Acupuncture and moxibustion at Baihui (GV 20), Sishencong (EX-HN 1), Shenmai (BL 62), and Zhaohai (KI 6) significantly improved insomnia symptoms in the experiment group compared with the control group.
Effect of acupuncture treatment of relieving depression and regulating mind on insomnia accompanied with depressive disorders

Luo WZ et al.
Zhongguo Zhen Jiu 210

65 patients with insomnia and depression were randomly divided into an acupuncture group and a western medication group (oral Trazodone). After 4 weeks treatment the cured/markedly effective rate in the acupuncture group was superior (73% v. 47%). Total scores of the Pittsburgh Sleep Quality Index and the Self-Rating Depression Scale were significantly reduced in both groups, but sleep quality and daytime function improved more with acupuncture than medication. The latter showed higher levels of side effects. Acupuncture treatment is superior to Trazodone for sleep quality and daytime function, with milder adverse reactions.
The effect of acupressure on quality of sleep in Iranian elderly nursing home residents.

Complement Ther Clin Pract. 2010
Reza H et al.

90 elderly patients with moderate to marked sleep disturbances were randomly assigned to acupressure, sham acupressure or a control group. There were significant differences between the acupressure groups and,control group in subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency and sleep disturbance; there were no significant differences in sleep indices between the sham and the control. Sleep log data showed a significant decrease in nocturnal awakenings in the acupressure group compared to the other two. The findings indicated that acupressure has an effect on improvement of sleep quality and can be endorsed for sleep-disturbed elderly people.
Electroacupuncture for primary insomnia: a randomized controlled trial.

Yeung WF et al.
Sleep 2009

A single-blind randomised controlled trial that compared the short-term (3 weeks) efficacy and safety of electroacupuncture with placebo acupuncture for the treatment of primary insomnia in 60 Chinese adult volunteers who reported having insomnia 3 or more nights per week. Both groups showed significant improvement compared with the pre-treatment baseline in the Insomnia Severity Index (the primary outcome measure), but there was no difference between groups. However, there were significantly greater improvements in sleep efficiency as measured by a sleep diary and actigraphy in the electroacupuncture group. Also, the proportions of subjects having less than 30 minutes awake after sleep onset and a sleep efficiency of at least 85% at the post-treatment visit were significantly higher in the electroacupuncture group. All adverse events were mild in severity.The trialists concluded that there was a slight advantage of electroacupuncture over placebo acupuncture in the short-term treatment of primary insomnia.
Intradermal acupuncture on shen-men and nei-kuan acupoints improves insomnia in stroke patients by reducing the sympathetic nervous activity: a randomized clinical trial.

Lee SY et al.
Am J Chin Med.2009

Hospitalized stroke patients,with insomnia received either real intradermal acupuncture) or sham acupuncture (at the same two points) for three days. Fifty-two subjects were included in the final analysis. Two insomnia-related scales showed greater improvement in the real acupuncture group than in the sham. Acupuncture was also associated with superior stabilization of sympathetic nervous system activity (according to measures of heart rate variability and numbers of patients with non-dipping nocturnal BP) and the authors concluded that it was a useful therapeutic method for post-stroke insomnia
The needle-rolling therapy for treatment of non-organic chronic insomnia in 90 cases.

Huang L.-S et al.
Journal of Traditional Chinese Medicine.2009.

180 cases of chronic insomnia were randomly divided into two groups, one treated by needle-rolling therapy and the control group with clonazepam. After four weeks, there were significant differences between the two groups in the effective rate of symptom relief (P<0.05) and in the total score of the Pittsburgh Sleep Quality Index (PSQI) and the scores of its 4 sub-items (sleep-quality, sleep-efficiency, hypnotic and daytime function). There was no significant difference in effective rate at 3-month follow-up, but the needle therapy was still superior for three of the PQSI items. As compared with clonazepam the needle-rolling therapy may show better therapeutic effects for chronic insomnia patients.
Treatment of moderate obstructive sleep apnea syndrome with acupuncture: a randomised, placebo-controlled pilot trial.

Freire AO et al.
Sleep Med. 2007

36 patients with sleep apnoea were randomly assigned to acupuncture, sham (needle insertion in non-acupoints), or no intervention. Treatment was given once a week for 10 weeks. The Apnea/Hypopnea index (AHI), the Apnea index and the number of respiratory events all decreased significantly in the acupuncture group but not in the sham group. The no treatment group deteriorated significantly in some of the polysomnographic parameters, Acupuncture treatment significantly improved several dimensions of the SF-36 and Epworth questionnaires. Acupuncture is more effective than sham acupuncture in ameliorating the respiratory events of patients presenting with sleep apnoea.
Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report.

Spence et al
J Neuropsychiatry Clin Neurosci. 2004

The response to acupuncture of 18 anxious adult subjects who complained of insomnia was assessed in an open prepost clinical trial study. Five weeks of acupuncture treatment was associated with a significant (p = 0.002) nocturnal increase in endogenous melatonin secretion (as measured in urine) and significant improvements in polysomnographic measures of sleep onset latency (p = 0.003), arousal index (p = 0.001), total sleep time (p = 0.001), and sleep efficiency (p = 0.002). Significant reductions in state (p = 0.049) and trait (p = 0.004) anxiety scores were also found. These objective findings are consistent with clinical reports of acupuncture’s relaxant effects. Acupuncture treatment may be of value for some categories of anxious patients with insomnia.
Research Conclusion
The effect of melatonin, magnesium, and zinc on primary insomnia in long-term care facility residents in Italy: a double-blind, placebo-controlled clinical trial.

Rondanelli et al / J Am Geriatr Soc. 2011

The administration of nightly melatonin, magnesium, and zinc appears to improve the quality of sleep and the quality of life in long-term care facility residents with primary insomnia.
Research Conclusion
Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleepdisturbances: a randomized clinical trial.

Black et al / JAMA Intern Med. 2015

The use of a community-accessible mind awareness practise intervention resulted in improvements in sleep quality at immediate postintervention, which was superior to a highly structured SHE intervention. Formalized mindfulness-based interventions have clinical importance by possibly serving to remediate sleep problems among older adults in the short term, and this effect appears to carry over into reducing sleep-related daytime impairment that has implications for quality of life.
A randomized controlled trial of mindfulness meditation for chronic insomnia.

Ong JC et al / Sleep. 2014

Mindfulness meditation appears to be a viable treatment option for adults with chronic insomnia and could provide an alternative to traditional treatments for insomnia.
Research Conclusion
Valerian/lemon balm,use for sleep disorders during menopause.

Complement Ther,Clin Pract. 2013 Nov;19(4):193-6. doi: 10.1016/j.ctcp.2013.07.002. Epub 2013,Sep 10.

Authors: Taavoni S, Nazem,Ekbatani N, Haghani H.

A significant difference was observed with reduced levels of sleep disorders amongst the experimental group when compared to the placebo group. Valerian/lemon balm may assist in reducing symptoms of sleep disorder during the menopause.
Preliminary examination of the efficacy and safety of a standardized chamomile extract for chronic primary insomnia: a randomized,placebo-controlled pilot study.

BMC Complement Altern Med.,2011

Zick SM, Wright BD, Sen A, Arnedt JT.

Chamomile could provide modest benefits of daytime functioning and mixed benefits on sleep diary measures relative to placebo in adults with chronic primary insomnia. However, further studies in select insomnia patients would be needed to investigate these conclusions.
A double-blind, placebo-controlled investigation of the effects of Passiflora incarnata (passionflower) herbal tea on subjective sleep quality.

Phytother Res.,2011

Ngan A, Conduit R.

Sleep quality showed a significantly better rating for passionflower compared with placebo (t(40) = 2.70, p < 0.01). These initial findings suggest that the consumption of a low dose of Passiflora incarnata, in the form of tea, yields short-term subjective sleep benefits for healthy adults with mild fluctuations in sleep quality.
Effect of crocetin from Gardenia jasminoides Ellis on sleep: a,pilot study.

Phytomedicine.,2010

Kuratsune H, Umigai N, Takeno R, Kajimoto,Y, Nakano T.

The results suggest that crocetin may contribute to improving the quality of sleep.
Sleep improving effects of a single dose administration of a valerian/hops fluid extract – a double blind, randomized, placebo-controlled sleep-EEG study in a parallel design using electrohypnograms

Eur J Med Res.,2008

Dimpfel W, Suter A.

The EEG derived parameter “sleep quantity” as calculated from the electrohypnogram proved superiority of the valerian/hops combination over placebo. Thus, the present investigation has shown evidence that a valerian/hops fluid extract can be used successfully using a single administration.
A randomized, double blind, placebo-controlled, prospective clinical study to demonstrate clinical efficacy of a fixed valerian hops extract combination (Ze 91019) in patients suffering from non-organic sleep disorder.

Phytother Res.,2007

Koetter U, Schrader E, Käufeler R,Brattström A.

The fixed extract combination was significantly superior to the placebo in reducing the sleep latency whilst the single valerian extract failed to be superior to the placebo. The result underlined the plausibility for adding hops extract to the valerian extract.
Phyto-Female Complex for the relief of hot flushes, night sweats and quality of sleep: randomized, controlled, double-blind pilot study.

Gynecol Endocrinol.,2007

Rotem C, Kaplan B.

Herbal formula Phyto-Female Complex (ingredients: standardized extracts of black cohosh, dong quai, milk thistle, red clover, American ginseng, chaste-tree berry) is safe and effective for the relief of hot flushes and sleep disturbances in pre- and postmenopausal women, at least for 3 months’ use.
Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial.

Sleep.,2005

Morin CM, Koetter U, Bastien C, Ware JC,,Wooten V.

The findings show a modest hypnotic effect for a valerian-hops combination and diphenhydramine relative to placebo. Sleepimprovements with a valerian-hops combination are associated with improved quality of life. Both treatments appear safe and did not produce rebound insomnia upon discontinuation during this study. Overall, these findings indicate that a valerian-hops combination and diphenhydramine might be useful adjuncts in the treatment of mild insomnia.
A randomised-controlled trial of the effects of a traditional herbal supplement on sleep onset insomnia.

Complement Ther Med.2003

Farag NH, Mills PJ.

The findings suggest that traditional herbal supplements may be of significant benefit to patients suffering from sleep onset insomnia while avoiding the negative side effects of commonly prescribed hypnotics.
Critical evaluation of the effect of valerian extract on sleep,structure and sleep quality.,Pharmacopsychiatry.,2000,Donath F, Quispe S, Diefenbach K, Maurer A,,Fietze I, Roots I. In conclusion, treatment with a herbal extract of radix valerianae demonstrated positive effects on sleep structure and sleep perception of insomnia patients, and can therefore be recommended for the treatment of patients with mild psychophysiological insomnia.
Research Conclusion
Int J Clin Exp Hypn. 2008 Jul;56(3):270-80.

Authors: Abramowitz EG1, Barak Y, Ben-Avi I, Knobler HY.

Hypnotherapy in the treatment of chronic combat-related PTSD patients suffering from insomnia: a randomized, zolpidem-controlled clinical trial

This study evaluated the benefits of add-on hypnotherapy in patients with chronic PTSD. Thirty-two PTSD patients treated by SSRI antidepressants and supportive psychotherapy were randomized to 2 groups: 15 patients in the first group received Zolpidem 10 mg nightly for 14 nights, and 17 patients in the hypnotherapy group were treated by symptom-oriented hypnotherapy, twice-a-week 1.5-hour sessions for 2 weeks. All patients completed the Stanford Hypnotic Susceptibility Scale, Form C, Beck Depression Inventory, Impact of Event Scale, and Visual Subjective Sleep Quality Questionnaire before and after treatment. There was a significant main effect of the hypnotherapy treatment with PTSD symptoms as measured by the Posttraumatic Disorder Scale. This effect was preserved at follow-up 1 month later. Additional benefits for the hypnotherapy group were decreases in intrusion and avoidance reactions and improvement in all sleep variables assessed.
Int J Psychosom. 1989;36(1-4):64-8.

Author: Stanton HE.

Hypnotic relaxation and the reduction of sleep onset insomnia.

In this study, a hypnotic relaxation technique was compared to stimulus control and placebo conditions as a means of reducing sleep onset latency (SOL). Forty-five subjects (Ss) were matched on their baseline SOL as measured through sleep diaries. They were randomly assigned to one of three groups: hypnotic relaxation; stimulus control; and placebo. These groups experienced four weekly sessions of 30-minutes duration with demand effects being controlled through the use of counter-demand instructions. Data generated by the study suggested that the particular hypnotic relaxation treatment used was effective in helping Ss go to sleep more quickly. Neither stimulus control nor placebo groups recorded similar improvement.

GET A GOOD NIGHT’S REST

5 TOP TIPS FOR IMPROVING SLEEP


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    TURN DOWN THE LIGHTS

    Melatonin release is inhibited by artificial light, which means it’s really important to avoid too much light at the end of the day. Research has shown that the blue light from our tablet and phone screens suppresses melatonin (1), so putting our devices away at least an hour or two before bed is essential. Prof Foster, a circadian neuroscientist, believes that even brushing our teeth in the dark can be really helpful (2).

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    PRACTICE YOGA NIDRA

    Yoga Nidra is an extremely restorative yoga practice, during which you are guided into a state of deep relaxation both physically and mentally, via visualisation, meditation and breathing techniques. Studies have shown that Yoga Nidra changes the brain waves to promote slow wave patterns which promote relaxation (3), and regular practice of this technique can make a profound difference to our ability to relax and achieve restful sleep.

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    EAT RIGHT, SLEEP TIGHT

    The amino acid tryptophan provides the building blocks to serotonin, which in turn is used to produce the sleep hormone melatonin. Eating protein-rich foods rich in tryptophan during the evening before bed time is a useful way to boost your chances of a good sleep – turkey, chicken, eggs, soya-bean products are all good examples as well as nuts and seeds. The other key nutrient is magnesium, also known as the ‘relaxation mineral’. Fundamental to hundreds of reactions throughout the body, it helps to reduce muscle tension, promotes cardiovascular function and has been shown to improve the quality and quantity of sleep, reducing stress hormones and promoting melatonin release (4). Try including magnesium rich foods in your evening meal such as nuts, whole grains and green leafy veg.

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    TRY SLEEPY TEAS

    Many herbal remedies have been used historically to improve sleep and help the mind to relax. Try strong infusions through the evening of ‘nervine’ herbs such as chamomile and passionflower (5,6).

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    A COURSE OF ACUPUNCTURE

    Acupuncture has a long tradition of treating stress, anxiety and poor sleep. There has been some encouraging research suggesting the acupuncture can improve the release of melatonin at night, and a 5 week course of treatment may be enough to break poor sleep patterns (7).

REFERENCECES

(1)  Chang, A et al (2014) Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. http://www.pnas.org/content/112/4/1232.full.pdf

(2) Knapton, S (2015) Brush your teeth in the dark to help sleep, says Oxford University neuroscientist. http://www.telegraph.co.uk/news/science/science-news/11966259/Brush-your-teeth-in-the-dark-to-help-sleep-says-Oxford-University-neuroscientist.html

(3) Nilsson R (2013). Pictures of the brain’s activity during Yoga Nidra.  http://www.yogameditation.com/Articles/Issues-of-Bindu/Bindu-11/Pictures-of-the-brain-s-activity-during-Yoga-Nidra

(4) Abassi et al (2012) The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial. J Res Med Sci. 17(12):1161-9

(5) Sick SM et al (2011) Preliminary examination of the efficacy and safety of a,standardized chamomile extract for chronic primary insomnia: a randomized,placebo-controlled pilot study. BMC Complement Altern Med.

(6) Ngan A, Conduit R (2011) A double-blind, placebo-controlled investigation of the effects,of Passiflora incarnata (passionflower) herbal tea on subjective sleep,quality. Phytother Res.

(7) Spence et al (2004) Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report. J Neuropsychiatry Clin Neurosci.