Summary of A Pilot Study Using AVS for Insomnia in Adults and Chronic Pain Patients

Here is my paper. I had to write a summary of the article that I read. At the bottom is the reference, which includes all of the information for the article if you are interested in finding it for yourself.

Summary of A Pilot Study of Audio-Visual Stimulation as a Self-Care Treatment for Insomnia in Adults with Insomnia in Chronic Pain

Chronic pain and sleep disturbances are comorbid conditions, meaning they are often diagnosed in the same patient. It is estimated that one in three Americans suffers from chronic pain, and as many as 88% of those suffering from chronic pain also suffer from some sort of regular sleep disturbance (Tang, Vitiello, Perlis, Mao, & Riegel, 2014); that equates to about 78 million American adults suffering from chronic pain, with about 68 million also suffering from sleep difficulties (Howden & Meyer, 2011). These statistics show a shockingly high level of comorbidity, and a need for a solution. It has also been suggested that the relationship between pain and sleep may be bidirectional, meaning that increased sleep disturbances increases pain levels and increased pain levels increases sleep disturbances. Sleep disturbances have also been linked to other physical and psychiatric problems, which have also been shown to cause chronic pain problems, suggesting that treatment for chronic pain should focus on sleep disturbances.

This pilot study, A Pilot Study of Audio-Visual Stimulation as a Self-Care Treatment for Insomnia in Adults with Insomnia in Chronic Pain by Hsin-Yi Tang, Michael V. Vitiello, Michael Perlis, Jun James Mao, and Barbara Riegel, was the first study to examine a self-administered audio-visual stimulation program as a treatment for adults with insomnia and chronic pain. As a pilot study, the main purpose of the study was to determine the feasibility of using a self-administered 30 minute audio-visual stimulation (AVS) program as treatment for insomnia in chronic pain patients prior to large scale research. Chronic insomnia is currently hypothesized to be due, in part, to a lack of ability to fully disengage the brain at night; medical intervention that causes brainwaves to slow may help improve sleep onset and maintenance, which could also help with chronic pain.

Because this was a pilot study, the participant group was quite small; only nine adults completed the study. To recruit study participants, the researchers placed flyers in community centers around the Philadelphia and Seattle community sites as well as placing a newspaper advertisement asking for participants. To participate in the study, subjects had to be at least 21 years old, have nonmalignant pain most days for more than 6 months, difficulty sleeping for 3 or more nights a week for 3 or more months, score an eight or higher on the Insomnia Severity Index (ISI), and score between a 3 and 10 on the “worst pain” item of the Brief Pain Inventory (BPI). Possible candidates were excluded if they had a history of seizures, had known photosensitivity, were night shift workers, had cognitive impairment as determined after a lengthy interview with a trained researcher, had any severe psychiatric disorders, or had any sleep disorder other than insomnia. Initially, 13 people were selected to participate in the study, but four withdrew. One person withdrew without providing a reason, two withdrew because they found the equipment cumbersome, and one withdrew due to discovering a sensitivity to the visual component of the study. The 9 remaining participants ranged in age from 21 to 49 (mean age was 33 ± 16), 8 were women, and 7 participants were from Seattle (Tang et al., 2014). All of the participants were capable of performing all of the required tasks.

The study had a pre-post design, meaning that the participants were asked to fill out tests prior to the administration of the AVS program, and then asked to take the same tests again after the program. The participants were asked to respond to the Insomnia Severity Index (ISI), the Brief Pain Inventory (BPI), and the Patient Health Questionnaire (PHQ-9). The ISI uses a seven item scale to measure insomnia severity: 0-7 means no clinically significant insomnia, 8-14 is “sub threshold” insomnia (extremely mild insomnia), 15-21 is clinical insomnia of moderate severity, and 21-28 is severe clinical insomnia (Tang et al., 2014). The BPI (the participants were only required to complete the “short form” version of the test) is a nine item assessment of pain and its impact on daily life. Results from the BPI provide two data categories: pain severity (pain now, average pain, worst and least pain in 24 hours) and pain interference (using seven common daily activities) on scales from 0-10 where zero is either no pain or no interference and ten is worst pain or most interference (Tang et al., 2014). The PHQ-9 measures how often the individual taking the questionnaire has been bothered by depression over the past two weeks; scores range from 0-27: 0-4 are no/minimal depression, 5-9 are mild depression, 10-14 are moderate depression, 15-19 are moderately severe depression, and 20-27 are scores for severe depression (Tang et al., 2014). After completing the questionnaires, but before beginning the AVS program, participants were asked to keep a detailed sleep diary for one week. The sleep diary was a standardized two-page log that asked questions about quantity and quality of sleep, including time the sleeper went to bed, number of times the sleeper woke up overnight, total sleep time, and time the sleeper got out of bed (Tang et al., 2014). The sleep diary also included details about daily activities that could impact sleep such as caffeine and alcohol consumption, daytime naps, exercise, and any other health conditions (Tang et al., 2014). After the one week sleep diary was completed, the participants were asked to begin the AVS program.

The audio-visual stimulation program was Procyon by MindPlace, which are wearable devices that administer personal sound and light stimulation; the visual stimulation comes from glasses that are very similar in shape to safety glasses, and the sound stimulation comes from a separate device that is shaped like a personal tape player with small headphones. The AVS program runs for 30 minutes, during which time the flickering of the light and pulsing of the sound slows from 8 Hz to 1 Hz (α to δ brainwave frequencies).  Participants were asked to continue keeping the sleep diary throughout the month they were using the AVS program, adding their AVS adherence to it. During the month they were using the AVS devices, weekly phone calls were made by the researchers to the participants to assess progress, address any questions, and check on usage. At the completion of the one month AVS program, participants were once again asked to complete the ISI, BPI, and PHQ-9 questionnaires and another one week sleep diary.

Even though the sample size was quite small, the results of this pilot study show promising trends. In the pre-program period, the results from the ISI had a mean of 19.2 ± 3.9, which is moderate to severe clinical insomnia (Tang et al., 2014). The BPI results had mean ratings for pain severity of 5.0 ± 1.2 and pain interference of 5.39 ± 1.9 (Tang et al., 2014). The baseline mood rating, according to the PHQ-9, was 11.9 ± 5.6, which is in the moderate depression range (Tang et al., 2014). According to the one week sleep diaries taken prior to the AVS program, participants were getting an average of 6 hours of sleep each night. All of the pre-program results indicate sleep and pain disorders in the participants. The participants reported using the AVS program 94% of the time, which is unusually high, indicating either extremely diligent participants or social expectation factors (Tang et al., 2014). After the one month program, significant improvements were observed in all numbers: the ISI mean was 12.8 ± 5.0, the BPI pain severity mean was 4.0 ± 1.6, the BPI pain interference mean was 3.8 ± 2.0, and the PHQ-9 was 9.0 ± 2.8 (Tang et al., 2014). The sleep diary also indicated that participants were getting an average of 7 hours of sleep each night after the one month study, as opposed to the 6 hours they were getting before. All of these results seemed in line with the hypothesis that calming brainwaves would improve sleep and possibly improve chronic pain.

This is the first study ever conducted using a self-administered AVS program to promote better sleep in patients suffering from chronic pain and insomnia. The vast improvement in pain due to improved sleep, however, suggests that sleep may take a leading role in this particular comorbid dyad (Tang et al., 2014). Because improved sleep did so much to improve pain levels, even with such a small study group, it is feasible that a self-administered AVS program could be used to effectively treat both insomnia and chronic pain. Further studies need to be conducted to validate these results. To get more accurate results, larger and randomized study groups must be compiled, and a control group must be utilized. Objective methods for measuring pain and sleep must also be developed to more accurately measure progress made during the study, and a method other than self-reporting the usage of the program would help keep human error to a minimum. Because chronic pain and insomnia impact such a large percentage of the population, it is essential to the health of America that something be done to relieve the problem.


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