ARTICLE
International Journal of Integrative Medicine
Open Trial of Ear Acupuncture for Sleep
Disturbances of Nurses Working Night
Shifts - Assessment of Sleep/Wake
Patterns Using a Wrist Actigraphy
Original Research Article
Kuniko Yuri1,* and Sohei Yoshida1
1 Graduate School of Kansai University of Health Sciences, Japan
* Corresponding author E-mail: [email protected]
Received 28 Sep 2012; Accepted 27 Nov 2012
© 2013 Yuri and Yoshida; licensee InTech. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract [Objective] Nurses working night shifts experience great stress due to the disturbance to their circadian rhythm and exhibit many health problems, including sleep disturbance. We sought to examine the clinical efficacy of ear acupuncture (EA) for their sleep problems. [Methods] In this open trial, wrist actigraphy and structured questionnaires were used to determine their sleep/wake patterns and psychosomatic conditions. The 17 female nurses performed shift work at night in wards with chronic invalid patients in three different hospitals. The data for their sleep/wake patterns were recorded in the first week as a control and, in the next week, these data were recorded during EA treatment. Intradermal needles were inserted at the two points of the auricle, innervated by the great auricular nerve (C2, 3). [Results] Actigraphy data were obtained from 13 of the 17 subjects. After EA, a scatter gram between sleep efficacy (SE) and wake after sleep onset (WASO) showed two groups distinguished by their responsiveness to EA (six www.intechopen.com
responders and seven non‐responders). There were no differences in the average age, or the use of drugs and alcohol, or differences in the frequency of night shifts. However, five out of the seven non‐responders were working in the same hospital caring for seriously handicapped children. The other two were in the ordinary hospitals for adult and elderly patients, involved in caring and rehabilitation. [Conclusions] EA may improve the quality of sleep for nurses working night shifts, but there remain problems regarding the susceptibility to EA, depending on their physical and/or social conditions. Keywords Night Shift Nurses, Sleep, Ear Acupuncture (EA), Wrist Actigraphy 1. Introduction Over the last 20 years, the number of people on shift work has grown due to increased social demands in Int. j. integr.
med.,Disturbances
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Kuniko Yuri and Sohei Yoshida: Open Trial of Ear Acupuncture
for Sleep
Nurses
Working Night Shifts - Assessment of Sleep/Wake Patterns Using a Wrist Actigraphy
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various occupations [1]. Alterations in the circadian rhythm of shift workers is considered as a risk factor for many sleep disorders and has many negative cognitive effects [2,3]. In addition, shift work can contribute to strains in marital, familial and other personal relationships. Among nurses working night shifts in particular [4,5,6], the alterations in circadian rhythm increase the risk of developing many health problems, including sleep disorders, shoulder stiffness and headaches, and may also strain their relationships with patients with disorders of varying degrees of severity. Various measures to alleviate some of the negative health consequences associated with night shift work were examined in a previous study [7]. In oriental medicine, acupuncture is one of the methods used for alleviating sleeping disorders. It has been reported that body acupuncture can have a role in treating comorbid insomnia through autonomic activation [8] and increase the serum content of melatonin during night time sleep, which alleviates the alterations in the circadian rhythm of patients with insomnia [9]. Ear acupuncture (EA) is another therapeutic method by which specific points on the auricle are stimulated to treat various conditions, including insomnia, but the evidence for its efficacy for sleep is still limited by the paucity and poor quality of data [10]. EA is one of the acupuncture therapies now practiced in both western and oriental medicine. In the middle of the 20th century, it was developed and systematized by Dr. Paul Nogier of Lyon, France, who discovered an “inversed foetus” in the ear [11]. This refers to the presence of an inverted topography of the whole human body in the ear, just like a foetus in the uterus. Neurological research has not yet revealed a connection between Nogier’s auricular map (the inverted foetus) and the neurological homunculus, similarly inverted, in the cerebral cortex. Therefore, an exciting area for future investigations would be to identify the neurophysiological connections between them [12]. In the developing embryo, a series of six tubercles begin to appear around days 26‐40 of the embryological development from a coalescence of the first and second brachial arches, those associated with cranial nerves V (trigeminal nerve) and VII (facial nerve), respectively. These elements grow and fuse into an auricle, in a mirror image to the progress of their associated brain structures, as a “mini copy” of the brain [13]. Additionally, the auricle is innervated by cranial nerves IX and X (glossopharyngeal and vagal nerves), and upper spinal nerves C1, C2 and C3, such as the greater and lesser occipital nerve (C1) and the great auricular nerve (C2, 3), in a mixed fashion (Fig.1) [13]. Due to these abundant innervations at the medullospinal junction, the auricle 2
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has important connections to the cerebrospinal and autonomic nervous systems. The afferents of cranial nerves V, VII and IX/X, and of cervical spinal nerves in the upper cervical cord exhibit an anatomic convergence of these two systems throughout the dorsal horn in the first and second cervical segments. The caudal part of the trigeminal spinal nucleus and the dorsal horn of the upper spinal cord (C2‐3), which share many cytoarchitectural and hodological similarities, are collectively called the trigeminocervical complex or convergence (TCC) [14,15,16]. Furthermore, these areas constitute a trigeminoreticular pathway regulating deep pain from the head and neck regions, and may be the trigeminal homologue of the spinoreticulothalamic pathway. The spinoreticulothalamic pathway, called the paleospinothalamic tract because of its early evolutionary origin, mediates arousal as well as the autonomic and emotional aspects of pain, possibly related to sleep disorders, shoulder stiffness and tension, as well as migraine headaches. With regards to EA for sleep disturbances, Sjöling et al. (2008) [17] reported that EA was considered to be effective, although only subjective methods were used for assessment: The Karolinska Sleep Diary (KSD) and questionnaires. Five acupoints, namely, Shenmen, Sympathetic nerve, Brain & Kidney, and Insomnia 1 and 2, were selected for the experimental group, compared with five sham‐acupoints for the control group. In addition to subjective questionnaires, Suen et al. (2002) [18] used wrist actigraphy to record precise movements in personal sleep/wake patterns objectively and quantitatively throughout the study period. They divided the subjects into three groups based on the species of acupressure grains: group A by Junco Medulla, group B by Semen Vicariate and group C by Magnetic Pearl. The ear acupressure points were selected at seven points, namely, Sherman, Heart, Kidney, Liver, Spleen, Occiput and Subcortex. On the basis of these reports, we have developed a study design to investigate the efficacy of EA for treating the sleep disturbances of nurses working night shifts, using both subjective and objective methods, as follows: 1) using subjective questionnaires with wrist actigraphy to collect objective data, 2) selecting ear acupoints, including Insomnia 2, objectively detected using an electrical detector (AGISCOPE DT, Sedatelec Co. Ltd.) within the area innervated by great auricular nerves (C2‐3), and 3) inserting four intradermal needles in total (two acupoints for each ear) and fixing them with a piece of tape, in order to stimulate the acupoints continuously for a week throughout each study period. In this open trial (before/after study), we have investigated the efficacy of EA in treating the sleep disturbances of nurses working night shifts, under various physical and psychological stresses. www.intechopen.com
Seirin Co. Ltd., Japan) were inserted and fixed with tape at the two acupoints of each ear, as detected using an electronic detector (AGISCOPE DT, Sedatelec Co. Ltd., France). The acupoints, including Insomnia 2, were within the area mainly innervated by the great auricular nerve (C2, 3), mixed with cranial nerves VII, IX and X, as shown in Fig. 2. Figure 1. In the developing embryo, a series of six tubercles begin to appear around days 26‐40 of embryological development from a coalescence of the first and second brachial arches, those associated with cranial nerves V (trigeminal nerve) and VII (facial nerve), respectively. In addition, the auricle is innervated by cranial nerves IX and X (glossopharyngeal and vagal nerves), and upper spinal nerves C1, C2 and C3,namely, the greater and lesser occipital nerve (C1) and the great auricular nerve (C2, 3), in a mixed fashion. 2. Subjects and methods Using wrist actigraphy (Motionlogger Watch; AMI Co. Ltd., USA) [19] and structured questionnaires, we obtained data from 17 female nurses aged 40.0±11.1 years old. They were working night shifts in three different hospitals under a common rotating two‐shift system, but caring for patients with various degrees of psychosomatic disability. In hospital A, six out of the 17 nurses were working in a ward for internal medicine and rehabilitation for invalid adult patients; in hospital B, five were working in a geriatric sanatorium ward for medical care and rehabilitation; and in hospital C, six were working in a paediatric ward caring for severely psychomotor‐disabled children. The most stressful working conditions for the nurses were in hospital C; conditions were also stressful in hospitals B and A, but to a lesser degree. In the study period lasting two weeks, the first week was considered as the control period, in which the baseline of the actigraphy data was monitored in each subject, and the second week was the intervention period, with EA for the sleep condition of each subject, from the middle of March to the end of August, 2010. The actigraphy has been developed with technological support from the National Institute of Health (NIH, USA), with the advantages of measuring very fine motions of 2~3 Hz/0.01G/rad/sec and over, and of enabling continuous monitoring for as long as three weeks. At the beginning of the first week, a wrist actigraph was attached to the non‐dominant hand of the subjects. The data were continuously collected throughout the first week of the study period. Next, at the beginning of the second week, four intradermal needles (0.14ømm x 5 mm; www.intechopen.com
Figure 2. Ear acupoints inserted with intradermal needles. Two acupoints of low impedance were chosen for insertion of the intradermal needles (0.14ømmx 5 mm; Seirin Co. Ltd., Japan) using an electrical detector (AGISCOP DT, Sedatelec Co. Ltd., France) within the oval area innervated by the great auricular nerve (C2). A week before starting the study, we had obtained the data for the subject’s basic sleep conditions using the questionnaires of the Pittsburgh Sleep Quality Index (PSQI), the Morningness‐Eveningness Questionnaire (MEQ) and our own original questionnaire, including the following items: age, night shift duties, physical conditions, morning arousal, sleep quality and drug and alcohol use as aids for sleeping. The Epworth Sleepiness Scale (JESS) and the Insomnia Severity Index (ISI‐J) were completed during the first and second weeks, and also at the end of the study period. Visual analogue scales regarding shoulder stiffness were completed every day throughout the study period. Data analysis: The actigraphy data were recorded as a life action time series of 24 hours per day and divided into three intervals: the up interval (up), down interval (down) and 0‐0 interval (0‐0). From among 22 parameters, Yoshida et al. (2008) [20] extracted two useful parameters for comparing sleep conditions, namely, sleep efficiency (SE) and wake after sleep onset (WASO), from the data of the 0‐0 interval. These data were plotted on normal probability paper, indicating a normal distribution in a linear manner. In a scatter gram, Pearson’s product‐
moment correlation coefficient (r) was used to study the relationship between SE and WASO. Comparisons between the responder and non‐responder groups were made using unpaired Student’s t‐test. The categorical data obtained from the questionnaires were assessed by non‐parametric methods, that is, χ2 test for independence, Mann‐Whitney’s U‐test and Wilcoxon’s signed rank test. Kuniko Yuri and Sohei Yoshida: Open Trial of Ear Acupuncture for Sleep Disturbances of Nurses
Working Night Shifts - Assessment of Sleep/Wake Patterns Using a Wrist Actigraphy
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In these parametric and non‐parametric data, differences were reported as significant if p < 0.05. Ethics: This study was approved by the 33rd Ethics Committee of Kansai University of Health Sciences. All participants from the three hospitals provided written informed consent after receiving an explanation of our study plan. sleep with or without medication, degree of stiff shoulders and number of night shifts worked, using subjective scales (VAS) and questionnaires (JESS and ISI‐
J). However, we failed to find any statistically significant differences among them. 3. Results Out of the 17 time‐series data recorded by wrist actigraphy, 13 were correctly recorded and available for data analysis. In the other four cases, there were failures in the recording of the data due to some problems with the actigraphy devices during the study period. The difference between the average values of SE before and after the intervention was not significant (before: 92.1±3.0%vs. after: 92.3±4.6%; Student’s t‐test, p>0.05), nor was that between the average values of WASO (before: 27.3±11.4%vs.after 25.9±13.5%; p> 0.05). However, using a scatter gram (Fig. 3), we found significant negative correlations between the SE and WASO before and after intervention(r=‐0.65079 (p<0.05) and r=‐0.92349 (p< 0.01), respectively). Moreover, the data before intervention were uniformly distributed as a group along the regression line, but the data after intervention were separated into two groups, namely, six responders (R group), with improved quality of sleep (WASO less than 25.9 times and SE more than 92.3%), and seven non‐
responders (non‐R group), with no improvement (WASO more than 25.9 times and SE less than 92.3%). Figure 3. The scatter gram shows significant negative correlations between SE and WASO before and after intervention (r=‐0.65079 (p<0.05) and r=‐0.92349 (p< 0.01), respectively). Moreover, the data before intervention were uniformly distributed as a group along the regression line, but the data after intervention were separated into two groups, namely, six responders (R group), with improved quality of sleep (WASO less than 25.9 times and SE more than 92.3%), and seven non‐
responders (non‐R group), without improvement (WASO more than 25.9 times and SE less than 92.3%). The changes in the mean values of SE and WASO before and after the interventions were compared among the R and non‐R groups, as shown in Fig. 4. Before the intervention, the mean values of SE and WASO were not different between the two groups. After the intervention, the mean value of SE in the R group was significantly increased compared with before the intervention (SE: 92.5±3.9% vs.95.4±3.9%, respectively; Student’s t‐test, p<0.01), but was not in the non‐R group (91.7±2.3% vs.89.7±3.4%). In contrast, the mean values of WASO in the R group after the intervention were significantly decreased compared with those before the intervention (WASO: 28.8±13.7 vs. 16.7±12.8min/0‐0 interval; p<0.01), but not in the non‐R group (26.1±7.8 vs. 33.9±8.3). Out of the six subjects in the R‐group, four were working in hospital A and the other two were in hospital B. In contrast, one out of the seven subjects in the non‐R group was working in hospital A, one in hospital B, and the other five in hospital C (Table 1: Pearsonʹs Chi‐squared test; χ2 = 7.0984, p = 0.02875). Between the R and non‐R groups, we examined a variety of other variables, including age, pattern and quality of 4
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Figure 4. Comparisons of sleep efficiency (SE) and wake after sleep onset (WASO) between the responder group (R) and the non‐responder (non‐R) group. The changes in the mean values of SE and WASO before and after the interventions were compared between the R and non‐R groups. Before the intervention, the mean values of SE and WASO did not differ between the two groups. After the intervention, the mean value of SE in the R group significantly increased compared with before the intervention (SE: 92.5±3.9% vs.95.4±3.9%, respectively; Student’s t‐test, p<0.01), but did not in the non‐R group (91.7±2.3% vs.89.7±3.4%). In contrast, the mean value of WASO in the R group after the intervention significantly decreased compared with before the intervention (WASO: 28.8±13.7 vs.16.7±12.8min/0‐0 interval, respectively; p<0.01), but did not in the non‐R group (26.1±7.8 vs.33.9±8.3). www.intechopen.com
Hospital A Hospital B Hospital C Total Non‐responder group 1 1 5 7 Responder group Total
4 5 2 3 0 5 6 13 Table 1. Contingency table of the responders and non‐
responders among nurses working night shifts among three hospitals. Out of the six subjects in the responder group (R‐group), four were working in hospital A and the other two were in hospital B. In contrast, one out of the seven subjects in the non‐responder group (non‐R group) was working in hospital A, one in hospital B, and the other five in hospital C (Pearsonʹs Chi‐squared test; χ2 = 7.0984, p = 0.02875). 4. Discussion Wrist actigraphy has been well validated for the estimation of night time sleep parameters, with the advantage of providing objective information on sleep habits in the patient’s natural sleep environment [19]. In our previous report (Yoshida et al., 2008), we extracted two useful parameters for evaluating quality of sleep: SE and WASO, from 22 parameters by using upward stepwise regression analysis [20]. In this clinical trial using actigraphy, it is suggested that, based on the two parameters of SE and WASO, EA may improve the quality of sleep of some nurses working night shifts. However, there remain problems regarding the responsiveness of subjects to EA; that is, there were responders and non‐responders. These problems may originate not only from individual physical conditions, but also from the social strain of relationships between the nurses and patients with various degrees of psychosomatic disability. The most stressful conditions for nurses working night shifts were found in hospital C, where the nurses were working in a paediatric ward caring for severely disabled children with mental retardation, and to a lesser degree in the geriatric sanatorium ward for medical care and rehabilitation in hospital B, and then finally in the ward for invalid adult patients, for internal medicine and rehabilitation, in hospital A. Other factors, such as age, pattern and quality of sleep, taking medication and alcohol, degree of stiff shoulders and the number of night shifts worked in a month, using subjective scales (VAS) and questionnaires (JESS and ISI‐J), were not significantly different among the nurses working in the three hospitals. In oriental medicine, the clinical approach for the diagnosis and treatment of patients differs quite markedly from that in western medicine. Conducting research into Kampo medicine, Odaguchi et al. (2006) [21] proposed a unique study design. They first selected patients with migraine belonging to a subgroup that www.intechopen.com
responded to Goshuyuto, (TJ‐31: TSUMURA & Co., Tokyo, Japan) before conducting a typical randomized controlled trial: 1) during stage 1, the subjects were instructed to consume Goshuyuto orally for 4 weeks, 2) only those subjects judged as responders advanced to stage 2, during which a double‐blind, randomized, placebo‐controlled study was conducted, and the subjects consumed the same dose of Goshuyuto or placebo for 12 weeks. Finally, they concluded that the responder‐limited design is useful for evaluating Kampo medicine. This responder‐limited design is, therefore, a very useful design for us with which to conduct further clinical studies, although our style of EA is rather western medicine‐oriented, being based on Nogier’s theory. It is also important to examine negative factors associated with the non‐responders. From a neurophysiological point of view, we chose ear acupoints, including Insomnia 2 (Chinese acupoint), in the auricular area mainly innervated by the great auricular nerve (C2, 3). The great auricular nerve is a superficial branch of the cervical plexus that provides sensory innervations to the skin overlaying the parotid gland, external ear and posterior auricular region [22]. The afferent of the great auricular nerve enters into the posterior horn of the upper cervical spinal cord at C2,3 levels, where the trigeminocervical complex (TCC) [14,15,16] is formed together with the trigeminal caudalis nucleus and the greater and lesser occipital nerve (C1). This brainstem and cervical trigeminal complex integrates somatosensory inputs from the orofacial and cranial receptive fields, including occipital and auricular, as well as the meninges. Interestingly, Piovesan et al. (2007) [14] reported that massaging over the great occipital nerve reduced the intensity of migraine attacks in a 39‐year‐old woman if the greater occipital nerve territory was massaged. Reviewing trigemino‐cervical convergence and diffuse nociceptive inhibitory control (DNIC) mechanisms, they provided further support for the existence of a trigemino‐cervical convergence mechanism and the influence of DNIC on this process. In light of this, we considered that, neurophysiologically, EA may be mainly based on the trigemino‐cervical convergence mechanism. The nuclei of all the nerves supplying the ear with both sensory and motor fibres are interconnected with the reticular formation (RF). In this context, the trigeminoreticular pathway regulating deep pain from the head and neck regions mediates arousal as well as the autonomic and emotional aspects of pain, possibly related to sleep disorders, shoulder stiffness and tension, as well as migraine headaches [16, 23]. Neurons in the TCC are subject to the modulation of pain and sleep/wake‐controlled circuits in the brainstem, such as the periaqueductal grey (PAG), nucleus Raphe (NR) and locus coeruleus (LC). They are also integrative relay neurons between peripheral and central pain Kuniko Yuri and Sohei Yoshida: Open Trial of Ear Acupuncture for Sleep Disturbances of Nurses
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mechanisms. Moreover, neurons in the caudal most ventral medulla (cmVLM), which is a component of the trigeminoreticular pathway, are considered as an interface between autonomic cardiovascular and deep pain systems. Huang et al. (2011) [8] and Ganguly (2011) [24] supposed that, through autonomic activation, body acupuncture may have a therapeutic benefit for a subset of chronic insomniacs, mostly those with comorbid insomnia secondary to a medical condition such as chronic pain syndrome. Therefore, the trigeminocervical and trigeminoreticular pathways should also be a key feature in understanding the mechanism of EA, namely, Nogier’s auricular theory. Although the concept of a pathophysiological connection between the ear and the rest of the body has a very long history in Europe and China, the mechanism remains unknown. 5. Conclusion Among the 13 nurses working night shifts, six responded to EA, improving the quality of their sleep, but seven did not respond, which was associated with the strain of taking care of disabled children. Thus, our study revealed that, for nurses working night shifts, EA is useful for improving their quality of sleep, but there remain problems in its responsiveness, that is, we witnessed the presence of both responders and non‐responders. These problems may originate not only from individual physical conditions, but also the strain of relationships between nurses and their patients. In future, a responder‐
limited design seems to be an appropriate candidate for evaluating the efficacy of EA in this context, although the causes of a lack of response to EA should also be investigated. 6. Acknowledgments The authors wish to thank Professor Tameko Kihira, Associate professor Makiko Tani at Faculty of Health Sciences, Kansai University of Health Sciences, and Professor Satiyo Tuji, Professor Leiko Ishino, Associate professor Kazumi Tumura, Associate professor Mitiho Nakano at Faculty of Health Nursing, Kansai University of Health Sciences for their valuable comments and suggestions on this work. 7. References [1] Parent‐Thirion A, Fernandez EM, Hurley J, Vermeylen G (2007) Fourth European Working Conditions Survey. Dublin: European Foundation for the Improvement of Living and Working Conditions. [2] Sack RL, Ackley D, Auger RR, Carskadon MA, Wright KP, et al. (2007) Circadian rhythm sleep disorders: part I, basic principles, shift work and jet lag disorders. An American Academy of Sleep Medicine review. Sleep 30:1460–1483. 6
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