Wine and Movement.

Motor. Motor. Motor. That's all you ever hear about when it comes to stroke recovery. In rehabilitation research we tend to obsess over movement. Movement quality, movement speed, and how movement effects function. Of course movement is only half the equation. The other half is the feeling of movement. Now-- I know, you're thinking, "Oooh, he's going to get all squishy with the feelings..." Nope. The feeling of a movement is an essential to learning how to move. If you cannot feel the movement, every time you do the movement, it's like the first time. Lack of feeling the eliminates an essential part of the motor learning feedback loop. I did a talk recently to therapists and between spiels a therapist came up and told me that, like me, she thought that the feeling of movement (called proprioception) could be re-taught after stroke. And she put it in a very interesting way. She said it's like learning to appreciate fine wine; at first you can't tell table wine from a 1939 Château-whatever. But over time, as your palate develops, you learn to taste subtle differences. Bottom line: proprioception can be re-taught.

Chicks dig smart...

I am currently reading the Cambridge handbook of expertise and expert performance. I do this all the time; I buy really fat books (this one has almost 900 pages) mostly to impress my wife. Then I find myself drawn into them bit by bit. It turns out that this book has quite a bit of information that relates to stroke recovery.

I do a lot of seminars talking to therapists about stroke recovery. I generally push neuroplasticity (“brain rewiring”) as the foundation for all recovery from stroke. And the easiest way to rewire the brain is to do repetition of whatever movement the stroke survivor is trying to recover. The therapists, curious lot that they are, always ask, “How many repetitions of the movement have to happen before the brain rewires?” The problem is that this question cannot be answered with a-one-number-fits-all answer. The number of repetitions needed depends on how much movement there is to begin with, how focused the stroke survivor is in the practice, how complicated the movement is, etc. etc. The very fat book I'm reading says that there is general agreement that to become an expert in anything takes 10 years. We also know that to become a very high-level athlete, musician, or acquire a skill like carpet weaving takes more than 1 million repetitions of the movement(s).

So the question I have is, when does recovery end? After 1 million repetitions? After 10 years? If either of these is in the right ballpark, another question follows, “Why are stroke survivors discharged from therapies within a year or so of their stroke?”

Yay!

Stronger After Stroke is one of the highest ranking books on stroke rehabilitation or stroke recovery. Luminaries such as Janet Carr (who I have a post about, further down) and Joel Stein, MD (a well known stroke recovery expert/physiatrist) have books out that are ranked a bit lower than Stronger. Jill Bolt-Taylor (A Stroke of Insight) is going to be on Oprah today. My book shows up on the same page as hers on web sites, so I fully expect to be able to buy a boat before the day is through.

Check out the screenshot for rankings.


And here's a photo of my new boat...


.

The Splint That Bounces Back

The wrists and hands of stroke survivors are always a challenge. In human beings the powerful muscles that close the hand and bend the fingers are essential for everything from climbing to carrying to to pulling.But after stroke, just like many of the muscles on the affected side, these large wrist and finger bending muscles get spastic. And when they do they overpower the much smaller muscles that extend the wrist and fingers.

    After stroke the fingers and wrist are flexed almost all the time and these muscles shorten and the wrist and fingers become even harder to straighten.
   The way occupational therapy has traditionally dealt with this problem is to splint the wrist and fingers. Occupational therapists (OT's) use a material called thermoplastic which is shaped into what is considered a good position for the wrist and fingers.

   But there's a problem with these splints. First of all, the splint is only as good as the OT's skill. Second these are static/rigid splints; that is, if the fingers get more flexible these rigid splints don't take advantage of these gains. Conversely if range of motion is lost and the fingers get tighter the splint does not reflect that change either. This can be damaging to the tissue around the fingers and wrist as the hand is forced into a rigid splint that's too "small".

   You could hire an OT every few months to fabricate a new splint, but that gets costly. I'm actually a big fan of a product called the SaeboStretch. This split is not static. It moves as your hand moves. If you want to bend your fingers, you can. This splint is made out of material that is flexible but elastic. That is, it can be bent but it always wants to return to its original position. This provides low-load pressure into the proper position. In this way this splint takes advantage of any increased elasticity in muscles and other soft tissue. I've had experts on splinting tell me point-blank that this is the only off-the-shelf splint that they'll recommend.

You can find information on the splint here.

A Good Excuse to Watch Football

When I worked at the Kessler Institute, a big rehab hospital in New Jersey, I worked with exercise physiologist Quin Bond. He changed my perspective about stroke recovery. The way athletic trainers and exercise physiologists look at stroke recovery is different from the way therapists typically view it. Therapists generally view recovery from stroke as a finite proposition. There is a beginning and an end. Most of scientific medicine views stroke recovery the same: finite. Exercise physiologists tend to see stroke recovery is infinite. Athletic trainers, the same. If you're used to working with athletes you're used to people who see progress is infinite. Athletes are always trying to make themselves better at their sport, stronger and faster. There is no difference between athletes and stroke survivors. Stroke survivor simply lower-level athletes playing higher stakes game. There's very little that works with athletes that doesn't work with stroke survivors. Every fundamental concept in athletic training can be superimposed on stroke recovery. Again, lower-level, but the same basic concepts hold true. Training concepts that athletes use can be used to recover from stroke. Basic concepts such as multiple hours (massed) practice, weight training, cardiovascular training, pushing the limits of ability and cross training, etc. all work superimposed on stroke recovery. The bottom line is that stroke survivors should see athletes as inspirational figures.

The photo is of Steve Prefontaine who exemplified the pursuit of the infinite.

Stroke recovery: A Leap Of Faith

I wrote this article recently. I describe Stroke recovery as a leap of faith, not unlike other leaps of faith we constantly take. Here are some highlights...

• I talked to a stroke group the other day. They were about 30 strong, and they were feisty. I do talks all over the country on the state of stroke recovery research. I have spoken to audiences that have included therapists, doctors and researchers. But nothing is quite like staring down the barrel of a group of stroke survivors. They've lived through stroke and have, to whatever degree, experienced the loss of control that defines brain damage. Each person who survives stroke is dealt a unique "hand of loss" causing the dispossession of everything from language to limbs, from emotions to personal independence. Stroke survivors have literally been there and back. They can be a bit prickly when someone suggests that they need to work harder. And that's just what I was suggesting.
• Much of what I believe helps a stroke survivor recover involves a leap of faith. I believe that massed practice works. Massed practice involves literally massing hours of practice together. I believe repetitive practice works. Repetitive practice involves doing the same movement, repeatedly, until long after sanity screams to stop.
• I believe that there is no way to recover unless the stroke survivor stays aware of new developments for stroke recovery as they emerge. I think stroke survivors need to have a strong cardiovascular and muscular foundation in order to have the energy to do all the other things necessary to recover to the highest level of potential. In short, I believe that stroke recovery is best served if efforts toward recovery are treated like a full-time job

Convincing the Experts

• When I speak to therapists about this emerging research-based paradigm shift, there is some push back. Therapists give me a sideways look and let me know that I'm whistling a bit of Dixie if I think that most stroke survivors are going to be willing to carry out a complicated and labor-intensive plan.
• Stroke survivors are more blunt. "Six hours a day of practice! I have better things to do, thanks!" They also ask questions that require absolute answers. "If I do put in the time and effort, what return can I expect?" they demand. "What about the repetitive practice? How many times do I have to repeat a movement before my brain rewires enough to do the movement right?"
• I've learned to be direct when answering. I tell them, "There are no guarantees. You could work very hard and get very little return. No one knows how many repetitions are needed. Some people think the magic number is 10,000. Others think it's closer to 150,000. Some researchers suggest a million or two. But even if we knew the 'optimal' number, the fact is that the number of repetitions needed is different for every survivor because of any number of variables." Well, to stroke survivors, this is the cherry on top of a mud pie, let me tell you. But I have an ace up my sleeve—and that ace is a mirror.
• I asked the members of the group what they did before their stroke. One gent had been a lawyer. Another was a farmer. And I have just spent three years writing a book. The three of us were a collective of experts in leaps of faith.
• I suggested to them that the monumental challenge of law school followed by the bar review then the bar exam (a three-day, six-hours-per-day exam) were several leaps of faith. Betting the farm on the mysterious and unpredictable miracle of life, year-in and year-out, through flood and draught, is the farmer's perpetual leap of faith. And what of the three years spent writing a book distilling the very message I was now telling them? This may have been the ultimate folly. I am guaranteed of selling only five copies—all of them to my mom."

Falls. Only funny in the movies.

There are few luminaries in the stroke recovery game that I really respect. Few bring anything new and most just add to an expanding din of quasi-misinformation. Two that I do respect are Carr and Shepard. These two Aussie therapists are vanguards of the paradigm shift that stroke recovery theory is now in. They have a book called Stroke Rehabilitation (go figure) that has some gems in it. One of those gems is about what causes falls after stroke. I hate falls. Heck, I’ve broken bones falling. For stroke survivors, falls can be the beginning of the end. There is a statistic that has always resonated with me: If someone is 65+ and they have a fall that lands them in hospital for at least one night they have a 50% chance of dying in the next year! And up to that 70 % of patients have a fall in the six months after their stroke.

So what do Carr and Shepard say about falling? Falls very often happen in four situations:

• Starting walking

• Stopping walking

• Turning

• Uneven surfaces

Posterior Pusher Syndrome (or) posterior pelvic tilting

Here are links to articles that provide ideas that may help with pelvic tilt problems.

Image is also clickable.

The core stabilization exercise consisted of three subparts, bed exercises, wedge exercises, and ball exercises using a Swiss ball. First, the bed exercises without devices consisted of bridge exercise, bridge exercise with legs crossed, bridge exercise with one leg, curl-ups with straight reaching, curl-ups with diagonal reaching, bird dog exercise, and side bridge exercise. Second, the wedge exercises consisted of curl-ups with straight reaching, curl-ups with diagonal reaching, and curl-ups with arms crossed. Finally, the ball exercises consisted of bridge exercise, bridge exercise to the side, bridge- ups, abdominal curl-ups, bird dog exercise, and push-ups.

Set up a consultation with Pete here

Reviews...

The consultation is personalized and organized. You'd probably get a lot of the material in Pete's book, but it's hard to read the whole book and know what's applicable to you. Pete takes the time to listen and find out what's important to you and tailors his consultation to you. Another thing I like about the consultation is that Pete is accessible afterwards. He always responded to my emails, and in a timely manner.

LQ, New Jersey

After my 28 year old son suffered an anoxic brain injury, we  had a very helpful consultation with Mr. Levine, which I highly recommend for personalized evaluation and treatment ideas.  It was done by video chat and he was incredibly thorough and offered many plans and suggestions. He is an amazing advocate and resource for those who have suffered a stroke, as well as their caregivers. Frankly, I think he is brilliant, a true healer combining science with compassion and encouragement. The consultation was an opportunity to get direct input tailored to my son’s situation. I especially appreciated the summary you sent afterwards.

RM, Connecticut

Our favorite aspect of the consultation was being able to benefit from Peter's rare combination of kindness and expertise while being miles away. Thanks to technology, it almost felt like we were physically in the same room with Peter. And it helped a lot that he kindly looked at material (emailed video) beforehand-- he was already knowledgeable to make the most of our consultation. Throughout our interactions, Peter was extremely amiable and willing to help. His empathetic approach was heartening for our survivor relative, and for everyone as a family. And his advice gave us hope that more can be done to take our patient to the best place she can go as her recovery progresses. Moreover, Peter's consultation report was thorough and full of actionable items---big and small---which we are enthusiastically implementing. Overall, Peter gave us the gift of his expertise, with patience, care, and kindness. We could not be more thankful.

JU, Mexico City

I felt it was so individualized to my Dad. I felt he really took the time to learn how my Dad was moving after his stroke.  I liked the convenience of Dad not having to leave his home for the consult.  I felt I was getting current expert research based advice.  I really appreciated that the consult was so thorough and with many helpful suggestions.  Also,  all my questions after the consult were responded to in a timely manner.  I felt Pete was really interested in how my Dad was recovering even though he never met him in person.  I really feel Pete is trying to improve the lives of stroke patients!

MF, New Jersey

How to set up a consultation	1. Email: StrongerAfterStroke@yahoo.com 2. Put Consultation in the subject line. 3. That's it. You'll be emailed back ASAP!
What happens and what you get	We have a video chat. Then I do the necessary research and make suggestions for recovery specific to your unique situation are made. A sort of "Your Recovery" document is emailed to you. It will have images, diagrams, and clickable links— all related to your recovery. Recovery suggestions will include recovery options that are “off the radar” to most clinicians.  Included will be suggestions about recovery of movement, but may also include suggestions for other post-stroke/ brain injury problems that we've discussed during our chat (i.e. visual problems, fatigue, cognition, etc.).  Recovery suggestions will be based on my clinical research, book, and talks.  Once the consultation is completed, follow-up questions are encouraged!
How the video observation is done	A 30 to 45 FaceTime, Zoom (preferred), Duo, or Skype video interview is done to discuss your progress so far, and your ambitions for the future.
What it costs	$250   Payment is made after the consultation is delivered.
What you should keep in mind	Suggestions are to be evaluated by the appropriate medical professional.

Technorati

Technorati Profile

Knowing all the symptoms of stroke, not just the symptoms you had, is essential for survivors and their caregivers. Why? I think this graphic says it all:

• Here's an amazing (and scary) statistic: In the five years after a stroke, women have a 1 in 4 and men almost a 1 in 2 chance of having another stroke. Know all the symptoms, not just the ones you know all too well.

Caveman Therapy

I’ve long believed that the amount of recovery after stroke is directly related to the amount of challenge. The more challenge, the more recovery. If you take yourself out of your “safety zone” that zone naturally expands. This happens no matter the endeavor. From stretching yourself as an artist or learning a new language, challenge = betterment (or at least the chance of betterment). Stroke survivors tend to decrease rather than increase the challenge. By using a growing number of assistive devices and energy saving strategies their safety zone contacts. I have this theory that when people had stroke in the distant past, they would actually recover more. This is from an Advance for PT/As article I wrote in 2006:

“It would be hard for our world to be a safer and easier place for survivors of stroke. And that just may be bad news. If a prehistoric tribe had decided to aid in the recovery of the stroke survivor, the "therapy" would have been ferocious by today's standards. The vise grip created between the survival of the tribe and the needs of the individual would have necessitated early rehabilitative intervention centering on mobility. For obvious reasons, the ability to walk in a hunter-gatherer tribe would have been of paramount significance to the individual and the tribe. Stroke survivors had to learn to feed themselves or starve, toilet or suffer bacterial disease, and ambulate or get left behind. Their "forced-use therapy," "gait training," and "ADL training," as well as the amount of energy they put into rehabilitation was dictated by one thing: survival." (Vol. 16 •Issue 9 • Page 35)

But I missed a key point: The flip-side of the equation is what the stroke survivor would say to the tribe. “Ugh-UG-Uh. Umph-duffKAAAAHH!”, which loosely translated means, “Get the hell out of my way because I know damned well what the stakes are!”

Relax and Recover?

This is a great study. It basically says that if a joint is moved passively (someone else moves it or you move it with your "good" hand) there will be neuroplastic (brain rewiring) change. This has big implications for folks who are low level and need to start moving. After there is enough brain rewiring, you may be able to rewire enough to begin moving the joint under its won power. This gives some credence to passive movement that therapists have been doing for decades, but has never been proven effective.

Hemi Man. One Bad Dude.

Here's an article I wrote recently for Advance for Directors in Rehabilitation. They added a really cool graphic. I call Him "Hemi Man".

I basically say that they way rehabilitation is delivered to stroke survivors is a problem before it even starts. It turns out that you need waaaay more practice to recover from stroke than payers are willing to bankroll and clinics are able to provide. Check it out.

Do We Really Use Only 10% Of Our Brains?

For decades "they" have been trying to sell us that we only use 10% of our brain. They were saying this before we could take pictures of the brain working, with MRI. So even if they were right we wouldn't know. Now we can see what parts of the brain are used. Turns out, "they" were wrong. We use 100%. This is important for stroke survivors because rewiring the brain after stroke asks more from your brain. And after stroke there is less brain to work with.

Here's a link to an article I wrote for StrokeSmart magazine about the 10% brain myth.

Ten rules for successful rehab for patients with stroke.

I wrote this in 2005 but it's still a good thumbnail sketch of how to get closer to the highest possible level of recovery. It's written for theapists, and so, written in 'therapist speak'.

Small Study. Small Recovery Gains. Big Message.

This is a small study that I was involved in. We used the NeuroMove to get stroke survivors who have no movement in the wrist, to have some wrist extension. This is really important because a little movement can be used to jumpstart much bigger movements. The important line is "However, both groups showed a 21 degree increase in active affected wrist extension after (NeuroMove) use."

Mobilization (walking) in the 1st 24h: Good or bad?

Mobilization in the 1st 24h

• The Cochrane review: At present there is insufficient evidence to support or refute the effects of routine very early mobilisation after stroke.
• An article looking at quality of life: Conclusions. Very early mobilization may help improve long-term quality of life after stroke, particularly in relation to functional independence, but this requires further examination.
• An article where they interviewed therapists, docs and nurses: Conclusion: Our study shows that most clinicians had concerns in relation to early mobilisation of stroke patients and more clinicians had concerns for haemorrhagic than for ischaemic stroke.
• An article looking at very early mobilization and depression: Conclusion: Very early mobilization may reduce depressive symptoms in stroke patients at 7 days post-stroke.
• Early mobilization out of bed after stroke may be all good: Conclusion: It seems to reduce severe complications but not cerebral blood flow:
• Early mobilization out of bed after stroke, maybe: Conclusions: Insufficient data are available to prove the beneficial effects of early mobilisation after stroke.
• A Very Early Rehabilitation Trial for Stroke (AVERT): Conclusions:Very early mobilzation of patients within 24 hours of acute stroke appears safe and feasible. 

Exercise programming for patients with Alzheimer's Disease

By James H. Rimmer, PhD, and Donald L. Smith, MS, RCEP This is an excerpt from ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, Third Edition, from the American College of Sports Medicine and edited by J. Larry Durstine, Geoffrey E. Moore, Patricia L. Painter, and Scott O. Roberts. Recommendations for Exercise Programming Exercise training for individuals with AD has three major considerations: to minimize problems arising from the declining physical and mental health of the participant to recognize behavioral changes that may cause the client to become agitated with the exercise program or the exercise setting to support caregivers’ willingness to continue bringing the person to the exercise program as the disease progresses Thus, a low-intensity program at the client’s usual ADL levels is recommended. For this level of involvement, exercise testing is unnecessary. During the early stages of AD, most clients should be able to participate in some form of physical activity. One of the most common problems associated with exercise programming for adults with AD is memory loss. Clients may forget to come to the exercise session or may find that they have forgotten how to perform certain activities. Depression is also quite common during the early stage of the disease and may result in the client’s withdrawal from the program. The cornerstones of an exercise program for this population are consistency, patience, and enjoyment. The exercise leader must constantly provide verbal encouragement and support to maintain the client’s interest in the program. During the early stages of exercise training, simple repetitive exercises like walking, riding a stationary bike, or lifting a certain amount of weight on various exercise machines will be easier than more complex routines (see table 48.2). Table 48.2 Click table below to make larger Precautions In the early stages of the condition, participation is extremely important in terms of establishing some sort of regular routine that the client can sustain for as long as possible. Emotional instability or outbursts may affect the exercise program in the later stages. Low-intensity exercise should be the main focus, involving activities that the person enjoys and can successfully perform. Constant supervision during physical activity is necessary during the mid to later stages of Alzheimer’s. The middle stage of AD presents a different set of challenges for the exercise leader. As the disease progresses, the program should become more simple and the leader should consider what reasonable criteria should be used to terminate the program. One of the major concerns during later stages of AD involves behavior. Because agitation is one of the hallmark symptoms of the disease, it is not unusual for a client to become resistant to continuing the exercise program. A client with good exercise adherence during the early stage may suddenly decide to drop out. Memory loss during this stage is more pronounced than earlier, and the client may need verbal or physical guidance in maintaining the exercise routine. Extreme outbursts of anger and physical aggression can occur during this stage. Often such behavior will last for only a few minutes and the client will immediately forget that the incident occurred. The exercise leader must remember that this is a symptom of the disease and therefore should not take such outbursts personally. He or she must work through the agitation with the support of the caregiver, who may or may not be present during the exercise session. For some caregivers, the brief period away from their loved one is much desired. However, if the individual has a high level of agitation, it may be necessary to have the caregiver present to work through certain behaviors. In some cases, the caregiver may be in the facility and “on call” but wouldn’t necessarily have to be in the same room. Sometimes music can help the person relax during the exercise session provided that it is not too loud and has a sound that is appealing to the participant. During the advanced and final stage of the disease, the client will require constant supervision and physical assistance. Language skills will be greatly diminished and language comprehension extremely limited. The exercise program must be guided on an individual basis. Incontinence and limited mobility are common. Range of motion and strength exercises will be the major focus during this stage. Special Considerations People with AD commonly have a higher level of restlessness or agitation at the end of the day, which experts have labeled “sundowning.” This increased state of agitation, activity, and negative behaviors is associated with high levels of fatigue and tiredness later in the day. Therefore the exercise program should be scheduled for an earlier time in the day, preferably in the morning, when the client’s agitation level is usually at its lowest and mental cognition is at its highest. If the client is exercising at home with a family member, a daily walk may be the optimal way to establish a structured routine. However, if the client refuses to exercise at home, attending a day care program once or twice a week may be better. As the disease progresses, walking may be the only exercise the individual is capable of carrying out; and once ambulation is no longer a possibility, because of either the inability to walk or the risk of wandering, maintenance of range of motion becomes crucial. The hallmark exercise program is one that keeps the client active at various times during the day (e.g., 10 min exercise routines), poses a low risk of injury from falls, and has a strong behavioral component (e.g., effective reinforcement strategies). When developing the training program be sure to consider the following elements: Strength Training: Therabands Strengthen postural muscles. Focus on areas of weakness (i.e., quadriceps, hip extensors). Use 10 to 12 reps or less as tolerated. Aerobic Training: Walking and Chair Aerobic Exercises Emphasize enjoyment. Maintain function. Flexibility Training Stretch postural muscle groups. Focus on exercises that can be done on a raised platform (i.e., mat table) or chair; getting down or up from the floor will be difficult. This is an excerpt from ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities, Third Edition, from the American College of Sports Medicine and edited by J. Larry Durstine, Geoffrey E. Moore, Patricia L. Painter, and Scott O. Roberts.

Mirror Therapy Suggestions

Some general suggestions: 

1. Be guided by a clinician who understands brain function. 

2. Presuming there is no jewelry on the affected side, remove wrist watches and rings. Try to make a total illusion. 

3. Depending on the pain and disability state, decide on an appropriate activity(ies) to perform with the good hand. This could range from just looking at the mirror image to finger movements, or taking weight through the hand. 

4. In general, the more severe the problem (eg. Severe Complex Regional Pain Syndrome), small movements, performed often, may be more appropriate. 

5. Feel comfortable with the selected movements(s)’, ie. ‘conquer the movement’ before progressing to a more challenging movement 

6. Once you feel comfortable with a movement, try and perform it in a different context. For example, do it with a song in your head, or with altered emotions by thinking of something good or bad. Overall, you will need to repeat movements, grade the movements and then context enriching the movements for best neurone health. 

7. Take care. If the hand in the box hurts or sweats, you may have taken the brain exercises too far even though the hand has not been moved. 

8. Move the painful hand in the box to the point where it starts to hurt a little and then move the good hand which is outside the box a little bit further. 

9. Do it simultaneously or reciprocally. 

10. By placing a mirror between the feet, a similar therapy can be performed for the for foot and leg problems.

 

Sleeping Tips & Tricks

Sleeping Tips & Tricks

     

Daytime Suggestions

·   Set an alarm to try to wake up at the same time every day.

·   Include meaningful activities in your daily schedule.

·   Get off the couch and limit TV watching.

·   Exercise every day. People with TBI who exercise regularly report fewer sleep problems.

·   Try to get outdoors for some sunlight during the daytime. If you live in an area with less sun in the wintertime, consider trying light box therapy.

·   Don't nap more than 20 minutes during the day.

Nighttime Suggestions

·   Try to go to bed at the same time every night and set your alarm for the next day.

·   Follow a bedtime routine. For example, put out your clothes for morning, brush your teeth and then read or listen to relaxing music for 10 minutes before turning out the light.

·   Avoid caffeine, nicotine, alcohol and sugar for five hours before bedtime.

·   Avoid eating prior to sleep to allow time to digest, but also do not go to bed hungry, as this can also wake you from sleep.

·   Do not exercise within two hours of bedtime but stretching or meditation may help with sleep.

·   Do not eat, read or watch TV while in bed.

·   Keep stress out of the bedroom. For example, do not work or pay bills there.

·   Create a restful atmosphere in the bedroom, protected from distractions, noise, extreme temperatures and light.

·   If you don't fall asleep in 30 minutes, get OOB and do something relaxing or boring until you feel sleepy.

·   Going to bed and getting up at the same time every day.

·   Removing electronic devices, such as televisions, computers or cellphones, from the bedroom.

·   Avoiding large meals, caffeine and alcohol before bedtime.

·   Making sure the sleep environment is quiet, dark and not too hot or too cold.

Steps to Better Sleep Hygiene:  Behavioral Changes

·   Regular risetime and bedtime—by doing this every day,you can help your internal clock by providing regular cues, thereby improving your sleep-wake cycle.  This should help in getting to sleep faster and reduce the number of nighttime awakenings.

·   Get plenty of bright natural light exposure, preferably in the morning along with exercise. This will give your internal clock a strong cue to run on time.

·   Avoid stimulants, such as caffeine and nicotine.  Avoid caffeine-containing drugs, drinks, and foods for eight hours before bedtime.  Avoid tobacco in the evening.

·   Avoid thoughts or discussions about topics that cause anxiety, anger, and frustration before bedtime. 

·   Institute and maintain a definite bedtime routine that is relaxing to help signal the body that sleep is to occur soon.  Examples might include: a bath, brushing teeth, a small glass of warm milk (4-6 oz.), or a light snack. This will help with getting to sleep and will reduce the need to awaken due to hunger.

·   Reserve the bedroom and especially the bed for sleeping. Avoid activities like reading and watching television in bed. Your body needs cues to associate the bed with sleeping and not other activities.

·   If you nap, try to do so at the same time every day and for no more than 1 hour, and ending by 3pm.

·   Don't spend more than 15 minutes trying to sleep—if you cannot sleep after 15 minutes get out of bed and engage in a quiet activity.  Ideally, the activity should be in low light and sedentary, for example, listening to soft relaxing music or meditating, not reading with a bright light or watching television.  Return to bed only when you are sleepy.

Staying asleep

·     Minimize light and noise at bedtime and throughout the night. This will reduce stimulation and promote normal function of the body’s melatonin rhythm that helps to promote and maintain sleep. Ear plugs may be helpful if the environment is noisy. Avoid alcohol within 4-6 hours of bedtime.  When taken at bedtime, alcohol may help induce sleep but disrupts sleep later in the night. 

·     Avoid heavy exercise within 6 hours of bedtime.  Exercise increases the body temperature. Sleep onset normally occurs as the core body temperature is decreasing. Artificially increasing body temperature can therefore give the wrong cue to the brain and contribute to sleep disruption. 

·     Avoid heavy late night meals. They can interfere with the ability to fall and stay asleep. A light snack at bedtime, however, may promote sleep.  Good bedtime snacks include dairy products and carbohydrates. 

·     Assure the bedroom environment is right for sleep: comfortable bed, dark, quiet, and a cool temperature for sleeping. 

·     Avoid looking at the bedroom clock if you awaken. If necessary, face the clock to the wall. 

Moving in bed

·     Use satin sheets on the bed or pajamas to help with moving in bed can minimize the effects of stiffness/pain.

Waking to go to the bathroom

·     Decrease evening fluids (3-4 hours before bedtime) to lessen the chance of waking up to go to the bathroom.  Make sure that you drink plenty of fluids in the morning hours.  If you often get dizzy when you stand, sit on the side of the bed for a moment or two while flexing your leg muscles before you stand up.

·     Go to the bathroom immediately before retiring.

·     Add some stress-relieving exercise to each day. Walking counts!

·     Helpful Hints: 

·     Stress can keep you from getting enough sleep

·     Exercise can relieve stress and help you sleep well at night

·     So can mindfulness, meditation and deep, diaphragmatic breathing

·     7-9 hours is considered “enough” sleep for most adults

·     Plug your phone and other electronic devices in away from your bed. Helpful Hints:Scrolling and staying connected late at night could be sabotaging your sleep cycle

·     Choosing to get enough sleep at night over getting more work done could help you be more productive

·     Bright, blue screens may inhibit melatonin production – keeping you awake longer

·     Set a “bedtime” alarm for each person in the family.

·     Helpful Hints:

·     Going to bed and waking up at a consistent time can help you sleep better

·     To set your bed time, figure out your ideal wake time and count backwards from there

·     A nightly routine with time to wind down could help you stick to your bedtime

·     If you’ve tried everything and still can’t sleep well, you may have a sleep disorder – talk to your doctor to find out what to do

·     Start your morning with a healthy habit, like a walk around the block or a moment of gratitude.

   

Helpful Hints

·     Adding a positive activity to your morning routine could make it easier to get up if you’re a late snoozer

·     Sleeping past your alarm can make you groggier in the morning

·     Habit chaining may help establish new habits, like doing a few push-ups right after you brush your teeth

·     Add a 20-minute power nap to your afternoon.

·     Helpful Hints:

·     An afternoon nap can help you re-energize and power through the rest of the day

·     “Catching up on sleep” is a myth – sleeping in on the weekend may be sabotaging your weekday sleep cycle

·     It may take a few weeks to get used to your new sleep cycle, so stick with a consistent bedtime and take naps when you need to