Weighted Blankets: Need for more evidence but definitely not no evidence

Weighted blankets are a popular Christmas present this year and have also been described by Time Magazine as one of the best inventions of 2018 (Source: Choice Magazine.)   Gravity weighted blankets have sold over $18 US million dollars worth of weighted blankets yet many experts say that there is no evidence that they work.

I must admit I am getting a little tired of ‘experts’ being interviewed who state that there is no evidence for weighted blankets. I wonder if they do a recent google search or if they are going on something that they read years ago when the research trials were just beginning.

 It would be more accurate to describe that there is strong evidence in some areas and limited evidence in other areas.  In research groups, strong and limited evidence is described according to levels of evidence. This table describes the categories of levels of evidence.

Level of evidence description (Winona State University Evidence Based Practice Tool kit)

Level     I

Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results.

 Level II

Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT).

 Level III               

Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental

 Level IV               

Evidence from well-designed case-control or cohort studies

 Level V

Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).

 Level VI               

Evidence from a single descriptive or qualitative study

 Level VII             

Evidence from the opinion of authorities and/or reports of expert committees.

As each research paper is published, the evidence is accumulating that weighted blankets work. In 2020 alone, a quick google scholar search will bring 15 articles up on weighted blankets. This includes a systemic review and randomised control trials. As soon as one systemic review is published it is out of date. For example the 2020 article on systemic review found that there were no randomised control studies for insomnia, but since their search was in 2018, there have been multiple randomised control studies published in this area. It is pretty hard to keep up.

In this blog, I will only refer to Level 1 and Level 2 evidence as this is considered the highest levels of evidence. There are hundreds of research papers for Level 3, 4, 5, 6, 7 levels of evidence.

Level 1: Evidence that a weighted blanket decreases anxiety

A systematic review was conducted on weighted blankets and concluded that ‘ the literature supports the use of weighted blankets for anxiety reduction’

(This article also looked at insomnia however there were less articles available at the time of the review and the ones that I have included here are more recent)

“Credible research suggests that weighted blankets may be an appropriate therapeutic tool. The intervention was reviewed for use in relieving anxiety and it was found to demonstrate some success in reducing anxiety. “

Level 2 Evidence in Insomnia, Adult patients receiving chemotherapy, Adult patients with eating disorders in inpatient setting.

Another systematic review on insomnia is warranted given the recent studies in the last 2 years. This includes:

A randomized controlled study of weighted chain blankets for insomnia in psychiatric disorders

Conclusion:  

Weighted chain blankets are an effective and safe intervention for insomnia in patients with major depressive disorder, bipolar disorder, generalized anxiety disorder, or attention deficit hyperactivity disorder, also improving daytime symptoms and levels of activity.

Worth The Weight: Weighted Blanket Improves Sleep And Increases Relaxation. (randomised control trial)

Results:

Objective sleep data from the 28 participants who completed all study requirements showed 7% improvement of Wake After Sleep Onset, 2% decrease in Light Sleep, and slight improvement in Sleep Efficiency (1.5%) and Sleep Maintenance (1.4%) during intervention (all ps < 0.05). Additionally, participants felt they fell asleep faster (13% faster), experienced better sleep quality (14% better), felt more rested in the morning (17% more rested), and felt they slept better through the night without waking up (36% improvement). They also reported feeling 13% less stressed at bedtime and 17% more relaxed while trying to fall asleep.

Conclusion

Using a weighted blanket reduces self-reported feelings of stress, enhances feelings of relaxation, and can improve sleep and reduce time awake at night in people with sleep onset and sleep maintenance issues.

Weighted Blankets: Anxiety Reduction in Adult Patients receiving chemotherapy.

Conclusion: “

This randomised control trial concluded that a standard-weight, medical-grade therapeutic weighted blanket can be safely used to reduce anxiety in patients of various weights, and a visual analog scale can be a reliable indicator of patients' state anxiety.

Assessing the Impact of Weighted Blankets on Anxiety for Patients With Eating Disorders in an Inpatient Setting: A Randomized Control Trial Pilot

An RCT that assesses the efficacy of weighted blankets on anxiety for patients with severe anorexia nervosa (AN) and avoidant restrictive food intake disorder (ARFID) in an inpatient medical setting. The results demonstrate clinical significance, advancing the field of OT as it supports the use of a sensory intervention to positively impact psychological and emotional states of a patient population with limited evidence to support best practices.

Low levels but not no evidence that weighted blankets improve sleep in Autistic children.

There has been some research on using weighted blankets with autistic children that have not found strong levels of evidence of the benefits. However, the weighted blanket was favored by children and parents, and blankets were well tolerated over this period in this study. There has also been some research with small number that have shown positive benefits, but these need to be larger scale and randomised to add to the evidence base .

 In my opinion, this is a tricky area to research due to the sensory over and under responsivity of Autistic People. For example, one child may really dislike deep pressure (and therefore weighted blankets) whilst another child may find it very calming. Ideally, the sensory preferences of autistic children would be identified as part of the protocol for future research.

The practice guideline: treatment for insomnia and disrupted sleep behaviour in children and adolescents with autism spectrum disorder stated that: Clinicians should counsel that there is currently no evidence to support the routine use of weighted blankets or specialized mattress technology for improving disrupted sleep. If asked about weighted blankets, clinicians should counsel that the trial reported no serious adverse events with blanket use and that blankets could be a reasonable nonpharmacological approach for some individuals.

 Special Mention:

One researcher stands out as having published multiple papers on Weighted Blankets and championing the benefits – Tina Champagne. We can thank Tina for all of her groundbreaking work that has contributed to weighted blankets being recognised as evidence based and  in such popular use that it is now considered a great Christmas present. This is one of Tina Champagnes articles:  

Mullen and Champagne et al (2008) explored the effectiveness of a thirty pound weighted blanket on thirty-two adults. Vital sign metrics showed that using the weighted blanket in a lying down position was safe. Thirty-three percent of participants experienced a lowering of electro-thermal activity, sixty-three percent reported lower anxiety and seventy eight percent preferred the weighted blanket as a calming modality.

Safety

For people with disabilities and medical conditions it is recommended to discuss the option of a weighted blanket with an Occupational Therapist and your treating Doctor. This blog is a general description of the benefits and is not advice specific to the individual.

Further Information

Weighted Blankets are a Sensory Modulation intervention using deep pressure stimulation.

Further information on Sensory Modulation is available from:

O Sullivan, J & Fitzgibbon, C (2018) Sensory Modulation Resource Manual

Champagne, T. (2011) Sensory Modulation & Environment: Essential elements of occupation

Using Sensory Modulation Online Course 5 hours CPD.

References

Rachel Ohene, MOT, OTR/L; Christina Logan, MS, OTR/L; Ashlie Watters, PhD; Figaro Loresto, PhD, RN; Kathryn Eron; Philip Mehler, MD, FACP, FAED (2020) Assessing the Impact of Weighted Blankets on Anxiety for Patients With Eating Disorders in an Inpatient Setting: A Randomized Control Trial Pilot

A randomized controlled study of weighted chain blankets for insomnia in psychiatric disorders

Ekholm B, Spulber S, Adler M. (2020) A randomized controlled study of weighted chain blankets for insomnia in psychiatric disorders. J Clin Sleep Med. 2020;16(9):1567–

Danoff-Burg, Sharon & Rus, Holly M & Martir, L & Raymann, Roy. (2020). 1203 Worth The Weight: Weighted Blanket Improves Sleep And Increases Relaxation. Sleep. 43. A460-A460. 10.1093/sleep/zsaa056.1197

Eron, K, Kohnert, L, Watters, A, Logan, C, WEisner-Rose, M, Mehler, P. (2020) Weighted Blanket Use: A systematic Review American Journal of Occupational Therapy, August 2020, Vol. 74, 7411515404. https://doi.org/10.5014/ajot.2020.74S1-PO5511

P Gringras, D Green, BWright, C Rush, M Sparrowhawk, K Pratt, V Allgar, Naomi Hooke, D Moore, Z Zaiwalla and L Wiggs (2014) Weighted Blankets and Sleep in Autistic Children—A Randomized Controlled Pediatrics August 2014, 134 (2) 298-306; DOI: https://doi.org/10.1542/peds.2013-4285

Choice article: https://www.choice.com.au/health-and-body/conditions/trouble-sleeping/articles/do-weighted-blankets-work

Mullen, B., Champagne, T. Krishnamurty, S. Dickson, D & Gao, R. (2008) Exploring the safety and therapeutic effects of deep pressure stimulation using a weighted blanket. Occupational Therapy in Mental Health, 24, 65 -89

Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

Ashura Williams Buckley, Deborah Hirtz, Maryam Oskoui, Melissa J. Armstrong, Anshu Batra, Carolyn Bridgemohan, Daniel Coury, Geraldine Dawson, Diane Donley, Robert L. Findling, Thomas Gaughan, David Gloss, Gary Gronseth, Riley Kessler, Shannon Merillat, David Michelson, Judith Owens, Tamara Pringsheim, Linmarie Sikich, Aubyn Stahmer, Audrey Thurm, Roberto Tuchman, Zachary Warren, Amy Wetherby, Max Wiznitzer, Stephen Ashwal First published February 12, 2020, DOI: https://doi.org/10.1212/WNL.0000000000009033

 Winona State University Evidence Based Practice Tool kit: https://libguides.winona.edu/c.php?g=11614&p=61584

: This level of effectiveness rating scheme is based on the following: Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. (p. 7). St. Louis, MO: Mosby Elsevier.

 https://pediatrics.aappublications.org/content/134/2/298.short

Bring back the paper bag for Panic involving hyperventilation

I have been reading about using paper bags for hyperventilation that is occurring for panic. An article written by M Tavel and published in an internal medicine journal (2017 ) has recommended paper bags or breath-holding. There is no mention of any of the other breathing techniques that are commonly used in mental health practice.

" Once recognized, prevention and control of at least this part of the disorder are usually successful through explanation of symptom causation and how the symptoms can be aborted by either breath-holding or rebreathing into a paper bag. Before one recommends paper bag rebreathing, however, diagnosis of hyperventilation syndrome must be secure, for adverse events may occur if one overlooks serious underlying conditions of acute Myocardial Infarction (MI), pneumothorax, pulmonary embolism, and others".

It is understandable that Paramedics stopped using paperbags whilst in an emergency situation and until the diagnosis of hyperventilation in panic was established. But when the diagnosis has been clearly established, it is unclear to me as to why paperbags have become so unfashionable in mental health practice in Australia? Does anyone else use them? At Sensory Modulation Brisbane , Julie and I find paperbags and other simple sensory techniques are very effective, even for mild hyperventilation.

Using Balance, Movement and Proprioceptive Input to Reduce Anxiety

There is growing evidence that balance, movement and proprioception (the sense or awareness of our body in space) can play an important role with managing anxiety.

Maintaining balance requires input from a number of systems, including proprioceptive and vestibular (movement) sensory systems. These sensory systems have direct pathways to the parts of the brain that modulate the autonomic nervous system, which controls the stress response. Research has shown that increasing balance, movement and proprioceptive input actually reduces sympathetic nervous system activation, effectively turning down the stress response and reducing anxiety.

It makes sense when you think about it. If we feel less balanced and more unsure/unsteady on our feet, or if we are not registering sufficient information from our muscles and joints about where our body is in the environment, this can heighten feelings of stress, anxiety, and feelings of being more unsafe/unstable as we are moving through the world.

Actively increasing balance, movement and proprioceptive input will help a person feel more connected to their body. This increases a sense of grounding, stability, safety and calm, which can reduce or even alleviate feelings of anxiety. This input can be increased by engaging in activities that require balance, movement, sustained muscle contractions or deep pressure input.

Examples of increasing balance, movement and proprioception input to reduce anxiety:

·         For children who are feeling anxious or nervous in the morning before school, play a game of ‘balancing on one foot’. To make it more fun, balance while waving arms, touching nose, wriggling raised leg or even use a balance board (now available in stores like Kmart). These activities are also useful during school, after breaks or between lessons.

·         Participating in movement and muscle resistance exercises at the beginning or end of the day, to increase feelings of calm and grounding, for example yoga or pilates poses, using repetitions with hand weights, skipping with a rope, or stretching exercises using therabands (now available in stores like Kmart).

·         Incorporating resistance and deep pressure input into your daily activities and routines, for example watering the garden with buckets of water, reading a book with a weighted cushion, weighted toy or pet in your lap, or going for a swim, a walk or a bike ride.

References

Medical News Today (2009). Link Between Anxiety and Balance Problems in Children Suggested By New Research From TAU https://www.medicalnewstoday.com/releases/136495.php

Science Daily (2009). Mind Out Of Balance, Body Out Of Balance. Tel Aviv University. http://www.sciencedaily.com/releases/2009/01/090122141226.htm

Research Ideas

Dear Students and researchers.

At Sensory Modulation Brisbane, we have clinicians who often identify topics for research, but who are unable to research them due to time or logistical restraints. We are very aware of the need for further research on Sensory Modulation, so we are going to list ideas through blogs when we have them.

We request that you acknowledge Sensory Modulation Brisbane (Carolyn Fitzgibbon and Julie O’ Sullivan) as inspiration. Also ,we request that you identify Sensory Modulation as an intervention being championed by Occupational Therapists. We would be very interested in hearing if you do proceed with any of our research ideas. Here are our first ideas:

Use of scent of a familiar person/place to decrease anxiety or panic .

Parents of babies and also people with puppies, use the scent of the person to provide calming. In older children and adults, scent could also be utilised with those who do not feel safe.

OT researchers could use this process:

1.     Identify a scent that reminds the person of a safe person, place or memory.

2.     Identify a way to incorporate this scent into daily occupations.

3.     Assess if anxiety is decreased.

Clinical applications include:

•  Mum sleeps with a hanky and then child with anxiety takes this to school to assist with separation anxiety

• Young man has a sprig of rosemary in his backpack as it reminds him of his Grand Dad’s garden.

• Young woman smells the deodorant that her Mum uses when she is anxious. (I had one client who ceased having panic attacks when she tried this)

• Person feels safe at the beach, so brings a little jar of sand home, and smells this when feeling anxious.

Soothing and Grounding Sensory Modulation Strategies for clients with Severe Anorexia Nervosa

Clients with severe anorexia nervosa are often asked by treating teams to not exercise due to the energy and calories that this takes. However ceasing exercise often takes away a strategy that has been being used to calm and ground. Other strategies for providing vestibular and proprioceptive input could be explored with this clinical population.

Researchers could use this process:

1.     Interview a person with Anorexia Nervosa to explore the type of exercise that they enjoyed.

In collaboration with the individual, explore options for sensory modulation that could be meeting a similar sensory need. This may include:

• grounding sensations – squeezing a hand grip or theraputty.

• soothing  – explore other vestibular options eg hammock , chair swing.

• feeling in control – tight clothes such as thermals, T-Jackets.

Or sensory modulation could be used to explore soothing options for clients with anorexia nervosa.

Using warmth with clients with Severe Anorexia Nervosa.

Clients with Anorexia Nervosa on inpatient units are often finding it difficult to maintain their core body temperature.

Sensory Modulation strategies could be increased with these clients including using electric blankets, electric hot water bottles, hand warmers, pyjamas heated in dryers etc.

Clients could be interviewed before and after using a heated item, to explore whether this improved their emotional state.

Reference:

"Sensory Modulation Resource Manual" (2018), J O' Sullivan and C Fitzgibbon

Ideas 2: 

The above blog generated some interest so we have added some more_

Do medical procedures increase oral hypersensitivity in children?

Some children develop oral hypersensitivity and some then have difficulty with eating foods with textures. Is it possible that the hypersensitivity developed after medical procedures involving anaesthetics, tubing, and needing medication in oral syringes?

Interview parents of children with oral hypersensitivity and also a control group of parents of children without oral sensitivity. Take a sensory history to identify if children were orally hypersensitive from birth (eg more difficulties with breast feeding, bottles etc) and also the rates of medical procedures. 

Are children who are super tasters also orally hypersensitive?

Some people are super tasters. Is there a link between taste sensitivity (super tasters) and oral motor sensitivity?

Nail Biting and Sensory Modulation

Nail biting can have a number of identified causes and solutions. Could sensory modulation work as an intervention? 

People who nail bite could be interviewed to identify if nail biting provides them with oral input, pain input, or other sensory input. Then alternative strategies for sensory input could be explored. These may be similar eg replacing oral input with another oral input? Or perhaps different sensory input eg do warm sensations, cool sensations, vibration or deep pressure sensations work to provide sensory input and decrease the need for nail biting? 

Using the dive reflex prior to an exam to decrease anxiety.

Many students experience anxiety prior to an exam. One option for decreasing the physiological impact of anxiety is to use cool water and breath holding to invoke the dive reflex. (eg cold water in zip lock bags and held over the eyes whilst breath holding). 

Fibromyalgia and light and deep touch.

We have had clinical experience with two clients with fibromyalgia who were sensitive to deep touch, and found light touch calming. Does this occur with other people with fibromyalgia?

Cleaning toilets with scent sensitivity. 

Some clients with scent sensitivity have difficulty cleaning toilets or other cleaning tasks. What strategies are the most useful for them to be able to complete this task?

Strategies for people who have sensory sensitivities and are in open plan offices

Several clients have had difficulties with misophonia or scent sensitivity or sound sensitivity within an open plan office. Research could be completed to identify the most useful strategies for coping with this. 

Intense Sensations and self-harming.

In the Sensory Modulation Resource Manual*, there is a worksheet with additional intense sensations to those traditionally used within DBT. Which of those intense sensations tend to be most useful for those with urges to self-harm?

5 strategies series.

In the Sensory Modulation Resource Manual*, there is a short list of 5 strategies to trial for symptoms including anxiety, agitation, hallucinations, etc. Research could be conducted to trial these in different clinical populations.

Reference:

"Sensory Modulation Resource Manual" (2018), J O' Sullivan and C Fitzgibbon