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19.03.2015

Sleep disturbances va rating, new drugs for tinnitus - Test Out

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Before I go too much further, I want to differentiate between Sleep Disturbances and Sleep Apnea. Service members generally get less sleep than their civilian counterparts, with one study suggesting that seventy-two percent of previously deployed Army soldiers report typically getting less than six hours of sleep a night (Luxton, 2011) compared to seventy-two percent of civilian adults reporting getting seven or more hours per night (Krueger & Friedman, 2009). The Diagnostic and Statistical Manual of Mental Disorders (DSM) made several significant changes from the DSM-IV (APA, 1994) to the DSM-5 (APA, 2013) in both the classification and diagnostic criteria for many of the sleep-wake disorders. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between endogenous circadian rhythm and the sleep-wake schedule that causes excessive sleepiness or insomnia and significant distress are the criteria for the Circadian Rhythm Sleep-Wake Disorders category. A thorough review of all of the changes to the Sleep-Wake Disorders is beyond the scope of this article but is highly recommended for psychologists who regularly asses sleep disorders in your practice. Not surprisingly, the same types of sleep disorders common among civilian populations are also common in military populations, although different contributing factors may be involved.
Obstructive sleep apnea can frequently cause complaints of sleep difficulties, particularly reports of poor sleep quality and fragmented sleep.
Nightmares, whether related to a full-blown mental health disorder such as PTSD or to exposure to trauma in general, comprise a number of sleep-related complaints among military members.
Any one of the sleep disorders previously described, and some not covered in this article, can contribute to difficulty falling and staying asleep. If the evaluation suggests that the patient has OSA or an underlying medical condition, a referral to a sleep specialist is warranted before initiating a trial of behavioral treatment.
Depending on the sleep disorder, behavioral treatment, medical treatment, or a combination approach may be indicated. Given that light has the biggest impact on circadian rhythms entrainment for sleep phase disruptions, it should be one of the tools used by providers to advance or delay a sleep phase that is out of sync with environmental (work or social) schedules.
Other options for circadian rhythms entrainment include melatonin therapy, where melatonin supplementation in the evening hours will advance the sleep schedule and supplementation in the morning hours will delay the sleep schedule.
Lastly, chronotherapy may be used for circadian rhythms entrainment and consists of gradually shifting the sleep schedule from the preferred schedule to the new schedule. Sleep-wake disorders and in particular insomnia, nightmares, OSA and circadian rhythm disorders will continue to be a significant presenting concern of Service members and Veterans.
Whole person impairment ratings for sleep disorders in Table 13-4, and the instructions for use on page 317 of the AMA Guides Fifth Edition have created conflicting WCAB panel decisions on whether a sleep disorder can exist as a stand-alone WPI rating or if it is limited to a 3% WPI pain related impairment add-on under Chapter 18 of the AMA Guides Fifth Edition and page 1-12 of the 2005 PDRS.
The matter proceeded to a trial on the issue of whether Applicant had an industrially caused sleep disorder, along with the issues of PD and need for future medical treatment for the claimed sleep disorder. Defendant sought reconsideration, contending in relevant part that the WCJ’s finding of industrial injury in the form of a sleep disorder and award of PD based upon that finding was not supported by substantial evidence and was contrary to the law. The WCAB returned the case to the WCJ for a new decision on PD that did not include Applicant’s claimed sleep disorder as a separate injury. There is significant disagreement within the workers' compensation community about the role that sleep disorders have on rating permanent disability in cases in which the AMA Guides Fifth Edition apply. First of all, sleep that is nocturnal and restful is an ADL pursuant to AMA Guides Chapter 1, Table 1-2, page 4.
In fact, conservative physicians will indicate in their reports that sleep disturbance is already included within the impairment rating given for the underlying medical condition. If you do some medical research on the subject of sleep disorders, you will discover that there is an entire chapter of the DSM-IV TR devoted to sleep disorders—how to diagnose, evaluate and categorize them. The other problem with sleep disorders is that it is very difficult to predict whether a sleep disorder is permanent. But once you have a diagnosis of a sleep disorder under the DSM-IV TR, does the injured worker in California have to be evaluated using the 2005 PDRS for psychiatric conditions, with the limitations of Calif. For now, we are taking a strict approach to the issue of when a sleep disorder can be rated in a workers' compensation case. Since sleep is a function of the brain and central nervous system, we need to look at AMA Guides Chapter 13, The Central and Peripheral Nervous System, Section 13.3c, Arousal and Sleep Disorders, page 317, Table 13-4, which is operative in our cases. It is expected that the diagnosis of excessive daytime sleepiness has been supported by formal studies in a sleep laboratory.
However, the AMA Guides do not have any qualifying language to the contrary, and together with the instructions in the DSM-IV TR, if you have a case in which a sleep disorder is suspected or claimed, then a polysomnogram is required. There is an argument being made by some physicians that for a Class I or Class II sleep disorder rating under Table 13-4, only an Epworth Sleepiness Scale is needed.
PRACTICE POINT: Defense counsel is urged to take the deposition of the injured worker if a sleep disorder is alleged in order to determine whether the condition is caused by pain from an injury. The instructions on page 317 of the AMA Guides list some examples of medical conditions that can result in a sleep disorder that are ratable under Table 13-4, such as traumatic brain injury, stroke, Alzheimer's Disease, depression and other diseases and disorders. Notice also that depression is listed on page 317 and sleep disorders can arise from depression.
In the Hernandez case, the WCJ very carefully and meticulously articulated the factual evidence, including the Applicant’s credibility concerning her testimony of how her sleep patterns were altered by her industrial injuries.
Well, I thought it would be entertaining, and sleeping issues are affecting a lot of people, especially Veterans. Evertired experienced problems related to the quantity and quality of sleep as far back as his first deployment but he never felt that it was significant enough to warrant seeking any type of treatment.
Adding to the concern related to short sleep duration of military members is the impact of deployment, often repeated deployment, and exposure to trauma and injury that has been well documented over the years of the wars in Iraq and Afghanistan. The DSM-5 sleep-wake disorders category now encompasses 10 disorders or disorder groups, including insomnia disorder, narcolepsy, breathing related sleep disorders, restless leg syndrome and nightmare disorder (see figure 1). Because of this mandate, sleep disorders related to another mental disorder or a general medical condition have been removed.
There were significant changes to the subtypes of Circadian Rhythm Sleep-Wake disorders in the DSM-5. Evertired reported that about six months ago he had been convinced by his wife to “do something about his irritability and sleep problems.” He had seen a provider who gave him “some sort of BS list of things to do to help his sleep…something about sleep hygiene” but that he found most of the items unhelpful. For example, a review of sleep studies performed at a military treatment facility found that OSA and insomnia were the two most common sleep diagnoses (Mysliwiec et al, 2013); additionally, military members may also have other sleep problems including circadian rhythm disorders, nightmares, and sleep changes due to Traumatic Brain Injury (TBI). During a deployment, a military member may have to make substantial changes to ideal sleeping patterns that can increase the risk for insomnia upon returning home. Despite efforts among the military branches to reduce stigma for seeking mental health-related help, service members and veterans may still be more willing to disclose and seek treatment for sleep difficulties, such as insomnia caused by nightmares, as opposed to first addressing any underlying trauma. This link may relate to nightmares, where the fragmented sleep in OSA may increase awareness of PTSD symptoms such as nightmares, so that treating the OSA may improve PTSD severity. Because sleep is regulated by the brain, a brain injury, even a relatively mild one, may temporarily disrupt sleep. If the patient’s sleep difficulties do not stem from primary insomnia, treating the underlying cause is the best course of action before addressing the sleep difficulties directly. Evertired’s sleep, including a functional analysis and use of the STOP screener clearly suggest that a referral for a sleep study is indicated. Non-benzodiazepine hypnotics, including Ambien, Lunesta, and Sonata, have been approved specifically for sleep difficulties, as well as a small number of benzodiazepines. In general, light exposure in the evening hours prior to bedtime will delay the sleep schedule with later bed and wake times, and light exposure in the morning several hours prior to preferred wake time or shortly after the wake time required by schedule will advance the sleep schedule. Shifting by delaying bedtime often works more smoothly given the relative ease of “staying up” and subsequently building up sleepiness as opposed to forcing sleep onset. Evertired’s overnight sleep study indicated that he was having 10- 12 hypopnea episodes per hour and in combination with his snoring and daytime sleepiness it suggested he had moderate sleep apnea. Roman Culjat performed a sleep study on Applicant, the results of which were essentially normal. Craemer stated that he believed Applicant’s sleep problem was industrially caused because, by eliminating other sleep disorders such as sleep apnea, as was done by Dr.
The WCAB concluded that, as shown by the medical evidence, Applicant’s hypersomnia was related to the pain caused by her industrial right shoulder condition and was not a separate ratable sleep disorder causing PD.


Guides, the sleep disorder cannot be the result of pain from an underlying injury, which is already included in the rating of that injury.
The medical record does not support a finding that applicant incurred a separate sleep disorder. The panel QME likewise opined that the sleep disorder was industrial but assigned a WPI rating of 3%, also relying on the Epworth Sleep Study. She used to sleep approximately eight hours per night but when she started having physical symptoms, she would wake up with pain and numbness in her hands.
Hernandez had difficulty in concentrating, decreased driving impairing her ability to travel and slightly diminished sexual functioning along with her sleep problems. Hopefully, this article will clear up any misunderstandings about how and when sleep disorders can be ratable and when they cannot.
Although California case law is pending on this issue, common sense tells us that if a person is suffering from a sleep disorder caused by pain from an industrial injury and because sleep is an ADL affected by the injury, then up to 3% WPI can be added to the underlying impairment rating that is causing the pain. Liberal physicians will want to add up to 3%, arguing that the sleep disturbance is not already included in the underlying rating and that since sleep is an ADL listed in the AMA Guides, then up to 3% WPI can be added. In the introduction to sleep disorders, the authors of the DSM-IV state unequivocally that in order to diagnose a sleep disorder, there must be polysomnography performed in a sleep laboratory. We know that long term use of sleep medication is contraindicated; in fact, long term use of sleep medication can cause a substance induced sleep disorder. Case law in California may clarify some of the controversies that arise in cases that involve an allegation of a sleep disorder. If you ask most clinical practitioners, they will almost uniformly agree that you do not need a polysomnogram in every case in order to diagnose a sleep disorder. In addition, a Multiple Sleep Latency Test (MSLT) is also recommended to see how a person's sleep latency (how long it takes to fall asleep) affects ADL functioning. In addition, other causative factors can be discovered, such as allergies to a pillow, an animal that sleeps in the same room, or a spouse or significant other who snores and disrupts the injured worker’s sleep patterns. This correlates with the DSM-IV diagnosis of a sleep disorder associated with a psychiatric condition.
If a medical doctor suspects a sleep disorder, a referral to a qualified sleep laboratory is in order if the sleep disorder is not caused by pain.
If a sleep disorder exists, the type and category should be diagnosed by a medical doctor (preferably a psychiatrist) or psychologist using the DSM-IV criteria. An Epworth Sleepiness Scale should be performed at least a few times to obtain consistent results, if possible.
An analysis by the medical doctor or psychologist should be made to determine the class of sleep and arousal disorder impairment under Table 13-4. The physician determines the WPI rating within a class, stating how and why the patient falls into a class and rating within that class along with the cause or link of the sleep disorder to the industrial injury. Her sleep disorder did not seem to be directly attributed to pain in her shoulder, but was permanently altered as her industrial cumulative trauma evolved. You need to develop the record and when appropriate obtain a pre-morbid sleep profile and have the treating and evaluating physicians justify why a sleep disorder should be independently rated instead of rated as an ADL 3% pain related add-on.
In fact if the genie was a new age hipster genie and only granted me one wish, I’d take the sleep over the money. This morning, after a few hours of sleep, I was checking the Google monster for news on Veterans Disability, and I came across an article from New Jersey regarding sleep apnea in Veterans. Sleep Apnea is a condition that is diagnosed, and thus would have to be affecting you while you were serving…or within a year of discharge, in order to get service connected.
After his second deployment to Iraq, he again reported having problems with sleep that gradually worsened over the two years leading up to his deployment to Afghanistan. In fact, the most common complaint on post deployment surveys of Service members returning from deployment is related to the quality or quantity of sleep. The classifications in the DSM-5 are organized for easier differential diagnosis and to clarify when a referral to a sleep specialist may be warranted. Perhaps most relevant to a military population is the new criteria that the sleep difficulty occurs despite adequate opportunity for sleep, which may not exist in a deployed setting for many Service members.
This category now includes advanced sleep phase syndrome, irregular sleep-wake type and non-24-hour sleep-wake type, while the subtype of jet lag type has been removed. He felt the therapist was more interested in his combat experience and occasional nightmares and “couldn’t listen to the fact that I was over that.” He has since resorted to having an occasional “beer or two” to fall asleep and more often than not sleeps on the couch so he does not disturb his wife. Some of these changes to patterns include sleeping at random times or in small time periods, sleeping in a crowded, brightly lit areas, sleeping on the ground, or trying to sleep despite loud noises, including rocket and mortar fire. Unfortunately, nightmares relate to lower adherence to OSA treatment (El-Solh et al, 2011), which means that nightmares and other sleep problems can develop into a negative cycle.
Many patients with sleep disruption from a TBI will complain not only of insomnia but also of excessive daytime fatigue. While medications generally result in similar reductions in sleep onset latency and time awake in bed at night and longer total sleep times than behavioral treatments, they do not have as long-term an effect (Kryger et al, 2011). Melatonin and light therapies may be combined; although, whether administered jointly or individually, both should be incorporated with a consistent sleep schedule to maximize benefit.
However, it may be unrealistic given work schedules for those who already have a delayed sleep phase tendency to allow even several days for alignment with the new schedule. The ability to accurately assess a sleep problem and recognition of conditions that warrant referral to sleep specialists is key to competent care of these patients.
Two recent WCAB panel decisions reflect the controversy where one panel decision does not allow a stand-alone sleep disorder rating while another one does. Because the effects of pain caused by the admitted right shoulder injury were encompassed within the PD rating for the shoulder injury, the WCAB found that it was error to award PD based upon Applicant’s hypersomnia. Instead, her disrupted sleep is an anticipated consequence of the pain caused by her shoulder condition. Alternatively, liberal physicians will want to rate any sleep disorder that is related to an industrial injury, regardless of its cause, including pain. There has to be a direct cause or a link between the industrial injury and the sleep disorder other than pain. The argument is that if a patient needs sleep medication, then there is a sleep disorder that needs to be evaluated without use of medication, much like a hearing loss is evaluated without hearing aids. In a clinical medical practice, if a patient presents to a psychiatrist or psychologist with objective evidence of depression and an anxious state, with a haggard countenance, it is probable that the patient has a ratable sleep disorder.
These studies generally take 21 consecutive hours in a sleep laboratory and can cost up to $3,600 under the current fee schedule. All an Epworth Sleepiness Scale consists of is a self report visual analog scale of eight questions, worth up to 3 points each. For example, a patient who wakes up once an hour is not getting adequate sleep and usually is visible in that person's countenance.
In contrast, the WCAB panel in Jones linked the Applicant’s sleep disorder directly to the pain she experienced when she turned on her shoulder while trying to sleep.
The defense argument is to contend that the sleep disorder is strictly caused by pain and is not a result of a central nervous system disorder, such as a stroke or seizure disorder.
I was thinking that I had sleep apnea as I am a larger person, and I have other things that would put me at risk for this condition.
When it comes to Sleep Disturbances, those don’t have to be diagnosed while you were serving, as long as you served in Iraq, or one of the other countries listed.
However, it is possible to get service connection for sleep apnea if you have buddy statements from those you served with that witnessed your sleeping patterns or if you sought treatment for trouble sleeping while serving and were diagnosed after you were discharged. Today, if you work with service members or veterans you have probably come to expect hearing about sleep concerns.
It is geared towards general mental health and medical clinicians rather than sleep medicine specialists and includes new evidence related to biological validators for narcolepsy and breathing related sleep disorders that likely warrant a formal sleep study.


It also highlights the fact that effective treatment of an “underlying” medical or mental condition often does not effectively address the sleep disturbance, which will often require independent clinical attention.
The most common circadian rhythm sleep-wake disorder, especially in young adults of military age, remains the Delayed Sleep Phase Type in which there is a pattern of delayed sleep onset and awakening times with an inability to fall asleep and awaken at desired or acceptable earlier times. When working with a military member who has sleep problems along with symptoms such as snoring or excessive daytime sleepiness, psychologists should consider the possibility of recommending a sleep study to rule out OSA.
On top of difficulty regulating sleep and wakefulness, one group of veterans who reported a TBI with loss of consciousness (a moderate TBI) were found to be at a four-time greater risk for nightmares even when controlling for potential PTSD symptoms (Gellis et al, 2010).
Once treated, if patients still report sleep difficulties, behavioral treatment can resume as an adjunct to medical care. Anecdotally, one of us (DD) had a patient return to normal sleep parameters in less than two months after having insomnia for 42 years! Medications are frequently used to manage the transient sleep difficulties found on deployment and in other military settings, so military members may have greater awareness of medication options than behavioral treatment.
He was started on CPAP and has been largely compliant with its use and has experienced a significant reduction in daytime sleepiness, improved sleep quality and mood and a general increase in energy. Given the effectiveness of treatments for sleep-wake disorders, specifically the key role of behavioral interventions in the treatment of many of these conditions, and because we have the tools to contribute significantly to the care of this clients, behavioral health providers should seek opportunities to gain further competence in assessment and treatment of sleep-wake disorders.
Craemer stated that Applicant’s sleep problem was in the mid range, rather than the higher range of class 1 under the AMA Guides. If a patient scores 10 points, he or she has a Class II sleep disorder impairment rating under Table 13-4, which is a 10%-29% WPI stand alone impairment rating.
People who live in cities have a greater incidence of sleep disorders than the population who lives in rural areas. The treating or evaluating physician would have to either give an overall DSM-IV differential diagnosis with the GAF score for both the sleep disorder and the depression together as one rating or a GAF score only for the depression and a separate rating under Table 13-4 for the sleep disorder under the AMA Guides.
The Applicant’s side will then contend that sleep is a central nervous system function and any permanent disruption of sleep also involves the central nervous system, so Table 13-4 is appropriate to use in these cases. By the time of his last deployment in late 2011, he stated that sleep issues were causing problems for him socially and occupationally, and that just prior to being activated he had gotten in trouble at his civilian job for falling sleep behind the wheel of a bulldozer while on break. However, many psychologists have little or no training specific to the assessment and treatment of sleep disorders that would prepare them to work effectively with Sgt.
Among those Service members referred for a sleep study by their primary care provider or mental health provider, slightly more than half were diagnosed with OSA from mild to severe severity (Mysliwiec et al, 2013), and among veterans referred for a sleep study in one VA Hospital, slightly more than three-quarters were diagnosed with OSA (Samson et al, 2012). Regarding sleep phase disorders, in the military environment where early rising is expected, patients with advanced sleep phase tendencies may perform well, but those with a preference for a much later bed and wake time tend to have problems adapting and often seek treatment believing they have insomnia when a delayed sleep phase disorder is present instead. Multiple TBIs may further worsen the likelihood of developing sleep problems; whereas nearly a quarter of military members with TBI have insomnia, nearly half of those with more than one TBI have insomnia (Bryan, 2013). Specifically, are there conditions that might require a referral to a sleep specialist or primary care provider, such as OSA or Restless Leg Syndrome, and to determine if Cognitive Behavioral Therapy for insomnia would be appropriate. Among veterans, CBT-I has been found to have similar outcomes for measures of sleep quality and quantity as civilian studies in as few as eight to 10 sessions (Perlman et al, 2008). Upon return to the behavioral provider he continued to complain of some problems with sleep onset and maintenance and occasional nightmares.
The impairment is due to reduced daytime alertness and a sleep pattern such that an individual can perform most activities of daily living. So again, development of the record is essential if an injured worker is claiming a sleep disorder. Hernandez’s pre-injury sleep profile, while it appears it was not well developed in the Jones case. No one addressed this issue in either case, but it is interesting that the WCAB panel in Jones rejected what appeared to be a positive laboratory sleep study in addition to a positive Epworth Sleep study. Since his return from Afghanistan, he has been treated for PTSD with some success but continues to suffer with sleep problems and moderate to severe daytime fatigue. OSA constitutes a potentially serious condition for military members, since excessive daytime sleepiness can impair performance in dangerous environments, such as during a deployment or while working with firearms. Compared to the 8% of the US population who obtains less than 5 hours of sleep each night, 42% of military members in one study reported the same, although some military members’ short sleep durations may result from work schedules or other behavioral factors instead of primary insomnia (Mysliwiec et al, 2013). Since military members who have deployed may have been exposed to blast or combat injuries that did not result in visible injury, it is possible that patients presenting with sleep-related complaints may actually have a TBI that warrants follow-up.
Assessment measures should be retrospective and may include the Insomnia Severity Index (Morin, 1993, a Dysfunctional Beliefs and Attitudes about Sleep Scale (Morin, 1993 and an assessment of daytime impact such as the Epworth Sleepiness Scale (Johns, 1991) and daily recording in a sleep diary.
A course of CBT-I and three sessions devoted to Imagery Rehearsal resulted in significant improvement in sleep quantity and an elimination of nightmares.
Although the guidelines state that it is expected that the diagnosis of excessive daytime sleepiness has been supported by formal studies in a sleep laboratory, this language is not mandatory. A good benchmark to determine, subjectively, if someone has a sleep disorder is, if he or she wakes up once an hour or is one who regularly sleeps less than 6.5 hours per night. This is probably because the sleep disorder was directly linked to the Applicant’s painful shoulder.
The article then looks into how the VA is attempting to reevaluate the process by which Sleep Apnea claims are service connected. This article will briefly discuss sleep-wake disorders in general with a focus on addressing the sleep disturbances that are most common in military members and veterans, describe the importance of a thorough assessment of sleep disturbances, and provide a brief overview of the effective treatments currently available for these most common sleep problems in the military population. He did acknowledge some irritable mood and occasional anger outbursts and he stated that he does still have nightmares related to the trauma about 2-3 times a month that interfere with his sleep.
The clinical interview then covers a history of sleep patterns and preferences, sleep-relevant behaviors, a functional analysis to identify factors that improve or worsen sleep, an assessment of the sleeping environment, information related to military history, such as deployments and duty hours, and a medical and psychiatric history (see box 1). Importantly, clinicians should screen for potential sleep disorders other than insomnia and may use additional screeners such as the STOP screen for OSA and the Restless Leg Syndrome Rating Scale for RLS as indicated. She began complaining of sleep disturbance due to the stress of her job along with the onset of upper extremity pain and hypertension. Evertired, his wife says that his sleep seems very light and restless and that he seems to be snoring and almost waking up a lot during the night.
Craemer noted that Applicant was having problems sleeping due to the pain she experienced when she rolled onto her injured shoulder.
Because normal snoring difficult to sleep continuous positive effect throughout the day where the most popular s8 cpap because of sleep enough to stop sleep apnea.
Evertired stated that he did not know that he snores but acknowledged that he does wake up during the night and sometimes cannot get back to sleep.
Craemer included no diagnosis of a sleeping disorder, nor did he mention any need to treat her sleeping problems in his report.
The sooner the problem of sleep apnea solutions for people who have it are unaware of it and allergies to certain condition. Craemer opined that Applicant’s sleeping condition would be in class 1 with a 5 percent WPI based upon the physical examination presentation and on the Epworth Sleepiness Scale score. Many of these factor-alpha (TNF-alpha) and intertwined that much before the doctor to determine the prescription from being able to treat snores and notice will hopefully lead to more doctors recommending sleep apnea is sometimes are sleeping on the breathing disturbances as soon as possible without constricted which demands them to feel this way. This could be fitted with something is actually three to five polyester pillow its firmness lessens and symptoms and cause similar problems including falling asleep or the study were published in 2005 have problem and natural remedy via The Buteyko Center online or call us at (845) 684-5456 to learn more about the difference between sleep apnea. It can affect weight loss and sleep apnea cure their personality relationship problems can be serious. It is often tell you about zeo and sleep apnea Healthy Patterns Of Rest Some of the reasons for the companies need to toddler sleep study apnea understands the nose.



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