On: 26 December 2014, At: 11:40 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Occupational Therapy in Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/womh20 Exploring the Safety and Therapeutic Effects of Deep Pressure Stimulation Using a Weighted Blanket a b Brian Mullen BS , Tina Champagne MEd, OTR/L , a Sundar Krishnamurty PhD , Debra Dickson APRN, BC b & Robert X. Gao PhD a a University of Massachusetts—Amherst, Department of Mechanical & Industrial Engineering—ELAB Building , 160 Governors Drive, Amherst, MA, 01003, USA b Cooley Dickinson Hospital, Acute Inpatient Behavioral Health Department , 30 Locust Street, Northampton, MA, 01060, USA Published online: 08 Sep 2008. To cite this article: Brian Mullen BS , Tina Champagne MEd, OTR/L , Sundar Krishnamurty PhD , Debra Dickson APRN, BC & Robert X. Gao PhD (2008) Exploring the Safety and Therapeutic Effects of Deep Pressure Stimulation Using a Weighted Blanket, Occupational Therapy in Mental Health, 24:1, 65-89, DOI: 10.1300/ J004v24n01_05 To link to this article: http://dx.doi.org/10.1300/J004v24n01_05 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no
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Exploring the Safety and Therapeutic Effects of Deep Pressure Stimulation Using a Weighted Blanket Brian Mullen, BS Tina Champagne, MEd, OTR/L Sundar Krishnamurty, PhD Debra Dickson, APRN, BC Robert X. Gao, PhD ABSTRACT. This paper presents the results of a concurrent, nested, mixed methods exploratory study on the safety and effectiveness of the use of a 30 lb weighted blanket with a convenience sample of 32 adults. Safety is investigated measuring blood pressure, pulse rate, and pulse oximetry, and effectiveness by electrodermal activity (EDA), the State Trait Anxiety Inventory-10 and an exit survey. The results reveal that Brian Mullen (E-mail: Bmullen@student.umass.edu), BS, is Graduate Research Assistant, Sundar Krishnamurty (E-mail: skrishna@ecs.umass.edu), PhD, is Interim Department Head and Associate Professor, and Robert X. Gao (E-mail: Gao@ecs.umass.edu), PhD, is Professor; all are at University of MassachusettsAmherst, Department of Mechanical & Industrial Engineering–ELAB Building, 160 Governors Drive, Amherst, MA 01003 . Tina Champagne (E-mail: Tina_Champagne@cooley-dickinson.org), MEd, OTR/L, is Occupational Therapy and Group Program Supervisor, and Debra Dickson (E-mail: Debra_Dickson@cooley-dickinson.org), APRN, BC, is Behavioral Health Clinical Nurse Specialist; both are at Cooley Dickinson Hospital, Acute Inpatient Behavioral Health Department, 30 Locust Street, Northampton, MA 01060. Address correspondence to Tina Champagne at the above address. The authors wish to acknowledge and thank the UMASS-Amherst School of Nursing for providing use of the nursing lab and vital signs monitoring equipment for the purposes of this study and to Dr. Keli Mu for his assistance with the revisions of this paper. Occupational Therapy in Mental Health, Vol. 24(1) 2008 Available online at http://otmh.haworthpress.com © 2008 by The Haworth Press. All rights reserved. doi:10.1300/J004v24n01_05 65
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66 OCCUPATIONAL THERAPY IN MENTAL HEALTH the use of the 30 lb weighted blanket, in the lying down position, is safe as evidenced by the vital sign metrics. Data obtained on effectiveness reveal 33% demonstrated lowering in EDA when using the weighted blanket, 63% reported lower anxiety after use, and 78% preferred the weighted blanket as a calming modality. The results of this study will be used to form the basis for subsequent research on the therapeutic influence of the weighted blanket with adults during an acute inpatient mental health admission. doi:10.1300/J004v24n01_05 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:
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Mullen et al. 67 prevention and/or crisis intervention tool, classifies as a primary and secondary crisis prevention approach (NASMHPD, 1999), which may ultimately help to decrease the need for the use of restraint and seclusion (Champagne & Stromberg, 2004; NETI, 2003). Therefore, given the potential of this humane and recovery supportive treatment option and the importance of engaging in evidence-based practice, it is necessary for occupational therapists to begin studying the safety and effectiveness of the use of the weighted blanket. Further, when requesting the allocation of resources to introduce a novel treatment modality into clinical practice it is necessary to present empirical evidence demonstrating that its use is within one’s scope of practice and that it is both safe and effective. This may be achieved through the application of principles from traditional social science and engineering data analysis. Such an analysis will not only lead to a better understanding of the therapeutic effects of deep pressure, but also will lay the foundation for technological advances in the remote sensing of anxiety (Luharuka, Gao, & Krishnamurty, 2003), and the engineering of new and improved modalities offering deep pressure stimulation. To this end, this paper presents the details of the first clinical study exploring both the safety and effectiveness of the use of a 30 lb weighted blanket, the heaviest available at the time of the study, with a heterogeneous convenience sample of 32 volunteer adults. Background Information Deep Pressure Stimulation (DPS) One of the qualities offered by the weighted blanket is DPS, which is generally referred to as a form of touch pressure applied to the body providing the feeling of a firm hug, holding, swaddling, or massage (Grandin, 1992). Although there is no published research regarding the use of the weighted blanket, there is a growing body of research supporting the use of DPS for varied therapeutic purposes. Interestingly, when using Grandin’s Hug Machine, the use of DPS had a calming influence for adults and children with anxiety, autism, and attention difficulties (Edelson, Edelson, Kerr, & Grandin, 1999; Grandin, 1992). Additionally, DPS applied through the use of the weighted vest, for children with pervasive developmental and attention disorders, influenced an increased ability to focus on fine motor tasks (Fertel-Daly, Bedell, & Hinojosa, 2001; Olson & Moulton, 2004a, 2004b; VandenBerg, 2001), and a decrease in self-stimulatory behaviors (Fertel-Daly et al., 2001).
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68 OCCUPATIONAL THERAPY IN MENTAL HEALTH Foam-padded splints to the arms applying firm pressure appeared to help reduce self-stimulatory and self-injurious behaviors in a child with autism (McClure & Holtz-Yotz, 1991). Wrist weights providing DPS influenced a reduction in self-injurious behaviors by 92% in a child with intellectual disabilities (Hanley, Piazza, Keeney, Blakeley-Smith, & Worsdell, 1998). These studies provide support for the use of DPS modalities for a variety of treatment purposes, such as the facilitation of attention, self-control, and a decrease in anxiety. While providing some evidence of the effectiveness of the use of DPS modalities these studies do not specifically explore the use of the weighted blanket or whether the modalities used are safe. Measuring Safety and Establishing Guidelines Safety guidelines established for the use of backpacks have been generalized to the use of the weighted vests and weighted blankets (Olson & Moulton, 2004a; Walker & McCormack, 2002). This includes recommendations according to body weight ratios (5-10%), the distribution of the weight, and wearing schedules. Weighted vests are typically used while in ambulatory and/or seated positions, whereas the weighted blanket is not meant for use while ambulating. Rather, the weighted blanket is used while in a lying down or seated position. Therefore, applying the same backpack safety guidelines to the use of the weighted blanket is unsubstantiated. Further, clinical experience of the authors suggests that for some consumers the use of a weighted blanket that is more than 10% of the person’s body weight may be preferred. Hence, there is a need to explore whether the use of the 30 lb weighted blanket has a negative influence on physiological safety and whether there are patterns or preferences according to body weight. Vital signs provide information regarding a person’s general health status and are used in this study to begin to assess whether the deep pressure provided from a 30 lb weighted blanket influences adverse changes in the vital signs of the test participants. Measuring Effectiveness Mixed research methodology, the use of a combination of quantitative and qualitative approaches, is considered a reliable way to measure the effectiveness of therapeutic interventions (Creswell, 2003). Edelson et al. (1999) used a mixed methods approach to explore the influence of DPS provided by Grandin’s Hug Machine on the anxiety levels of children with autism using the Connors Parent Rating Scale and electrodermal activity (EDA). Skin conductance (SC), a measure of EDA, provides a
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Mullen et al. 69 direct measure of sympathetic activity and has been one of the most widely used quantitative metrics in psychophysiology research (Boucsein, 1992; Cacioppo, Tassinary, & Bernston, 2000). Although only a marginal reduction in anxiety was revealed using SC, a significant decrease in tension (a behavioral measure of anxiety) occurred, and researchers concluded, “deep pressure appears beneficial for children with high levels of anxiety or arousal, and there may be a threshold of anxiety or arousal required for deep pressure to be beneficial” (Edelson et al., 1999, p. 151). Krauss (1987) examined the influence of DPS among college students using a self-controlled mechanical device to self-administer DPS with a pulley system, using qualitative surveys and body temperature to monitor anxiety. Temperature is also a measure of sympathetic arousal (Boucsein,1992). Although the results from Krauss’ study were found to be inconclusive, these studies demonstrate the value of the use of mixed methodology, including psychophysiological metrics in addition to subjective self-report, when studying the influence of DPS. Evidence demonstrates that sympathetic arousal is directly linked to emotional and other cognitive processes such as attention, decision-making, and memory (Damasio, Tranel, & Damasio, 1991; Damasio, 1994; Bechara, Tranel, Damasio, & Damasio, 1996; Bechera, Damasio, Tranel, & Damasio, 1997; Cahill, 1997). Further, chronic high levels of sympathetic arousal are hallmarks of anxiety disorders and stress, which are conditions associated with high levels of psychological and physical morbidity (Russek, King, Russek, & Russek, 1990; Steptoe, Cropley, & Joekes, 1999). It has also been demonstrated that treatments influencing the reduction of autonomic arousal often reduce anxiety and distress (Critchley, Melmed, Featherstone, Mathias, & Dolan, 2001). Thus, it is hypothesized that the weighted blanket assists in helping consumers decrease anxiety and levels of distress. Since SC is a direct measure of sympathetic nervous system activity, which is influenced by anxiety, SC is a quantitative measure used to explore effectiveness. The State Trait Anxiety Inventory-10 (STAI-10) and an exit survey are selfrating metrics, also used to explore effectiveness. METHOD Experimental Design A concurrent, nested, mixed methods design was used to gather quantitative and qualitative data. The qualitative data gathering process was
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OCCUPATIONAL THERAPY IN MENTAL HEALTH Downloaded by [Korea University] at 11:40 26 December 2014 embedded within the quantitative procedures. Figure 1 shows the experimental design. Sample A convenience sample of 34 people including 20 males and 14 females participated in the study. Testing was interrupted for two participants; therefore, the data for these two participants were not included in the statistical analysis or results. Consequently, the final sample size of the study was n = 32. The age range was 18-58, with a mean of 31 and a standard deviation of 11.7. The population was skewed toward younger people because a large number of the volunteers were undergraduate and graduate students. The lowest body weight of the participants was 112 lb and the maximum was 234 lb with a mean of 165 lb and a standard deviation of 27.8 lb. Inclusion criteria required consenting, non-hospitalized, volunteer adults with no apparent medical conditions or physical FIGURE 1. Experimental design overview.
Mullen et al. 71 injuries between the ages of 18 and 64. Because this was an exploratory study, a diverse group of people participated. It is understood however, that age, sex, weight, and race may have varying influences on psychophysiological processes and responses. Using random assignment and a cross over design the participants were divided into two groups, each person receiving an even or odd code and number designation. All persons participated in two-test sessions, one session with the treatment (the 30 lb weighted blanket) and one session without the treatment. The code the person was assigned determined whether the treatment was given during the first or second testing session. An even code required the use of the treatment (30 lb weighted blanket) during the first testing session, an odd code required use of the treatment during the second testing session. Before any testing or data collection occurred age, sex, and weight were recorded and all participants signed an informed consent document. The informed consent document explained potential risks or harm that could arise from being a participant in the experiment, provided a general summary of the instruments to be used, and also the procedures that would take place throughout the course of the experiment. Before starting the experiment, the participants were each individually introduced to the test environment, room, and equipment, and the procedures of the experiment were thoroughly explained. Questions were encouraged and answered before the volunteers were asked to sign the consent form. Being fully informed helps to reduce uncertainty regarding the testing procedures; otherwise, the novelty of the experience may influence the test responses. Setting The study was conducted at the nursing resource room at Skinner Hall at the University of Massachusetts-Amherst (UMASS). Two nursing resource rooms were set up to replicate a hospital-like setting, which was determined to best afford a relatively controlled environment, allowing for comparisons to be made in future studies conducted in an acute mental health care hospital setting. Hospital beds with pull curtains were used to seclude participants from the monitoring equipment and most of the stimulation of the rest of the room. During the experiment, the resource room door was locked, a sign was placed on the door to inform the public that an experiment was taking place, and only the participant and data collector were allowed in the room. Before the data collection phase of the test session, the curtain was closed around the bed; the data and all the equipment connected to the sensors were behind
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