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Improving Sleep in Rehabilitation After Stroke

Why did we do this research?

After stroke people often have problems with their sleep. As bad sleep has been related to worse mood, quality of life, and recovery, it is important to look at ways to improve sleep after stroke.


The current recommended treatment for sleep difficulty is Cognitive Behavioural Therapy for Insomnia (CBT), which can be done online using a sleep improvement programme called Sleepio. In a previous study, it was shown that this online CBT programme could be used by people with stroke if additional information was given, as they have specific needs.


It is important to know if online CBT for sleep is effective at improving sleep in people with stroke before recommending it for use. This study is called INSPIRES, which stands for “improving sleep in rehabilitation after stroke”. It is one of several studies that our group are running to try to better understand how sleep is affected by stroke and what can be done to try to improve sleep and recovery.


What did we aim to find out?

The main aim of this study was to find out if stroke survivors using online CBT experience greater improvements in their sleep than people who are given a brochure about sleep hygiene.  


The study also aimed to find out if the programme would help to improve mood, quality of life, and self-confidence in people with stroke.


Who did we include in the study?

84 stroke survivors who were interested in improving their sleep.


What did the participants do?

All participants filled out questionnaires about sleep, mood, self-confidence, and quality of life and most of the participants also wore a sleep monitor on their wrist. They were then randomly put into one of two groups:

-       Online CBT programme group: This involved doing 6 online sessions about ways to improve sleep and completing an online sleep diary each day for about 8-10 weeks.


-       Sleep hygiene group:  this group received a booklet with details and tips on how to improve sleep and access to an online sleep diary for one week at the beginning and one week about 8-10 weeks later.


So that we could see if there were any changes, both groups filled out the same questionnaires immediately after finishing the programme and at a follow up assessment 2 months later.


How did we measure everything?

What we measured

How we measured it







Sleep Condition Indicator (SCI)

A questionnaire used to ask people about their sleep over the past month and about the impact of sleep difficulties on their daily life.

Activity/sleep monitor

Worn on the wrist for 1 week to record sleep disruption by looking at movement overnight.Wrist worn sleep/activity monitor




Patient Health Questionnaire


A questionnaire used to ask people about depressive feelings over the past 2 weeks.

Generalised Anxiety Disorder Questionnaire

A questionnaire used to ask people about anxious feelings over the past 2 weeks.



Quality of Life



A questionnaire used to ask people about their health and life on that day.

  Stroke Impact Scale


A questionnaire used to ask people about stroke specific health and life over the past month.


Stroke Self-Efficacy Questionnaire

A questionnaire used to ask people about stroke specific self-confidence.


What did we find out?

Responses to the SCI sleep questionnaire showed that people who did the online CBT programme had more improvements in sleep than those who received the sleep hygiene information booklet. The sleep questionnaire is scored out of 32, with higher numbers representing better sleep. At the end of the programme, people from the online CBT group were on average more than 3 points higher in their ratings.

Graph 4

Picture above shows how sleep rating changes for each group. The online CBT for sleep group show a bigger increase (improvement) in sleep rating (SCI questionnaire) from the start of the study to the end of the programme and this difference remains at follow up 2 months later.


We also found that mood was better (less depression and anxiety) after using the online CBT programme compared to the sleep hygiene information group. We found some evidence that improvement in sleep may have been the reason for the better mood. There was also slightly more self-confidence in the online CBT group after the programme.

Mood graphic

Finally, there were no clear differences found between the two groups when looking at the quality of life measures.


The data from the sleep monitoring watches showed some suggestion that sleep disruption might be improved at the 2 month follow up assessment, but this was quite variable across people and our statistical tests did not show significant differences. Future studies should look into these measures more.


What does this mean?

Overall, the online CBT for sleep programme (Sleepio) helped to improve sleep and mood for people with stroke, and this effect on sleep seems to be maintained for at least 2 months after finishing the programme. This improvement was better than for the group of stroke survivors who received the sleep hygiene information booklet.


The improvement in sleep and mood means that online CBT for sleep (Sleepio) is an effective tool. Although we still need to do more research to understand who will benefit most, we think there is reason to think that it should be considered as a treatment option for people who have been discharged from hospital and are living in the community following stroke.


It would be useful for future research to look at the effects of Sleepio over a longer time period to see if the improvements are maintained, and to try to better understand the impact on sleep disturbances measured by the activity monitor over time.


If you have any questions about the information provided in this summary, or about our research in general, please get in touch





Thank you to everyone who took part in this study or helped to advertise the study to stroke survivors.

Thank you to The Wellcome Trust for funding this research

Our team