Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis

Mild traumatic brain injuries with loss of consciousness are associated with increased inflammation and pain in military personnel

Mild traumatic brain injuries (mTBI) are a pervasive concern for military personnel. Determining the impact of injury severity, including loss of consciousness (LOC) may provide important insights into the risk of psychological symptoms and inflammation commonly witnessed in military personnel and veterans following mTBI. US military personnel and veterans were categorized into three groups; TBI with LOC (n = 36), TBI without LOC (n = 25), Controls (n = 82). Participants reported their history of mTBI, psychological symptoms (post-traumatic stress disorder [PTSD] and depression), health-related quality of life (HRQOL), and underwent a blood draw. ANCOVA models which controlled for insomnia status and combat exposure indicated that both mTBI groups (with/without LOC) reported significantly greater depression and PTSD symptoms compared to controls; however, they did not differ from each other. The mTBI with LOC did report greater pain than both controls and mTBI without LOC. The TBI with LOC group also had significantly elevated IL-6 concentrations than both TBI without LOC and control groups. Within the mTBI groups, increased TNFα concentrations were associated with greater PTSD symptoms. These findings indicate that sustaining an mTBI, with or without LOC is detrimental for psychological wellbeing. However, LOC may be involved in perceptions of pain and concentrations of IL-6.

Treatment of Acute Sports-Related Concussion

PURPOSE OF REVIEW

Here, we summarize the current scientific literature on the management of sports-related concussion (SRC) in the acute period (< 6 weeks post-injury) with a focus on rest, return to learn, return to play, and emerging treatments.

RECENT FINDINGS

While relative rest is recommended for the first 24-48 h following acute SRC, the most recent guidelines highlight the lack of evidence for complete rest and in fact show that prolonged cognitive and physical rest can be detrimental. Gradual return to learn and play is recommended. Return to sport should only occur once the patient is symptom free. While there are no FDA-approved medications for acute treatment of concussion, there is preclinical data for the benefit of omega 3 fatty acids. Evidence is limited around the benefits of treating sleep disorders, vestibular-ocular dysfunction, and neck pain in the acute period. After 24-48 h of rest, SRC patients may gradually resume cognitive and physical activity. More research is needed to determine if any supplements, medications, and/or physical therapy are indicated in the management in acute SRC.

Before-bedtime passive body heating by warm shower or bath to improve sleep: A systematic review and meta-analysis

Water-based passive body heating (PBH_WB) as a warm shower or bath before bedtime is often recommended as a simple means of improving sleep. We searched PubMed, CINAHL, Cochran, Medline, PsycInfo, and Web of Science databases and extracted pertinent information from publications meeting predefined inclusion and exclusion criteria to explore the effects of PBH_WB on sleep onset latency (SOL), wake after sleep onset, total sleep time, sleep efficiency (SE), slow wave sleep, and subjective sleep quality. The search yielded 5322 candidate articles of which 17 satisfied inclusion criteria after removing duplicates, with 13 providing comparable quantitative data for meta-analyses. PBH_WB of 40-42.5 °C was associated with both improved self-rated sleep quality and SE, and when scheduled 1-2 h before bedtime for little as 10 min significant shortening of SOL. These findings are consistent with the mechanism of PBH_WB effects being the extent of core body temperature decline achieved by increased blood perfusion to the palms and soles that augments the distal-to-proximal skin temperature gradient to enhance body heat dissipation. Nonetheless, additional investigation is required because the findings regarding PBH_WB are limited by the relative scarcity of reported research, especially its optimal timing and duration plus exact mechanisms of effects.

Systematic Review Investigating the Effects of Nonpharmacological Interventions During Sleep to Enhance Physical Rehabilitation Outcomes in People With Neurological Diagnoses

OBJECTIVE

Conduct a systematic review of nonpharmacological interventions applied during sleep to enhance physical rehabilitation outcomes of individuals with a neurological diagnosis.

DATA SOURCES

Three online databases were searched for original research.

STUDY SELECTION

Intervention studies were included that used outcome measures of impairment, activity, and/or participation.

DATA EXTRACTION

Two reviewers independently screened 2287 titles and abstracts, reviewed 101 full texts, extracted data, and assessed study quality and risk of bias for 9 included studies.

DATA SYNTHESIS

All included studies were randomized controlled trials involving continuous positive airway pressure (CPAP) with inpatient individuals with stroke and sleep apnea. Several studies also included long-term outpatient follow-ups. Results in terms of outcomes based on impairment, activity, and participation were mixed. However, several studies found that the use of CPAP following stroke and sleep apnea during early stroke recovery had benefits relative to no CPAP.

CONCLUSIONS

The only nonpharmacological intervention to be administered during sleep in a neurological population to improve physical rehabilitation outcomes was found to be CPAP. This review was complicated by the variety of outcome measures used, lack of physical rehabilitation description, and CPAP compliance. In general, participants who had acceptable to good CPAP compliance saw the largest improvements in physical rehabilitation outcomes. Several other promising methods of brain stimulation during sleep are discussed.

Traumatic Brain Injury and Psychiatric Co-Morbidity in the United States

The objective of the present study was to provide a nationally representative psychiatric epidemiologic investigation of traumatic brain injury (TBI) and its co-morbid conditions. Data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III) collected between 2012 and 2013 was used. Results indicated that TBI was significantly associated with any lifetime mental health (AOR = 2.32, 95% CI = 1.65-3.70), substance use disorder (AOR = 1.57-1.01-2.42), and violent (AOR = 1.65, 95% CI = 1.03-2.65) and nonviolent (AOR = 1.84, 95% CI = 1.25-2.70) criminal behaviors. In our study, TBI was highly comorbid with psychiatric disorders and especially antisocial behaviors, both violent and non-violent.

Sleep after TBI: How the TBI Model Systems have advanced the field

BACKGROUND

Identification and management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Recent meta-analyses highlight sleep disturbance and sleep disorders following TBI (Mathias & Alvaro, 2012). Improving the recognition and treatment of sleep disorders in TBI should be a central focus of rehabilitation. The Traumatic Brain Injury Model System (TBIMS) has created an infrastructure allowing multi-center investigations into sleep dysfunction in those who have had a moderate to severe TBI and received inpatient rehabilitation.

OBJECTIVE

This paper will describe the 1) infrastructure used to advance sleep dysfunction/disorders research following TBI, 2) preliminary findings from these studies, and 3) repository of data which can be accessed for secondary analyses by investigators outside of the TBIMS infrastructure.

METHODS

Two internal mechanisms allow investigators at TBIMS sites to collaborate on projects of shared interest: Research Modules and Special Interest Groups (SIG).

RESULTS

To date, five studies have resulted from the TBIMS collaborative process focusing on insomnia, circadian disruption, and sleep apnea.

CONCLUSIONS

Future directions for the SIG include continued development of available knowledge and understanding of the multidimensional factors that contribute to TBI-related sleep disturbance, optimal assessment tools, effectiveness of available treatments, and treatment compliance in this population.

Sleep and fatigue after TBI

BACKGROUND

Whilst post traumatic brain injury fatigue (PTBIF) and sleep disturbance are common sequelae following brain injury, underlying mechanisms, and the potential for targeted interventions remain unclear.

OBJECTIVE

To present a review of recent studies exploring the epidemiology of PTBIF and sleep disturbance, the relationship and neuropsychological correlates of these issues, potential approaches to intervention, and implications for neurorehabilitation.

METHODS

A review of relevant literature was undertaken, with a focus on PTBIF relating to sleep disturbance, the neuropsychological correlates of these issues and implications for neurorehabilitation. This paper does not set out to provide a systematic review.

RESULTS

Multidimensional approaches to assessment and treatment of sleep disturbance and PTBIF are required.

CONCLUSIONS

There is a need for more robust findings in determining the complex nature of relationships between PTBIF, sleep disturbance, and correlates. Longitudinal prospective data is required to increase our understanding of the nature and course of PTBIF and sleep disturbance post TBI. Large scale clinical trials are required in evaluating the potential benefits of interventions.

Sleep disorders in traumatic brain injury

BACKGROUND

Sleep disorders play a significant role in the care of those with Traumatic Brain Injury (TBI).

OBJECTIVE

To provide a literature review on the interaction of sleep and circadian processes on those with TBI.

METHODS

A literature review was conducted on PubMed using the following key words and their combination: "Sleep Apnea", "Traumatic Brain Injury", "Circadian", "Parasomnia", "Insomnia", "Hypersomnia", "Narcolepsy", and "Restless Legs". We review the spectrum of traumatic brain injury associated sleep disorders and discuss clinical approaches to diagnosis and treatment.

RESULTS

Disordered sleep and wakefulness after TBI is common. Sleep disruption contributes to morbidity, such as the development of neurocognitive and neurobehavioral deficits, and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of traumatic brain injury and improve neuro recovery/patient outcomes.

CONCLUSIONS

A more focused approach to sleep health is appropriate when caring for those with TBI.

Neurobehavioral Management of the Polytrauma Veteran

Since the inception of the Afghanistan and Iraq wars, an increasing number of veterans have sought treatment from the Department of Veterans Affairs for combat-related injuries. Many veterans experience postconcussive symptoms, traumatic stress, chronic pain, sensory deficits, and/or headaches. The goal of this article was to highlight some of the challenges treatment providers may face, while providing rehabilitation specialists with important evaluation and treatment considerations in working with this population to maximize outcomes for these veterans.

Update on Insomnia after Mild Traumatic Brain Injury

Sleep disturbance after traumatic brain injury (TBI) has received growing interest in recent years, garnering many publications. Insomnia is highly prevalent within the mild traumatic brain injury (mTBI) population and is a subtle, frequently persistent complaint that often goes undiagnosed. For individuals with mTBI, problems with sleep can compromise the recovery process and impede social reintegration. This article updates the evidence on etiology, epidemiology, prognosis, consequences, differential diagnosis, and treatment of insomnia in the context of mild TBI. This article aims to increase awareness about insomnia following mTBI in the hopes that it may improve diagnosis, evaluation, and treatment of sleeping disturbance in this population while revealing areas for future research.

Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire

Classifying concussion in key subtypes according to presenting symptomatology at an early post-injury stage is an emerging approach that may allow prediction of clinical trajectories and delivery of targeted treatments. The Rivermead Post-concussion Symptoms Questionnaire (RPQ) is a simple, freely available, and widely used tool for assessment of the presence and severity of various post-concussion symptoms. We aimed to probe the prevalence among athletes of symptom classes associated with identified concussion phenotypes using the RPQ at baseline and acutely after a concussion. Participants of organized sports aged 12–30 years were baseline-assessed with the expectation that some would experience a concussion during the study period. Concussed athletes were re-assessed within 2 weeks of their injuries. The RPQ was supplemented with three specific questions and reworded for baseline assessment. A binomial test was used to contrast the prevalence of an attribute in the concussed cohort against the probability established by the baseline observation. Three thousand and eighty-eight athletes were baseline-assessed and eighty-nine were re-assessed post-concussion. All concussed athletes endorsed having some elevated symptoms in the RPQ, and such endorsements were more prevalent than those among normal athletes. Moderate-to-severe post-concussion symptoms of specific classes tended to be endorsed with few additional symptoms of other classes of similar intensities. Elevated symptoms detected with the RPQ within as short as 2 weeks after a concussion may help delineate patients' clinical subtypes and guide their treatment. Further refinement of symptom questionnaires and use of objective measures will be needed to properly populate the concussion subtype classification.

Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder

STUDY OBJECTIVES

Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD.

METHODS

Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63).

RESULTS

The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups.

CONCLUSIONS

These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.

Neuroendocrine aspects of improving sleep in epilepsy

Sleep plays an intricate role in epilepsy and can affect the frequency and occurrence of seizures. With nearly 35% of U.S. adults failing to obtain the recommended 7 h of sleep every night, understanding the complex relationship between sleep and epilepsy is of utmost relevance. Sleep deprivation is a common trigger of seizures in many persons with epilepsy and sleep patterns play a role in the occurrence of seizures. Some patients have their first seizure or repeated seizures after an "all-nighter" at college or after a long period of chronic sleep deprivation. The strength of the relationship between sleep and seizures varies between patients, but improving sleep and optimizing seizure control can have significant positive effects on the quality of life for all these patients. Research has shown that the changes in the brain's electrical and hormonal activity occurring during normal sleep-wake cycles can be linked to both sleep and seizure patterns. Many questions remain to be answered about sleep and epilepsy. How can sleep deprivation trigger an epileptic seizure? How do circadian and hormonal changes influence sleep pattern and seizure occurrence? Can hormones or sleeping pills help with sleep in epilepsy? In this article we discuss these and many other questions on sleep in epilepsy, with an emphasis on sleep architecture, hormone changes, mechanistic factors, and possible prevention strategies.

Sleep disturbance and cognition in people with TBI

BACKGROUND

Sleep disturbance plays a significant role in cognitive impairment following traumatic brain injury (TBI).

OBJECTIVES

To summarize recent findings that examine sleep disturbance and cognition in TBI.

METHODS

Epidemiological information on sleep disorders in people with TBI is presented. A simple introduction to the role of sleep in normal cognition provides context for the literature on clinical populations. Current theory on the mechanisms underlying cognitive problems in people with sleep disorder is briefly described. Findings on the relationship between sleep disorder and cognitive problems in TBI is examined in more detail.

RESULTS

Consistent reports of an association between sleep duration and cognition include several studies noting positive associations (shorter sleep duration accompanies cognitive impairment) and others observing negative associations (longer sleep duration accompanies cognitive problems). Both insomnia and hypersomnolence are forms of sleep disturbance that disrupt key mental processes such as memory consolidation. Obstructive sleep apnea, cerebral structural abnormalities, neurochemical changes and psychiatric pathology are implicated.

CONCLUSIONS

Additional information is needed on how severity of injury impacts sleep and cognition. Hypothesized mechanisms underlying the effects of sleep on cognition in TBI should be empirically tested. Further, discrepancies between objective and subjective measures of sleep and cognition must be explored.

Unraveling the Biopsychosocial Factors of Fatigue and Sleep Problems After Traumatic Brain Injury: Protocol for a Multicenter Longitudinal Cohort Study

Background

Fatigue and sleep problems are common after a traumatic brain injury (TBI) and are experienced as highly distressing symptoms, playing a significant role in the recovery trajectory, and they can drastically impact the quality of life and societal participation of the patient and their family and friends. However, the etiology and development of these symptoms are still uncertain.

Objective

The aim of this study is to examine the development of fatigue and sleep problems following moderate to severe TBI and to explore the changes in underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors across time.

Methods

This study is a longitudinal multicenter observational cohort study with 4 measurement points (3, 6, 12, and 18 months postinjury) including subjective questionnaires and cognitive tasks, preceded by 7 nights of actigraphy combined with a sleep diary. Recruitment of 137 moderate to severe TBI patients presenting at emergency and neurology departments or rehabilitation centers across the Netherlands is anticipated. The evolution of fatigue and sleep problems following TBI and their association with possible underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors will be examined.

Results

Recruitment of participants for this longitudinal cohort study started in October 2017, and the enrollment of participants is ongoing. The first results are expected at the end of 2020.

Conclusions

To the authors’ knowledge, this is the first study that examines the development of both post-TBI fatigue and sleep longitudinally within a biopsychosocial model in moderate to severe TBI using both subjective and objective measures. Identification of modifiable factors such as mood and psychosocial stressors may give direction to the development of interventions for fatigue and sleep problems post-TBI.

Trial Registration

Netherlands Trial Register NTR7162; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=7162 (Archived by WebCite at http://www.webcitation.org/6z3mvNLuy)

International Registered Report Identifier (IRRID)

RR1-10.2196/11295

A systematic review and meta-analysis of sleep architecture and chronic traumatic brain injury

Sleep quality appears to be altered by traumatic brain injury (TBI). However, whether persistent post-injury changes in sleep architecture are present is unknown and relatively unexplored. We conducted a systematic review and meta-analysis to assess the extent to which chronic TBI (>6 months since injury) is characterized by changes to sleep architecture. We also explored the relationship between sleep architecture and TBI severity. In the fourteen included studies, sleep was assessed with at least one night of polysomnography in both chronic TBI participants and controls. Statistical analyses, performed using Comprehensive Meta-Analysis software, revealed that chronic TBI is characterized by relatively increased slow wave sleep (SWS). A meta-regression showed moderate-severe TBI is associated with elevated SWS, reduced stage 2, and reduced sleep efficiency. In contrast, mild TBI was not associated with any significant alteration of sleep architecture. The present findings are consistent with the hypothesis that increased SWS after moderate-severe TBI reflects post-injury cortical reorganization and restructuring. Suggestions for future research are discussed, including adoption of common data elements in future studies to facilitate cross-study comparability, reliability, and replicability, thereby increasing the likelihood that meaningful sleep (and other) biomarkers of TBI will be identified.

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda

A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.

Heading and unintentional head impacts have opposing associations with Patient Reported Outcomes in amateur soccer players

The effects of soccer-related head impacts, beyond overt concussions, on Patient Reported Outcomes (PROs) have not been explored to date. Generalized estimating equations were employed to determine the association between soccer-related head impacts (headers in the prior 2 weeks, unintentional head impacts in the prior 2 weeks, headers in the prior 12 months and lifetime concussions) on PROs including depression, anxiety, sleep disturbance and sleep impairment. Compared to players with no unintentional head impacts in the prior 2 weeks, players with one unintentional exposure reported more symptoms of anxiety (p = 0.002) and players with 2+ exposures reported more symptoms of depression (p = 0.006) and anxiety (p < 0.001). In contrast, players in the 3rd Quartile of 12 mo. headers reported less anxiety (p = 0.001), sleep disturbance (p = 0.002) and sleep impairment (p < 0.001) compared to those in the 1st quartile. Unintentional head impacts are associated with worse PROs while more headers are paradoxically associated with better PROs.

Understanding Health-Related Quality of Life in Caregivers of Civilians and Service Members/Veterans With Traumatic Brain Injury: Establishing the Reliability and Validity of PROMIS Fatigue and Sleep Disturbance Item Banks

OBJECTIVE

To examine the reliability and validity of Patient-Reported Outcomes Measurement Information System (PROMIS) measures of sleep disturbance and fatigue in traumatic brain injury (TBI) caregivers and to determine the severity of fatigue and sleep disturbance in these caregivers.

DESIGN

Cross-sectional survey data collected through an online data capture platform.

SETTING

A total of 4 rehabilitation hospitals and Walter Reed National Military Medical Center.

PARTICIPANTS

Caregivers (N=560) of civilians (n=344) and service member/veterans (SMVs) (n=216) with TBI.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

PROMIS sleep and fatigue measures administered as both computerized adaptive tests (CATs) and 4-item short forms (SFs).

RESULTS

For both samples, floor and ceiling effects for the PROMIS measures were low (<11%), internal consistency was very good (all α≥0.80), and test-retest reliability was acceptable (all r≥0.70 except for the fatigue CAT in the SMV sample r=0.63). Convergent validity was supported by moderate correlations between the PROMIS and related measures. Discriminant validity was supported by low correlations between PROMIS measures and measures of dissimilar constructs. PROMIS scores indicated significantly worse sleep and fatigue for those caring for someone with high levels versus low levels of impairment.

CONCLUSIONS

Findings support the reliability and validity of the PROMIS CAT and SF measures of sleep disturbance and fatigue in caregivers of civilians and SMVs with TBI.

Change in body mass index within the first-year post-injury: a VA Traumatic Brain Injury (TBI) model systems study

OBJECTIVE

To describe change in body mass index (BMI) and weight classification 1-year post- traumatic brain injury (TBI) among Veterans and service members.

DESIGN

Prospective observational cohort study.

SETTING

VA Polytrauma Rehabilitation Centers.

PARTICIPANTS

Veterans and service members (N = 84) enrolled in VA Traumatic Brain Injury Model Systems (VA TBIMS) study with BMI scores at enrollment and 1-year post-injury.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

BMI scores from height and weight and weight classifications (underweight, normal weight, overweight, obese classes 1-3) defined by WHO.

RESULTS

Twenty per cent were obese at time of injury and 24% were obese at 1-year post-injury. Cross-tab analyses revealed 7% of normal weight and 24% overweight participants at time of injury as obese Class 1 one-year post-injury. Univariate models found BMI and tobacco smoking at time of injury were significant predictors of higher BMI scores 1-year post-TBI. Multivariable models found BMI at time of injury and motor functioning, were significant predictors. Preinjury BMI, tobacco smoking and PTSD symptom severity predicted change in weight category.

CONCLUSION

While obesity among service members and Veterans post-TBI is below national averages, trends in weight gain between time of injury and 1-year follow-up were observed. Implications for health promotion and chronic disease management efforts with regards to rehabilitation for injured military are discussed. List of Abbreviations: BMI, Body mass index; BRFSS, Behavioural Risk Factor Surveillance; GCS, Glasgow Coma Scale; FIM, Functional Independence Measure; NIDILRR, National Institute on Independent Living and Rehabilitation Research; PCL-C, PTSD checklist-civilian; PSTD, Post-traumatic stress disorder; VA, Veterans Affairs; VA PRC, Veterans Affairs Polytrauma Rehabilitation; VA TBIMS, Veterans Affairs TBI Model Systems.

Dietary therapy restores glutamatergic input to orexin/hypocretin neurons after traumatic brain injury in mice

Study Objectives

In previous work, dietary branched-chain amino acid (BCAA) supplementation, precursors to de novo glutamate and γ-aminobutyric acid (GABA) synthesis, restored impaired sleep-wake regulation and orexin neuronal activity following traumatic brain injury (TBI) in mice. TBI was speculated to reduce orexin neuronal activity through decreased regional excitatory (glutamate) and/or increased inhibitory (GABA) input. Therefore, we hypothesized that TBI would decrease synaptic glutamate and/or increase synaptic GABA in nerve terminals contacting orexin neurons, and BCAA supplementation would restore TBI-induced changes in synaptic glutamate and/or GABA.

Methods

Brain tissue was processed for orexin pre-embed diaminobenzidine labeling and glutamate or GABA postembed immunogold labeling. The density of glutamate and GABA immunogold within presynaptic nerve terminals contacting orexin-positive lateral hypothalamic neurons was quantified using electron microscopy in three groups of mice (n = 8 per group): Sham/noninjured controls, TBI without BCAA supplementation, and TBI with BCAA supplementation (given for 5 days, 48 hr post-TBI). Glutamate and GABA were also quantified within the cortical penumbral region (layer VIb) adjacent to the TBI lesion.

Results

In the hypothalamus and cortex, TBI decreased relative glutamate density in presynaptic terminals making axodendritic contacts. However, BCAA supplementation only restored relative glutamate density within presynaptic terminals contacting orexin-positive hypothalamic neurons. BCAA supplementation did not change relative glutamate density in presynaptic terminals making axosomatic contacts, or relative GABA density in presynaptic terminals making axosomatic or axodendritic contacts, within either the hypothalamus or cortex.

Conclusions

These results suggest TBI compromises orexin neuron function via decreased glutamate density and highlight BCAA supplementation as a potential therapy to restore glutamate density to orexin neurons.

Actigraphically Measured Sleep-Wake Behavior After Mild Traumatic Brain Injury: A Case-Control Study

OBJECTIVE

To characterize and compare the sleep-wake behavior of individuals following a mild traumatic brain injury (mTBI) with that of noninjured healthy controls.

SETTING

Community.

PARTICIPANTS

Fourteen participants with a recent mTBI (Mage = 28.07; SD = 10.45; n = 10 females) and 34 noninjured controls (Mage = 23.70; SD = 7.30; n = 31 females).

DESIGN

Cross-sectional.

MAIN MEASURES

Battery of subjective sleep measures and 14 days of sleep-wake monitoring via actigraphy (objective measurement) and concurrent daily sleep diary.

RESULTS

Participants who had sustained an mTBI self-reported significantly higher sleep-related impairment, poorer nightly sleep quality, and more frequently met criteria for clinical insomnia, compared with controls (d = 0.76-1.11, large effects). The only significant between-group difference on objective sleep metrics occurred on sleep timing. On average, people with a recent history of mTBI fell asleep and woke approximately 1 hour earlier than did the controls (d = 0.62-0.92, medium to large effects).

CONCLUSION

Participants with a history of mTBI had several subjective sleep complaints but relatively few objective sleep changes with the exception of earlier sleep timing. Future research is needed to understand the clinical significance of these findings and how these symptoms can be alleviated. Interventions addressing subjective sleep complaints (eg, cognitive behavior therapy for insomnia) should be tested in this population.

[Sleepiness, continuous positive airway pressure and the obstructive sleep apnea hypopnea syndrome]

Excessive daytime sleepiness is a major symptom in cases of the obstructive sleep apnea-hypopnea syndrome. Most often, it is vastly improved by treatment with continuous positive airway pressure (CPAP). The most effective way to confirm its disappearance is through wakefulness maintenance testing. If residual sleepiness remains, despite CPAP, further diagnostic investigation must be carried out. Firstly, it must be assessed whether the treatment is fully effective (apnea hypopnea index<10/h) by examining flow limitations under treatment (polysomnography) and whether it is sufficiently used (>6h/night). If this is the case, the possibility of other situations responsible for excessive daytime sleepiness must be reviewed and eliminated, whether they are depression, sleep insufficiency, use of intoxicants, obesity, restless legs syndrome, or circadian sleep-wake cycle disorder. If not, the multiple sleep latency tests make it possible to assess sleepiness (latency<8min) and can lead to a diagnosis of central hypersomnia (narcolepsy, idiopathic hypersomnia, hypersomnia due to a medical pathology). In some rare cases (about 6% of patients) investigations will reveal central hypersomnia due to the obstructive sleep apnea-hypopnea syndrome or "lesional" hypersomnia due to intermittent hypoxia. Since 2011, medications treating excessive sleepiness have had marketing authorization only for narcolepsy in France. However, they can be administered by way of derogation to other neurological hypersomnias on prescription by a reference centre or a centre with expertise in hypersomnia.

Efficacy of melatonin for sleep disturbance following traumatic brain injury: a randomised controlled trial

BACKGROUND

The study aimed to determine the efficacy of melatonin supplementation for sleep disturbances in patients with traumatic brain injury (TBI).

METHODS

This is a randomised double-blind placebo-controlled two-period two-treatment (melatonin and placebo) crossover study. Outpatients were recruited from Epworth and Austin Hospitals Melbourne, Australia. They had mild to severe TBI (n = 33) reporting sleep disturbances post-injury (mean age 37 years, standard deviation 11 years; 67% men). They were given prolonged-release melatonin formulation (2 mg; Circadin®) and placebo capsules for 4 weeks each in a counterbalanced fashion separated by a 48-hour washout period. Treatment was taken nightly 2 hours before bedtime. Serious adverse events and side-effects were monitored.

RESULTS

Melatonin supplementation significantly reduced global Pittsburgh Sleep Quality Index scores relative to placebo, indicating improved sleep quality [melatonin 7.68 vs. placebo 9.47, original score units; difference -1.79; 95% confidence interval (CI), -2.70 to -0.88; p ≤ 0.0001]. Melatonin had no effect on sleep onset latency (melatonin 1.37 vs. placebo 1.42, log units; difference -0.05; 95% CI, -0.14 to 0.03; p = 0.23). With respect to the secondary outcomes, melatonin supplementation increased sleep efficiency on actigraphy, and vitality and mental health on the SF-36 v1 questionnaire (p ≤ 0.05 for each). Melatonin decreased anxiety on the Hospital Anxiety Depression Scale and fatigue on the Fatigue Severity Scale (p ≤ 0.05 for both), but had no significant effect on daytime sleepiness on the Epworth Sleepiness Scale (p = 0.15). No serious adverse events were reported.

CONCLUSIONS

Melatonin supplementation over a 4-week period is effective and safe in improving subjective sleep quality as well as some aspects of objective sleep quality in patients with TBI.

TRIAL REGISTRATION

Identifier: 12611000734965; Prospectively registered on 13 July 2011.

Investigating ioflupane I123 injection and single photon emission tomography as an imaging biomarker for long-term sequelae following mild traumatic brain injury

OBJECTIVE

To determine whether there were differences in clinical outcomes for ioflupane I¹²³ injection (DaTscan) and single photon emission tomography consistent with early Parkinson's disease (PD) among individuals with a history of mild traumatic brain injury (mTBI).

METHODS

We performed a case-control study among patients presenting to the Emergency Room (ER) during 2006-2013 with mTBI (cases, n = 34) or without mTBI (controls, n = 33). We performed clinical and imaging measurements in cases and controls at least 1-year post-presentation to the ER (average three years four months).

RESULTS

All DaTscans obtained were qualitatively normal. There were no qualitative DaTscan differences between cases and controls. There was, however, a significant increase in caudate asymmetry in controls versus cases (p = 0.02), but this finding was no longer significant after correction for multiple comparisons. There was a suggestion of a trend of poorer clinical score test measures among those with mTBI, although the overall mean score difference between cases and controls was not clinically significant.

CONCLUSION

Our small study does not provide support for DaTscan changes suggestive of PD in the one to seven years following mTBI. A trend towards poorer clinical measures was seen but was not clinically relevant in our small sample. Further work in a large population is necessary to support these findings.

A pilot randomized controlled trial of on-line interventions to improve sleep quality in adults after mild or moderate traumatic brain injury

Objective:

To explore feasibility and potential efficacy of on-line interventions for sleep quality following a traumatic brain injury (TBI).

Design:

A two parallel-group, randomized controlled pilot study.

Setting:

Community-based.

Subjects:

In all, 24 participants (mean age: 35.9 ± 11.8 years) who reported experiencing sleep difficulties between 3 and 36 months after a mild or moderate TBI.

Interventions:

Participants were randomized to receive either a cognitive behaviour therapy or an education intervention on-line. Both interventions were self-completed for 20–30 minutes per week over a six-week period.

Main measures:

The Pittsburgh Sleep Quality Index assessed self-reported sleep quality with actigraphy used as an objective measure of sleep quality. The CNS Vital Signs on-line neuropsychological test assessed cognitive functioning and the Rivermead Post-concussion Symptoms and Quality of Life after Brain Injury questionnaires were completed pre and post intervention.

Results:

Both programmes demonstrated feasibility for use post TBI, with 83.3% of participants completing the interventions. The cognitive behaviour therapy group experienced significant reductions ( F = 5.47, p = 0.04) in sleep disturbance (mean individual change = −4.00) in comparison to controls post intervention (mean individual change = −1.50) with a moderate effect size of 1.17. There were no significant group differences on objective sleep quality, cognitive functioning, post-concussion symptoms or quality of life.

Conclusion:

On-line programmes designed to improve sleep are feasible for use for adults following mild-to-moderate TBI. Based on the effect size identified in this pilot study, 128 people (64 per group) would be needed to determine clinical effectiveness.