Sleep Disturbances Following Traumatic Brain Injury

Normative values of resting heart rate variability in young male contact sport athletes: Reference values for the assessment and treatment of concussion

Objective

The objective of this study was to identify the main determinants of heart rate variability (HRV) in male athletes aged 14 to 21 years who practice competitive contact sports and to integrate these determinants with the aim of defining normative values of short-term HRV in the time and frequency domains.

Methods

Participants (n = 369) were aged 14 to 21 years and included 221 football players and 148 ice hockey players. HRV was measured for 5 min at rest, and standard HRV parameters in the time and frequency domains were calculated. Heart rate (HR), age, body mass index (BMI), number of sports weekly practices (WSP) and concussion history (mTBI) were considered determinants potentially able to influence HRV.

Results

Multiple regression analysis revealed that HR was the primary determinant of standard HRV parameters. The models accounted for 13% to 55% of the total variance of HRV and the contribution of HR to this model was the strongest (β ranged from -0.34 to -0.75). HR was the only determinant that significantly contributes to all HRV parameters. To counteract this dependence, we calculated HRV corrected by the mean RR interval (RRm). Such corrections do not remove any physiological differences in HRV; they simply remove the mathematical bias. HRV parameters were therefore normalized, and their normative limits were developed relative to the mean heart rate. After correction, the correlation coefficients between HR and all corrected HRV parameters were not statistically significant and ranged from -0.001 to 0.045 (p > 0.40 for all). The automatically corrected HRV calculator, which recalculates standard HRV parameters and converts them into corrected parameters in addition to determining whether a given value is within normal limits, facilitates clinical interpretation.

Conclusion

This study provides for the first time corrected normative values of short-term and resting state HRV parameters in competitive contact sport athletes aged 14 to 21 years. These values were developed independently of the major determinants of HRV. The baseline values for HRV parameters given here could be used in clinical practice when assessing and monitoring cerebral concussions. They may assist in decision making for a safe return to play.

Neurobehavior and Mild Traumatic Brain Injury

Neurobehavioral sequelae after mild traumatic brain injury are multifactorial, often necessitating a multidisciplinary approach. Neurobehavioral sequelae generally resolve within 3 months; when more persistent, a search for contributing factors beyond a brain injury should be done. To accomplish this, a systematic and comprehensive evaluation is recommended to place the complaint in context of the patient's premorbid state. The treatment of neurobehavioral sequelae cannot be accomplished without a clear understanding of the underlying cause, and the treatment must be placed within a patient's social and functional framework. Normalizing the experience through education of patients and their families facilitates recovery.

Multipotential and systemic effects of traumatic brain injury

Traumatic brain injury (TBI) is one of the leading causes of disability and mortality of people at all ages. Biochemical, cellular and physiological events that occur during primary injury lead to a delayed and long-term secondary damage that can last from hours to years. Secondary brain injury causes tissue damage in the central nervous system and a subsequent strong and rapid inflammatory response that may lead to persistent inflammation. However, this inflammatory response is not limited to the brain. Inflammatory mediators are transferred from damaged brain tissue to the bloodstream and produce a systemic inflammatory response in peripheral organs, including the cardiovascular, pulmonary, gastrointestinal, renal and endocrine systems. Complications of TBI are associated with its multiple and systemic effects that should be considered in the treatment of TBI patients. Therefore, in this review, an attempt was made to examine the systemic effects of TBI in detail. It is hoped that this review will identify the mechanisms of injury and complications of TBI, and open a window for promising treatment in TBI complications.

Concussive head injury exacerbates neuropathology of sleep deprivation: Superior neuroprotection by co-administration of TiO2-nanowired cerebrolysin, alpha-melanocyte-stimulating hormone, and mesenchymal stem cells

Sleep deprivation (SD) is common in military personnel engaged in combat operations leading to brain dysfunction. Military personnel during acute or chronic SD often prone to traumatic brain injury (TBI) indicating the possibility of further exacerbating brain pathology. Several lines of evidence suggest that in both TBI and SD alpha-melanocyte-stimulating hormone (α-MSH) and brain-derived neurotrophic factor (BDNF) levels decreases in plasma and brain. Thus, a possibility exists that exogenous supplement of α-MSH and/or BDNF induces neuroprotection in SD compounded with TBI. In addition, mesenchymal stem cells (MSCs) are very portent in inducing neuroprotection in TBI. We examined the effects of concussive head injury (CHI) in SD on brain pathology. Furthermore, possible neuroprotective effects of α-MSH, MSCs and neurotrophic factors treatment were explored in a rat model of SD and CHI. Rats subjected to 48h SD with CHI exhibited higher leakage of BBB to Evans blue and radioiodine compared to identical SD or CHI alone. Brain pathology was also exacerbated in SD with CHI group as compared to SD or CHI alone together with a significant reduction in α-MSH and BDNF levels in plasma and brain and enhanced level of tumor necrosis factor-alpha (TNF-α). Exogenous administration of α-MSH (250μg/kg) together with MSCs (1×10⁶) and cerebrolysin (a balanced composition of several neurotrophic factors and active peptide fragments) (5mL/kg) significantly induced neuroprotection in SD with CHI. Interestingly, TiO₂ nanowired delivery of α-MSH (100μg), MSCs, and cerebrolysin (2.5mL/kg) induced enhanced neuroprotection with higher levels of α-MSH and BDNF and decreased the TNF-α in SD with CHI. These observations are the first to show that TiO₂ nanowired administration of α-MSH, MSCs and cerebrolysin induces superior neuroprotection following SD in CHI, not reported earlier. The clinical significance of our findings in light of the current literature is discussed.

Impact of Traumatic Brain Injury on Clinical Institute Withdrawal Assessment Use in Trauma Patients: A Descriptive Study

BACKGROUND

Alcohol withdrawal syndrome (AWS) and traumatic brain injury (TBI) present with similar signs and symptoms, yet their treatment strategies differ greatly. AWS treatment includes the Clinical Institute Withdrawal Assessment (CIWA) protocol, which grades withdrawal signs and symptoms. A major purpose of CIWA is to guide the addition and titration of central nervous system (CNS) depressants, most commonly benzodiazepines. Conversely, best practice is to avoid these same CNS depressants in the setting of TBI. Thus, patients with TBI presenting with AWS risk may receive undesirable interventions that could worsen outcome.

OBJECTIVE

To describe the relationship of TBI diagnosis with CIWA protocol scores and intervention implementation.

DESIGN

Retrospective cohort observational study.

SETTING

Single university-based, level one trauma center.

PATIENTS

Three hundred seventy-five patients with head trauma or AWS classification, identified through the trauma center's trauma registry.

INTERVENTIONS

CIWA protocol and related medication use.

MAIN OUTCOME MEASURES

Frequency of elevated CIWA score, length of CIWA administration, and medication administration incidence were abstracted from patients' medical records.

RESULTS

The percentage of elevated CIWA scores increased significantly with TBI severity, from 4.5%(0-60) in the No TBI group, up to 12.5% (0-36) in the Mild TBI group, 27.1% (0-57) in the Moderate TBI group, and 50.0% (14-77) in the Severe TBI group. Nominally, lorazepam use showed a similar pattern of escalation with TBI severity, but it did not reach statistical significance. Haloperidol use did significantly escalate with higher TBI severity. No group differences were observed for total lorazepam equivalents or length on the CIWA protocol.

CONCLUSIONS

TBI diagnosis and higher TBI severity level correlate with higher CIWA scores, but neither increased nor decreased benzodiazepine usage was observed. Antipsychotic use did escalate with TBI diagnosis and severity. The risks versus benefits of minimizing benzodiazepines in patients with TBI who are at risk for AWS warrant future study.

Repetitive mild traumatic brain injury alters diurnal locomotor activity and response to the light change in mice

Mild traumatic brain injury (mTBI) is a common cause of brain damage with a high incidence of multiple mTBIs found among athletes and soldiers. The purpose of this study is to examine the diurnal behavioral changes after multiple mTBIs. Adult mice were anesthetized; mTBI was conducted by dropping a 30-g weight to the right temporal skull once (mTBI1) or three times (mTBI3) over 3-week. Open-field motor behavior was recorded for 3 days after the last mTBI. In the first 4-hour exploratory phase, mTBI1 or mTBI3 equally reduced locomotor activity. A significant reduction of locomotor activity was found in the dark cycle between 4–72 hour in mTBI1 or mTBI3 mice; higher motor activity was seen after mTBI3 compared to mTBI1. In the light cycle, mTBI3 mice demonstrated an earlier immobilization followed by hyperactivity. The response to light change significantly correlated with the number of impacts. The IBA1 and BAX protein levels were equally increased in the lesioned cortex after mTBI1 and mTBI3. mTBI3 selectively upregulated the expression of circadian clock gene Per1 in hypothalamus and hippocampus as well as iNOS expression in the lesioned side cortex. Our data suggest multiple mTBIs alter diurnal locomotor activity and response to the change of light, which may involve Per1 expression in the lesioned brain.

Treatment of Pediatric Concussion

Concussions have gained attention in medical literature, legal literature, and lay media over the past several years as a public health affecting children, particularly those who do not improve in the first few days after an injury. We discuss strategies for acute management immediately after a concussion and an introduction to medical and non-medical options for treatment of the complex symptoms that persist in some patients with concussions. We examine the role of rest and exercise during recovery. We briefly discuss the role of the multidisciplinary approach to concussion in a setting that engages multiple specialists. Finally, we address policy changes related to sport-concussions and their efficacy in improving long term outcomes.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Sleep Disorders Following Mild and Moderate Traumatic Brain Injury

(1) Background: Sleeping disorders are frequently reported following traumatic brain injury (TBI). Different forms of sleeping disorders have been reported, such as sleepiness, insomnia, changes in sleeping latency, and others. (2) Methods: A case-control study with 62 patients who were victims of mild or moderate TBI with previous admissions to Iraqi tertiary neurosurgical centers were enrolled as the first group, and 158 patients with no history of trauma were considered as the control. All were 18 years of age or older, and the severity of the trauma and sleep disorders was assessed. The Pittsburgh sleep quality index was used to assess sleep disorders with average need for sleep per day and average sleep latency were assessed in both groups. Chi-square and t-test calculations were used to compare different variables. (3) Results: 39 patients (24.7%) of the controlled group experienced sleeping disorders compared to TBI group with 45 patients (72.6%), P-value < 0.00001. A total of 42 patients were diagnosed on admission as having a mild degree of TBI (mean GCS 13.22 ± 1.76) and 20 patients were diagnosed with moderate TBI (mean GCS11.05 ± 1.14. 27). A total of 27 (46.28%) patients with mild severity TBI and 18 patients (90%) of moderate severity were considered to experience sleeping disorders, P-value 0.0339. Each of the mild and moderate TBI subgroups show a P-value < 0.00001 compared to the control group. Average sleep hours needed per day for TBI and the control were 8.02 ± 1.04 h and 7.26 ± 0.58 h, respectively, P-value < 0.00001. Average sleep latency for the TBI and the control groups were 13.32 ± 3.16 min and 13.93 ± 3.07 min respectively, P-value 0.065. (4) Conclusion: Sleep disturbances are more common following mild and moderate TBI three months after the injury with more hours needed for sleep per day and no significant difference in sleep latency. Sleep disturbances increase in frequency with the increase in the severity of TBI.

Sports-Related Concussion: Acute Management and Chronic Postconcussive Issues

Sports-related concussion (SRC) is a common problem in youth sports. Concussion may occur after a forceful hit to the body or head, resulting in transient neuropathological changes that spontaneously resolve with relative rest and activity modification in most patients. Most SRCs are effectively managed by primary care physicians and sports medicine specialists. In some cases, symptoms may persist and the child and adolescent psychiatrist may be consulted. This article reviews important background information regarding SRC and highlights a variety of pharmacologic and nonpharmacologic treatment options that consultant psychiatrists should know.

Sleep-Wake Disturbances After Traumatic Brain Injury: Synthesis of Human and Animal Studies

Sleep-wake disturbances following traumatic brain injury (TBI) are increasingly recognized as a serious consequence following injury and as a barrier to recovery. Injury-induced sleep-wake disturbances can persist for years, often impairing quality of life. Recently, there has been a nearly exponential increase in the number of primary research articles published on the pathophysiology and mechanisms underlying sleep-wake disturbances after TBI, both in animal models and in humans, including in the pediatric population. In this review, we summarize over 200 articles on the topic, most of which were identified objectively using reproducible online search terms in PubMed. Although these studies differ in terms of methodology and detailed outcomes; overall, recent research describes a common phenotype of excessive daytime sleepiness, nighttime sleep fragmentation, insomnia, and electroencephalography spectral changes after TBI. Given the heterogeneity of the human disease phenotype, rigorous translation of animal models to the human condition is critical to our understanding of the mechanisms and of the temporal course of sleep-wake disturbances after injury. Arguably, this is most effectively accomplished when animal and human studies are performed by the same or collaborating research programs. Given the number of symptoms associated with TBI that are intimately related to, or directly stem from sleep dysfunction, sleep-wake disorders represent an important area in which mechanistic-based therapies may substantially impact recovery after TBI.

Sleep disturbance in patients with chronic concussive effects

Aim:

Sleep disturbance is relatively overlooked in concussion treatment although sleep disorders may prolong or exacerbate symptoms after a concussion. We looked at the incidence of both sleep disturbance and postconcussion symptoms in a sample of recently concussed individuals.

Methods & results:

We evaluated scores on the insomnia severity index (ISI) and postconcussion symptom scale (PCSS) in 96 participants with persistent symptoms. Sleep disturbance significantly contributed to the severity of postconcussive symptoms and length of recovery; this effect was less pronounced in athletes.

Conclusion:

These results suggest a relationship between sleep problems and the time course of recovery from concussive injury. Clinicians who regularly treat concussion would benefit from a more thorough consideration of sleep function in the assessment of postconcussive symptoms.

Hypocretinergic and cholinergic contributions to sleep-wake disturbances in a mouse model of traumatic brain injury

Disorders of sleep and wakefulness occur in the majority of individuals who have experienced traumatic brain injury (TBI), with increased sleep need and excessive daytime sleepiness often reported. Behavioral and pharmacological therapies have limited efficacy, in part, because the etiology of post-TBI sleep disturbances is not well understood. Severity of injuries resulting from head trauma in humans is highly variable, and as a consequence so are their sequelae. Here, we use a controlled laboratory model to investigate the effects of TBI on sleep-wake behavior and on candidate neurotransmitter systems as potential mediators. We focus on hypocretin and melanin-concentrating hormone (MCH), hypothalamic neuropeptides important for regulating sleep and wakefulness, and two potential downstream effectors of hypocretin actions, histamine and acetylcholine. Adult male C57BL/6 mice (n=6-10/group) were implanted with EEG recording electrodes and baseline recordings were obtained. After baseline recordings, controlled cortical impact was used to induce mild or moderate TBI. EEG recordings were obtained from the same animals at 7 and 15 days post-surgery. Separate groups of animals (n=6-8/group) were used to determine effects of TBI on the numbers of hypocretin and MCH-producing neurons in the hypothalamus, histaminergic neurons in the tuberomammillary nucleus, and cholinergic neurons in the basal forebrain. At 15 days post-TBI, wakefulness was decreased and NREM sleep was increased during the dark period in moderately injured animals. There were no differences between groups in REM sleep time, nor were there differences between groups in sleep during the light period. TBI effects on hypocretin and cholinergic neurons were such that more severe injury resulted in fewer cells. Numbers of MCH neurons and histaminergic neurons were not altered under the conditions of this study. Thus, we conclude that moderate TBI in mice reduces wakefulness and increases NREM sleep during the dark period, effects that may be mediated by hypocretin-producing neurons and/or downstream cholinergic effectors in the basal forebrain.

Insomnia in workers with delayed recovery from mild traumatic brain injury

OBJECTIVE/BACKGROUND/AIM

Insomnia has not been explored as it relates to recovery after mild traumatic brain injury (mTBI). We aimed to evaluate the prevalence of insomnia among Ontario workers with delayed recovery from mTBI, and its relationship with sociodemographic, TBI- and claim-related, behavioral, and clinical factors.

PATIENTS/METHODS

This was a cross-sectional study carried out over a period of 24 months in a large rehabilitation hospital in Ontario. To assess the prevalence of insomnia, we used the Insomnia Severity Index (ISI). Data were collected from standardized questionnaires, insurer records, and clinical assessment at the time of recruitment. Bivariate associations were calculated using the Spearman's correlation coefficient or analysis of variance. We established stepwise multivariate linear regression models of factors associated with insomnia. Additional analyses, including the assessment of the internal consistency of the ISI, were performed.

RESULTS

Of the 94 participants diagnosed with mTBI, clinical insomnia was reported by 69.2%. The mean age was 45.20 ± 9.94 years; 61.2% were men. No sex-related differences were observed in insomnia prevalence or severity. Insomnia was significantly associated with certain sociodemographic, claim-related, behavioral, and clinical variables. In the multivariable regression analysis, several determinants explained 53% of the insomnia variance. The internal consistency of the ISI, as measured by Cronbach's α, was 0.86.

CONCLUSIONS

Insomnia is common in persons with delayed recovery from mTBI, and is significantly associated with potentially modifiable clinical and nonclinical variables. Care of persons with brain injury requires greater attention with regard to the diagnosis and management of insomnia and associated disorders.

Armodafinil for the treatment of excessive sleepiness associated with mild or moderate closed traumatic brain injury: a 12-week, randomized, double-blind study followed by a 12-month open-label extension

OBJECTIVE

To evaluate the efficacy and tolerability of armodafinil in patients with excessive sleepiness following mild or moderate closed traumatic brain injury (TBI).

DESIGN

Randomized, placebo-controlled, double-blind trial followed by open-label extension.

SETTING

40 US centers.

PATIENTS

Adults with closed TBI (N = 117), Glasgow Coma Scale score >8 at time of injury; baseline Epworth Sleepiness Scale (ESS) ≥10; sleep latency <8 minutes on multiple sleep latency test (MSLT); and Clinical Global Impression-Severity of Illness (CGI-S) score ≥4 for excessive sleepiness.

INTERVENTION

Patients received armodafinil (50, 150, or 250 mg/day) or placebo for 12 weeks followed by an optional 12-month open-label extension.

MEASUREMENTS AND RESULTS

Outcomes included MSLT, ESS, Clinical Global Impression-Change (CGI-C), TBI-Work Instability Scale (TBI-WIS), CGI-S, and tolerability. The study was terminated early due to low enrollment. Patients receiving 250 mg armodafinil showed significant improvement in sleep latency from baseline to final visit versus placebo (+7.2 minutes vs. +2.4 minutes; p = 0.0010). CGI-C ratings were much/ very much improved in approximately 50% of patients receiving 150 and 250 mg armodafinil, compared to 38% on placebo. ESS and TBI-WIS scores were not significantly different between groups. In the open-label extension (N = 49), patients demonstrated gradual improvement in ESS, TBI-WIS, and CGI-S scores up to 48 weeks post-baseline. Armodafinil was generally well tolerated, with headache the most common adverse event in both double-blind and open-label portions.

CONCLUSIONS

Armodafinil 250 mg significantly improved sleep latency in patients with excessive sleepiness associated with mild or moderate TBI. Efficacy and tolerability of armodafinil were sustained throughout the open-label extension.

TRIAL REGISTRATION

NCT00893789, NCT00983437.

An empirical review of treatment and rehabilitation approaches used in the acute, sub-acute, and chronic phases of recovery following sports-related concussion

OPINION STATEMENT

Several treatment and rehabilitation approaches for sport-related concussion have been mentioned in recent consensus and position statements. These options range from the more conservative behavioral management approaches to aggressive pharmacological and therapeutic interventions. Moreover, clinical decision-making for sport-related concussion changes as symptoms and impairments persist throughout recovery. The current article provides an empirical review of proposed treatment and rehabilitation options for sport-related concussion during the acute, subacute, and chronic phases of injury.

The spectrum of neurobehavioral sequelae after repetitive mild traumatic brain injury: a novel mouse model of chronic traumatic encephalopathy

There has been an increased focus on the neurological sequelae of repetitive mild traumatic brain injury (TBI), particularly neurodegenerative syndromes, such as chronic traumatic encephalopathy (CTE); however, no animal model exists that captures the behavioral spectrum of this phenomenon. We sought to develop an animal model of CTE. Our novel model is a modification and fusion of two of the most popular models of TBI and allows for controlled closed-head impacts to unanesthetized mice. Two-hundred and eighty 12-week-old mice were divided into control, single mild TBI (mTBI), and repetitive mTBI groups. Repetitive mTBI mice received six concussive impacts daily for 7 days. Behavior was assessed at various time points. Neurological Severity Score (NSS) was computed and vestibulomotor function tested with the wire grip test (WGT). Cognitive function was assessed with the Morris water maze (MWM), anxiety/risk-taking behavior with the elevated plus maze, and depression-like behavior with the forced swim/tail suspension tests. Sleep electroencephalogram/electromyography studies were performed at 1 month. NSS was elevated, compared to controls, in both TBI groups and improved over time. Repetitive mTBI mice demonstrated transient vestibulomotor deficits on WGT. Repetitive mTBI mice also demonstrated deficits in MWM testing. Both mTBI groups demonstrated increased anxiety at 2 weeks, but repetitive mTBI mice developed increased risk-taking behaviors at 1 month that persist at 6 months. Repetitive mTBI mice exhibit depression-like behavior at 1 month. Both groups demonstrate sleep disturbances. We describe the neurological sequelae of repetitive mTBI in a novel mouse model, which resemble several of the neuropsychiatric behaviors observed clinically in patients sustaining repetitive mild head injury.

Diffuse brain injury does not affect chronic sleep patterns in the mouse

PRIMARY OBJECTIVE

To test if the current model of diffuse brain injury produces chronic sleep disturbances similar to those reported by TBI patients.

METHODS AND PROCEDURES

Adult male C57BL/6 mice were subjected to moderate midline fluid percussion injury (n = 7; 1.4 atm; 6-10 minutes righting reflex time) or sham injury (n = 5). Sleep-wake activity was measured post-injury using a non-invasive, piezoelectric cage system. Chronic sleep patterns were analysed weekly for increases or decreases in percentage sleep (hypersomnia or insomnia) and changes in bout length (fragmentation).

MAIN OUTCOMES AND RESULTS

During the first week after diffuse TBI, brain-injured mice exhibited increased mean percentage sleep and mean bout length compared to sham-injured mice. Further analysis indicated the increase in mean percentage sleep occurred during the dark cycle. Injury-induced changes in sleep, however, did not extend beyond the first week post-injury and were not present in weeks 2-5 post-injury.

CONCLUSIONS

Previously, it has been shown that the midline fluid percussion model used in this study immediately increased post-traumatic sleep. The current study extended the timeline of investigation to show that sleep disturbances extended into the first week post-injury, but did not develop into chronic sleep disturbances. However, the clinical prevalence of TBI-related sleep-wake disturbances warrants further experimental investigation.

Transcranial magnetic stimulation and sleep disorders: pathophysiologic insights

The neural mechanisms underlying the development of the most common intrinsic sleep disorders are not completely known. Therefore, there is a great need for noninvasive tools which can be used to better understand the pathophysiology of these diseases. Transcranial magnetic stimulation (TMS) offers a method to noninvasively investigate the functional integrity of the motor cortex and its corticospinal projections in neurologic and psychiatric diseases. To date, TMS studies have revealed cortical and corticospinal dysfunction in several sleep disorders, with cortical hyperexcitability being a characteristic feature in some disorders (i.e., the restless legs syndrome) and cortical hypoexcitability being a well-established finding in others (i.e., obstructive sleep apnea syndrome narcolepsy). Several research groups also have applied TMS to evaluate the effects of pharmacologic agents, such as dopaminergic agent or wake-promoting substances. Our review will focus on the mechanisms underlying the generation of abnormal TMS measures in the different types of sleep disorders, the contribution of TMS in enhancing the understanding of their pathophysiology, and the potential diagnostic utility of TMS techniques. We also briefly discussed the possible future implications for improving therapeutic approaches.

Association of sleep and co-occurring psychological conditions at 1 year after traumatic brain injury

OBJECTIVES

To compare individuals' sleep 1 year after traumatic brain injury (TBI) with that of a healthy comparison group, and examine the relationship between sleep, co-occurring conditions, and functional status in those with TBI.

DESIGN

Longitudinal assessment of a prospectively studied sample of individuals with moderate to severe TBI. Assessment of sleep occurred at 1 year after TBI.

SETTING

Inpatient acute rehabilitation for TBI and community follow-up at 1 year postinjury.

PARTICIPANTS

Individuals with TBI (N=174) were recruited from consecutive admissions to an inpatient rehabilitation unit and enrolled into the TBI Model Systems study. Participant mean age was 38, and mean Glasgow Coma Scale score on admission was 9.3. Seventy-eight percent of the sample were men.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI). Depression, anxiety, and pain were measured with the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 Scale, and an analog pain rating scale, respectively.

RESULTS

Participants with TBI reported significantly greater sleep difficulties than the healthy comparison group. Forty-four percent of participants with TBI reported significant sleep problems (PSQI>5). Participants with 1 or more co-occurring conditions (depression, pain, or anxiety) had significantly worse sleep than those without such a condition. The highest level of sleep problems was reported by participants with multiple co-occurring conditions. Sleep problems were also associated with poor functional status.

CONCLUSIONS

Sleep difficulties are a frequent problem at 1 year after TBI, and often co-occur with depression, anxiety, and pain. Assessment and treatment of sleep difficulties should be included in clinical practice. Future research on the potential causal relationship among co-occurring conditions may assist in additional intervention planning.

Traumatic brain injury-induced dysregulation of the circadian clock

Circadian rhythm disturbances are frequently reported in patients recovering from traumatic brain injury (TBI). Since circadian clock output is mediated by some of the same molecular signaling cascades that regulate memory formation (cAMP/MAPK/CREB), cognitive problems reported by TBI survivors may be related to injury-induced dysregulation of the circadian clock. In laboratory animals, aberrant circadian rhythms in the hippocampus have been linked to cognitive and memory dysfunction. Here, we addressed the hypothesis that circadian rhythm disruption after TBI is mediated by changes in expression of clock genes in the suprachiasmatic nuclei (SCN) and hippocampus. After fluid-percussion TBI or sham surgery, male Sprague-Dawley rats were euthanized at 4 h intervals, over a 48 h period for tissue collection. Expression of circadian clock genes was measured using quantitative real-time PCR in the SCN and hippocampus obtained by laser capture and manual microdissection respectively. Immunofluorescence and Western blot analysis were used to correlate TBI-induced changes in circadian gene expression with changes in protein expression. In separate groups of rats, locomotor activity was monitored for 48 h. TBI altered circadian gene expression patterns in both the SCN and the hippocampus. Dysregulated expression of key circadian clock genes, such as Bmal1 and Cry1, was detected, suggesting perturbation of transcriptional-translational feedback loops that are central to circadian timing. In fact, disruption of circadian locomotor activity rhythms in injured animals occurred concurrently. These results provide an explanation for how TBI causes disruption of circadian rhythms as well as a rationale for the consideration of drugs with chronobiotic properties as part of a treatment strategy for TBI.

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

BACKGROUND

Sleep is often disrupted following a traumatic brain injury (TBI), which may compromise recovery and quality of life. Prevalence rates vary widely, reflecting differences in the criteria and measures that are used to assess sleep, as well as sample differences. This meta-analysis examined the prevalence of general and specific, and formally and informally diagnosed, sleep disturbances following TBI in order to establish the nature and extent of these sequelae and their potential impact on recovery.

METHODS

Data from 21 studies, which assessed (1) sleep disturbances, regardless of type or severity, (2) diagnosed sleep disorders, and (3) specific sleep problems following TBI, were analyzed and compared to data for the general population.

RESULTS

Overall, 50% of people suffered from some form of sleep disturbance after a TBI and 25-29% had a diagnosed sleep disorder (insomnia, hypersomnia, apnea) - rates that are much higher than those seen in the general population. They were also two to four times more likely to experience problems with sleep maintenance and efficiency, nightmares, excessive sleepiness, early awakenings, and sleep walking.

CONCLUSION

Sleep disturbances are very common after TBI and have the potential to seriously undermine patient rehabilitation, recovery, and outcomes; making it important to routinely screen for such problems in order to assess both treatment needs and their potential impact on recovery and outcome.

What is the role of brain mechanisms underlying arousal in recovery of motor function after structural brain injuries?

PURPOSE OF REVIEW

Standard neurorehabilitation approaches have limited impact on motor recovery in patients with severe brain injuries. Consideration of the contributions of impaired arousal offers a novel approach to understand and enhance recovery.

RECENT FINDINGS

Animal and human neuroimaging studies are elucidating the neuroanatomical bases of arousal and of arousal regulation, the process by which the cerebrum mobilizes resources. Studies of patients with disorders of consciousness have revealed that recovery of these processes is associated with marked improvements in motor performance. Recent studies have also demonstrated that patients with less severe brain injuries also have impaired arousal, manifesting as diminished sustained attention, fatigue, and apathy. In these less severely injured patients, it is difficult to connect disorders of arousal with motor recovery because of a lack of measures of arousal that are independent of motor function.

SUMMARY

Arousal impairment is common after brain injury and likely plays a significant role in recovery of motor function. A more detailed understanding of this connection will help to develop new therapeutic strategies applicable for a wide range of patients. This requires new tools that continuously and objectively measure arousal in patients with brain injury, to correlate with detailed measures of motor performance and recovery.

Traumatic brain injury and its neurobehavioral sequelae

The neurobehavioral sequelae of TBI consist of a spectrum of somatic, neurologic, and psychiatric symptoms. The challenge for clinicians lies in understanding the interface of the various symptoms and how they interrelate with other entities. Specifically, the challenge is differentiating post-TBI-related symptoms from preexisting or de novo psychiatric, neurologic, and/or systemic disorders. A comprehensive evaluation and a multidisciplinary approach to evaluating patients are essential to be able to develop the differential diagnosis needed to design a management plan that maximizes recovery.

Medical therapies for concussion

Clinicians who manage sport-related concussions have excellent guidelines by which most injuries can be managed. Because sport-related concussions typically resolve within a short time frame, most can be managed with physical and cognitive rest alone. However, clinicians who specialize in the assessment and management of this diagnosis encounter patients with prolonged recovery courses, persistent symptoms, and significant deficits in cognitive functioning. These patients require more involved therapy, which may include additional education, academic accommodations, physical therapy, cognitive rehabilitation, and medication. This article reviews the main medical therapies for the management of concussive brain injury.

Traumatic brain injury and its neurobehavioral sequelae

The neurobehavioral sequelae (NBS) of traumatic brain injury (TBI) consist of a spectrum of somatic, neurological, and psychiatric symptoms. The challenge for clinicians lies in understanding the interface of the various symptoms and how they interrelate with other entities. Specifically, the challenge is differentiating post-TBI-related symptoms from pre-existing or de novo psychiatric, neurological, and/or systemic disorders. A comprehensive evaluation and a multidisciplinary approach to evaluating patients are essential to be able to develop the differential diagnosis needed to design a management plan that maximizes recovery.

The effect of sleep medications on cognitive recovery from traumatic brain injury

OBJECTIVE

To summarize the literature on the available pharmacotherapy for insomnia and the adverse cognitive effects of those options in persons with traumatic brain injury (TBI).

DESIGN

Ovid/MEDLINE databases were searched by using the following key words: "brain injury," "sleep initiation and maintenance disorders," "hypnotics and sedatives," "benzodiazepines," "trazodone," and "neuronal plasticity."

RESULTS

The reviewed literature consistently reported that benzodiazepines and atypical gamma-aminobutyric acid (GABA) agonists result in cognitive impairment when plasma levels are at their peak. Evidence of residual effects on cognition was reported for benzodiazepines but was seen less often in atypical GABA agonists. However, evidence has also been presented that GABA agonists have adverse effects on neuroplasticity, raising concerns about their use in patients recovering from TBI.

CONCLUSIONS

Use of benzodiazepines in TBI has been discouraged and some authors also advocate caution in prescribing atypical GABA agonists. Alternate treatments including trazodone and a newer class of agents, melatonin agonists, are highlighted, along with the limited data available addressing the use of these medications in TBI. Finally, suggestions are offered for further research, especially on topic related to neural plasticity and functional recovery.

Neurobehavioral sequelae of traumatic brain injury

The neurobehavioral sequelae of traumatic brain injury consist of a spectrum of somatic and neuropsychiatric symptoms. The neuropsychiatric symptoms are divided into cognitive and behavioral presentations. In the literature, these neurobehavioral sequelae have been called postconcussive symptoms, postconcussive syndrome, and postconcussive disorder; however, the authors of this review do not use this terminology because the symptoms are not restricted to patients with concussion but instead can be found in all traumatic brain injury patients of all injury severities. The development of neurobehavioral sequelae after traumatic brain injury is a multifactorial process. The patient evaluation requires a multidisciplinary approach in order to delineate physiologic dysfunction and place deficits in the context of the patient's preinjury and postinjury psychiatric status. Consequently, the evaluation of the posttraumatic brain injury patient with neurobehavioral sequelae requires a carefully structured history and physical examination with an emphasis on neurological and psychiatric function. Adjunctive evaluations must be tailored to the patient with neuroimaging, neurophysiological, and neuropsychiatric testing. Maximized outcomes may be achieved by the performance of a careful and detailed assessment that places complaints within the context of the individual.

Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design

OBJECTIVE

To test the efficacy of a cognitive-behavioral therapy (CBT) for insomnia in persons having sustained traumatic brain injury (TBI).

DESIGN

Single-case design with multiple baselines across participants.

SETTING

Outpatient rehabilitation center.

PARTICIPANTS

Eleven subjects having sustained mild to severe TBI who developed insomnia after the injury.

INTERVENTION

Eight-week CBT for insomnia including stimulus control, sleep restriction, cognitive restructuring, sleep hygiene education, and fatigue management.

MAIN OUTCOME MEASURES

Total wake time, sleep efficiency, and diagnostic criteria.

RESULTS

Visual analyses, corroborated by intervention time series analyses and t tests, revealed clinically and statistically significant reductions in total wake time and sleep efficiency for 8 (73%) of 11 participants. An average reduction of 53.9% in total wake time was observed across participants from pre- to post-treatment. Progress was in general well maintained at the 1-month and 3-month follow-ups. The average sleep efficiency augmented significantly from pretreatment (77.2%) to post-treatment (87.9%), and also by the 3-month follow-up (90.9%). Improvements in sleep were accompanied by a reduction in symptoms of general and physical fatigue.

CONCLUSIONS

The results of this study show that psychologic interventions for insomnia are a promising therapeutic avenue for TBI survivors.

Lasting Neuroendocrine-Immune Effects of Traumatic Brain Injury in Rats

Traumatic brain injury (TBI) is a principal cause of long-term physical, cognitive, behavioral, and social deficits in young adults, which frequently coexist with a high incidence of substance abuse disorders. However, few studies have examined the long-term effects of TBI on the neuroendocrine-immune system. TBI was induced in adult male rats under isoflurane anesthesia by cortical contusion injury with a pneumatic piston positioned stereotaxically over the left parietal cortex. Controls underwent sham surgery without injury. At 4 weeks post-injury, the plasma corticosterone response to 30-min restraint stress was significantly blunted in TBI rats compared to the sham controls. One week later, transmitters were implanted for continuous biotelemetric recording of body temperature and spontaneous locomotor activity. At 6 weeks post-injury, the febrile response to i.p. injection of the bacterial endotoxin, lipopolysaccharide (LPS; 50 microg/kg), was significantly lower in TBI than in sham rats. At 8 weeks, swimming in the forced swim test was significantly less in TBI than sham rats. At 9 weeks, rats were rendered ethanol (EtOH) dependent by feeding an EtOH-containing liquid diet for 14 days. Cosine rhythmometry analysis of circadian body temperature Midline Estimating Statistic of Rhythm (MESOR), amplitudes, and acrophases indicated differential effects of EtOH and withdrawal in the two groups. Light- and dark-phase activity analysis indicated that TBI rats were significantly more active than the sham group, and that EtOH and withdrawal differentially affected their activity. Given the extensive interactions of the neuroendocrine-immune systems, these results demonstrate that TBI produces lasting dysregulation amidst the central substrates for allostasis and circadian rhythmicity.

Self-reported changes to nighttime sleep after traumatic brain injury

OBJECTIVES

To explore subjective sleep reports from people in the chronic stages of traumatic brain injury (TBI) and to examine the extent and nature of sleep complaints in this population.

DESIGN

Survey.

SETTING

All participants were community based at the time of data collection.

PARTICIPANTS

Sixty-three subjects with TBI consecutively recruited after discharge from rehabilitation and 63 age- and sex-matched controls from the general community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A 7-day self-reported sleep-wake diary assessing sleep and wake times, sleep onset latency, frequency, and duration of nocturnal awakenings and daytime naps; a general sleep questionnaire used to evaluate sleep changes and quality; and the Epworth Sleepiness Scale to measure daytime sleepiness.

RESULTS

Group-wise comparisons showed a significantly higher frequency of reported sleep changes after TBI (80%) relative to the control group (23%), supporting previous findings. The TBI group reported more nighttime awakenings and longer sleep onset latency; these changes were more frequently reported by participants with TBI with milder injuries. Increased levels of anxiety and depression were associated with increased reporting of sleep changes.

CONCLUSIONS

These findings confirm the experience of changes to sleep after TBI and may at least in part account for the reported increased daytime sleepiness in this population. Sleep disturbance should be addressed during rehabilitation. Treatments need to focus on correcting the underlying cause of the sleep problem and to address patients' subjective experiences of their sleep, possibly through education and mood stabilization.

Consciousness, coma, and caring for the brain-injured patient

In this article, a preliminary conceptual framework is presented for exploring nursing interventions and research aimed at improving care of the unconscious brain-injured patient during the early subacute phase of brain injury. The cue-response framework presented is derived from multidisciplinary sources and has specific clinical relevance to critical care nurses caring for unconscious brain-injured patients. A key aspect of this framework is the attention focused on the timing of nursing interventions in response to how nurses interpret the physical, physiological, and secondary cues they observe when caring for comatose patients. A case exemplar is used to present one example of how this framework may be used in the clinical setting.

Selective attention deficits and subjective fatigue following traumatic brain injury

The present study aimed to investigate the relationship between subjective fatigue and selective attention deficits following traumatic brain injury (TBI). Forty-six participants with mild-severe TBI and 46 healthy controls completed fatigue scales (Visual Analogue Scale--Fatigue, Fatigue Severity Scale [FSS] and Causes of Fatigue Questionnaire [COF]), and attentional measures including subtests from the Test of Everyday Attention, and the Complex Selective Attention Task (C-SAT). TBI participants reported greater fatigue on the FSS and COF, performed more slowly on attentional measures, and made more errors on the C-SAT. After controlling for anxiety and depression, fatigue was significantly correlated with performance only on the C-SAT. Findings suggest a relationship between subjective fatigue and impairment on tasks requiring higher order attentional processes.

Aging with traumatic brain injury: long-term health conditions

Although traumatic brain injury (TBI) is a leading cause of death and disability in young adults, older adults over the age of 75 are also at high risk for TBI. As even mild injury can lead to disabling consequences, the long-term consequences of TBI need to be better understood, especially as the survival rate has increased dramatically in the last few decades. This research examined the prevalence of long-term health conditions after TBI. Using a retrospective cohort design, we examined consecutive records of adults with moderate to severe TBI discharged from a large rehabilitation hospital in Pennsylvania from 1974 to 1989. Baseline clinical information was abstracted from medical records. We interviewed consenting participants up to 24 years after injury. Our findings show a higher than expected prevalence of self-reported arthritis in the middle-aged population. There was also a high prevalence of problems with sleep and nerves many years post-injury. Some of the health conditions documented in this study could potentially be addressed early in rehabilitation; this study supports the screening of more physical health conditions in persons aging with TBI.

Quality of life after traumatic brain injury: a review of research approaches and findings11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To assess existing knowledge of quality of life (QOL) of people with traumatic brain injury (TBI) and to make recommendations for methodologic and substantive research in this area.

DATA SOURCES

Published research on QOL of persons with TBI, identified from databases, ancestry search, and the author's files.

STUDY SELECTION

Empirical, theoretical, and methodologic articles relevant to 5 areas: QOL as achievements, QOL as subjective well-being (SWB), QOL as utility, QOL experienced, and QOL measurement instruments applicable to TBI or specifically developed for people with this impairment.

DATA EXTRACTION

Selection of QOL indicators, with focus on TBI versus non-TBI differences.

DATA SYNTHESIS

Studies of QOL as achievements show that in almost all areas, people with TBI score lower than they did before injury and lower than comparisons groups. There are limited gaps in our knowledge in this area. Research into QOL as SWB shows that after TBI, people typically report, for example, somewhat lower life satisfaction and affect than do comparison groups, and that injury severity is not necessarily a predictor of SWB. There are almost no studies of QOL as utility of life after TBI.

CONCLUSIONS

Major research recommendations include: exploring the ability of TBI subjects to self-report; determining the salience of domains of life for this group; developing utility instruments that are sensitive to differences in deficits in cognition and other health and life domains; and doing qualitative studies that explore the experience of QOL.