Screening for sleep dysfunction after traumatic brain injury

Sleep quantity and quality during the first week postinjury and time to symptom resolution in youth with concussion

OBJECTIVE

To examine bidirectional associations between objective measures of sleep quantity and quality with postconcussion symptoms (PCS) scores in concussed youth during the first week postinjury and to explore the associations between sleep measures and time to symptom resolution.

STUDY DESIGN

We conducted a secondary analysis of a prospectively enrolled cohort of youth (11-17 years) with a physician diagnosed concussion within 72 hours of injury. During the first week postconcussion, sleep quantity (time in bed, total sleep time and daytime sleep) and sleep quality (sleep efficiency, WASO and number of awakenings) were measured using an ActiGraph. We evaluated bidirectional temporal associations between the sleep measures and PCS during the first week postinjury using cross-lagged panel models. We assessed the associations between sleep measures and time to symptom resolution using Cox proportional hazard models.

RESULTS

Participants included 78 concussed youth, 34.6% females, mean age of 14.2 years (SD=2.1). Significant bidirectional associations were observed between PCS and both total sleep time and daytime total sleep in the first week postinjury. Increased daytime sleep was also associated with a decreased likelihood of symptom resolution, adjusted HR (aHR)=0.88, 95% CI=0.78, 0.999. An optimal total sleep time of 418 min per day was associated with a 2.1-fold increased likelihood of symptom resolution (aHR=2.1, 95% CI=1.3, 3.2).

CONCLUSIONS

Clinicians should provide guidance on sleep hygiene, including limiting daytime sleep/naps and getting the appropriate amount of nighttime sleep acutely postconcussion to aid recovery in youth.

Sleep Disturbance During Post-Traumatic Amnesia and Early Recovery After Traumatic Brain Injury

After moderate to severe traumatic brain injury (TBI), sleep disturbance commonly emerges during the confused post-traumatic amnesia (PTA) recovery stage. However, the evaluation of early sleep disturbance during PTA, its recovery trajectory, and influencing factors is limited. This study aimed to evaluate sleep outcomes in patients experiencing PTA using ambulatory gold-standard polysomnography (PSG) overnight and salivary endogenous melatonin (a hormone that influences the sleep-wake cycle) assessment at two time-points. The relationships between PSG-derived sleep-wake parameters and PTA symptoms (i.e., agitation and cognitive disturbance) were also evaluated. In a patient subset, PSG was repeated after PTA had resolved to assess the trajectory of sleep disturbance. Participants with PTA were recruited from Epworth HealthCare's inpatient TBI Rehabilitation Unit. Trained nurses administered overnight PSG at the patient bedside using the Compumedics Somté portable PSG device (Compumedics, Ltd., Australia). Two weeks after PTA had resolved, PSG was repeated. On a separate evening, two saliva specimens were collected (at 24:00 and 06:00) for melatonin testing. Results of routine daily hospital measures (i.e., Agitated Behavior Scale and Westmead PTA Scale) were also collected. Twenty-nine patients were monitored with PSG (mean: 41.6 days post-TBI; standard deviation [SD]: 28.3). Patients' mean sleep duration was reduced (5.6 h, SD: 1.2), and was fragmented with frequent awakenings (mean: 27.7, SD: 15.0). Deep, slow-wave restorative sleep was reduced, or completely absent (37.9% of patients). The use of PSG did not appear to exacerbate patient agitation or cognitive disturbance. Mean melatonin levels at both time-points were commonly outside of normal reference ranges. After PTA resolved, patients (n = 11) displayed significantly longer mean sleep time (5.3 h [PTA]; 6.5 h [out of PTA], difference between means: 1.2, p = 0.005). However, disturbances to other sleep-wake parameters (e.g., increased awakenings, wake time, and sleep latency) persisted after PTA resolved. This is the first study to evaluate sleep disturbance in a cohort of patients as they progressed through the early TBI recovery phases. There is a clear need for tailored assessment of sleep disturbance during PTA, which currently does not form part of routine hospital assessment, to suggest new treatment paradigms, enhance patient recovery, and reduce its long-term impacts.

A randomized clinical trial for a self-guided sleep intervention following moderate-severe traumatic brain injury: Study protocol

BACKGROUND

Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI.

METHODS

This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention.

CONCLUSION

This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI.

The effect of sleep disorders on dementia risk in patients with traumatic brain injury: A large-scale cohort study

Introduction

We investigated the association between sleep disorders (SDs) and incident dementia in adults with traumatic brain injury (TBI).

Methods

Adults with a TBI between 2003 and 2013 were followed until incident dementia. Sleep disorders at TBI were predictors in Cox regression models, controlling for other dementia risks.

Results

Over 52 months, 4.6% of the 712,708 adults (59% male, median age 44, <1% with SD) developed dementia. An SD was associated with a 26% and a 23% of increased risk of dementia in male and female participants (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.11-1.42 and HR 1.23, 95% CI 1.09-1.40, respectively). In male participants, SD was associated with a 93% increased risk of early-onset dementia (HR 1.93, 95% CI 1.29-2.87); this did not hold in female participants (HR 1.38, 95% CI 0.78-2.44).

Discussion

In a province-wide cohort, SDs at TBI were independently associated with incident dementia. Clinical trials testing sex-specific SD care after TBI for dementia prevention are timely.

Highlights

TBI and sleep disorders are linked to each other, and to dementia.It is unclear if sleep disorders pose a sex-specific dementia risk in brain injury.In this study, presence of a sleep disorder increased dementia risk in both sexes.The risk differed by type of sleep disorder, which differed between the sexes.Sleep disorder awareness and care in persons with brain injury is vital for dementia prevention.

The Utility of Melatonin for the Treatment of Sleep Disturbance After Traumatic Brain Injury: A Scoping Review

OBJECTIVE

To investigate the utility of melatonin supplementation as a treatment option for individuals with sleep disturbance after traumatic brain injury (TBI).

DATA SOURCES

A systematic search was conducted in 6 electronic databases (Medline, AMED, CINAHL, Embase, Scopus, and SPORTDiscus) from earliest records to April 2022.

STUDY SELECTION

Studies were eligible for inclusion if they met the following criteria: a) human participants with sleep disturbance after TBI, b) melatonin or melatonergic agent used as an intervention to treat sleep disturbance, and c) outcomes of melatonin administration reported. All TBI severity types (mild, moderate, and severe) were eligible. The initial search retrieved a total of 595 articles, with 9 studies meeting the eligibility criteria.

DATA EXTRACTION

Two reviewers independently extracted data from eligible studies and assessed methodological quality. Extracted data consisted of participant and injury characteristics, melatonin interventional properties, and sleep outcome. Methodological quality was assessed via the Downs and Black checklist.

DATA SYNTHESIS

A total of 251 participants with TBI-induced sleep disturbance (mean age range: 14.0-42.5 years) were included. Melatonin, Circadin (prolonged-release melatonin), or Ramelteon (melatonin receptor agonist) were administered. Dosages and intervention duration ranged from 2 to 10 mg and 3 to 12 weeks, respectively. Eight out of 9 studies reported positive outcomes after melatonin treatment. Significant improvements in subjective sleep quality, objective sleep efficiency, and total sleep time were found with melatonin. Reductions in self-reported fatigue, anxiety, and depressive symptoms were also observed with melatonin treatment. No serious adverse events were reported after melatonin administration.

CONCLUSION

Melatonin has good tolerability after short-term use and the potential to be a therapeutic agent for those with sleep disturbance after TBI. Melatonin was shown to be beneficial to sleep quality, sleep duration, and sleep efficiency. Additional clinically relevant outcomes of improved mental health suggest that melatonin use may be a promising treatment option for individuals experiencing co-occurring disorders of mood and sleep disturbance post-injury.

A comparison of agreement between actigraphy and polysomnography for assessing sleep during posttraumatic amnesia

STUDY OBJECTIVES

Sleep disturbance often emerges in the early recovery phase following a moderate to severe traumatic brain injury, known as posttraumatic amnesia. Actigraphy is commonly employed to assess sleep, as it is assumed that patients in posttraumatic amnesia (who display confusion, restlessness, and agitation) would better tolerate this measure over gold-standard polysomnography (PSG). This study evaluated the agreement between PSG and actigraphy for determining (sleep/wake time, sleep efficiency, sleep latency, and awakenings) in patients experiencing posttraumatic amnesia. It also compared the epoch-by-epoch sensitivity, specificity, and accuracy between the Actigraph device's 4 wake threshold settings (low, medium, high, and automatic) to PSG.

METHODS

The sample consisted of 24 inpatients recruited from a traumatic brain injury inpatient rehabilitation unit. Ambulatory PSG was recorded overnight at bedside and a Philips Actiwatch was secured to each patient's wrist for the same period.

RESULTS

There were poor correlations between PSG and actigraphy for all parameters (Lin's concordance correlation coefficient = < 0.80). The low threshold displayed the highest correlation with PSG for wake and sleep time, albeit still low. Actigraphy displayed low specificity (ranging from 17.1% to 36.6%). There appears to be a greater disparity between actigraphy and PSG for patients with increased wake time.

CONCLUSIONS

Actigraphy, while convenient, demonstrated poorer performance in determining sleep-wake parameters in patients with significantly disturbed sleep. Ambulatory PSG can provide a clearer understanding of the extent of sleep disturbances in these patients with reduced mobility during early rehabilitation. Study findings can help design future protocols of sleep assessment during posttraumatic amnesia and optimize treatment.

CITATION

Fedele B, McKenzie D, Williams G, Giles R, Olver J. A comparison of agreement between actigraphy and polysomnography for assessing sleep during posttraumatic amnesia. J Clin Sleep Med. 2022;18(11):2605-2616.

Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury

Background

Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.

Materials and Methods

This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).

Results

87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).

Discussion

Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.

Sleep Disorders in Traumatic Brain Injury

SUMMARY

Sleep disorders are common after traumatic brain injury (TBI). This study will review the spectrum and proposed mechanisms of TBI-associated sleep disorders and discuss the clinical approach to diagnosis and management of them. Disordered and fragmented sleep with insomnia and daytime sleepiness is very common after TBI. Sleep disruption contributes to morbidity and neurocognitive and neurobehavioral deficits and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of TBI and improve patient outcomes. Evaluating sleep disorders in TBI should be an important component of TBI assessment and management. Finally, newer research techniques for early diagnosis, prognosis, and improved outcomes after TBI will also be addressed.

The association of sleep quality and aggression: A systematic review and meta-analysis of observational studies

Poor sleep quality is closely related to aggression, but despite the promise of new therapeutic possibilities, a systematic synthesis of observational research on the association between sleep quality and aggression is lacking. This systematic review and meta-analysis examined the association between sleep quality and aggression, using the academic databases PubMed and PsycINFO. Subjective and objective measures of sleep quality were included, as well as multiple measures of aggression, assessing aggressive and externalizing behavior, anger, hostility and irritability. Ninety-two observational articles, containing 96 studies, encompassing a total of 58.154 children, adolescents and adults were sourced out of 7161 references identified. Methodological quality was moderate or strong in 76% of studies. Data for meta-analysis was available from 74 studies. Poorer sleep quality was associated with higher aggression in 80.8% of studies. Pooled results showed a correlation of 0.28 (95%CI 0.25-0.31; I² = 90.1%) and odds ratio of 3.61 (95%CI 1.13-11.51; I² = 88.3%). Effect estimates and heterogeneity varied according to population type and measurement instruments, but not according to article quality or age group. Our findings confirm that poor sleep quality is consistently associated with higher aggression. As most evidence is cross-sectional, more prospective and high-quality experimental evidence is required to elucidate cause-effect and optimize prevention and treatment of aggression.

The Prevalence and Stability of Sleep-Wake Disturbance and Fatigue throughout the First Year after Mild Traumatic Brain Injury

In this prospective, longitudinal study, we aimed to determine the prevalence and stability of sleep-wake disturbance (SWD) and fatigue in a large representative sample of patients (Trondheim mild traumatic brain injury [mTBI] follow-up study). We included 378 patients with mTBI (age 16-60), 82 matched trauma controls with orthopedic injuries, and 83 matched community controls. Increased sleep need, poor sleep quality, excessive daytime sleepiness, and fatigue were assessed at 2 weeks, 3 months, and 12 months after injury. Mixed logistic regression models were used to evaluate clinically relevant group differences longitudinally. Prevalence of increased sleep need, poor sleep quality, and fatigue was significantly higher in patients with mTBI than in both trauma controls and community controls at all time points. More patients with mTBI reported problems with excessive daytime sleepiness compared to trauma controls, but not community controls, at all time points. Patients with complicated mTBI (intracranial findings on computed tomography or magnetic resonance imaging) had more fatigue problems compared to those with uncomplicated mTBI, at all three time points. In patients with mTBI who experienced SWDs and fatigue 2 weeks after injury, around half still had problems at 3 months and approximately one third at 12 months. Interestingly, we observed limited overlap between the different symptom measures; a large number of patients reported one specific problem with SWD or fatigue rather than several problems. In conclusion, our results provide strong evidence that mTBI contributes significantly to the development and maintenance of SWDs and fatigue.

Circadian rhythm in the assessment of postconcussion insomnia: a cross-sectional observational study

BACKGROUND

Insomnia is a major predictor of adverse outcomes in mild traumatic brain injury (mTBI), including concussion; although insomnia symptoms may be due to various sleep disorders, those related to circadian rhythm sleep-wake disorders (CRSWDs) require specific assessment and treatment. The objective of the current study was to determine the prevalence of CRSWD in a sample of treatment-seeking people with chronic insomnia symptoms after an mTBI.

METHODS

Participants aged 17-65 years who had experienced an mTBI and reported chronic insomnia were recruited from diverse community clinics in Ontario 3-24 months after their injury to participate in this cross-sectional observational study. Potential participants were screened by both telephone and intake interview. Exclusion criteria were alcohol or substance use disorders, preexisting brain disorder or previous neurosurgery, recent travel across more than 2 time zones or shift work. Assessments included a clinical interview, questionnaires, 2 weeks of actigraphy and a sleep diary, and a dim-light melatonin onset test. The main outcome measure was the proportion of patients with CRSWDs.

RESULTS

Of the 50 participants (32 [64%] female; median age 39.5 yr), 13 (26% [standard deviation 12%]) had an CRSWD. The most common circadian diagnosis was delayed sleep-wake phase disorder (10 participants [20%]).

INTERPRETATION

The prevalence of CRSWDs may be exceptionally high among people with chronic insomnia symptoms following mTBI. Proper detection and treatment of CRSWDs in this population is essential to facilitate recovery. The findings emphasize the relevance of a diagnostic circadian assessment in patients with mTBI presenting with chronic insomnia symptoms.

Subacute sleep disturbance in moderate to severe traumatic brain injury: a systematic review

Objective: This systematic review evaluated subacute sleep disturbance following moderate to severe traumatic brain injury (TBI) and the impact of secondary factors such as mood or pain.Methods: A comprehensive search strategy was applied to nine databases. Inclusion criteria included: adults ≥18 years, moderate and severe TBI and within 3 months of injury. Eligible studies were critically appraised using the McMaster Quantitative Critical Review Form. Study characteristics, outcomes, and methodological quality were synthesized. This systematic review was registered with PROSPERO (Registration number: CRD42018087799).Results: Ten studies were included. Research identified early-onset sleep disturbances; characterized as fragmented sleep periods and difficulty initiating sleep. Alterations to sleep architecture (e.g. rapid eye movement sleep) were reported. Sleep disturbance appears to associate with alterations of consciousness. Sleep disturbance tended to be particularly increased during the phase of post-traumatic amnesia (PTA) (78.7%).Conclusions: There is a limited amount of research available, which has inherent measurement and sample size limitations. The gold standard for measuring sleep (polysomnography) was rarely utilized, which may affect the detection of sleep disturbance and sleep architecture. Secondary factors potentially influencing sleep were generally not reported. Further evaluation on associations between sleep and PTA is needed.

Sex-specific incident dementia in patients with central nervous system trauma

Introduction

Despite evidence that central nervous system (CNS) trauma, including traumatic brain injury and spinal cord injury, can cause sustained neurocognitive impairment, it remains unclear whether trauma-related variables are associated with incident dementia independently of other known risk factors.

Methods

All adults without dementia entering the health-care system with diagnoses of CNS trauma were examined for occurrence of dementia. All trauma-related variables were examined as predictors in sex-specific Cox regression models, controlling for other known risk factors.

Results

Over a median follow-up of 52 months, 32,834 of 712,708 patients (4.6%) developed dementia. Traumatic brain injury severity and spinal cord injury interacted with age to influence dementia onset; women were at a greater risk of developing dementia earlier than men, all other factors being equal.

Discussion

Risk stratification of patients with CNS trauma by sex is vital in identifying those most likely to develop dementia and in understanding the course and modifying factors.

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.

Sleep stage distribution in persons with mild traumatic brain injury: a polysomnographic study according to American Academy of Sleep Medicine standards

OBJECTIVE AND BACKGROUND

Sleep stage disruption in persons with mild traumatic brain injury (mTBI) has received little research attention. We examined deviations in sleep stage distribution in persons with mTBI relative to population age- and sex-specific normative data and the relationships between such deviations and brain injury-related, medical/psychiatric, and extrinsic factors.

PATIENTS AND METHODS

We conducted a cross-sectional polysomnographic investigation in 40 participants diagnosed with mTBI (mean age 47.54 ± 11.30 years; 56% males).

MEASUREMENTS

At the time of investigation, participants underwent comprehensive clinical and neuroimaging examinations and one full-night polysomnographic study. We used the 2012 American Academy of Sleep Medicine recommendations for recording, scoring, and summarizing sleep stages. We compared participants' sleep stage data with normative data stratified by age and sex to yield z-scores for deviations from available population norms and then employed stepwise multiple regression analyses to determine the factors associated with the identified significant deviations.

RESULTS

In patients with mTBI, the mean duration of nocturnal wakefulness was higher and consolidated sleep stage N2 and REM were lower than normal (p < 0.0001, p = 0.018, and p = 0.010, respectively). In multivariate regression analysis, several covariates accounted for the variance in the relative changes in sleep stage duration. No sex differences were observed in the mean proportion of non-REM or REM sleep.

CONCLUSIONS

We observed longer relative nocturnal wakefulness and shorter relative N2 and REM sleep in patients with mTBI, and these outcomes were associated with potentially modifiable variables. Addressing disruptions in sleep architecture in patients with mTBI could improve their health status.

Sleep Disturbances in Traumatic Brain Injury: A Meta-Analysis

STUDY OBJECTIVES

Sleep disturbances are frequently reported following traumatic brain injury (TBI); however, the exact disturbances remain unclear. This meta-analysis aimed to characterize sleep disturbance in community dwelling patients with TBI as compared to controls.

METHODS

Two investigators independently conducted a systematic search of multiple electronic databases from inception to May 27, 2015. Studies were selected if they compared sleep in community dwelling individuals with TBI relative to a control population without head injury. Data were pooled in meta-analysis with outcomes expressed as the standard mean difference (SMD) and 95% confidence interval (CI). The primary outcomes were derived from polysomnography and secondary outcomes were derived from subjective sleep measures.

RESULTS

Sixteen studies were included, combining 637 TBI patients and 567 controls, all of whom were community dwelling. Pooled polysomnography data revealed that TBI patients had poorer sleep efficiency (SMD = -0.47, CI: -0.89, -0.06), shorter total sleep duration (SMD = -0.37, CI: -0.59, -0.16), and greater wake after sleep onset time (SMD = 0.60, CI: 0.33, 0.87). Although sleep architecture was similar between the groups, a trend suggested that TBI patients may spend less time in REM sleep (SMD = -0.22, CI: -0.45, 0.01). Consistent with polysomnographic derangement, TBI patients reported greater subjective sleepiness and poorer perceived sleep quality.

CONCLUSIONS

The evidence suggests that TBI is associated with widespread objective and subjective sleep deficits. The present results highlight the need for physicians to monitor and address sleep deficits following TBI.

Sleep Disorders Associated With Traumatic Brain Injury-A Review

BACKGROUND

Sleep disorders are common are common following traumatic brain injury.

METHODS

In this article we review the spectrum and proposed mechanisms of traumatic brain injury associated sleep disorders and discuss the clinical approach to diagnosis and management of these disorders.

RESULT

Disordered sleep and wakefulness after traumatic brain injury 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 patient outcomes.

CONCLUSION

Evaluating sleep disorders in traumatic brain injury should be an important component of post-traumatic brain injury assessment and management.

The relationship between insomnia and disability in workers with mild traumatic brain injury/concussion: Insomnia and disability in chronic mild traumatic brain injury

AIM/BACKGROUND

The principal aim of this study was to, for the first time, examine the relationship between insomnia and perceived disability among workers with mild traumatic brain injury (mTBI)/concussion.

PATIENTS/METHODS

A cross-sectional study was conducted at the Workplace Safety and Insurance Board Clinic of the largest rehabilitation teaching hospital in Canada. Data from questionnaires, insurer records and clinical investigations were analysed. The Insomnia Severity Index measured the primary independent variable, and the Sheehan Disability Scale measured disability outcomes, classified as 'mild/moderate' or 'marked/extreme'. Two-sided t-tests and Chi-squared tests were used for bivariate associations. A binomial logistic regression model was fit using previously identified variables.

RESULTS

The sample comprised 92 workers (45.1 ± 9.9 years old, 61% male) with mTBI/concussion at median time 196 days after injury. When compared with workers reporting lower disability, workers with higher disability were found with more severe insomnia, depression, anxiety and pain. In the multivariable analysis, the odds of reporting higher global disability increased with increasing insomnia and pain [adjusted odds ratio (OR) 1.16 (95% CI 1.03-1.31) and 1.117 (95% CI 1.01-1.24), respectively]. Insomnia was the only significant covariate in a fully adjusted work disability model. None of the variables studied were statistically significant in the social and family life disability models.

CONCLUSIONS

Greater attention should be given to the diagnosis and management of insomnia in persons with mTBI/concussion.

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.

Sleep difficulties one year following mild traumatic brain injury in a population-based study

BACKGROUND

Sleep quality affects all aspects of daily functioning, and it is vital for facilitating recovery from illness and injury. Sleep commonly becomes disrupted following moderate to severe brain injury, yet little is known about the prevalence of sleep disruption over time and how it impacts on recovery following mild injury.

METHODS

This was a longitudinal study of 346 adults who experienced a mild brain injury (aged ≥16 years) identified within a population-based incidence sample in New Zealand. The prevalence of sleep difficulties was assessed at baseline (within two weeks), one, six and 12 months, alongside other key outcomes.

RESULTS

One year post injury, 41.4% of people were identified as having clinically significant sleep difficulties, with 21.0% at a level indicative of insomnia. Poor sleep quality at baseline was significantly predictive of poorer post-concussion symptoms, mood, community integration, and cognitive ability one year post injury. The prevalence of insomnia following mild traumatic brain injury (TBI) was more than three times the rate found in the general population. Of those completing a sleep assessment at six and 12 months, 44.9% of the sample showed improvements in sleep quality, 16.2% remained stable, and 38.9% worsened.

CONCLUSIONS

Screening for sleep difficulties should occur routinely following a mild brain injury to identify adults potentially at risk of poor recovery. Interventions to improve sleep are needed to facilitate recovery from injury, and to prevent persistent sleep difficulties emerging.

Matrix metalloproteinase-9 involvement in the structural plasticity of dendritic spines

Dendritic spines are the locus for excitatory synaptic transmission in the brain and thus play a major role in neuronal plasticity. The ability to alter synaptic connections includes volumetric changes in dendritic spines that are driven by scaffolds created by the extracellular matrix (ECM). Here, we review the effects of the proteolytic activity of ECM proteases in physiological and pathological structural plasticity. We use matrix metalloproteinase-9 (MMP-9) as an example of an ECM modifier that has recently emerged as a key molecule in regulating the morphology and dysmorphology of dendritic spines that underlie synaptic plasticity and neurological disorders, respectively. We summarize the influence of MMP-9 on the dynamic remodeling of the ECM via the cleavage of extracellular substrates. We discuss its role in the formation, modification, and maintenance of dendritic spines in learning and memory. Finally, we review research that implicates MMP-9 in aberrant synaptic plasticity and spine dysmorphology in neurological disorders, with a focus on morphological abnormalities of dendritic protrusions that are associated with epilepsy.