Sleep disturbance and recovery during rehabilitation after traumatic brain injury: a systematic review

Sleep Disruptions in Hospitalized Adults Sustaining a Traumatic Brain Injury: A Scoping Review

OBJECTIVE

Adults sustaining a traumatic brain injury (TBI) are at risk of sleep disturbances during their recovery, including when such an injury requires hospitalization. However, the sleep-wake profile, and internal and external factors that may interfere with sleep initiation/maintenance in hospitalized TBI patients are poorly understood. This review aimed to: (1) identify/summarize the existing evidence regarding sleep and sleep measurements in TBI adults receiving around-the-clock care in a hospital or during inpatient rehabilitation, and (2) identify internal/external factors linked to poor sleep in this context.

METHODS

A scoping review was conducted in accordance with the PRISMA Scoping Review Extension guidelines. A search was conducted in MEDLINE, PsycINFO, CINAHL, and Web of Science databases.

RESULTS

Thirty relevant studies were identified. The most common sleep variables that were put forth in the studies to characterize sleep during hospitalization were nighttime sleep time (mean = 6.5 hours; range: 5.2-8.9 hours), wake after sleep onset (87.1 minutes; range: 30.4-180 minutes), and sleep efficiency (mean = 72.9%; range: 33%-96%) using mainly actigraphy, polysomnography, and questionnaires (eg, the sleep-wake disturbance item of the Delirium Rating Scale or the Pittsburgh Sleep Quality Index). Twenty-four studies (80%) suggested that hospitalized TBI patients do not get sufficient nighttime sleep, based on the general recommendations for adults (7-9 hours per night). Sleep disruptions during hospitalization were found to be associated to several internal factors including TBI severity, cognitive status, and analgesia intake. External and modifiable factors, such as noise, light, and patient care, were consistently associated with sleep disruptions in this context.

CONCLUSION

Although the literature on sleep disturbances in hospitalized TBI patients has been increasing in recent years, many gaps in knowledge remain, including phenotypes and risk factors. Identifying these factors could help clinicians better understand the multiple sources of TBI patients' sleep difficulties and intervene accordingly.

Sleep Disruption Persists and Relates to Memory Disability After Traumatic Brain Injury: A Cross-Sectional Study of Adults in the Chronic Phase of Injury

OBJECTIVE

To examine sleep disruption in chronic traumatic brain injury (TBI) across 3 aims: (1) to examine differences in self-reported sleep disruption between adults with and without a chronic history of TBI; (2) to query reported changes in sleep after TBI; and (3) to explore the relationship between self-reported sleep disruption and memory failures in daily life.

SETTING

Community-dwelling participants completed self-report sleep and memory surveys as part of their participation in a larger patient registry.

PARTICIPANTS

This study included 258 participants, and half (n = 129) of them have a chronic history of moderate-severe TBI (mean time since injury is 5.1 [SD 6.5] years).

DESIGN

We report descriptive statistics from this matched cross-sectional study on sleep in the chronic phase of injury. We also used planned Wilcoxon ranked-sum tests and exploratory correlations to examine the relationships of sleep disruption with TBI diagnosis, injury chronicity, and memory.

MAIN MEASURES

We used the Pittsburgh Sleep Quality Index to measure sleep disruption and the Epworth Sleepiness Scale to measure daytime sleepiness. Participants answered questions about postinjury sleep and responded to the Everyday Memory Questionnaire as a measure of memory failures in daily life.

RESULTS

Individuals with TBI had significantly higher rates of sleep disruption than those without TBI, as measured by the Pittsburgh Sleep Quality Index but not on the Epworth Sleepiness Scale. Sleep disruption in TBI manifested more in sleep quality than quantity. Half of the participants with TBI reported a negative change in sleep postinjury. In an exploratory analysis, sleep disruption was related to memory failure in daily life in the TBI sample.

CONCLUSIONS

Sleep disruption persists long after TBI but may be under-recognized in people with chronic TBI. Given that sleep is critical for memory and rehabilitation outcomes well into the chronic phase of injury, steps to improve the identification and management of sleep disruption are needed. Key words:chronic, memory, sleep, traumatic brain injury.

Non-pharmacological interventions for sleep disruptions and fatigue after traumatic brain injury: a scoping review

OBJECTIVE

The aim of this study was to conduct a scoping review to determine the nature, variety, and volume of empirical evidence on nonpharmacological interventions for sleep disturbances with potential implications for fatigue in adults sustaining a traumatic brain injury (TBI).

METHODS

A systematic literature search was conducted across four databases to identify primary studies testing a single non-pharmacological intervention or a combination of non-pharmacological interventions for sleep disturbances and fatigue in community-dwelling adults with TBI.

RESULTS

Sixteen studies were reviewed addressing six non-pharmacological interventions for sleep disruptions and fatigue after TBI including light therapy, cognitive-behavioral therapy, warm footbath application, shiatsu, and sleep hygiene protocol. Non-pharmacological interventions involving light or cognitive-behavioral therapy were reported in 75% of the studies. Actigraphy-based estimation of total sleep time and subjective level of fatigue were frequent outcomes.

CONCLUSION

While this scoping review has utility in describing existing non-pharmacological approaches to manage sleep and fatigue after TBI, the findings suggest that interventions are often developed without considering TBI individuals' source of motivation and the need for support in self-administration. Future studies may achieve greater sustainability by considering the evolving needs of TBI patients and their families and the drivers and barriers that might influence non-pharmacological intervention use at home.

Measurement of Sleep in Chronic Traumatic Brain Injury: Relationship Between Self-report and Actigraphy

OBJECTIVE

To examine the relationship between self-report and actigraphy measurement of sleep in people with and without traumatic brain injury (TBI) by addressing 2 aims: (1) to assess the relationship between self-report and actigraphy for sleep quantity in people with and without TBI; and (2) to explore how self-report and actigraphy capture sleep quality in TBI.

SETTING

Participants completed the study over 2 weeks in their own homes. They wore activity monitors, day and night, throughout the experiment and completed morning sleep diaries while interacting with an experimenter on videoconference.

PARTICIPANTS

This project was embedded in a larger study on sleep and word learning in 100 adults: 50 with chronic, moderate-severe TBI and 50 demographically matched noninjured peers. Of the 100 participants who completed the larger study, 92 participants (45 with TBI and 47 noninjured peers) had sufficient actigraphy data for inclusion in the current study.

DESIGN

We used multilevel linear regression models and correlation analyses to assess how well participants' self-report corresponded to actigraphy measurement of sleep.

MAIN MEASURES

Actigraphy measures included nightly sleep duration and nighttime wakeups. Sleep diary measures included self-reported nightly sleep duration, nighttime wakeups, sleep quality, and morning fatigue.

RESULTS

People with and without TBI did not differ in the relationship between self-reported and actigraphy measurement of sleep quantity. Performance on a neuropsychological memory assessment did not correlate with the difference in self-reported and actigraphy-measured sleep in the TBI group. Sleep characteristics that were measured by actigraphy did not predict subjective experiences of sleep quality or fatigue.

CONCLUSIONS

Short-term self-report diaries capture accurate information about sleep quantity in individuals with TBI and may support self-report of other daily habits. Future research is needed to identify reliable metrics of sleep quality, and how they relate to other domains such as memory and mood, in the chronic phase of TBI.

Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study

STUDY OBJECTIVES

To explore the relationship between polysomnography-derived respiratory indices and chronic pain status among individuals following traumatic brain injury (TBI).

METHODS

Participants (n = 66) with moderate to severe TBI underwent polysomnography during inpatient acute rehabilitation and their chronic pain status was assessed at 1- to 2-year follow-up as part of the TBI Model Systems Pain Collaborative Study. Pairwise comparisons across pain cohorts (ie, chronic pain, no history of pain) were made to explore differences on polysomnography indices.

RESULTS

Among our total sample, approximately three-quarters (74.2%) received sleep apnea diagnoses utilizing American Academy of Sleep Medicine criteria, with 61.9% of those endorsing a history of chronic pain. Of those endorsing chronic pain, the average pain score was 4.8 (standard deviation = 2.1), with a mean interference score of 5.3 (2.7). Pairwise comparisons revealed that those endorsing a chronic pain experience at follow-up experienced categorically worse indicators of sleep-related breathing disorders during acute rehabilitation relative to those who did not endorse chronic pain. Important differences were observed with elevations on central (chronic pain: 2.6; no pain: 0.8 per hour) and obstructive apnea (chronic pain: 15.7; no pain: 11.1 per hour) events, as well as oxygen desaturation indices (chronic pain: 19.6; no pain: 7.9 per hour).

CONCLUSIONS

Sleep-disordered breathing appears worse among those who endorse chronic pain following moderate-to-severe TBI, but additional research is needed to understand its relation to postinjury pain. Prospective investigation is necessary to determine how clinical decisions (eg, opioid therapy) and intervention (eg, positive airway pressure) may mutually influence outcomes.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS); URL: https://clinicaltrials.gov/ct2/show/NCT03033901; Identifier: NCT03033901.

CITATION

Martin AM, Pinto SM, Tang X, et al. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med. 2023;19(1):135-143.

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.

Mild-to-Moderate Traumatic Brain Injury: A Review with Focus on the Visual System

Traumatic Brain Injury (TBI) is a major global public health problem. Neurological damage from TBI may be mild, moderate, or severe and occurs both immediately at the time of impact (primary injury) and continues to evolve afterwards (secondary injury). In mild (m)TBI, common symptoms are headaches, dizziness and fatigue. Visual impairment is especially prevalent. Insomnia, attentional deficits and memory problems often occur. Neuroimaging methods for the management of TBI include computed tomography and magnetic resonance imaging. The location and the extent of injuries determine the motor and/or sensory deficits that result. Parietal lobe damage can lead to deficits in sensorimotor function, memory, and attention span. The processing of visual information may be disrupted, with consequences such as poor hand-eye coordination and balance. TBI may cause lesions in the occipital or parietal lobe that leave the TBI patient with incomplete homonymous hemianopia. Overall, TBI can interfere with everyday life by compromising the ability to work, sleep, drive, read, communicate and perform numerous activities previously taken for granted. Treatment and rehabilitation options available to TBI sufferers are inadequate and there is a pressing need for new ways to help these patients to optimize their functioning and maintain productivity and participation in life activities, family and community.

The Impact of Opioid Medications on Sleep Architecture and Nocturnal Respiration During Acute Recovery From Moderate to Severe Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications.

SETTING

Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites.

DESIGN

Cross-sectional, secondary analyses.

MAIN MEASURES

The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index.

RESULTS

After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids.

CONCLUSION

Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

Evaluation of rest-activity cycles in patients with severe acquired brain injury: an observational study

BACKGROUND

There is little knowledge about rest-activity cycles (RAC) in patients with severe-acquired brain injury (sABI) during early in-hospital rehabilitation. This study aimed to investigate if patients with sABI displayed unconsolidated RACs at the beginning of in-hospital rehabilitation, and how these changed over time.

METHODS

This study was a prospective observational study. All patients consecutively admitted to one ward were screened for eligibility. We recorded accelerometric activity for 20 days. The Daytime Activity Ratio (DAR) of activity between daytime (7-22) and the total activity during the entire day was calculated and used to estimate consolidation.

RESULTS

Fifty-five patients were screened and 20 patients were included. Complete day 1 & 2 data was obtained on 18 patients. Fifty-six percentage of these had a consolidated RAC at the beginning of rehabilitation. On day 19 & 20, complete data could be obtained from 15 patients, 80% of these had consolidation of RAC. When comparing these a significant mean increase of 5.8% 95%CI(0.52; 11.01) in DAR was found p < .05, and the model of all data also showed a significant increase in median DAR over time p < .01.

CONCLUSION

RAC consolidation improves over time in patients admitted for in-hospital early neurorehabilitation.

Sleep after Traumatic Brain Injury

Sleep disturbances are common after traumatic brain injury of all levels of severity, interfere with acute and long-term recovery, and can persist for years after injury. There is increasing evidence of the importance of sleep in improving brain function and recovery. Noticing and addressing sleep disturbances are important aspects of nursing care, especially for the prevention or early recognition of delirium. Nonpharmacologic interventions can improve sleep. Teaching about the importance of sleep after traumatic brain injury, promoting sleep hygiene, and multidisciplinary approaches to addressing sleep problems and improving sleep are important for recovery from traumatic brain injury.

Perspective: Cognitive Behavioral Therapy for Insomnia Is a Promising Intervention for Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is a significant public health problem. Insomnia is one of the most common symptoms of TBI, occurring in 30–50% of patients with TBI, and is more frequently reported in patients with mild as opposed to moderate or severe TBI. Although insomnia may be precipitated by mTBI, it is unlikely to subside on its own without specific treatment even after symptoms of mTBI reduce or remit. Insomnia is a novel, highly modifiable treatment target in mTBI, treatment of which has the potential to make broad positive impacts on the symptoms and recovery following brain injury. Cognitive-behavioral therapy for insomnia (CBT-I) is the front-line intervention for insomnia and has demonstrated effectiveness across clinical trials; between 70 and 80% of patients with insomnia experience enduring benefit from CBT-I and about 50% experience clinical remission. Examining an existing model of the development of insomnia in the context of mTBI suggests CBT-I may be effective for insomnia initiated or exacerbated by sustaining a mTBI, but this hypothesis has yet to be tested via clinical trial. Thus, more research supporting the use of CBT-I in special populations such as mTBI is warranted. The current paper provides a background on existing evidence for using CBT-I in the context of TBI, raises key challenges, and suggests considerations for future directions including need for increased screening and assessment of sleep disorders in the context of TBI, examining efficacy of CBT-I in TBI, and exploring factors that impact dissemination and delivery of CBT-I in TBI.

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.