Sleep Quantity and Quality during Acute Concussion: A Pilot Study

Sleep After Concussion: A Scoping Review of Sensor Technologies

Sleep disturbances following a concussion/mild traumatic brain injury are associated with longer recovery times and more comorbidities. Sensor technologies can directly monitor sleep-related physiology and provide objective sleep metrics. This scoping review determines how sensor technologies are currently used to monitor sleep following a concussion. We searched Ovid (Medline, Embase), Web of Science, CINAHL, Compendex Engineering Village, and PsycINFO from inception to June 20, 2022, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews. Included studies objectively monitored sleep in participants with concussion. We screened 1081 articles and included 37 in the review. A total of 17 studies implemented polysomnography (PSG) months to years after injury for a median of two nights and provided a wide range of sleep metrics, including sleep-wake times, sleep stages, arousal indices, and periodic limb movements. Twenty-two studies used actigraphy days to weeks after injury for a median of 10 days and nights and provided information limited to sleep-wake times. Sleep stages were most reported in PSG studies, and sleep efficiency was most reported in actigraphy studies. For both technologies there was high variability in reported outcome measures. Sleep sensing technologies may be used to identify how sleep affects concussion recovery. However, high variability in sensor deployment methodologies makes cross-study comparisons difficult and highlights the need for standardization. Consensus on how sleep sensing technologies are used post-concussion may lead to clinical integration with subjective methods for improved sleep monitoring during the recovery period.

Concussion and the Sleeping Brain

BACKGROUND

Emerging research has suggested sleep to be a modifier of the trajectory of concussion recovery in adolescent and adult populations. Despite the growing recognition of the relationship between sleep and concussion, the mechanisms and physiological processes governing this association have yet to be established.

MAIN BODY

Following a concussion, a pathophysiologic cascade of events occurs, characterized by numerous factors including microglia activation, ionic imbalance, and release of excitatory neurotransmitters. Importantly, each of these factors plays a role in the regulation of the sleep-wake cycle. Therefore, dysregulation of sleep following injury may be a function of the diffuse disruption of cerebral functioning in the wake of both axonal damage and secondary physiological events. As the onset of sleep-related symptoms is highly variable following a concussion, clinicians should be aware of when and how these symptoms present. Post-injury changes in sleep have been reported in the acute, sub-acute, and chronic phases of recovery and can prolong symptom resolution, affect neurocognitive performance, and influence mood state. Though these changes support sleep as a modifier of recovery, limited guidance exists for clinicians or their patients in the management of sleep after concussion. This may be attributed to the fact that research has correlated sleep with concussion recovery but has failed to explain why the correlation exists. Sleep is a complex, multifactorial process and the changes seen in sleep that are seen following concussion are the result of interactions amongst numerous processes that regulate the sleep-wake cycle.

SHORT CONCLUSION

The assessment and management of sleep by identifying and considering the biological, sociological, and psychological interactions of this multifactorial process will allow for clinicians to address the dynamic nature of changes in sleep following concussion.

Actigraphic and nursing sleep log measures in moderate-to-severe traumatic brain injury: Identifying discrepancies in total sleep time

BACKGROUND

Sleep disturbances are common in patients with traumatic brain injury (TBI). In an inpatient rehabilitation setting, clinicians often use information from sleep logs filled out by trained nurses to identify and treat sleep disturbances. However, there are limited data related to accuracy of sleep logs, and patient-reported sleep diaries are poor predictors of total sleep time, which raises concern about the accuracy of sleep logs filled out by a third party.

OBJECTIVE

To examine the reliability of sleep logs for participants with TBI by comparing total sleep time determined by sleep logs versus actigraphy.

DESIGN

Prospective, cross-sectional study.

SETTING

Free-standing, academic inpatient rehabilitation facility.

PARTICIPANTS

Thirty individuals (n = 30) participated in the study. Inclusion criteria were (1) diagnosis of moderate-to-severe TBI; (2) age ≥ 18 years at the time of TBI; and (3) participating in inpatient rehabilitation with no prior inpatient rehabilitation admissions.

INTERVENTIONS

Actigraph monitoring using ActiGraph GT9X Link devices was initiated within 72 hours of admission and continued for 7 consecutive days. Sleep logs were concurrently filled out by trained nurses.

MAIN OUTCOME MEASURES

Sleep parameter correspondence between actigraphy and sleep logs in moderate-to-severe TBI.

RESULTS

Only 51.4% of participants' sleep logs and actigraph total sleep time measurements were within 1 hour of each other, and only 23.8% were within 30 minutes. On average, sleep logs overestimated actigraphy-determined total sleep time by 60 minutes compared to actigraphic measurement.

CONCLUSIONS

For those with moderate-to-severe TBI undergoing inpatient rehabilitation, sleep logs are poor predictors of sleep time because they overestimate total sleep time compared to actigraphy. Therefore, clinicians should use caution when using sleep log data to make decisions regarding treatment for sleep disturbances in TBI.

Sleep/Wake Disorders After Sports Concussion: Risks, Revelations, and Interventions

SUMMARY

Sleep-wake disturbances (SWDs) are among the most prevalent, persistent, and often disregarded sequelae of traumatic brain injury. Identification and treatment of SWDs in patients with traumatic brain injury is important and can complement other efforts to promote maximum functional recovery. SWDs can accentuate other consequences of traumatic brain injury, negatively affect mood, exacerbate pain, heighten irritability, and diminish cognitive abilities and the potential for recovery. The risk for sports injuries increases when athletes are sleep deprived. Sleep deprivation increases risk-taking behaviors, predisposing to injuries. SWDs are an independent risk factor for prolonged recovery after sports-related concussion. SWDs following sports-related concussion have been shown to impede recovery, rehabilitation, and return to preinjury activities.

Electroencephalographic Changes in Sleep During Acute and Subacute Phases After Sports-Related Concussion

Purpose

Little is known about sleep after a concussion, a form of mild traumatic brain injury. Given the importance of sleep for both maintaining brain health and recovery from injury, we sought to examine sleep acutely and subacutely after concussion.

Methods

Athletes who experienced a sports-related concussion were invited to participate. Participants underwent overnight sleep studies within 7 days of the concussion (acute phase), and again eight-weeks after the concussion (subacute phase). Changes in sleep from both the acute and subacute phases were compared to population normative values. Additionally, changes in sleep from acute to subacute phase were analysed.

Results

When compared to normative data, the acute and subacute phases of concussion showed longer total sleep time (p < 0.005) and fewer arousals (p < 0.005). The acute phase showed longer rapid eye movement sleep latency (p = 0.014). The subacute phase showed greater total sleep spent in Stage N3% (p = 0.046), increased sleep efficiency (p < 0.001), shorter sleep onset latency (p = 0.013), and reduced wake after sleep onset (p = 0.013). Compared to the acute phase, the subacute phase experienced improved sleep efficiency (p = 0.003), reduced wake after sleep onset (p = 0.02), and reduced latencies for both stage N3 sleep (p = 0.014) and rapid eye movement sleep (p = 0.006).

Conclusion

This study indicated sleep during both the acute and subacute phases of SRC was characterised by longer and less disrupted sleep, along with improvements in sleep from the acute to subacute phases of SRC.

Effects of docosahexaenoic acid and eicosapentaoic acid supplementation on white matter integrity after repetitive sub-concussive head impacts during American football: Exploratory neuroimaging findings from a pilot RCT

Context

Repetitive sub-concussive head impacts (RSHIs) are common in American football and result in changes to the microstructural integrity of white matter. Both docosahexaenoic acid (DHA) and eicosapentaoic acid (EPA) supplementation exerted neuroprotective effects against RSHIs in animal models and in a prior study in football players supplemented with DHA alone.

Objective

Here, we present exploratory neuroimaging outcomes from a randomized controlled trial of DHA + EPA supplementation in American football players. We hypothesized that supplementation would result in less white matter integrity loss on diffusion weighted imaging over the season.

Design setting participants

We conducted a double-blind placebo-controlled trial in 38 American football players between June 2019 and January 2020.

Intervention

Participants were randomized to the treatment (2.442 g/day DHA and 1.020 g/day EPA) or placebo group for five times-per-week supplementation for 7 months. Of these, 27 participants were included in the neuroimaging data analysis (n = 16 placebo; n = 11 DHA + EPA).

Exploratory outcome measures

Changes in white matter integrity were quantified using both voxelwise diffusion kurtosis scalars and deterministic tractography at baseline and end of season. Additional neuroimaging outcomes included changes in regional gray matter volume as well as intra-regional, edge-wise, and network level functional connectivity. Serum neurofilament light (NfL) provided a peripheral biomarker of axonal damage.

Results

No voxel-wise between-group differences were identified on diffusion tensor metrics. Deterministic tractography using quantitative anisotropy (QA) revealed increased structural connectivity in ascending corticostriatal fibers and decreased connectivity in long association and commissural fibers in the DHA+EPA group compared to the placebo group. Serum NfL increases were correlated with increased mean (ρ = 0.47), axial (ρ = 0.44), and radial (ρ = 0.51) diffusivity and decreased QA (ρ = -0.52) in the corpus callosum and bilateral corona radiata irrespective of treatment group. DHA + EPA supplementation did preserve default mode/frontoparietal control network connectivity (g = 0.96, p = 0.024).

Conclusions

These exploratory findings did not provide strong evidence that DHA + EPA prevented or protected against axonal damage as quantified via neuroimaging. Neuroprotective effects on functional connectivity were observed despite white matter damage. Further studies with larger samples are needed to fully establish the relationship between omega-3 supplementation, RSHIs, and neuroimaging biomarkers.

Trial registration

ClinicalTrials.gov-NCT04796207.

Effect of Sleep-Related Symptoms on Recovery From a Sport-Related Concussion

Background

Sleep issues are commonly reported in athletes after a sport-related concussion (SRC). Further studies are needed to evaluate screening methods for sleep disturbances and the risk of persisting symptoms after an SRC.

Purpose

To evaluate the association between the Sport Concussion Assessment Tool 5 (SCAT5) symptoms of trouble falling asleep, fatigue (or low energy), and drowsiness and the risk of persisting symptoms (≥28 days to recovery) in adolescent athletes.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 519 athletes aged 13 to 18 years reported any sleep-related symptoms with an SRC, scored as none (0), mild (1-2), moderate (3-4), or severe (5-6), at their initial office visit (median, 5.4 days after an SRC). Scores were correlated with the risk of persisting symptoms. A composite "sleep cluster" score (range, 0-18) was calculated by summing the SCAT5 component items for trouble falling asleep, fatigue, and drowsiness.

Results

The results indicated that, compared with athletes who reported that they did not have each symptom, (1) athletes who reported mild, moderate, or severe trouble falling asleep were 3.0, 4.6, and 6.7 times more likely to have persisting symptoms, respectively; (2) athletes reporting mild, moderate, or severe fatigue (or low energy) were 2.6, 4.8, and 7.6 times more likely to have persisting symptoms, respectively; and (3) athletes reporting mild, moderate, or severe drowsiness were 1.9, 4.6, and 6.8 times more likely to have persisting symptoms, respectively (P < .001 for all). For every 1-point increase in the sleep cluster score, there was a 1.2-fold increased risk of persisting symptoms and an additional 2.4 days of recovery required (P < .001 for both).

Conclusion

Athletes who reported mild, moderate, or severe sleep-related symptoms on the SCAT5 were at a proportionally increased risk of persisting symptoms at the initial office visit.

Characterizing Sleep and Wakefulness in the Acute Phase of Concussion in the General Population: A Naturalistic Cohort from the Toronto Concussion Study

Growing literature links concussion to changes in sleep and wakefulness in humans and in rodent models. Sleep has been linked with synaptic reorganization under other conditions; however, the characterization and role of sleep after acute concussion remains poorly understood. While much research has focused on insomnia among patients with chronic or persistent concussion symptoms, there is limited understanding of sleep and acute concussion, its potential role in recovery, and associated risk factors for the development of chronic sleep disturbance. Studies to date are limited by small sample sizes of primarily athlete or military populations. Additional studies among the general population are critical to inform best practice guidelines. We examined the sleep and daytime wakefulness of 472 adults from a naturalistic general population cohort (mean age, 33.3 years, females = 60.8%) within seven days of diagnosed concussion, using a validated, condition-specific measure, the Sleep and Concussion Questionnaire. Participants identified immediate changes in sleep characterized by hypersomnia and difficulty maintaining daytime wakefulness; 35% considered these changes as moderate to severe and 79% required monitoring or follow-up. Females experienced significantly greater severity of changes in sleep compared with males. Positive correlations between severity of sleep and pain and headache were identified. Differences by sex are an important consideration for early intervention and long-term monitoring. Because sleep was compromised by pain, pain management is also an integral part of early intervention. Our findings suggest that assessment of sleep beginning in the acute stage is a critical component of concussion management in the general population.

Gaze stability in young adults with previous concussion history

BACKGROUND

Disruption of visual-vestibular interaction after concussion can cause gaze instability with head movements. The long-term impact of concussion on gaze stability is unknown.

OBJECTIVE

This cross-sectional comparative pilot study examined gaze stability in the chronic stage after concussion (greater than one year). A secondary objective was to examine the relationship between gaze stability and sleep.

METHODS

Outcome measures included: 1. Gaze stability in logMAR (mean loss of dynamic visual acuity (DVA) in the yaw and pitch planes); 2. Pittsburgh Sleep Quality Index (PSQI); 3. Epworth Sleepiness Scale (ESS). Post-Concussion Symptom Scale (PCSS), time since injury, and number of concussions were collected for the people with concussion.

RESULTS

The study sample included thirty-four adults (mean age 23.35±1.3 years). Seventeen had a history of 1-9 concussions, with a mean duration of 4.4±1.9 years since last concussion; and 17 were age and sex-matched controls. Mean pitch plane DVA loss was greater in the concussion group compared to the control group (p = 0.04). Participants with previous concussion had lower sleep quality based on the PSQI (p = 0.01) and increased daytime sleepiness based on the ESS (p = 0.01) compared to healthy controls. Mean DVA loss in the pitch plane was significantly correlated with the PSQI (r = 0.43, p = 0.01) and the ESS (r = 0.41, p = 0.02).

CONCLUSION

Significant differences in dynamic visual acuity may be found in young adults long after a concussion, compared with those who have no concussion history. Furthermore, loss of dynamic visual acuity was associated with poorer sleep quality and higher daytime sleepiness.

Daily Morning Blue Light Therapy Improves Daytime Sleepiness, Sleep Quality, and Quality of Life Following a Mild Traumatic Brain Injury

OBJECTIVE

Identify the treatment effects of 6 weeks of daily 30-minute sessions of morning blue light therapy compared with placebo amber light therapy in the treatment of sleep disruption following mild traumatic brain injury.

DESIGN

Placebo-controlled randomized trial.

PARTICIPANTS

Adults aged 18 to 45 years with a mild traumatic brain injury within the past 18 months (n = 35).

MAIN OUTCOME MEASURES

Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Beck Depression Inventory II, Rivermead Post-concussion Symptom Questionnaire, Functional Outcomes of Sleep Questionnaire, and actigraphy-derived sleep measures.

RESULTS

Following treatment, moderate to large improvements were observed with individuals in the blue light therapy group reporting lower Epworth Sleepiness Scale (Hedges' g = 0.882), Beck Depression Inventory II (g = 0.684), Rivermead Post-concussion Symptom Questionnaire chronic (g = 0.611), and somatic (g = 0.597) symptoms, and experiencing lower normalized wake after sleep onset (g = 0.667) than those in the amber light therapy group. In addition, individuals in the blue light therapy group experienced greater total sleep time (g = 0.529) and reported improved Functional Outcomes of Sleep Questionnaire scores (g = 0.929) than those in the amber light therapy group.

CONCLUSION

Daytime sleepiness, fatigue, and sleep disruption are common following a mild traumatic brain injury. These findings further substantiate blue light therapy as a promising nonpharmacological approach to improve these sleep-related complaints with the added benefit of improved postconcussion symptoms and depression severity.

Sleep quality in the chronic stage of concussion is associated with poorer recovery: A systematic review

Background

Recovery from a concussion varies based on a multitude of factors. One such factor is sleep disturbances. In our prior review, it was observed that in the acute phase, sleep disturbances are predictive of poor outcomes following a concussion. The literature gap remains on how sleep in the chronic phase of recovery affects outcomes.

Objective

To examine the association between sleep quality during the chronic stage of concussion and post-concussion outcomes. Literature Survey: Literature searches were performed during 1 July to 1 August 2019 in selected databases along with searching grey literature. Out of the 733 results, 702 references were reviewed after duplicate removal.

Methods

Three reviewers independently reviewed and consented on abstracts meeting eligibility criteria ( n = 35). The full-text articles were assessed independently by two reviewers. Consensus was achieved, leaving four articles. Relevant data from each study was extracted using a standard data-extraction table. Quality appraisal was conducted to assess potential bias and the quality of articles.

Results

One study included children (18–60 months) and three studies included adolescents and/or adults (ranging 12–35 years). The association between sleep and cognition (two studies), physical activity (one study), and emotion symptoms (one study) was examined. Sleep quality was associated with decreased cognition and emotional symptoms, but not with meeting physical activity guidelines six months post-concussion injury.

Conclusions

The heterogeneity in age of participants and outcomes across studies and limited number of included studies made interpretations difficult. Future studies may consider if addressing sleep quality following concussion will improve outcomes.

Should We Lose Sleep Over Sleep Disturbances After Sports-Related Concussion? A Scoping Review of the Literature

OBJECTIVE

A single, severe traumatic brain injury can result in chronic sleep disturbances that can persist several years after the incident. In contrast, it is unclear whether there are sleep disturbances after a sports-related concussion (SRC). Considering growing evidence of links between sleep disturbance and neurodegeneration, this review examined the potential links between diagnosed SRCs and sleep disturbances to provide guidance for future studies.

METHODS

The scoping review undertook a systematic search of key online databases (Scopus, MEDLINE, SportDiscus, and Web of Science) using predetermined search terms for any articles that examined sleep after concussion. A screening criterion using agreed inclusion and exclusion criteria was utilized to ensure inclusion of relevant articles.

DESIGN

This scoping review is guided by the PRSIMA Scoping Review report.

RESULTS

Ten studies met the inclusion criteria, reporting on 896 adults who had experienced an SRC. Comparison with 1327 non-SRC adults occurred in 8 studies. Nine studies subjectively examined sleep, of which all but one study reported sleep disturbances after an SRC. Three studies objectively measured sleep, with 2 studies indicating large coefficients of variation of sleep duration, suggesting a range of sleep responses after an SRC. The only study to examine overnight polysomnography showed no differences in sleep metrics between those with and without an SRC. No studies examined interventions to improve sleep outcomes in people with concussion.

CONCLUSIONS

This scoping review indicates preliminary evidence of sleep disturbances following an SRC. The heterogeneity of methodology used in the included studies makes consensus on the results difficult. Given the mediating role of sleep in neurodegenerative disorders, further research is needed to identify physiological correlates and pathological mechanisms of sleep disturbances in SRC-related neurodegeneration and whether interventions for sleep problems improve recovery from concussion and reduce the risk of SRC-related neurodegeneration.

Preliminary Validation of the Sleep and Concussion Questionnaire as an Outcome Measure for Sleep Following Brain Injury

BACKGROUND

Sleep and wakefulness disturbances are common with traumatic brain injury (TBI); however, there are no condition-specific measures to evaluate sleep following TBI.

OBJECTIVE

To assess the convergent validity of the Sleep and Concussion Questionnaire (SCQ), a condition-specific (TBI) measure is compared to polysomnography and existing self-report sleep questionnaires.

PARTICIPANTS INCLUDED

Thirty-two adults diagnosed with mild TBI, 3-24 months post-injury, average age, 38.9 years, predominantly female (63%) and with symptoms of chronic insomnia.

METHODS

Participants underwent polysomnographic evaluation of sleep and completed the SCQ, Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and the Fatigue Severity Scale (FSS). Correlations were assessed using Pearson's correlations. The sample was sufficiently powered (0.85) to detect a moderate to strong correlation of 0.5 or greater.

RESULTS

SCQ sub-questions were meaningfully correlated with corresponding objective sleep parameters (time awake, number of awakenings, sleep efficiency, sleep onset latency, wake after sleep onset) as measured with polysomnography. Additional significant correlations were seen between total scores on the SCQ and ISI and between SCQ sub questions and total ESS scores.

CONCLUSIONS

This work provides initial evidence of the convergent validity of the SCQ with objective sleep parameters and existing self-report measures in patients after mild TBI.

Traumatic Brain Injury and Incidence Risk of Sleep Disorders in Nearly 200,000 US Veterans

OBJECTIVE

To test the hypothesis that veterans with traumatic brain injury (TBI) have an increased subsequent risk of sleep disorders, we studied the longitudinal association between TBI and incident sleep disorders in nearly 200,000 veterans.

METHODS

We performed a cohort study of all patients diagnosed with a TBI in the Veterans Health Administration system from October 1, 2001, to September 30, 2015, who were age-matched 1:1 to veterans without TBI. Veterans with prevalent sleep disorders at baseline were excluded. Development of sleep disorders was defined as any inpatient or outpatient diagnosis of sleep apnea, hypersomnia, insomnia, or sleep-related movement disorders based on ICD-9 codes after the first TBI diagnosis or the random selection date for those without TBI. We restricted the analysis to those with at least 1 year of follow-up. We used Cox proportional hazards models to examine the association between TBI and subsequent risk of sleep disorders.

RESULTS

The study included 98,709 veterans with TBI and 98,709 age-matched veterans without TBI (age 49 ± 20 years). After an average follow-up of 5 (1-14) years, 23,127 (19.6%) veterans developed sleep disorders. After adjustment for demographics, education, income, and medical and psychiatric conditions, those who had TBI compared to those without TBI were 41% more likely to develop any sleep disorders (hazard ratio 1.41 [95% confidence interval 1.37-1.44]), including sleep apnea (1.28 [1.24-1.32]), insomnia (1.50 [1.45-1.55]), hypersomnia (1.50 [1.39-1.61]), and sleep-related movement disorders (1.33 [1.16-1.52]). The association was stronger for mild TBIs, did not differ appreciably by presence of posttraumatic stress disorder, and remained after a 2-year time lag.

CONCLUSION

In 197,418 veterans without sleep disorders, those with diagnosed TBI had an increased risk of incident sleep disorders over 14 years. Improved prevention and long-term management strategies for sleep are needed for veterans with TBI.

Daily Morning Blue Light Therapy for Post-mTBI Sleep Disruption: Effects on Brain Structure and Function

Background: Mild traumatic brain injuries (mTBIs) are associated with novel or worsened sleep disruption. Several studies indicate that daily morning blue light therapy (BLT) is effective for reducing post-mTBI daytime sleepiness and fatigue. Studies demonstrating changes in brain structure and function following BLT are limited. The present study's purpose is to identify the effect of daily morning BLT on brain structure and functional connectivity and the association between these changes and self-reported change in post-mTBI daytime sleepiness. Methods: A total of 62 individuals recovering from a mTBI were recruited from two US cities to participate in a double-blind placebo-controlled trial. Eligible individuals were randomly assigned to undergo 6 weeks of 30 min daily morning blue or placebo amber light therapy (ALT). Prior to and following treatment all individuals completed a comprehensive battery that included the Epworth Sleepiness Scale as a measure of self-reported daytime sleepiness. All individuals underwent a multimodal neuroimaging battery that included anatomical and resting-state functional magnetic resonance imaging. Atlas-based regional change in gray matter volume (GMV) and region-to-region functional connectivity from baseline to post-treatment were the primary endpoints for this study. Results: After adjusting for pre-treatment GMV, individuals receiving BLT had greater GMV than those receiving amber light in 15 regions of interest, including the right thalamus and bilateral prefrontal and orbitofrontal cortices. Improved daytime sleepiness was associated with greater GMV in 74 ROIs, covering many of the same general regions. Likewise, BLT was associated with increased functional connectivity between the thalamus and both prefrontal and orbitofrontal cortices. Improved daytime sleepiness was associated with increased functional connectivity between attention and cognitive control networks as well as decreased connectivity between visual, motor, and attention networks (all FDR corrected p < 0.05). Conclusions: Following daily morning BLT, moderate to large increases in both gray matter volume and functional connectivity were observed in areas and networks previously associated with both sleep regulation and daytime cognitive function, alertness, and attention. Additionally, these findings were associated with improvements in self-reported daytime sleepiness. Further work is needed to identify the personal characteristics that may selectively identify individuals recovering from a mTBI for whom BLT may be optimally beneficial.

Sleep Disturbances in the Acute Stage of Concussion are Associated With Poorer Long-Term Recovery: A Systematic Review

OBJECTIVE

To examine the association between sleep during the acute stage of concussion and long-term outcomes.

LITERATURE SURVEY

Literature searches were performed 1 July 2018 to 1 August 2018 in Ovid MEDLINE, CINAHL, and Web of Science, along with hand searching for gray literature and cited references. Of the 610 search results, 359 unique references were reviewed after duplicates were removed.

METHODOLOGY

Two reviewers independently reviewed and came to consensus on which titles/abstracts met inclusion/exclusion criteria (n = 23). The 23 full-text articles were assessed independently by the same two reviewers for eligibility. Consensus was achieved, leaving four articles for quality assessment and data extraction. One person extracted relevant data from each study using a standard data-extraction table. The data extraction table was reviewed by two reviewers and consensus was achieved for completeness and accuracy. Quality appraisal was conducted to assess the risk for potential bias and quality of included articles.

SYNTHESIS

Two of the articles included children younger than 16 years old and two included a wide age range. In general, poorer sleep was associated with poorer outcomes following concussion at reassessments across any age population. In addition, poorer sleep in the acute stage of concussion was associated with poorer long-term outcomes and recovery.

CONCLUSIONS

The variability in sleep assessments used, symptoms assessed, length of time to reassessments, and comparator group included made data synthesis challenging. The use of standard valid and reliable sleep assessments is recommended. Future studies may consider if addressing sleep disturbances early following concussion will improve longer-term outcomes.

Early physical activity and clinical outcomes following pediatric sport-related concussion

OBJECTIVE

The objective of the study was to evaluate the clinical outcomes among patients who did and did not report engaging in early physical activity (PA) following sport-related concussion.

METHODS

We evaluated pediatric patients seen within 21 days of concussion. The independent variable was early PA engagement (since the injury and before initial clinical evaluation). Dependent variables included demographics, injury details, medical history, Health and Behavior Inventory (HBI) score, and balance, vestibular, and oculomotor function tests.

RESULTS

We examined data from 575 pediatric patients: Sixty-nine (12%) reported engaging in early PA (mean age=14.3±2.4 years; 30% female). The no PA group (mean age=14.5±2.4 years; 35% female) had significantly longer symptom resolution times than the early PA group (median= 16 [interquartile range (IQR)=8-24] vs. 10.5 [IQR=4-17] days; p=0.02). When controlling for pre-existing headache history and time from injury-evaluation time, the early PA group demonstrated lower odds of reporting current headache (adjusted odds ratio=0.14; 95% CI=0.07, 0.26), and reported lower symptom frequency ratings than the no PA group (b=-5.58, 95% CI=-8.94, -2.22).

CONCLUSIONS

Patients who did not engage in early PA had longer symptom duration, greater odds of post-injury headache, and greater symptoms at initial clinical evaluation. We cannot determine if patients engaged in early PA due to the lower symptom burden and higher functioning at the time of assessment, or if early PA positively affected outcomes. However, as early PA was associated with better post-injury outcomes, clinicians may consider supervised and structured early PA programs as a method to improve clinical outcomes following concussion.

RELEVANCE FOR PATIENTS

Children and adolescents who were engaged in PA after concussion presented to a clinic with less severe symptoms and had symptoms that resolved sooner compared to those who did not engage in early PA after concussion.

A Longitudinal Investigation of Sleep and Daytime Wakefulness in Children and Youth With Concussion

A high proportion of adults who sustain a concussion identify changes in their sleep during the acute stage, typically reporting an increased need for sleep or nonrestful sleep. Our understanding of sleep following concussion is less well understood within a pediatric population. In this study, we investigated the trajectory of sleep and daytime sleepiness in a prospective cohort of 40 children and youth (6-18 years old) with concussion, 40 age-and sex-matched healthy children and youth, and 40 with upper-extremity orthopedic injury. Evaluations occurred during the acute stage (<2 weeks) and at 3-, 6-, and 12-month postinjury using the Sleep Disturbance Scale for Children and the Postconcussion Symptom Scale. There were no significant differences within- or between-group differences in sleep across all four time points with analysis of the groups as a whole. When groups were divided by age (6-11 and 12- < 18 years), there was a significant difference in the ability to initiate sleep for the younger concussed group during the acute stage, compared with healthy controls, as well as significantly greater daytime nap duration that decreased over time. Significant correlations were also found between the frequency and duration of daytime naps and Postconcussion Symptom Scale total score and subscores (cognitive, physical/migraine, mood, and sleep) in the concussed group during the acute stage. Our results suggest that in a group with noncomplicated concussion, children and youth have transient alterations in daytime sleepiness that are related to concussion symptoms. Younger children may be more vulnerable to disturbances in sleep and daytime wakefulness.

High Sleep Disturbance and Longer Concussion Duration in Repeat Concussions

Objectives: The relationship between repeated concussions and sleep disturbance is yet to be fully understood. The objective of this study was to examine the relationship between sleep disturbance, concussion duration, and repeated concussions by assessing postconcussive symptoms and cognition. Methods: Subjects (ages 13-33 years) underwent postconcussion cognitive function evaluation and reported postconcussion symptoms including severity of disturbed sleep (drowsiness, trouble falling asleep, sleeping more than usual, and sleeping less than usual), mood disturbance (sadness, irritability, nervousness, and emotional lability), and headache. Data on cognitive function and concussive symptoms were collected for 430 subjects after first concussion, 192 subjects after second concussion, and 118 subjects after three or more concussions. A subset of subjects (119) were monitored longitudinally to assess concussion duration. Analyses included group comparisons, regression, and correlation; data were adjusted for age and gender. Results: Sleep disturbance differed significantly by group (mean[SEM]: 1st concussion = 2.56[0.2]; 2nd concussion = 3.65[0.34]; 3+ concussions = 4.32[0.43]). Concussion history predicts concussion duration (R² = 0.20, F[1,116] = 27.33, p < 0.001). Furthermore, trouble falling asleep (β = 0.15) and sleeping less than usual (β = 0.15) predicted concussion duration (R² = 0.062, F[1,116] = 3.15, p = 0.047). Reported sleep disturbance after repeated concussions was higher in patients with higher headache (F[2,732] = 3.15, p = 0.043) and mood disturbance (F[2,733] = 3.35, p = 0.036) severity. In addition, after repeated concussions, the positive correlation between sleep disturbance and cognitive dysfunction strengthened. Conclusions: History of repeated concussion is associated with longer concussion duration and higher reported sleep disturbance. Furthermore, those with sleep disturbance after repeated concussion exhibit more severe headaches, mood disturbance, and cognitive dysfunction.Abbreviations: ImPACT: Immediate Postconcussion Assessment and Cognitive Assessment (ImPACT); this is a computer-based test that assesses an individual's cognitive function and cumulatively documents current concussion symptoms. PCSS: Post Concussion Symptom Scale; this scale assesses the severity of concussion symptoms. SPSS: Statistical Package for Social Sciences. This is a statistical software package.

Relationships between Post-Concussion Sleep and Symptom Recovery: A Preliminary Study

Post-concussion sleep disturbances can be debilitating and may influence days to symptom recovery; however, evidence is minimal. The purpose of this study was to explore relationships between days to symptom recovery and aspects of sleep, as measured by actigraphy and subjective sleep questionnaires in a concussed sample. Thirty-one college students were physician-diagnosed with a concussion and asked to complete a daily sleep symptom checklist. Participants (n = 14) were excluded based on lack of compliance/early termination (22.6%), recorded <5 nights of data (12.9%), and protracted recoveries (3.2%). Final concussed sample included 17 college-aged students (varsity student-athletes, n = 5; university students, n = 12). A wrist-worn ActiGraph GT9X Link was provided during initial evaluation (within 72 h post-injury) and worn continuously until symptom recovery (follow-up evaluation; 14.3 ± 5.9 days post-injury). The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) also were completed at follow-up. Pearson's correlations were conducted to determine relationships between days to symptom recovery and actigraphy sleep outcomes (sleep onset latency, wake after sleep onset (WASO_norm), total sleep time, sleep efficiency (SE), and number of awakenings) across recovery stages (2-3 days post-injury, mid-point, and end). Spearman's rho correlations were used to determine relationships between subjective sleep (PSQI global), sleepiness (ESS total), and sleep cluster symptom severity and days to symptom recovery. At recovery mid-point, individuals who were awake longer throughout the night (24.1 ± 9.0%) and/or were less efficient at sleeping (73.7 ± 9.7%) took longer to recover (WASO_norm: r = 0.58, p = 0.015; SE: r = -0.51, p = 0.035). Poorer post-concussion sleep quality (based on PSQI) was correlated with longer recovery (r_s = 0.70, p = 0.001). Post-concussion sleep-wake disturbances at recovery mid-point and overall poorer sleep quality may be associated with longer symptom recovery. Our findings provide preliminary guidance on identifying those who may be at risk for longer recoveries based on poorer sleep post-injury.

Differences in sleep between concussed and nonconcussed college students: a matched case-control study

Study Objectives

To describe sleep 2-3 days postconcussion through symptom recovery and make comparison to well-matched nonconcussed controls.

Methods

Twenty college students were physician diagnosed with a concussion and compared with 20 nonconcussed controls matched on age, sex, physical activity, and sleep quality. A wrist-worn ActiGraph GT9X Link was provided during initial evaluation (within 72 hr postinjury for concussed) and worn continuously until symptom resolution (duration matched for nonconcussed). All participants completed a sleep symptom severity checklist, the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale (ESS). Separate 2(group) × 3(time points) mixed model ANOVAs were conducted to compare actigraphy sleep outcomes (sleep onset latency [SOL], normalized wake after sleep onset [WASOnorm], total sleep time [TST], sleep efficiency, and number of awakenings) across recovery stages (2-3 days postinjury, mid-point, and end of recovery). Intraindividual coefficient of variation was calculated for each sleep outcome. Mann-Whitney U tests compared PSQI global score, ESS total score, and sleep symptom severity between groups (α = 0.05).

Results

At 2-3 days postinjury, concussed individuals took longer to fall asleep compared with controls (p = 0.002). Greater intraindividual variability in WASOnorm (p = 0.017) and TST (p = 0.044) existed in concussed individuals across recovery. Poorer sleep quality (p < 0.001), excessive daytime sleepiness (p = 0.014), and worse sleep symptoms (p < 0.001) existed in concussed compared with controls.

Conclusions

Concussed individuals took longer to fall asleep 2-3 days postconcussion, experienced greater variation in sleep fragmentation and sleep time until symptom resolution, and reported worse sleep quality. Our preliminary findings may guide researchers interested in better understanding sleep postconcussion.

Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment

The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. J Orthop Sports Phys Ther 2019;49(11):799-810. doi:10.2519/jospt.2019.8926.

The role of sleep deficiency in the trajectory of postconcussive symptoms in adolescents

Objective: To investigate the trajectory of sleep deficiency after concussion and examine its role as a predictor of postconcussive symptoms (PCS) over 3 weeks and at 3 months post-concussion. Design: This was a prospective pilot study of 29 adolescents recruited from a pediatric Emergency Department (69% female, mean age = 14.0 years, SD = 1.8) following a concussion. Methods: Adolescents completed questionnaire assessments at baseline, Weeks 1, 2, and 3 on PCS and sleep patterns. Concurrently, adolescents also completed a daily diary and wore an actigraph continuously to monitor sleep activity. At 3 months post-concussion, adolescents repeated questionnaire measures. Results: At enrollment, 53.6% reported severe PCS, and 12% maintained severe symptoms at 3 months. Over the first 3 weeks, sleep duration and daytime sleepiness gradually declined; however, insomnia symptoms remained unchanged. After accounting for age, sex and time since concussion, greater insomnia symptoms at enrollment were associated with more severe PCS at 3 weeks and 3 months (β = 1.17, p < .001). In contrast, sleep duration, efficiency, and waketime after sleep onset were not predictors. Conclusions: Study findings suggest that insomnia symptoms after concussion may provide a target for early intervention to reduce prolonged severity and duration of PCS.

Insomnia and daytime sleepiness: risk factors for sports-related concussion

OBJECTIVE/BACKGROUND

Poor quality and inadequate sleep are associated with impaired cognitive, motor, and behavioral components of sport performance and increased injury risk. While prior work identifies sports-related concussions as predisposing factors for poor sleep, the role of sleep as a sports-related concussion risk factor is unknown. The purpose of this study was to quantify the effect of poor sleep quality and insomnia symptoms on future sports-related concussion risk.

PATIENTS/METHODS

In this study, 190 NCAA Division-1 athletes completed a survey battery, including the Insomnia Severity Index (ISI) and National Health and Nutrition Examination Survey (NHANES) Sleep module. Univariate risk ratios for future sports-related concussions were computed with ISI and NHANES sleepiness scores as independent predictors. An additional multiple logistic regression model including sport, sports-related concussion history, and significant univariate predictors jointly assessed the odds of sustaining a concussion.

RESULTS

Clinically moderate-to-severe insomnia severity (RR = 3.13, 95% CI: 1.320-7.424, p = 0.015) and excessive daytime sleepiness two or more times per month (RR = 2.856, 95% CI: 0.681-11.977, p = 0.037) increased concussion risk. These variables remained significant and comparable in magnitude in a multivariate model adjusted for sport participation.

CONCLUSION

Insomnia and daytime sleepiness are independently associated with increased sports-related concussion risk. More completely identifying bidirectional relationships between concussions and sleep requires further research. Clinicians and athletes should be cognizant of this relationship and take proactive measures - including assessing and treating sleep-disordered breathing, limiting insomnia risk factors, improving sleep hygiene, and developing daytime sleepiness management strategies - to reduce sports-related concussion risk and support overall athletic performance.

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

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

Diffusion Tensor Imaging (DTI) Correlates of Self-Reported Sleep Quality and Depression Following Mild Traumatic Brain Injury

Background: Mild traumatic brain injuries (mTBIs) are a significant social, sport, and military health issue. In spite of advances in the clinical management of these injuries, the underlying pathophysiology is not well-understood. There is a critical need to advance objective biomarkers, allowing the identification and tracking of the long-term evolution of changes resulting from mTBI. Diffusion-weighted imaging (DWI) allows for the assessment of white-matter properties in the brain and shows promise as a suitable biomarker of mTBI pathophysiology. Methods: 34 individuals within a year of an mTBI (age: 24.4 ± 7.4) and 18 individuals with no history of mTBI (age: 23.2 ± 3.4) participated in this study. Participants completed self-report measures related to functional outcomes, psychological health, post-injury symptoms, and sleep, and underwent a neuroimaging session that included DWI. Whole-brain white matter was skeletonized using tract-based spatial statistics (TBSS) and compared between groups as well as correlated within-group with the self-report measures. Results: There were no statistically significant anatomical differences between the two groups. After controlling for time since injury, fractional anisotropy (FA) demonstrated a negative correlation with sleep quality scores (higher FA was associated with better sleep quality) and increasing depressive symptoms in the mTBI participants. Conversely, mean (MD) and radial diffusivity (RD) demonstrated positive correlations with sleep quality scores (higher RD was associated with worse sleep quality) and increasing depressive symptoms. These correlations were observed bilaterally in the internal capsule (anterior and posterior limbs), corona radiata (anterior and superior), fornix, and superior fronto-occipital fasciculi. Conclusion: The results of this study indicate that the clinical presentation of mTBI, particularly with respect to depression and sleep, is associated with reduced white-matter integrity in multiple areas of the brain, even after controlling for time since injury. These areas are generally associated not only with sleep and emotion regulation but also cognition. Consequently, the onset of depression and sleep dysfunction as well as cognitive impairments following mTBI may be closely related to each other and to white-matter integrity throughout the brain.

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.