How do traumatic brain injuries affect sleep?
There are 1.5 million new mild traumatic brain injuries (mTBI’s) in the United States each year. These injuries result in a wide range of deficits in cognitive and motor performance as well as changes in mental health, pain, and sleep. Most of these cognitive and motor deficits resolve quickly, except for sleep deficits which can persist for months to years post-injury. In fact, 90% of individuals with mTBI’s report sleep-related symptoms such as insomnia, poor quality sleep, and daytime fatigue. It is even reported that one to two years post-TBI, 43%-67% of the patients retain their symptoms.
Insufficient sleep may adversely impact physiological recovery from an mTBI. Both sleep disruption and daytime fatigue are associated with post-mTBI symptoms and depression severity. Additionally, both mTBI history and sleep disruption are risk factors for both musculoskeletal injury and future mTBIs.
Because of lack of quality of sleep, patients with TBI essentially exacerbate their symptoms. From more nighttime awakenings, to loss of concentration, these symptoms are often correlated with TBI patients, but the decline in quality of sleep can hinder the patient's cognitive functions even more. Quality sleep is defined by sufficient levels and intensity of REM, PSG profiles, and PSQI scores (Gilbert).
Can sleep disturbances in patients with TBI predict potential mental instability?
Research done in the article, "Does acute TBI-related sleep disturbance predict subsequent neuropsychiatric disturbances?" brought up the question of the possible detection of further mental instability in TBI patients through the medium of sleep quality. The research wanted to know if sleep disturbance in acute TBI period predict other mental instabilities (i.e. depression, anxiety, etc.) within couple of months after TBI.
They followed 343 people with moderate/severe TBI for one to two years after injury while taking notes of the individual's sleep quality (insomnia, fatigue). They also conducted a retrospective chart analysis in 443 patients with mild TBI and also noted their sleep patterns/sleep disturbances. They noted pre and post-injury sleep disturbances to connect to any potential indication of mental degeneration.
Results of the study:
The 343 patients with the moderate-severe TBI who noted insomnia/fatigue compared to those who didn't indicated higher rates of depression and anxiety disorders. They also witnessed that patients that have sleep disturbances around ten days after injury were six to four times more likely to have these mental instabilities.
Although this study had directly correlated mental degeneration and lack of sleep in TBI patients, this must be explored further through more sample sizes and longer periods of time.The authors of the research asked to consider the following questions as we navigate into future studies of this caliber:
"Is sleep disturbance soon after trauma a prognostic marker of subsequent neuropsychiatric symptoms?"
"Can early treatment of sleep disturbance during the post-TBI period reduce subsequent development of neuropsychiatric symptoms?"
(Rao, V. et al 2014)
Such questions and research correlated to this study may pave way to treatment protocols more accessible and fruitful.
Here is a quick video on some of the common sleep disorders after TBI done by Dr.Panettiere.
What treatments are available?
With the exception of blue light therapy,
“no widely accepted, evidence-based, efficacious non-pharmacologic treatments have been identified.”
(Raikes, A. et al. 2020)
Pharmacologic therapies have yielded conflicting results.Blue light therapy re-synchronizes the circadian system, enhances alertness, and acts on serotonin pathways. Morning exposure to blue light suppresses nocturnal melatonin secretion from the pineal body resulting in the reduction of daytime sleepiness and insomnia at night, as well as improve alertness.
Future directions?
Considering the lack of treatment options to improve sleep among individuals suffering from traumatic brain injuries, there is plenty of work to be done. Blue light therapy has shown promising results for improving sleep and symptoms related to a lack thereof. Future studies are needed with larger sample-size to optimize treatment dosage. More research is also needed to tease out effective pharmacologic interventions.
Speaking of more research, the scientific community had come to the consensus that they must develop a way in which we can accurately define quality of sleep, and create a systematic approach to researching these types of subjects. Unfortunately, due to many array of variables present in sleep-research across different subtopics. Specifically, the literature review journal, "Sleep disturbances, TBI and PTSD," had noted that there has to be more information in the predictors and moderators of natural recovery when it comes to studies that associate sleep and TBI. Additionally, much of the studies already done rarely take commonalities to the account which can dramatically affect the patient's quality of sleep, with or without TBI. Studies should also include interdisciplinary teams in order to help treat patients that may be associated with comorbidities.
References:
Brainline. (2014). Common Sleep Issues After TBI and/or PTSD [Video]. Youtube.
https://www.youtube.com/watch?v=lLb39CoMreg
Gilbert, K. S., Kark, S. M., Gehrman, P., & Bogdanova, Y. (2015). Sleep disturbances, TBI and
PTSD: Implications for treatment and recovery. Clinical Psychology Review, 40, 195-212. doi:10.1016/j.cpr.2015.05.008
Raikes, A. C., Dailey, N. S., Shane, B. R., Forbeck, B., Alkozei, A., & Killgore, W. D. S. (2020).
Daily Morning Blue Light Therapy Improves Daytime Sleepiness, Sleep Quality, and Quality of Life Following a Mild Traumatic Brain Injury. The Journal of Head Trauma Rehabilitation, 35(5), E405–E421. https://doi.org/10.1097/HTR.0000000000000579
Rao, V., McCann, U., Han, D., Bergey, A., & Smith, M. T. (2014). Does acute TBI-related sleep
disturbance predict subsequent neuropsychiatric disturbances? Brain Injury, 28(1), 20-26. doi:10.3109/02699052.2013.847210
Srisurapanont, K., Samakarn, Y., Kamklong, B., Siratrairat, P., Bumiputra, A., Jaikwang, M., et
al. (2021). Blue-wavelength light therapy for post-traumatic brain injury sleepiness, sleep disturbance, depression, and fatigue: A systematic review and network meta-analysis. PloS One, 16(2), e0246172. doi:10.1371/journal.pone.0246172
Wolfe, Lisa F., Ashima S. Sahni, and Hrayr Attarian. "Sleep Disorders in Traumatic Brain
Injury." NeuroRehabilitation (Reading, Mass.), vol. 43, no. 3, 2018, pp. 257-266, doi:10.3233/NRE-182583.
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