Traumatic Brain Injury (TBI) and Sleep Disturbances: A Beginner’s Guide for Caregivers, Professionals, and Impacted IndividualsPosted October 30, 2020 | By csponline
Given its high prevalence, combined with the lack of routine clinical training on its signs and symptoms and its association with disability and mortality across the globe, traumatic brain injury (TBI) — a change in brain structure or functioning caused by an outside force — is a major public health issue. The annual incidence of new cases of TBI in the United States is over 2.5 million, according to the Centers for Disease Control (2015), resulting primarily from falls, motor vehicle accidents, blows to the head by an object, and assaults. Although the majority of patients diagnosed TBI are classified as mild cases (mTBI), TBI of any severity usually can affect the patient’s physical (e.g., fatigue and sexual dysfunction), cognitive (e.g., memory and attention problems), and socioemotional wellbeing (e.g., mood problems and lack of engagement in recreational activities). For a list of symptoms commonly associated with TBI, see Box 1. A common consequence of TBI that can significantly impact recovery is that of sleep disturbances, which impact over 50% of TBI-sufferers (Mathias & Alvaro, 2012).
Although sleep is of the utmost importance for the body to heal itself following TBI, the condition has been found to result in significant sleep-wake disturbances that often go unrecognized. These disturbances can include formal diagnoses such as insomnia, sleep apnea, and narcolepsy as well as specific sleep-related complaints such as snoring, delayed sleep onset, and poor-quality sleep (see Box 2). These issues have been attributed to damage to the areas of the brain which control circadian rhythm, changes in vascular tone, as well as increases in intracranial pressure that impact the parasympathetic nervous system. They can result in individuals experiencing longer rehabilitation periods, prolonged or exacerbated cognitive problems, poorer vocational and educational outcomes, problems engaging in activities of daily living, and an overall reduction in quality of life.
Although TBI can cause sleep disturbances, having a sleep disturbance can also place an individual at risk for incurring a brain injury (e.g., fatigue from lack of sleep resulting in a car accident). In addition, TBI and sleep disturbances can have shared predisposing factors which should be uncovered and addressed early in the rehabilitative process (e.g., organic conditions such as chronic pain or bladder incontinence, as well as psychiatric conditions such as generalized anxiety, major depression, or post-traumatic stress disorder). Hence, screening and assessing for co-occurring disorders and other causative factors should be a priority during triage.
If it has been determined that TBI has causally resulted in a sleep disturbance, tailored interventions can be made available to manage those post-traumatic brain injury symptoms. Common interventions include medication, psychological counseling, dietary changes (e.g., reduction in tobacco, sugar, and caffeine consumption), and improved digestive health as part of a multidisciplinary approach. In addition, the use of sleep logs and actigraphy can be useful in both determining the extent of the disturbances as well as in tracking the progress of therapeutic strategies. Finally, it is important that individuals impacted by TBI be encouraged by their family and team of professionals to report sleep difficulties before they become severe. This includes not just reporting in the post-acute period but also in the chronic rehabilitation period. As part of this effort, the impacted individual as well as their support system should receive education on future TBI prevention as well as the consequences of recurrent TBI and associated sleep disturbances.
Jerrod Brown, Ph.D., is an Assistant Professor and Program Director and lead developer for the Master of Arts degree in Human Services with an emphasis in Forensic Behavioral Health for Concordia University, St. Paul, Minnesota. Jerrod has also been employed with Pathways Counseling Center in St. Paul, Minnesota for the past seventeen years. Pathways provides programs and services benefiting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS) and the Editor-in-Chief of Forensic Scholars Today (FST). Jerrod has completed four separate master’s degree programs and holds graduate certificates in Autism Spectrum Disorder (ASD), Other Health Disabilities (OHD), and Traumatic-Brain Injuries (TBI). Jerrod has published numerous articles and book chapters. Email address: Jerrod01234Brown@live.com
Arbour, C., Khoury, S., Lavigne, G. J., Gagnon, K., Poirier, G., Montplaisir, J. Y., … & Gosselin, N. (2015). Are NREM sleep characteristics associated to subjective sleep complaints after mild traumatic brain injury? Sleep medicine, 16(4), 534-539.
Barshikar, S., & Bell, K. R. (2017). Sleep disturbance after TBI. Current Neurology and Neuroscience Reports, 17, 1-7.
Beaulieu-Bonneau, S., Fortier-Brochu, E., Ivers, H., & Morin, C. M. (2017). Attention following traumatic brain injury: Neuropsychological and driving simulator data, and association with sleep, sleepiness, and fatigue. Neuropsychological Rehabilitation, 27(2), 216-238.
Beaulieu-Bonneau, S., & Morin, C. M. (2012). Sleepiness and fatigue following traumatic brain injury. Sleep Medicine, 13(6), 598-605.
Bogdanov, S., Brookes, N., Epps, A., Naismith, S. L., Teng, A., & Lah, S. (2019). Sleep disturbance in children with moderate or severe traumatic brain injury compared with children with orthopedic injury. The Journal of Head Trauma Rehabilitation, 34(2), 122- 131.
Castriotta, R. J., & Murthy, J. N. (2011). Sleep disorders in patients with traumatic brain injury. CNS Drugs, 25(3), 175-185.
De La Rue‐Evans, L., Nesbitt, K., & Oka, R. K. (2013). Sleep hygiene program implementation in patients with traumatic brain injury. Rehabilitation Nursing, 38(1), 2-10.
Draganich, C., Gerber, D., Monden, K. R., Newman, J., Weintraub, A., Biggs, J., … & Makley, M. (2019). Disrupted sleep predicts next day agitation following moderate to severe brain injury. Brain Injury, 1-6.
Fogelberg, D. J., Hoffman, J. M., Dikmen, S., Temkin, N. R., & Bell, K. R. (2012). Association of sleep and co-occurring psychological conditions at 1 year after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 93(8), 1313-1318.
Gagner, C., Landry-Roy, C., Lainé, F., & Beauchamp, M. H. (2015). Sleep-wake disturbances and fatigue after pediatric traumatic brain injury: A systematic review of the literature. Journal of Neurotrauma, 32(20), 1539-1552.
Grima, N., Ponsford, J., Rajaratnam, S. M., Mansfield, D., & Pase, M. P. (2016). Sleep disturbances in traumatic brain injury: A meta-analysis. Journal of Clinical Sleep Medicine, 12(03), 419-428.
Grima, N. A., Ponsford, J. L., St. Hilaire, M. A., Mansfield, D., & Rajaratnam, S. M. (2016). Circadian melatonin rhythm following traumatic brain injury. Neurorehabilitation and Neural Repair, 30(10), 972-977.
Hou, L., Han, X., Sheng, P., Tong, W., Li, Z., Xu, D., … & Dong, Y. (2013). Risk factors associated with sleep disturbance following traumatic brain injury: Clinical findings and questionnaire based study. PLoS One, 8(10), e76087.
Huang, T. Y., Ma, H. P., Tsai, S. H., Chiang, Y. H., Hu, C. J., & Ou, J. (2015). Sleep duration and sleep quality following acute mild traumatic brain injury: A propensity score analysis. Behavioural Neurology, 2015.
Imbach, L. L., Büchele, F., Valko, P. O., Li, T., Maric, A., Stover, J. F., … & Baumann, C. R. (2016). Sleep–wake disorders persist 18 months after traumatic brain injury but remain underrecognized. Neurology, 86(21), 1945-1949.
Imbach, L. L., Valko, P. O., Li, T., Maric, A., Symeonidou, E. R., Stover, J. F., … & Baumann, C. R. (2015). Increased sleep need and daytime sleepiness 6 months after traumatic brain injury: A prospective controlled clinical trial. Brain, 138(3), 726-735.
Jain, A., Mittal, R. S., Sharma, A., Sharma, A., & Gupta, I. D. (2014). Study of insomnia and associated factors in traumatic brain injury. Asian Journal of Psychiatry, 8, 99-103.
Lim, M. M., & Mysliwiec, V. (2019). Overlooked implications of disturbed sleep in traumatic brain injury. JAMA Neurology, 76(1), 114-115.
Lu, W., Cantor, J. B., Aurora, R. N., Gordon, W. A., Krellman, J. W., Nguyen, M., … & Ambrose, A. F. (2015). The relationship between self-reported sleep disturbance and polysomnography in individuals with traumatic brain injury. Brain Injury, 29(11), 1342-1350.
Lucke-Wold, B. P., Smith, K. E., Nguyen, L., Turner, R. C., Logsdon, A. F., Jackson, G. J., … & Miller, D. B. (2015). Sleep disruption and the sequelae associated with traumatic brain injury. Neuroscience & Biobehavioral Reviews, 55, 68-77.
Mani, A., Dastgheib, S. A., Chanor, A., Khalili, H., Ahmadzadeh, L., & Ahmadi, J. (2015). Sleep quality among patients with mild traumatic brain injury: A cross-sectional study. Bulletin of Emergency & Trauma, 3(3), 93-96.
Mantua, J., Henry, O. S., Garskovas, N. F., & Spencer, R. M. (2017). Mild traumatic brain injury chronically impairs sleep-and wake-dependent emotional processing. Sleep, 40(6), zsx062.
Mollayeva, T., Mollayeva, S., & Colantonio, A. (2016). The risk of sleep disorder among persons with mild traumatic brain injury. Current Neurology and Neuroscience Reports, 16, 1-15.
Piantino, J., Lim, M. M., Newgard, C. D., & Iliff, J. (2019). Linking traumatic brain injury, sleep disruption and post-traumatic headache: A potential role for glymphatic pathway dysfunction. Current pain and headache reports, 23(9), 62.
Singh, K., Morse, A. M., Tkachenko, N., & Kothare, S. V. (2016). Sleep disorders associated with traumatic brain injury—a review. Pediatric Neurology, 60, 30-36.
Baumann, C. R. (2012). Traumatic brain injury and disturbed sleep and wakefulness. Neuromolecular Medicine, 14(3), 205-212.
Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. Atlanta, GA: National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention.
Chaput, G., Giguère, J. F., Chauny, J. M., Denis, R., & Lavigne, G. (2009). Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury. Sleep medicine, 10(7), 713-716.
Mathias, J. L., & Alvaro, P. K. (2012). Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: A meta-analysis. Sleep Medicine, 13(7), 898-905.
Ouellet, M. C., & Morin, C. M. (2006). Subjective and objective measures of insomnia in the context of traumatic brain injury: A preliminary study. Sleep medicine, 7(6), 486-497.
Parcell, D. L., Ponsford, J. L., Redman, J. R., & Rajaratnam, S. M. (2008). Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study. Archives of Physical Medicine and Rehabilitation, 89(5), 843-850.
Schreiber, S., Barkai, G., Gur-Hartman, T., Peles, E., Tov, N., Dolberg, O. T., & Pick, C. G. (2008). Long-lasting sleep patterns of adult patients with minor traumatic brain injury (mTBI) and non-mTBI subjects. Sleep Medicine, 9(5), 481-487.