NeuroRehabilitation

Sleep disorders play a significant role in the care of those with Traumatic Brain Injury (TBI).

To provide a literature review on the interaction of sleep and circadian processes on those with TBI.

A literature review was conducted on PubMed using the following key words and their combination: “Sleep Apnea”, “Traumatic Brain Injury”, “Circadian”, “Parasomnia”, “Insomnia”, “Hypersomnia”, “Narcolepsy”, and “Restless Legs”. We review the spectrum of traumatic brain injury associated sleep disorders and discuss clinical approaches to diagnosis and treatment.

Disordered sleep and wakefulness after TBI is common. Sleep disruption contributes to morbidity, such as the development of neurocognitive and neurobehavioral deficits, and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of traumatic brain injury and improve neuro recovery/patient outcomes.

A more focused approach to sleep health is appropriate when caring for those with TBI.

Individuals who have sustained a TBI often present with complaints of disturbed sleep. Identifying sleep disorders in the TBI population has not been standardized. Much of the confusion may come from the heterogeneity of the research that has been conducted on sleep problems after traumatic brain injury. This review focused attention to current research findings in order to develop an evidenced-based approach to assessment of sleep disturbances within this unique population.

To review various methods used in the assessment of disorders of sleep after TBI and offer recommendations for best approaches for clinical assessment of sleep.

The authors describe various methods such as history, questionnaires, physical examination and objective sleep measurement, their usefulness and limitations based on the available evidence and experience for assessment of sleep in individuals who have sustained a TBI.

An evidence-driven method for the assessment of sleep disorders following TBI is discussed.

Through skilled assessment, clinicians can assess sleep following TBI and the most applicable interventions can be chosen with the hopes of reducing additional symptom burden and optimizing functioning.

As awareness of disrupted sleep in patients with traumatic brain injury (TBI) increases so does interest in finding objective measures of sleep. As a result, many clinicians are turning to actigraphs to monitor sleep in patients with altered consciousness. Actigraphs are accelerometers which have been used in sleep research for over four decades.

The purpose of the present study was to determine the best method for scoring actigraphs in a TBI population and to describe the benefits and pitfalls of using actigraphs with patients on a brain injury rehabilitation unit.

A retrospective chart review of 43 patients compared three different ways of scoring night time rest periods: autoscoring, manual scoring, and set interval scoring for the sleep parameters of sleep efficiency, wakefulness after sleep onset, and total sleep time. Nursing compliance with using the event marker on the device to set rest period was also analyzed.

The autoscoring method of determining the rest interval showed an inflation of sleep efficiency. For each sleep parameter compared, the strongest correlations were observed between the manual and set interval scoring methods. Compliance using event markers to set rest interval was low (16.7%).

Set interval scoring is the most efficient method to determine the rest interval in TBI patients. The use of event markers was an unreliable method to determine rest period.

Identification and management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Recent meta-analyses highlight sleep disturbance and sleep disorders following TBI (Mathias & Alvaro, 2012). Improving the recognition and treatment of sleep disorders in TBI should be a central focus of rehabilitation. The Traumatic Brain Injury Model System (TBIMS) has created an infrastructure allowing multi-center investigations into sleep dysfunction in those who have had a moderate to severe TBI and received inpatient rehabilitation.

This paper will describe the 1) infrastructure used to advance sleep dysfunction/disorders research following TBI, 2) preliminary findings from these studies, and 3) repository of data which can be accessed for secondary analyses by investigators outside of the TBIMS infrastructure.

Two internal mechanisms allow investigators at TBIMS sites to collaborate on projects of shared interest: Research Modules and Special Interest Groups (SIG).

To date, five studies have resulted from the TBIMS collaborative process focusing on insomnia, circadian disruption, and sleep apnea.

Future directions for the SIG include continued development of available knowledge and understanding of the multidimensional factors that contribute to TBI-related sleep disturbance, optimal assessment tools, effectiveness of available treatments, and treatment compliance in this population.

Sleep disturbance plays a significant role in cognitive impairment following traumatic brain injury (TBI).

To summarize recent findings that examine sleep disturbance and cognition in TBI.

Epidemiological information on sleep disorders in people with TBI is presented. A simple introduction to the role of sleep in normal cognition provides context for the literature on clinical populations. Current theory on the mechanisms underlying cognitive problems in people with sleep disorder is briefly described. Findings on the relationship between sleep disorder and cognitive problems in TBI is examined in more detail.

Consistent reports of an association between sleep duration and cognition include several studies noting positive associations (shorter sleep duration accompanies cognitive impairment) and others observing negative associations (longer sleep duration accompanies cognitive problems). Both insomnia and hypersomnolence are forms of sleep disturbance that disrupt key mental processes such as memory consolidation. Obstructive sleep apnea, cerebral structural abnormalities, neurochemical changes and psychiatric pathology are implicated.

Additional information is needed on how severity of injury impacts sleep and cognition. Hypothesized mechanisms underlying the effects of sleep on cognition in TBI should be empirically tested. Further, discrepancies between objective and subjective measures of sleep and cognition must be explored.

Whilst post traumatic brain injury fatigue (PTBIF) and sleep disturbance are common sequelae following brain injury, underlying mechanisms, and the potential for targeted interventions remain unclear.

To present a review of recent studies exploring the epidemiology of PTBIF and sleep disturbance, the relationship and neuropsychological correlates of these issues, potential approaches to intervention, and implications for neurorehabilitation.

A review of relevant literature was undertaken, with a focus on PTBIF relating to sleep disturbance, the neuropsychological correlates of these issues and implications for neurorehabilitation. This paper does not set out to provide a systematic review.

Multidimensional approaches to assessment and treatment of sleep disturbance and PTBIF are required.

There is a need for more robust findings in determining the complex nature of relationships between PTBIF, sleep disturbance, and correlates. Longitudinal prospective data is required to increase our understanding of the nature and course of PTBIF and sleep disturbance post TBI. Large scale clinical trials are required in evaluating the potential benefits of interventions.

Sleep disturbance is a common sequela after traumatic brain injury (TBI). Many of the impairments following TBI may be exacerbated by impaired sleep-wake cycle regulation.

To investigate the relationship between total sleep time (TST), measured by wrist actigraphy and observational sleep logs, and neurobehavioral impairments during inpatient rehabilitation after TBI.

Twenty-five subjects undergoing inpatient rehabilitation for traumatic brain injury were included. TST was measured using wrist actigraphy and observational sleep logs. Neurobehavioral impairments were assessed using the Neurobehavioral Rating Scale-Revised (NRS-R), a multidimensional clinician-based assessment.

Of 25 subjects enrolled, 23 subjects completed the study. A significant negative correlation was found between total NRS-R and TST calculated by observational sleep logs (r = –0.28, p = 0.007). The association between total NRS-R and TST, as calculated by actigraphy, was not significantly correlated (R = –0.01, p = 0.921).

Sleep disturbance during inpatient rehabilitation is associated with neurobehavioral impairments after TBI. TST measured by actigraphy may be limited by sleep detection algorithms that have not been validated in certain patient populations. Considerations should be made regarding the feasibility of using wearable sensors in patients with cognitive and behavioral impairments. Challenges regarding actigraphy for sleep monitoring in the brain injury population are discussed.

Sleep and endocrine disruptions are prevalent after traumatic brain injury (TBI) and are likely to contribute to morbidity.

To describe the interaction between sleep and hormonal regulation following TBI and elucidate the impact that alterations of these systems have on cognitive responses during the posttraumatic chronic period.

Review of preclinical and clinical literature describing long-lasting endocrine dysregulation and sleep alterations following TBI. The bidirectional relationship between sleep and hormones is described. Literature describing co-occurrence between sleep-wake disturbances and hormonal dysregulation will be presented. Review of literature describing cognitive effects of seep and hormones. The cognitive and functional impact of sleep disturbances and hormonal dysregulation is discussed within the context of TBI.

Sleep and hormonal alterations impact cognitive and functional outcome after TBI. Diagnosis and treatment of these disturbances will impact recovery following TBI and should be considered in the post-acute rehabilitative setting.

Sleep plays an integral role in several physiologic functions such as cognition and functional ability. Sleep disturbances are common after brain injury and can interfere with rehabilitation and recovery. There are several pathways by which sleep is initiated, and thus various ways to target common complaints as well.

To review alternative and non-pharmacological treatment approaches to sleep disorders following TBI.

The authors present a review of the literature on various alternative treatment methods for treating sleep disorders, and discuss evidence for safety and efficacy.

Typical management include conservative measures and pharmacologic treatment. This article provides a review of the available nonpharmacologic treatment options for sleep disorders in patients with traumatic brain injury. There are a number of non-pharmacological treatment methods available for treatment of sleep disorders in this population.