Prevalence of insomnia and insomnia symptoms following mild-traumatic brain injury: A systematic review and meta-analysis

Postconcussion Clinical Insomnia is Associated With Heightened Symptom Severity and Delayed Recovery in Children and Adolescents

BACKGROUND

There is limited evidence on the prevalence and implications of specific types of sleep disturbance in pediatric concussion. This study aimed to (1) identify the prevalence of postconcussion clinical insomnia (PCCI) in children, (2) determine the impact of PCCI on concussion recovery outcomes, and (3) ascertain clinical characteristics associated with PCCI.

METHODS

A cross-sectional study was conducted in patients (n = 164, aged 9-17 years) presenting to a pediatric tertiary referral concussion clinic from January 2021 to December 2022. PCCI was identified using the Insomnia Severity Index. Characteristics, including symptom severity, cognitive function, sleep hygiene behavior, and exercise tolerance, were compared between patients presenting with and without insomnia postinjury. A subgroup analysis of recovered patients was undertaken to determine the impact of PCCI on concussion recovery duration.

RESULTS

Over one third of patients (n = 59, 36%) presented with PCCI. Symptom severity was three times greater in patients with PCCI compared with patients without insomnia postconcussion (P < 0.001). Patients with PCCI had inferior cognitive function in verbal memory (P = 0.01) and visual memory (P = 0.02) cognitive test domains and poorer sleep hygiene behavior (P < 0.001). The subgroup analysis of recovered patients (n = 113) revealed that patients with PCCI had a significantly prolonged recovery duration, taking over one month longer to recover compared with patients without insomnia postinjury (mean recovery duration: 89 vs 57 days, P = 0.004).

CONCLUSIONS

PCCI is an important contributing factor of symptom burden and severity in pediatric concussion.

Cognitive symptoms in veterans with migraine or traumatic brain injury: A Million Veteran Program study

OBJECTIVE

To examine the spectrum and severity of cognitive symptoms in veterans with migraine, traumatic brain injury (TBI), or both; and to evaluate the extent to which psychiatric conditions contribute to the relationship of migraine and TBI with cognitive symptoms.

BACKGROUND

Migraine contributes significantly to global disability, with veterans facing additional burdens due to high comorbidity of TBI and psychiatric conditions. Understanding the intersection of these conditions is crucial for improving veterans' health-care outcomes.

METHODS

This observational study used self-reported data from 338,217 veterans enrolled in the Million Veteran Program (MVP) to assess cognitive symptoms using the Medical Outcomes Study Cognitive Functioning Scale Revised (MOS-Cog-R) and psychiatric conditions in veterans with migraine only, TBI only, both, or neither.

RESULTS

Of the participants, 30,080/338,217 (8.9%) veterans reported migraine, 31,906/338,217 (9.4%) reported TBI, and 7828/338,217 (2.3%) reported both migraine and TBI. Veterans with only migraine or only TBI reported similar levels of cognitive symptoms (M = 74.19, standard deviation [SD] = 25.18; M = 73.87, SD = 24.98, respectively), which were substantially higher than veterans without these conditions (M = 62.52, SD = 27.90). Veterans with both conditions reported the most cognitive symptoms (M = 83.01, SD = 22.13) and psychiatric conditions (depression = 5041/7828 [64.4%], anxiety = 3735/7828 [47.7%], post-traumatic stress disorder = 4243/7828 [54.2%]). The association of migraine and TBI with cognitive symptoms persisted beyond the influence of psychiatric conditions (B = -2.20, standard error = -0.36, p < 0.001).

CONCLUSION

Veterans with migraine reported cognitive challenges analogous to veterans with TBI, indicating a need for careful attention to cognitive symptoms in veterans with migraine. Further, the associations of migraine and TBI with cognitive symptoms in veterans were not explained by psychiatric conditions. These findings encourage future research to elucidate the association between self-reported and objective cognitive symptoms and to identify factors, including environmental exposure and genetic influences, contributing to cognitive impairment to optimize the assessment and treatment of veterans with migraine.

Preliminary feasibility and efficacy of a brief behavioural treatment for insomnia after acquired brain injury: A case series

Insomnia after acquired brain injury (ABI) is common and can negatively impact an individual's rehabilitation, recovery, and quality of life. The present study investigated the feasibility and preliminary efficacy of a Brief Behavioural Treatment for Insomnia (BBTI) in a community sample following ABI. Ten participants were recruited. Seven participants attended four weekly sessions of BBTI and kept a daily sleep diary. Participants completed a semi-structured sleep interview at baseline and self-report measures of sleep, anxiety, and depression pre- and post-treatment as well as a treatment acceptability questionnaire post-treatment. Follow-up data were collected at 1-, 2-, and 3-months post-treatment. Visual analyses of the data were performed on a case-by-case basis. Five of the seven participants (71%) no longer met the criteria for insomnia disorder on the Sleep Condition Indicator (SCI) post-treatment. Treatment effects on sleep outcomes were either maintained or augmented at follow-ups. BBTI was found to be well tolerated, as evidenced by the high overall retention rates (70%) and positive feedback on the treatment acceptability questionnaire. These results provide preliminary evidence of BBTI being both feasible to use and potentially efficacious in individuals with post-brain-injury insomnia. Larger-scale randomised controlled trials are needed to establish the effectiveness of BBTI following ABI.

Effects of mTBI with loss of consciousness on neurobehavioral symptoms, depression, and insomnia in former collegiate and NFL football athletes

OBJECTIVE

Considering that diagnostic decisions about mTBI are often predicated on clinical symptom criteria, it is imperative to determine which initial presentation features of mTBI have prognostic significance for identifying those at high risk for long-term functional impairment.

SETTING

Zoom interview Participants: Male, former NCAA Division I, and professional-level National Football League (NFL) athletes (n = 177) between the ages of 27 and 85 (M = 54.1, SD = 14.7).

DESIGN

Cross-sectional case-control. Main Measures: History of mild TBI, history of loss of consciousness (LOC), depression symptoms, insomnia, neurobehavioral symptoms.

RESULTS

Number of mTBI exposures did not predict neurobehavioral symptoms (B = 0.21, SE = 0.18, p = 0.23), but number of mTBI + LOC events did (B = 2.27, SE = 0.64, p = <.001). Further analysis revealed that the number of mTBI + LOC events predicted neurobehavioral symptoms indirectly through both depression (B = 0.85, 95% CI = [0.27, 1.52) and insomnia (B = 0.81, 95% CI = [0.3, 1.4]). Further, the direct effect of mTBI + LOC events on neurobehavioral symptoms became non-significant when depression and insomnia were added to the model (B = 0.78, SE = 0.45, p = 0.08).

CONCLUSIONS

Findings support LOC at time of injury as an important predictor of long-term outcomes. Additionally, results suggest depression and insomnia as potential mediators in the association between mTBI + LOC and neurobehavioral symptoms. These findings provide justification for early depression and insomnia symptom monitoring following mTBI + LOC.

Increased Risk for Clinically Significant Sleep Disturbances in Mild Traumatic Brain Injury: An Approach to Leveraging the Federal Interagency Traumatic Brain Injury Research Database

STUDY OBJECTIVES

The Federal Interagency Traumatic Brain Injury Research (FITBIR) Informatics System contains individual-patient-level traumatic brain injury (TBI) data, which when combined, allows for the examination of rates and outcomes for key subpopulations at risk for developing sleep disturbance.

METHODS

This proof-of-concept study creates a model system for harmonizing data (i.e., combining and standardizing data) across FITBIR studies for participants with and without a history of TBI to estimate rates of sleep disturbance and identify risk factors.

RESULTS

Three studies were eligible for harmonization (N = 1753). Sleep disturbance was common among those with a history of mild TBI (63%). Individuals with mild TBI were two to four times more likely to have sleep disturbance compared to those with no history of TBI.

CONCLUSIONS

This study established methods, harmonization code, and meta-databases that are publicly available on the FITBIR website. We demonstrated how the harmonization of FITBIR studies can answer TBI research questions, showing that associations between TBI and sleep disturbance may be influenced by demographic factors.

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.

The Frequency of Neuropsychiatric Sequelae After Traumatic Brain Injury in the Global South: A systematic review and meta-analysis

This study aimed to assess the prevalence of neuropsychiatric sequelae following traumatic brain injury (TBI) among the Western Asian, South Asian and African regions of the global south. All studies on psychiatric disturbances or cognitive impairment following TBI conducted (until August 2021) in the 83 countries that constitute the aforementioned regions were reviewed; 6 databases were selected for the literature search. After evaluating the articles using the Joanna Briggs Institute guidelines, the random effects model was used to estimate the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), TBI-related sleep disturbance (TBI-SD), obsessive-compulsive disorder (OCD) and cognitive impairment. Of 56 non-duplicated studies identified in the initial search, 27 were eligible for systematic review and 23 for meta-analysis. The pooled prevalence of depression in 1,882 samples was 35.35%, that of anxiety in 1,211 samples was 28.64%, that of PTSD in 426 samples was 19.94%, that of OCD in 313 samples was 19.48%, that of TBI-SD in 562 samples was 26.67% and that of cognitive impairment in 941 samples was 49.10%. To date, this is the first critical review to examine the spectrum of post-TBI neuropsychiatric sequelae in the specified regions. Although existing studies lack homogeneous data due to variability in the diagnostic tools and outcome measures utilised, the reported prevalence rates are significant and comparable to statistics from the global north.

Associations between Sleep Disturbances, Personality Traits and Self-Regulation in a Sample of Healthy Adults

Background: Scientific evidence and everyday experience show that sleep disturbances and self-regulation as a proxy of stress reactivity are linked. Particular personality traits such as neuroticism, internalizing and externalizing problems are also associated with sleep disturbances. Here, we combined self-regulation and personality traits and associated these variables with subjective sleep disturbances. Methods: A total of 846 adults (mean age: 33.7 years; 78.7% females) completed questionnaires covering sleep disturbances, self-regulation and personality traits. Results: Higher scores for sleep disturbances were associated with higher scores for externalization, internalization, and instability and with lower scores for stability (all trait variables) and with poorer self-regulation (state variable). The regression model showed that higher scores for externalization and internalization (traits), and lower scores for self-regulation (state) predicted higher scores for sleep disturbance. Next, self-regulation had both a direct effect on sleep disturbance, and an indirect effect via personality traits. Conclusions: Sleep disturbances were related to both state (i.e., self-regulation) and trait (e.g., internalization and instability) dimensions. The current data analysis leapfrogs the state-trait dichotomy discussion and reconciles the state-and-trait approach in the prediction of poor sleep, though self-regulation appeared to have both direct and indirect effects on sleep disturbances.

Sleep disorders among patients suffering from road traffic injuries in an urban setting of Vietnam: an exploratory study

Sleep quality is an important indicator of treatment outcome for patients with traffic accident injuries. In Vietnam, the impacts of injury on sleep status are usually amplified in urban areas due to disproportionate distribution of mental care services between the city and less developed settings. Our study investigated deterioration in sleep quality and identified associated demographic factors among traffic injury patients in an small urban setting of Vietnam. A cross-sectional study was conducted among 408 patients in one provincial hospital and five district hospitals in Thai Binh, Vietnam from October to December 2018. A structured questionnaire was designed based on 3 standardized scales: Health-related Quality of Life, the Pittsburgh Sleep Quality Index and the Kessler Scale. Face-to-face interviews and medical records were conducted by trained health professionals on patients hospitalized in the Trauma-Orthopedic/Burn Department and Surgery and General Department. About 16.9% of respondents had sleep disturbances, and there was a statistically significant difference between age group (p < 0.01), education level (p < 0.01), and monthly household income (p < 0.01) between participants who with and without sleep disturbances. Furthermore, more than half (50.7%) of respondents sleep less than 5 h per day, while 18.7% of the sampled also reported that the habitual sleep efficiency was below 85%. Current results indicated that people being female, suffering from traumatic brain injury, being comatose at hospitalization, and having higher psychological distress scores were more likely to suffer from sleep problems. Our study is one of the first evidence in Vietnam to assess sleep disturbances in road traffic injury patients and their correlated factors. It is important to identify patients who are at risk of sleep disturbances based on socio-demographic and clinical characteristics, as well as psychological distress status. Therefore, a holistic approach should be taken to include sleep quality and psychological state in the treatment process and outcome assessment for road traffic injury patients.

Circadian therapy interventions for glymphatic dysfunction in concussions injuries: A narrative review

There are two primary threats to the brain after concussion. The first is a buildup of neurotoxic proteins in the brain. The second, a partial consequence of the first, is a sustained neuroinflammatory response that may lead to central sensitization and the development of persistent post-concussive symptoms. These threats make neurotoxin clearance a high clinical priority in the acute period after injury. The glymphatic system is the brain's primary mechanism for clearing neurotoxic waste. The glymphatic system is intimately tied to the sleep cycle and circadian dynamics. However, glymphatic dysfunction and sleep disturbances are nearly ubiquitous in the acute period after concussion injury. Because of this, sleep optimization via circadian therapy is a time-sensitive and critical tool in acute concussion management.

What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review

OBJECTIVE

To determine what tests and measures accurately diagnose persisting post-concussive symptoms (PPCS) in children, adolescents and adults following sport-related concussion (SRC).

DESIGN

A systematic literature review.

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus through March 2022.

ELIGIBILITY CRITERIA

Original, empirical, peer-reviewed findings (cohort studies, case-control studies, cross-sectional studies and case series) published in English and focused on SRC. Studies needed to compare individuals with PPCS to a comparison group or their own baseline prior to concussion, on tests or measures potentially affected by concussion or associated with PPCS.

RESULTS

Of 3298 records screened, 26 articles were included in the qualitative synthesis, including 1016 participants with concussion and 531 in comparison groups; 7 studies involved adults, 8 involved children and adolescents and 11 spanned both age groups. No studies focused on diagnostic accuracy. Studies were heterogeneous in participant characteristics, definitions of concussion and PPCS, timing of assessment and the tests and measures examined. Some studies found differences between individuals with PPCS and comparison groups or their own pre-injury assessments, but definitive conclusions were not possible because most studies had small convenience samples, cross-sectional designs and were rated high risk of bias.

CONCLUSION

The diagnosis of PPCS continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.

The Utility of Melatonin for the Treatment of Sleep Disturbance After Traumatic Brain Injury: A Scoping Review

OBJECTIVE

To investigate the utility of melatonin supplementation as a treatment option for individuals with sleep disturbance after traumatic brain injury (TBI).

DATA SOURCES

A systematic search was conducted in 6 electronic databases (Medline, AMED, CINAHL, Embase, Scopus, and SPORTDiscus) from earliest records to April 2022.

STUDY SELECTION

Studies were eligible for inclusion if they met the following criteria: a) human participants with sleep disturbance after TBI, b) melatonin or melatonergic agent used as an intervention to treat sleep disturbance, and c) outcomes of melatonin administration reported. All TBI severity types (mild, moderate, and severe) were eligible. The initial search retrieved a total of 595 articles, with 9 studies meeting the eligibility criteria.

DATA EXTRACTION

Two reviewers independently extracted data from eligible studies and assessed methodological quality. Extracted data consisted of participant and injury characteristics, melatonin interventional properties, and sleep outcome. Methodological quality was assessed via the Downs and Black checklist.

DATA SYNTHESIS

A total of 251 participants with TBI-induced sleep disturbance (mean age range: 14.0-42.5 years) were included. Melatonin, Circadin (prolonged-release melatonin), or Ramelteon (melatonin receptor agonist) were administered. Dosages and intervention duration ranged from 2 to 10 mg and 3 to 12 weeks, respectively. Eight out of 9 studies reported positive outcomes after melatonin treatment. Significant improvements in subjective sleep quality, objective sleep efficiency, and total sleep time were found with melatonin. Reductions in self-reported fatigue, anxiety, and depressive symptoms were also observed with melatonin treatment. No serious adverse events were reported after melatonin administration.

CONCLUSION

Melatonin has good tolerability after short-term use and the potential to be a therapeutic agent for those with sleep disturbance after TBI. Melatonin was shown to be beneficial to sleep quality, sleep duration, and sleep efficiency. Additional clinically relevant outcomes of improved mental health suggest that melatonin use may be a promising treatment option for individuals experiencing co-occurring disorders of mood and sleep disturbance post-injury.

Biomechanics of Traumatic Head and Neck Injuries on Women: A State-of-the-Art Review and Future Directions

The biomechanics of traumatic injuries of the human body as a consequence of road crashes, falling, contact sports, and military environments have been studied for decades. In particular, traumatic brain injury (TBI), the so-called "silent epidemic", is the traumatic insult responsible for the greatest percentage of death and disability, justifying the relevance of this research topic. Despite its great importance, only recently have research groups started to seriously consider the sex differences regarding the morphology and physiology of women, which differs from men and may result in a specific outcome for a given traumatic event. This work aims to provide a summary of the contributions given in this field so far, from clinical reports to numerical models, covering not only the direct injuries from inertial loading scenarios but also the role sex plays in the conditions that precede an accident, and post-traumatic events, with an emphasis on neuroendocrine dysfunctions and chronic traumatic encephalopathy. A review on finite element head models and finite element neck models for the study of specific traumatic events is also performed, discussing whether sex was a factor in validating them. Based on the information collected, improvement perspectives and future directions are discussed.

"Hidden gains"? Measuring the impact of mindfulness-based interventions for people with mild traumatic brain injury: a scoping review

BACKGROUND

Mindfulness-based interventions can support recovery from mild traumatic brain injury (mTBI). Although measurement is a key determinant of outcomes, there is no comprehensive assessment of measurement approaches used to capture outcomes of these programs. Here, we review the domains targeted, measurement techniques used, and domains and techniques most affected by mindfulness-based interventions for mTBI.

METHODS

We conducted a scoping review. After screening and full-text review, we included 29 articles and extracted data related to measurement domains, techniques, and results.

RESULTS

We identified 8 outcome domains, each with multiple subdomains. The most common domains were cognitive symptoms and general health/quality of life. No quantitative studies directly assessed sleep, physical-function, or pain-catastrophizing. Self-report was the most common measurement technique, followed by performance-based methods. Coping, somatic symptoms, emotional symptoms, stress response, and domains of cognition (particularly attention) were the most frequently improved domains. Qualitative results described benefits across all domains and suggested novel areas of benefit. Biomarkers did not reflect significant change.

CONCLUSIONS

Mindfulness-based interventions for mTBI impact a range of clinical domains and are best captured with a combination of measurement approaches. Using qualitative methods and expanding the breadth of outcomes may help capture underexplored effects of mindfulness-based interventions for mTBI.