Sleep Disturbance Following Concussion
Article by Kids Concussion Service, Children's Hospital Westmead
by Kids Concussion Service, Children's Hospital Westmead
What is concussion?
Concussion is a mild traumatic brain injury caused by an impacting force, such as blow to the head, fall, shake, or bump. This is often the result of a contact or collision event. The force, direct or indirect, results in the brain moving back and forth quickly within the skull. Although the force imparted in this event might have no outward or visible signs, it causes transient and sudden chemical changes and cell dysfunction in the brain. Brain activation patterns, or neural connectivity, become slow or are impeded. Neural connectivity enables us to integrate, modulate and fine tune the neural pathways and networks used in higher level functioning. Good sleep health is essential for brain efficiency at this level, and particularly during brain maturation in adolescence.
Sleep and Concussion
Following a concussion, the most common sleep complaints found in children and adolescents are excessive daytime sleepiness, fatigue and insomnia, which are not always distinguished from one another. In the Children’s Hospital Institute of Sports Medicine (CHISM) Kids Concussion Service at the Children’s Hospital at Westmead in Sydney, around 95% of children and adolescents with a recent concussive injury report sleep disturbance.
Sleep is a critical factor in brain healing following a concussive injury and is the subject of a major research undertaking at the Research Unit of the CHISM Kids Concussion Service. Our research has been very careful not to confuse insomnia with the condition of delayed sleep phase syndrome where an individual’s biological rhythm is disrupted. With this condition, the individual’s normal sleep cycle is shifted; they cannot fall asleep until late at night, and thus have a later morning wake time. This is an important distinction, as many adolescents have a biological tendency to a delayed circadian phase without concussion occurring.
At the CHISM Kids Concussion Service, we believe that persistent insomnia both inhibits brain healing and exacerbates further symptomatology such as fatigue. If not managed in a timely fashion, long-term brain health issues such as post-concussion syndrome, depression and/or anxiety may result. Further, we believe that excessive daytime sleepiness following a concussion is temporary and is mostly reported only for the few days following injury. The excessive sleepiness is a sign that the brain is attempting to heal itself.
As sleep is so important, it has been incorporated into our post-injury Concussion Action Plan.This is an easy-to-follow plan designed to guide caregivers and medical professionals in the expected clinical recovery trajectory of a young person following a concussion.
Sleep, Concussion and Current CHISM Research
Young people in whom sleep remains dysfunctional following injury report persistent, prolonged or progressive concussion symptoms, well beyond the expected timeframe for recovery. There is now clear evidence that long-term recovery from a concussive injury in young people requires healthy, adequate sleep, in addition to rest and controlled activity. Concussion can make it very difficult to get the vital sleep needed to assist the brain to heal, and in these cases long-term consequences may occur.
Important research into the connection between concussions and sleep health is being undertaken at CHISM to better understand the complex and intricate links that affect sleep following injury. Sleep is not only important for physical, mental, and cognitive wellbeing, but also plays a pivotal role in the recovery of the brain following a concussion.
At the CHISM Kids Concussion Service, children and adolescents with a recent concussive injury report excessive daytime sleepiness (hypersomnia) in the initial days and weeks following the injury. They need to sleep more frequently during the day and for longer than usual. Most importantly, if the hypersomnia is not managed readily, the young person will develop fatigue throughout the day. If the fatigue progresses, the young person is at risk of developing symptoms of exhaustion, stress, and most importantly, intractable insomnia (difficulty falling asleep or the inability to fall asleep for three nights a week or more for at least three months).
Our research will focus on the sleeping patterns of young people following a concussive injury, particularly insomnia, and the quality of sleep on brain healing.
A key part of this study is to evaluate the effectiveness of measures to manage sleep insomnia following a concussion. Specifically, the study will address the following research question: How do the benefits of education and standard sleep hygiene alone compare with education, standard sleep hygiene and the use of melatonin (a sleep hormone)? Melatonin is responsible for controlling sleep-wake patterns and regulating our body clock. Taken as a supplement, Melatonin is already widely used to relieve insomnia or jet lag in adults and has been shown to be relatively safe and effective for children. This is very important, as parents or young people with sleep dysfunction may seek over-the-counter medication and/or unproven remedies to help manage their sleep dysfunction.
Our research will give a better understanding of sleep dysfunction following a concussion and will offer a standardised approach to management that is evidence-based. This will provide clear guidance to young people, caregivers and medical professionals on how to optimally manage sleep disturbance following concussion.
For more information, please refer to the concussion resources listed below:
- Concussion Action Plan https://kidshealth.schn.health.nsw.gov.au/sites/default/files/kih5294_concussion_action_plan_for_clinicians_fa2-_final_2019_0.pdf
- Concussion Aftercare Infosheet: Sleep https://kidshealth.schn.health.nsw.gov.au/sites/default/files/concussion_aftercare_-sleep_infosheet_2018.pdf
For more information regarding the sleep study, please contact:
Kids Concussion Service
Children’s Hospital Institute of Sports Medicine
Children’s Hospital Westmead
Phone: 02 9845 0761