BLOG: 5 things you should know about sleep and concussions
by Michael S. Jaffee, MD, FAAN, FANA
You might not think about sleep as being related to concussions, but there are a number of ways that a good night’s rest affects (or is affected) by traumatic brain injury.
Sleep problems are a common symptom
Sleep dysfunction, ranging from insomnia to hypersomnia, is very common after traumatic brain injury (TBI). In moderate to severe TBI, where there may be a focal injury to one specific area of the brain, we often see circadian rhythm disturbances and hypersomnia related to hypothalamic injury, while damage to the brain stem’s locus coeruleus has been associated with worsening sleep apnea.
But sleep dysfunction is also commonly associated with mild TBI, or concussion, from which it is more likely to be due to transient impairment of the brain’s neural networks. Sleep dysfunction usually resolves as the concussion resolves, but in some cases, intervention may be needed.
Sleep can affect everything else
It is important to recognize that symptoms don’t occur in silos. If a patient is having trouble sleeping, it can make it more difficult for them to overcome headaches or respond well to therapy for vestibular-ocular dysfunction. Yet sleep problems often fall through the cracks of concussion management.
Optometrists can help by asking something as simple as, “Has your sleep been different since the injury?” If the answer is yes, get more detail on what has changed, and make sure that sleep is on the radar of the team managing the concussion.
Think twice before taking a sleeping pill
Concussion patients should avoid some common sleep aids that can actually worsen recovery due to their effects on brain plasticity and cognition.
For example, I would advocate avoiding benzodiazepines, as well as any drug with anti-cholinergic effects that can contribute to cognitive symptoms. Patients with chronic insomnia often benefit from cognitive behavioral therapy for insomnia, and there is some research suggesting that acupuncture and other behavioral modalities may be beneficial.
Extra sleep may help
We know that one of the physiological functions of sleep in general is to make synaptic function more efficient by recalibrating neurotransmitters and their receptors to reduce “noise” in these neuronal signals.
In addition, we have recently discovered that sleep helps the glymphatic system remove abnormal protein waste products, including the protein amyloid that is associated with Alzheimer’s disease and other cognitive problems. This suggests that adequate sleep after a TBI may be an essential component in brain healing and recovery, especially for older patients.
Sleep and TBI can have bidirectional relationship
Sleep dysfunction is pretty common in the population overall, so it is important to understand what the patient’s sleep was like before their injury.
Someone with pre-existing insomnia or obstructive sleep apnea (OSA) would be expected to be tired and have slower reaction times, which may have increased their risk for an athletic injury or car accident.
OSA has been associated with a host of ocular signs and conditions, including lid laxity or floppy eyelid syndrome (which can itself lead to other problems, such as dry eye, exposure-related corneal complications and even keratoconus), nonarteritic anterior ischemic optic neuropathy, glaucoma, papilledema (especially in young women), central serous chorioretinopathy, diabetic retinopathy with cotton-wool spots and retinal vein occlusion.
By keeping an eye out for these signs, especially if combined with other OSA risk factors, optometrists can play a key role in referring patients for treatment of OSA by a sleep specialist, whether that is in the course of concussion management or not.
Jaffee MS, et al. Brain Inj. 2015;doi:10.3109/02699052.2014.983978.
Santos M, et al. J Clin Sleep Med. 2017;doi:10.5664/jcsm.6812.
Skorin L, et al. J Am Osteopath Assoc. 2016; doi:10.7556/jaoa.2016.105.
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Michael S. Jaffee, MD, FAAN, FANA, is board certified in neurology, psychiatry, sleep medicine and brain injury medicine. He is currently the Bob Paul Family Professor of Neurology and vice chair of the Department of Neurology and director of the Trauma, Concussion and Sports Neuromedicine Program at the University of Florida. He previously served as medical director of the Brain Injury and Sports Concussion Institute at the University of Virginia, where he was also director of the Neurology Sleep Service. Jaffee served 21 years in the U.S. Air Force, including time as active duty medical staff in Iraq, and retired at the rank of colonel. He has served on two White House-appointed panels and as the national director of the Defense and Veterans Brain Injury Center.
Disclosure: Jaffee reports no relevant financial disclosures.
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