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Craig Research Looks at Optimizing Sleep During Early Brain Injury Recovery

May 30, 2019

Whether you call it getting a little shut-eye, snoozing or catching some zzz’s, getting a proper amount of quality sleep is important to everyone’s health and well-being. Research at Craig is helping clinicians understand the relationship between sleep and recovery for individuals with moderate-to-severe traumatic brain injury.

Under the direction of CNS physicians Dr. Michael Makley and Dr. Alan Weintraub and Craig Hospital neuropsychologist Dr. Don Gerber, the Optimized Sleep After Brain Injury (OSABI) study is addressing the gap in knowledge about the nature, incidence and effect of sleep disturbances on recovery from moderate-to-severe TBI during the early rehabilitation period. It is also testing a sleep hygiene protocol to improve sleep for individuals in the early rehabilitation phase after TBI.

This study builds on previous research started by Makley at the University of Maryland and continued at Craig.

In uninjured populations, sleep deprivation has been associated with significant negative effects on attention, reaction time, visual-motor performance, language functions, memory processes and executive functions.

“We’ve all experienced a bad night of sleep, and we know that when we don’t get a good night’s sleep, we are not functioning optimally,” says Makley. “We see similar things in patients.”

In individuals with moderate-to-severe TBI, sleep disturbance has been estimated to be as high as 86% and has been associated with the presence of post-traumatic amnesia (PTA); a period of disorientation, confusion; and an inability to store memories that occur after TBI.

According to Makley, there are a variety of reasons for sleep disruption during this period, including injuries to the sleep centers in the brain’s cortical, subcortical and brainstem regions, as well as medical care needs during the nighttime.The disruptions can range from difficulty falling and staying asleep to snoring, sleepwalking and nightmares.

Previous studies have found that sleep disturbances could make cognitive problems worse after TBI and could even prolong the amount of time that a patient remains in the PTA phase of recovery. This suggests that therapies aimed at improving sleep problems after TBI may also improve cognitive recovery.

The OSABI study, which is funded by a $300,000 grant from the Colorado TBI Trust Fund, monitors the sleep patterns of clinically-appropriate patients using an actigraph, a wristwatch size accelerometer that can monitor activity levels and sleep. Participants’ cognitive functions are also tested multiple times a week to monitor orientation, attention and memory.

Study participants who exhibit sleep problems are allocated into one of two groups - either into the group that receives Craig’s typical rehabilitation and care routines or into the group that has an experimental seven-days-a-week sleep hygiene protocol.

Many of the sleep medications commonly used in non-TBI populations have side effects that may negatively affect individuals with TBI who are cognitively compromised. Thus, the protocol tests the efficacy of a non-pharmacological, behavioral-environmental approach. Participants are housed in specially modified rooms designed to provide a dark, quiet sleep environment, including light blocking shades, dim lights, dim light cameras, and meters to record ambient light and sound levels through the period of sleep. Nursing care is minimized unless clinically necessary. Participants don’t consume caffeine after noon, maintain a consistent waking schedule seven days a week, and are exposed to blue light therapy for 30 minutes after awakening to turn off the sleep signals in the brain. Prolonged daytime sleep is discouraged, and the room is kept bright when the patient is resting during the day between therapies and appointments.

Participants’ sleep in both groups is monitored with 24-hour actigraphy and several different scales and measures. The study is overseen by a team of representatives from Craig’s research, neuropsychology, speech pathology and nursing departments. The steering committee meets weekly to review progress.

“There are many aspects of institutionalized care that impact sleep, and until we understand how that impacts a person’s sleep and recovery, we can’t move any further in treating this,” says Makley. “This study is helping us understand our institutional impact and the impact of our patterns of behavior.”

According to the study’s principal investigators, it is anticipated that two manuscripts will be developed and submitted to peer-reviewed journals based on the study findings. The findings will also be presented to Craig’s Research Task Force and to clinical staff to upgrade Craig’s clinical approach to managing sleep disturbances after TBI. If the pilot trial shows that the sleep hygiene protocol is feasible and effective, the research department will plan  a larger study.

The Craig research team is also working on a multi-site study with the Patient-Centered Outcomes Research Institute. The Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome study will identify sleep apnea during inpatient TBI rehabilitation and compare existing screening and diagnostic tools.