Sleep disturbance
More than 50% of people report sleep disturbances following mTBI/concussion, specifically symptoms that may indicate insomnia, hypersomnia, obstructive sleep apnoea, poor sleep maintenance, poor sleep efficiency, early awakening, delayed sleep onset, or alterations in circadian cycle.214-219 While the need for sleep may increase in the immediate acute stage of mTBI/concussion,214 this decreases over time. The key is to recognise sleep disturbance and its cause.
Insomnia is the most common form of sleep disturbance reported in the subacute and chronic stages of mTBI/concussion, occurring in as many as 70% of people especially older adults and women.220-224 Always check for the possibility of other sleep disorders such as obstructive sleep apnoea, restless legs syndrome and depression, treating as appropriate. Simple management strategies for insomnia can help including education about normal sleep and normal waking during sleep and by initiating sleep hygiene measures.
Relaxation techniques such as mindfulness, progressive muscle relaxation, meditation, and breathing techniques can help manage insomnia.225 Adolescents commonly report circadian rhythm problems such as delayed sleep phase disorder where sleep is delayed two or more hours from usual sleep patterns making it harder to wake in time for work or school. These need management strategies targeted for circadian rhythm disorders (including avoidance of long sleep-ins on the weekend; using light exposure after latest getting up time and moving this earlier every 3 days and adding in/increasing exercise according to return to activity guidelines). Melatonin has been shown to improve sleep following mTBI/concussion; this should occur in conjunction with sleep hygiene, insomnia, and circadian rhythm disorder management.
Sleep monitoring devices such as a sleep diary, and technological solutions for monitoring sleep (e.g. smart watches) can help recognise patterns in sleep habits.226 Sleep trackers (e.g. smart watches) don’t measure sleep directly and this can only be done with a medical sleep study. When used with professional guidance, sleep trackers may aid in assessment of sleep quantity and the efficacy of current treatments in relation to the number of hours of sleep per night, the number of times one wakes up throughout the night, antecedents, and disturbances which may be impacting sleep.226
CBR 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
226. Morse AM, Kothare SV. Sleep disorders and concussion. Handb Clin Neurol. 2018;158:127-34.Adapted30 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29 The Australasian Sleep Association provides guidance on assessment and management of insomnia that is endorsed by the RACGP.
Sleep disturbance is common following mTBI/concussion, with most people having mild symptoms and achieving full recovery with time.221 While most sleep-related problems will resolve spontaneously targeted intervention may be required to facilitate recovery.221 Poor sleep may exacerbate other symptoms such as headache, fatigue, mood disturbances and cognitive problems possibly contributing to delayed recovery.222, 227, 228 Targeted treatment of sleep disturbances, alongside other more disabling symptoms of headache, fatigue and mood is likely to improve overall recovery.
Evidence is lacking about when it is safe or appropriate to intervene earlier for sleep disturbances, and what is the appropriate treatment if earlier intervention is required. Further research on this question is required.
EBR (conditional)164, 186, 218, 220, 224, 227, 229-236 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
164. Hromas GA, Houck ZM, Asken BM, Svingos AM, Greif SM, Heaton SC, et al. Making a Difference: Affective Distress Explains Discrepancy Between Objective and Subjective Cognitive Functioning After Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2021;36(3):186-95. doi: 10.1097/HTR.0000000000000618.
186. Rakers SE, Timmerman ME, Scheenen ME, de Koning ME, van der Horn HJ, van der Naalt J, et al. Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study. Arch Phys Med Rehabil. 2021;102(10):1965-71 e2. doi: 10.1016/j.apmr.2021.06.004.
218. Theadom A, Cropley M, Parmar P, Barker-Collo S, Starkey N, Jones K, et al. Sleep difficulties one year following mild traumatic brain injury in a population-based study. Sleep Med. 2015;16(8):926-32. doi: 10.1016/j.sleep.2015.04.013.
220. Wiseman-Hakes C, Foster E, Langer L, Chandra T, Bayley M, Comper P. Characterizing sleep and wakefulness in the acute phase of concussion in the general population: a naturalistic cohort from the Toronto Concussion Study. J Neurotrauma. 2022;39(1-2):172-80. doi: 10.1089/neu.2021.0295.
221. Montgomery MC, Baylan S, Gardani M. Prevalence of insomnia and insomnia symptoms following mild-traumatic brain injury: A systematic review and meta-analysis. Sleep Med Rev. 2022;61:101563. doi: 10.1016/j.smrv.2021.101563.
222. Wickwire EM, Albrecht JS, Capaldi VF, 2nd, Jain SO, Gardner RC, Werner JK, et al. Trajectories of insomnia in adults after traumatic brain injury. JAMA Netw Open. 2022;5(1):e2145310. doi: 10.1001/jamanetworkopen.2021.45310.
224. Oyegbile TO, Delasobera BE, Zecavati N. Gender differences in sleep symptoms after repeat concussions. Sleep Med. 2017;40:110-5. doi: 10.1016/j.sleep.2017.09.026.
227. Kalmbach DA, Conroy DA, Falk H, Rao V, Roy D, Peters ME, et al. Poor sleep is linked to impeded recovery from traumatic brain injury. Sleep. 2018;41(10). doi: 10.1093/sleep/zsy147.
228. Wickwire EM, Schnyer DM, Germain A, Williams SG, Lettieri CJ, McKeon AB, et al. Sleep, sleep disorders, and circadian health following mild traumatic brain injury in adults: review and research agenda. J Neurotrauma. 2018;35(22):2615-31. doi: 10.1089/neu.2017.5243.
229. Chan LG, Feinstein A. Persistent sleep disturbances independently predict poorer functional and social outcomes 1 year after mild traumatic brain injury. J Head Trauma Rehabil. 2015;30(6):E67-75. doi: 10.1097/HTR.0000000000000119.
230. Mollayeva T, Sharma B, Vernich L, Mantis S, Lewko J, Gibson B, et al. Sleep before and after work-related concussion: Sex differences in effects and functional outcomes. Work. 2020;67(4):927-38. doi: 10.3233/WOR-203343.
231. Sullan MJ, Crocker LD, Thomas KR, Orff HJ, Davey DK, Jurick SM, et al. Baseline sleep quality moderates symptom improvement in veterans with comorbid PTSD and TBI receiving trauma-focused treatment. Behav Res Ther. 2021;143:103892. doi: 10.1016/j.brat.2021.103892.
232. Tkachenko N, Singh K, Hasanaj L, Serrano L, Kothare SV. Sleep disorders associated with mild traumatic brain injury using Sport Concussion Assessment Tool 3. Pediatr Neurol. 2016;57:46-50 e1. doi: 10.1016/j.pediatrneurol.2015.12.019.
233. Kraemer Y, Maki K, Marinkovic I, Nybo T, Isokuortti H, Huovinen A, et al. Post-traumatic headache after mild traumatic brain injury in a one-year follow up study – risk factors and return to work. J Headache Pain. 2022;23(1):27. doi: 10.1186/s10194-022-01398-9.
234. Skandsen T, Stenberg J, Follestad T, Karaliute M, Saksvik SB, Einarsen CE, et al. Personal factors associated with postconcussion symptoms 3 months after mild traumatic brain injury. Arch Phys Med Rehabil. 2021;102(6):1102-12. doi: 10.1016/j.apmr.2020.10.106.
235. Anderson JFI, Jordan AS. An observational study of the association between sleep disturbance, fatigue and cognition in the post-acute period after mild traumatic brain injury in prospectively studied premorbidly healthy adults. Neuropsychol Rehabil. 2021;31(9):1444-65. doi: 10.1080/09602011.2020.1781665.
236. Brett BL, Meier TB, Savitz J, Guskiewicz KM, McCrea MA. Research letter: Sleep mediates the association between prior concussion and depressive symptoms. J Head Trauma Rehabil. 2021;36(4):E284-E8. doi: 10.1097/HTR.0000000000000663.Adapted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
237. Barlow Karen M, Brooks Brian L, Esser Michael J, Kirton A, Mikrogianakis A, Zemek Roger L, et al. Efficacy of melatonin in children with postconcussive symptoms: A randomized clinical trial. Pediatrics. 2020;145(4). doi: 10.1542/peds.2019-2812.
238. Grima NA, Rajaratnam SMW, Mansfield D, Sletten TL, Spitz G, Ponsford JL. Efficacy of melatonin for sleep disturbance following traumatic brain injury: a randomised controlled trial. BMC medicine. 2018;16(1):8. doi: 10.1186/s12916-017-0995-1.Adapted29 Further information on providing education about sleep disturbance is available from the RACGP.
Box E: Sleep hygiene suggestions could include: – Get up at same time each day
– Go to bed only when sleepy
– Stay in bed only when asleep– Do not nap during the day
– Limit caffeine/alcohol/cigarettes at night
– Exercise regularlySource: HANDI RACGP
Supplements
Melatonin is a natural hormone supplement that is used to adjust the body’s internal clock, or circadian rhythm. It has been demonstrated to have efficacy in children with persisting post-concussion symptoms 237 and adults with traumatic brain injury.238
Several supplements have been found useful to promote sleep. Magnesium can cause drowsiness, which can help people to fall asleep. Additionally, dietary zinc has been shown to help increase the amount of quality sleep.
EBR (strong)239-242 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
237. Barlow Karen M, Brooks Brian L, Esser Michael J,
Kirton A, Mikrogianakis A, Zemek Roger L, et al. Efficacy of melatonin in
children with postconcussive symptoms: A randomized clinical trial. Pediatrics.
2020;145(4). doi: 10.1542/peds.2019-2812.
238. Grima NA, Rajaratnam SMW, Mansfield D, Sletten TL, Spitz G, Ponsford JL. Efficacy of
melatonin for sleep disturbance following traumatic brain injury: a randomised
controlled trial. BMC medicine. 2018;16(1):8. doi: 10.1186/s12916-017-0995-1.
239. Barlow KM, Kirk V, Brooks B, Esser MJ, Yeates KO, Zemek R, et al. Efficacy of melatonin for sleep disturbance in children with persistent post-concussion symptoms: secondary analysis of a randomized controlled trial. J Neurotrauma. 2021;38(8):950-9. doi: 10.1089/neu.2020.7154.
240. Srisurapanont K, Samakarn Y, Kamklong B, Siratrairat P, Bumiputra A, Jaikwang M, et al. Blue-wavelength light therapy for post-traumatic brain injury sleepiness, sleep disturbance, depression, and fatigue: A systematic review and network meta-analysis. PLoS ONE. 2021;16(2):e0246172. doi: 10.1371/journal.pone.0246172.
241. Bajaj S, Vanuk JR, Smith R, Dailey NS, Killgore WDS. Blue-light therapy following mild traumatic brain injury: effects on white matter water diffusion in the brain. Front Neurol. 2017;8:616. doi: 10.3389/fneur.2017.00616.
242. Raikes AC, Dailey NS, Forbeck B, Alkozei A, Killgore WDS. Daily morning blue light therapy for post-mTBI sleep disruption: effects on brain structure and function. Front Neurol. 2021;12:625431. doi: 10.3389/fneur.2021.625431.Adapted29 EBR (conditional)243 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
243. Connolly LJ, Rajaratnam SMW, Murray JM, Spitz G, Lockley SW, Ponsford JL. Home-based light therapy for fatigue following acquired brain injury: a pilot randomized controlled trial. BMC Neurol. 2021;21(1):262. doi: 10.1186/s12883-021-02292-8.Adapted29 N/A New
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is established as the treatment of choice for sleep-wake disorders following mTBI/concussion.244-246 If CBT provided by a licensed practitioner is not available, remote delivery of CBT and self-management strategies are also effective to reduce sleep wake disturbances. CBT for persistent insomnia incorporates:
- sleep restriction: limiting time spent in bed during the day
- stimulus control: build associations between the bedroom and sleep
- relaxation: e.g. deep breathing, progressive muscular relaxation
- cognitive therapy: address thoughts, beliefs, and attitudes related to sleep and consequences of sleep problems
- meditation
EBR (conditional)244, 245 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
244. Sullivan KA, Blaine H, Kaye SA, Theadom A, Haden C, Smith SS. A systematic review of psychological interventions for sleep and fatigue after mild traumatic brain injury. J Neurotrauma. 2018;35(2):195-209. doi: 10.1089/neu.2016.4958.
245. Theadom A, Barker-Collo S, Jones K, Dudley M, Vincent N, Feigin V. A pilot randomized controlled trial of on-line interventions to improve sleep quality in adults after mild or moderate traumatic brain injury. Clin Rehabil. 2018;32(5):619-29. doi: 10.1177/0269215517736671.
246. Ymer L, McKay A, Wong D, Frencham K, Grima N, Tran J, et al. Cognitive behavioural therapy versus health education for sleep disturbance and fatigue after acquired brain injury: A pilot randomised trial. Ann Phys Rehabil Med. 2021;64(5):101560. doi: 10.1016/j.rehab.2021.101560.Adapted29 For virtual CBT resources, please view the following: Shut-I: Online application offering CBT-I, CBT-I coach, Sleep Foundation.
Additional resources are available from the Western Australian government, Sleep Therapy Australia, ThisWayUp, and Calm.
Pharmacological treatment
Short-term pharmacological treatment options can be used in people with post-concussive sleep disturbances to establish a more routine sleep-wake pattern using agents with minimal risk of dependency and adverse effects.
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29
Receiving adequate sleep has been shown to facilitate health140 and, when not adequate, adversely affects medical conditions, including TBI.103-105 Maintenance of appropriate sleep and the management of disrupted sleep may be a critical target of treatment for the people with mTBI/concussion.106-108
EBR (conditional)103-108 4. Lumba-Brown A, Yeates Keith O, Sarmiento K, Breiding Matthew J, Haegerich Tamara M, Gioia Gerard A, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):1-13. doi: 10.1001/jamapediatrics.2018.2853.
103. Baumann CR, Werth E, Stocker R, Ludwig S, Bassetti CL. Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study. Brain. 2007;130(Pt 7):1873-83. doi: 10.1093/brain/awm109.
104: Owens JA, Mindell JA. Pediatric insomnia. Pediatr Clin North Am. 2011;58(3):555-69. doi: 10.1016/j.pcl.2011.03.011.
105. Venter R. Role of sleep in performance and recovery of athletes: a review article. S Afr J Res Sport Phys Educ Recreation. 2012;34(1):167–84. doi:
106. Kemp S, Biswas R, Neumann V, Coughlan A. The value of melatonin for sleep disorders occurring post-head injury: a pilot RCT. Brain Inj. 2004;18(9):911-9. doi: 10.1080/02699050410001671892.
107. Broglio SP, Macciocchi SN, Ferrara MS. Neurocognitive performance of concussed athletes when symptom free. J Athl Train. 2007;42(4):504-8.
108. Mollayeva T, Pratt B, Mollayeva S, Shapiro CM, Cassidy JD, Colantonio A. The relationship between insomnia and disability in workers with mild traumatic brain injury/concussion: insomnia and disability in chronic mild traumatic brain injury. Sleep Med. 2016;20:157–66.Adapted4
Fatigue
Fatigue may be perceived as a lack of mental or physical energy which may impair daily functional activities. A standardised scale is appropriate when symptoms of fatigue are suspected. Symptoms of fatigue following mTBI/concussion are common247 and are associated with a constellation of disabling symptoms which may lead to poor outcomes post-injury.248, 249 250 Acute fatigue can be associated with mTBI/concussion. Fatigue that lasts longer than 1 month requires further assessment for medical and psychological comorbidities. The management of acute fatigue or chronic fatigue where comorbidities have been excluded should include the management of insomnia, and encourage gradual return to activities of daily living, maintenance of interpersonal relationships, and return to school and work and activity.
Due to the complex interplay of concurrent symptoms, fatigue may persist and be exacerbated by an array of other contributing factors. These may include mood disorders, sleep disturbances, post-traumatic migraine, metabolic diseases, endocrine disorders, cognitive slowing, electrolyte abnormalities,251 consequences of adverse effects of medications and supplements,252 polypharmacy, alcohol, substance use, and/or nutritional deficiencies.29
EBR (conditional)186, 210, 253 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
186. Rakers SE, Timmerman ME, Scheenen ME, de Koning ME, van der Horn HJ, van der Naalt J, et al. Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study. Arch Phys Med Rehabil. 2021;102(10):1965-71 e2. doi: 10.1016/j.apmr.2021.06.004.
210. Meltzer KJ, Juengst SB. Associations between frequent pain or headaches and neurobehavioral symptoms by gender and TBI severity. Brain Inj. 2021;35(1):41-7. doi: 10.1080/02699052.2020.1857438.
253. Andelic N, Roe C, Brunborg C, Zeldovich M, Lovstad M, Loke D, et al. Frequency of fatigue and its changes in the first 6 months after traumatic brain injury: results from the CENTER-TBI study. J Neurol. 2021;268(1):61-73. doi: 10.1007/s00415-020-10022-2.Adapted29 Characteristics – Frequency
– Intensity
– Time of day
– Type of fatigue (i.e. physical or cognitive)
– Aggravating factors (i.e. physical activity, cognitive load, social and environmental exposure)Assessment – Focused history
– Validated scale to assess fatigue (i.e. Barrow Neurological Institute Fatigue Scale, Fatigue Severity Scale)
– Consider blood test screening if appropriate (CBC, TSH, electrolytes)Contributing causes of fatigue – Affective disorder, including depression, anxiety
– Sleep disorder
– Cognitive slowing and attentional problems
– Metabolic causes, including hypothyroidism, anaemia or chronic disease (e.g. rheumatoid arthritis)
– Electrolyte abnormality (e.g. hyponatraemia, hypocalcaemia etc.)
– Polypharmacy and medication adverse effect
– Nutritional statusSource: Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 Additional information on assessment of fatigue is available from the RACGP and BMJ Best Practice.
Various behavioural management strategies may be employed to reduce symptoms of fatigue in people with mTBI/concussion.254 For example, distributing activities and breaks across the day may assist people to achieve more without exceeding tolerance levels.250, 254 This may be facilitated with the use of a notebook or diary to plan and record activities. Self-monitoring and planning may also aid in identifying patterns of fatigue and contributing factors.254 Good sleep management strategies, such as regular sleep-wake schedules and avoidance of stimulants and alcohol may also be of benefit (see Section 4.2).
EBR (strong)244, 254, 255 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
244. Sullivan KA, Blaine H, Kaye SA, Theadom A, Haden C, Smith SS. A systematic review of psychological interventions for sleep and fatigue after mild traumatic brain injury. J Neurotrauma. 2018;35(2):195-209. doi: 10.1089/neu.2016.4958.
254. Caldwell JA, Caldwell JL, Thompson LA, Lieberman HR. Fatigue and its management in the workplace. Neurosci Biobehav Rev. 2019;96:272-89. doi: 10.1016/j.neubiorev.2018.10.024.
255. Ali A, Morfin J, Mills J, Pasipanodya Elizabeth C, Maas Yvonne J, Huang E, et al. Fatigue after traumatic brain injury: A systematic review. J Head Trauma Rehabil. 2021.Adapted29
Cognitive Behavioural therapy
Cognitive behavioural therapy may be used successfully to address fatigue as well as sleep disturbance following traumatic brain injury.246, 256 Such therapy focuses on monitoring and adjusting the daily routine to intersperse periods of activity with rest, often requiring adjustment of ways of thinking about activity levels, and learning specific strategies to manage cognitive slowing.
Melatonin
Melatonin is a natural hormone supplement that is used to help regulate the body’s internal clock, or circadian rhythm. Taking 2–5mg of melatonin 2 hours before bedtime can help restore sleep and improve daytime alertness.255
EBR (conditional)255 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
255. Ali A, Morfin J, Mills J, Pasipanodya Elizabeth C, Maas Yvonne J, Huang E, et al. Fatigue after traumatic brain injury: A systematic review. J Head Trauma Rehabil. 2021.Adapted29
Blue wavelength light therapy
Daily morning blue light therapy for 30 minutes over the course of 6 weeks may reduce daytime sleepiness following mTBI/concussion.240, 257
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29
Interdisciplinary approaches to mTBI/concussion treatment may be effective. People with post-concussive fatigue may benefit from referral to an interdisciplinary mTBI/concussion clinic wherein practitioners from multiple disciplines coordinate care by providing diagnostic, educational, physical, cognitive, functional and emotional support.147, 258-260 Interventions that may be effective in individuals with symptoms of fatigue include cognitive behavioural therapy, psychoeducation, psychotherapy, and exercise.182
EBR (conditional)255 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
255. Ali A, Morfin J, Mills J, Pasipanodya Elizabeth C, Maas Yvonne J, Huang E, et al. Fatigue after traumatic brain injury: A systematic review. J Head Trauma Rehabil. 2021.Adapted29
Additional resources to assist with sleep/fatigue include the “Four Ps”, strategies to promote good sleep and alertness and “Sleep for Youth”.