Sleep disturbance and fatigue

    • CBR30. 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
    • CBR29. 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
    • CBR29. 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
    • CBR29. 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
    • EBR (conditional)164, 186, 218, 220, 224, 227, 229-23629. 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
    • CBR29. 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
    • CBR29. 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
    • 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 regularly
      Source: HANDI RACGP
    • EBR (strong)239-24229. 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)24329. 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
    • 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, 24529. 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
    • CBR29. 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
    • EBR (conditional)103-1084. 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
    • EBR (conditional)186, 210, 25329. 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 status
      Source: 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
    • EBR (strong)244, 254, 25529. 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
    • EBR (conditional)25529. 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
    • CBR29. 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
    • EBR (conditional)25529. 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