Poor Sleep After Concussion Signals Longer Recovery

Fran Lowry

November 05, 2018

ORLANDO, Florida — Children who suffer poor sleep quality after a sports-related concussion take almost twice as long to recover than such patients whose sleep is considered good, results from a new study suggest.

Dr Jane Chung

For patients whose quality of sleep was poor, symptoms were also more severe, both at initial presentation and at 3-month follow-up, compared to their counterparts.

"Sleep is important. It plays a crucial role in physical, mental, and cognitive function and also in concussion recovery," said lead author Jane Chung, MD, from the Texas Scottish Rite Hospital for Children in Dallas, Texas.

"For clinicians, recognizing those athletes with poor sleep quality at the initial visit may help them predict those at risk for a more prolonged recovery," she said here at the American Academy of Pediatrics (AAP) 2018 National Conference.

Chung and her colleagues reviewed prospectively collected data on 356 participants seen between October 2015 and June 2017 who were enrolled in the North Texas Concussion Network Prospective Registry.

The participants were treated at 1 of 4 outpatient clinics in North Texas that specialized in concussions. They were included in the analysis if they had been diagnosed with a sports-related concussion and were younger than 19 years at enrollment.

Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). According to PSQI guidelines, a composite score of ≤5 of a possible total score of 21 indicates good sleep quality; poor sleep quality is indicated by a score of >5.

Girls and boys were equally represented in the study, with 180 girls (50.6%) and 176 boys (49.4%). The mean age of the participants was 14 years (range, 7 to 18 years).

Most of the participants (n = 261, 73.3%) had good sleep quality, with a PSQI composite score ≤5 at their initial clinic visit, but 95 participants (26.7%) had scores >5, indicating poor sleep quality.

The poor-sleep group also had a higher total symptom score, as measured by the Sport Concussion Assessment Tool 3 (SCAT3).

Table. Sleep Scores, Symptom Severity, and Time to Resolution

Mean Score Poor Sleep Group Good Sleep Group P Value
PSQI at baseline 8.7 2.6 <.0001
PSQI at 3 months 5.7 3.0 <.0001
SCAT3 at baseline 39.2 20.4 <.0001
SCAT3 at 3 months 12.2 5.2 <.0001
Time to symptom resolution 0 – 14 days >30 days <.0001


Participants in the poor-sleep group also experienced more fatigue, drowsiness, and trouble falling asleep, as indicated on the SCAT3, at both the initial visit and the 3-month follow-up when compared with the good-sleep group (P <.01).

More girls (61%) had poor sleep than boys (38.9%, P = .02).

Dr Cynthia LaBella

"This study alerts clinicians to the fact that sleep symptoms are common among young athletes with concussion and that it is definitely a topic they should discuss with their patients when they come in for concussion evaluation," said Cynthia LaBella, MD, from Northwestern University's Feinberg School of Medicine and the Institute for Sports Medicine, Ann amd Robert H. Lurie Children's Hospital of Chicago, in Illinois.

Ask About Sleep

Sleep can be affected in several ways following a concussion, LaBella, who is chairperson of the AAP Council on Sports Medicine and Fitness, told Medscape Medical News.

Some people are excessively sleepy and sleep more than usual, whereas others have a hard time falling asleep at night or wake up frequently during the night and then wake up tired, she said. They are then "completely wiped out after school and take a 4-hour nap, which just compounds the problem about falling asleep at night, as it shifts their sleep cycle."

Adolescents are particularly prone to such disruptions because their circadian rhythm is different, she explained. "Their cortisol levels peak at a different time, and this is unique to adolescents. That's why teenagers are night owls naturally. They stay up later and sleep in later, and it's all biological."

These are the majority of youth who experienced concussions in this study, "and in my experience, it seems they are almost set up for having sleep issues disrupt their rhythm and their daily routine," she added.

Sleep hygiene tips may help.

LaBella advised that youth who experience concussions avoid using screens or electronics 30 to 60 minutes before bed and that they avoid doing homework, talking on the telephone, or engaging in other activities in bed besides sleep. However, "it's OK to read a chapter of a book, because there is something different about reading words on a page rather than on a screen," she said.

She also suggests limiting caffeine intake, especially after noon, and going to bed at the same time every night.

Children should be encouraged to take it easy during the school day, she added, and naps should be limited to no more than 30 minutes, because sleeping excessively during the day can upset sleep patterns at night.

"They don't necessarily have to sleep," she told Medscape Medical News. "They could go to a quiet place and just relax, and that can help limit the need for that big long nap."

In the end, good sleep quality is important for recovery, regardless of the injury.

"No matter if it's a concussion or a knee sprain or an ankle sprain — it's super important to talk about sleep with your patients, and this study is a great reminder of that," LaBella said.

Funding for the study was provided by the Texas Institute for Brain Injury and Repair at Univeristy of Texas Southwestern Medical Center. Dr Chung and Dr LaBella report no relevant financial relationships.

American Academy of Pediatrics (AAP) 2018. Presented November 3, 2018.

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