We note a high percentage of athletes who come to a post-injury assessment after 7 or less hours of sleep. Limited sleep can interfere in assessment results whether injured or not. Sleep may be one of the most important treatments to aid in recovery of concussion; however, there are several issues to consider. Sleep in recovery is a big deal, but little is known.
Is poor sleep as cause or effect of response to injury?
There is very little evidence to answer this question; however, sleep is a universal medicine and so the answer may be irrelevant.
In a small sample of youth (11 concussed, 9 controls, mean age 12, median of 5 days post-injury) matched for age, sex and race, we examined one night of sleep of these recently concussed participants (in their homes) using actigraphy, rating scales and three salivary samples analyzed for melatonin and cortisol via enzyme-linked immunoassays.*
The salivary melatonin and cortisol showed upon waking (marginally significant). Sleep metrics of the injured group indicated poorer sleep quantity and quality, with sleep latency six times longer in the injured group than the controls. Further, the injured youth endorsed high levels of injury-related stress. This perceived stress also significantly correlated with fatigue ratings and length of sleep onset (latency). While the small sample sizes impacted results, partial support for a relationship between perceived stress, fatigue, and both biological and behavioral measures of sleep following concussion was indicated.
This study raises the question of the role of anxiety in sleep and recovery. It is well known that anxiety interferes in recovery. It is also known that anxiety affects sleep. The stress of injury, both physically and psychologically likely impacts sleep onset. Whether autonomic responses to injury interfere in other aspects of sleep is not yet known, but encouraging sleep seems to be important.
Sleep schedules and disrupting natural routines
We recommend napping during early stages of recovery. Admittedly, there is little data on this. Some say that napping will interfere in normal sleep patterns. That is something to consider, but as with all chronic sleep debt in children, making it up is seen as useful. Chronic sleep debt is a very large problem in schools where adolescents start the day too early to accommodate normal circadian sleep rhythms. We recommend later start times when feasible (transportation, work schedules, etc).
Social activities and sleep
One of the unforeseen consequences of concussion and being in a concussion protocol is the effect on social relationships. Bullying has been identified as a problem for both male and female athletes when concussed, so maintaining relationships is important. Further, not being able to maintain usual activity levels is a known contributor to depression in youth. Thus, finding ways to maintain some team activity without interfering in recovery is an important goal. Sleep is one of those things that should not be disrupted any more than necessary.
Some practice caveats: Attending practices is risky (and the goal of management is to reduce risk of re-injury). Attending early morning practices is not helpful from a sleep perspective. Anecdotally, it seems athletes who stand on the sidelines are magnets for balls, pucks, sticks. Also, the noise and lighting may increase symptoms. Attendance at practices can be good thing, but needs to be monitored.
Social media is another sleep-interfering activity. Again, limiting social contact should be done on the basis of its effects on the student. Much social activity – even face to face – involves keeping one eye on a phone or screen. If screen viewing is generally symptom-exacerbating, then this should be limited. But keeping the phone by the bed and interacting past 10 or 11 PM will interfere in sleep (10-11 is the normal time Circadian rhythms produce melatonin for sleep in adolescents).
Current knowledge supports the idea that recovering from a concussion is supported by sleep. If the student feels tired, fatigued, or sleepy, they should sleep. This is particularly true in the first 1-2 weeks of recovery. Assessing sleep hygiene should be a part of the concussion assessment protocol. However, if napping begins to make night-time sleep problematic, reducing naps makes sense. While symptomatic, starting school later (rather than skipping school altogether) is a more appropriate procedure as it supports an active rehabilitation approach. If sleep continues to be problematic, and hygiene appears appropriate, referral to a sleep specialist is recommended. Facilitating sleep medically may improve the body’s ability to restore equilibrium and recovery.
* Study funded by Nebraska Research Initiative.