The Importance of Sleep after a Brain Injury

Disturbance of healthy sleep patterns is a well-known impact of a traumatic brain injury (TBI). Sleep is important for everyone, but insufficient sleep after a brain injury may intensify post-injury symptoms and can even impair long-term recovery outcomes ⁽¹⁾. Studies show that sleep disturbances can occur in up to 85% of brain injury survivors ⁽²⁾.

This means what we need most can be just out of reach for us. I’ve posted before on sleep hygiene and its importance for all brain injury survivors. Last week, I was reminded of just how important my sleep is. I bought a pickup truck after being without one for several months. In the middle of the night, after I bought the truck, I woke up and my brain turned on, thinking about all the projects I can finally complete now that I have a truck again. Still awake at 4:00 am, I decided to go ahead and get out of bed, even though I’d only had about four hours of sleep. That was a particularly challenging day for me, and I ended up taking a half day off of work.

That was an unusual circumstance, but it makes me grateful for the quality of sleep I have on most nights. Getting to a point where I could consistently have restful sleep required that I develop a daily practice of good sleep hygiene.

How Much Sleep is Right?

Age is an important indicator of our sleep requirements. Babies need about 12 to 18 hours of sleep each day, which often happens in short intervals, and about 50% of their time is in REM sleep. Children tend to need around 10 hours, with teenagers needing 8 to 9, and adults only require 7 to 8 hours. A brain injury can change this dramatically; I can tell you that in the first years after my injury, I only felt rested when I hit or exceeded the 10-hour mark.

Sleep Cycles

When we sleep, we cycle through four different stages of sleep that consists of both rapid-eye-movement (REM) and non-rapid eye movement (NREM) sleep. These cycles average around 90 minutes in each stage, and we average four to six cycles each night until we wake.

There are three different NREM cycles characterized by how deep our sleep is, called N1, N2 and N3, with N1 being the lightest. This is when we first drift off, and our muscles are still alert, our breathing occurring at a regular rate as if we were awake. When our heart rate and body temperature drop and our brain activity slows a bit, this is N2. N3 is our deepest stage of sleep and is when much of our physical healing occurs.

Finally, there is the REM sleep cycle, associated with dreaming. Our brains become highly active, similar to awake levels, but our voluntary muscle system is mostly shut down so that we don’t react physically to our dreams. It is believed that this stage of sleep is important for memory consolidation.

Everyone Sleeps Differently

When we call an end to our day and go to bed, some of us are fortunate and can fall sleep quickly, others may take a while. My wife can be in bed sometimes an hour or more before drifting off, whereas I’m typically asleep anywhere from 5 to 15 minutes after lying down.

We both wear smart watches that have a sleep tracking function. Our watches use a sensor that detects heart rate and uses heart rate variability to determine our breathing rate. The app then uses these measurements to identify sleep stages through the night. I take some of it with the proverbial grain of salt because it will sometimes report we were sleeping lightly when we were awake but lying still.

My typical sleep record shows that within about 15 to 30 minutes of drifting off I enter a deep sleep phase that usually runs for about 45 minutes to an hour before beginning to cycle through light and REM sleep stages. Marcie often sees her deep sleep cycle split into two or three periods through the night. As interesting as our sleep records are to review, the true measure of how good our sleep was is how rested we feel the next morning.

Sleep Disturbances after a Brain Injury

A brain injury can have a number of significant impacts on our sleep. Studies show reduced sleep efficiency, shorter total sleep time, and increrased wake after sleep onset times ⁽³⁾⁽⁴⁾. TBI patients tend to spend less time in REM sleep, and this is still true for me. My sleep tracking app shows that my REM sleep typically comes in between 50% to 75% of the typical range. One morning a few weeks back I woke feeling especially energized and awake. My app showed that my REM sleep was in the typical range the previous night – so I’ve learned that my REM sleep can make a big difference in how I feel the next day.

Studies show that there is a strong relationship between sleep quality and TBI patient rehabilitation outcomes.

Getting Better Sleep

The foundation of better-quality sleep is having a consistent daily sleep routine. This starts with going to sleep and getting up at the same time each day. Stay away from caffeinated beverages later in the day. And if you do choose to enjoy an alcoholic drink in the evening, remember that while alcohol may help you fall asleep, it can also disrupt your sleep cycle later in the night.

A practice of no screen time at least 30 minutes before bed can also make a difference. The blue wavelengths of light emitted by your phone, computer screen, television, and even energy efficient lights are disruptive to our circadian rhythms and can make it more difficult to fall asleep. In addition, studies are even showing light exposure at night to be detrimental to our health, potentially contributing to obesity, diabetes, and even cancer ⁽⁵⁾⁽⁶⁾. Having a dark and quiet bedroom at a comfortable temperature is essential to efficient sleep. Remember that even a small nightlight in your bedroom can negatively impact your sleep cycles. Wearing a sleeping mask can help reduce the impact of light on your sleep.

Eating Before Bed

Studies show that eating right before bed can impact how long it takes us to go to sleep and how much deep sleep we get. Eating a large meal before bed can increase nocturnal awakenings and adversely affect sleep quality. That said, there are studies showing that eating kiwi fruit before bed improves both sleep quality and duration. I plan to give this one a try, I really like kiwi fruit – and if it can improve my sleep, it’s a win-win situation.

Pink Noise

We live close to the road, so road noise is something we contend with. A few months back, I started using a pink noise track at night to help mask such noises. Pink noise is similar to white noise, but with deeper frequencies similar to steady rain, a gentle waterfall, or perhaps rustling leaves. Nature is full of pink noise. The pink noise not only masks background noises, but it’s also shown to increase our deep sleep time ⁽⁷⁾. You can find many pink noise tracks across the internet, and there are also pink noise generator devices you can use. My meditation app (Insight Timer) has several that I can start up on my phone as I’m going to bed. I find that it makes a real difference in both going to sleep and staying asleep.

In Closing

Ok, I see now that I could keep going here and write several pages on this topic, so I’ll reserve some material for my next post on sleep. The key take-aways here include that sleep is critical for our recovery from a brain injury, and that the changes in our sleep patterns may last a long time. Practicing proper sleep hygiene is so important for all brain injury survivors.

Resources

1. Emerson M. Wickwire, Scott G. Williams, Thomas Roth, Vincent F. Capaldi, Michael Jaffe, Margaret Moline, Gholam K. Motamedi, Gregory W. Morgan, Vincent Mysliwiec, Anne Germain, Renee M. Pazdan, Reuven Ferziger, Thomas J. Balkin, Margaret E. MacDonald, Thomas A. Macek, Michael R. Yochelson, Steven M. Scharf, and Christopher J. Lettieri, (2016), Sleep, Sleep Disorders, and Mild Traumatic Brain Injury. What We Know and What We Need to Know: Findings from a National Working Group
2. Emerson M. Wickwire, PhD, FAASM, (2020), Why Sleep Matters After Traumatic Brain Injury
3. Natalie Grima, DPsych, Jennie Ponsford, PhD, Shantha M. Rajaratnam, PhD, Darren Mansfield, MD, PhD, Matthew P. Pase, PhD, (2016), Sleep Disturbances in Traumatic Brain Injury: A Meta-Analysis
4. Alex Lowe, Aidan Neligan, Richard Greenwood, (2020), Sleep Disturbance and Recovery During Rehabilitation After Traumatic Brain Injury: A Systematic Review
5. Giulia Fleury, Anayanci Masís‐Vargas, and Andries Kalsbeek, (2020), Metabolic Implications of Exposure to Light at Night: Lessons from Animal and Human Studies
6. Redhwan A. Al-Naggar and Shirin Anil, (2016), Artificial Light at Night and Cancer: Global Study
7. Junhong Zhou, Dongdong Liu, Xin Li, Jing Ma, Jue Zhang, Jing Fang, (2012), Pink Noise: Effect on Complexity Synchronization of Brain Activity and Sleep Consolidation