Sleep disturbances are a very common complaint seen with concussions in both the adult and pediatric populations. Headaches and dizziness are also common symptoms with a concussion, and they can contribute to difficulty falling asleep, trouble staying asleep, or both which leads to drowsiness during the day. This can make afternoon naps seem like a good option but frequent napping can actually compound the problem by disrupting the normal sleep/wake cycle, called the circadian rhythm. This results in poor nighttime sleep that decreases the quality of brain rest. Why does this matter? Brain rest is essential for brain recovery, even brain recovery from normal daily activities and learning. In the setting of a concussion, if brain rest is impaired it can delay recovery resulting in lingering of symptoms, particularly headache and dizziness which continue to make it difficult to get a good night’s sleep. It can be a vicious cycle extending recovery time and preventing you or your child from getting back to normal activities. So what can be done to stop this cycle? The good news is that there are several relatively easy changes that can be made to help prevent sleep from being a roadblock on the path to concussion recovery. The following are just a few examples of how you can set yourself up for sleep success.
The first step to sleeping better is sleeping, better. Wait, what? This is called sleep hygiene and involves developing a bedtime routine with a regular bedtime and an environment for restful sleep.
Developing a sleep schedule
Establishing a regular bedtime & wakeup schedule, including weekends, is important for protecting the circadian rhythm and preventing disruption. The circadian rhythm is your body’s normal sleep-wake cycle, following the cycling of nighttime and daytime periods. This is what tells your body to sleep at night and be awake during the day. The cycle is sensitive to disruptions like traveling, illness or even just changes in normal behaviors, in addition to head injury or concussion. Disruption in this schedule can make it difficult to sleep at “normal” times. Part of resetting the cycle involves maintaining a regular schedule. Early on in the concussion recovery, it can be difficult to fall asleep and stay asleep, lowering the quality and duration of nighttime sleep. However, after a few nights of building sleep debt, it will be easier for your brain to fall asleep and rest, helping to reinforce this wake-sleep cycle. Additionally, your brain recovers best when it gets consolidated sleep at night, rather than taking long daytime naps that confuse the sleep-wake cycle.
While rest is important and we definitely want to ensure that there is plenty of brain rest, there is such a thing as getting too much of a good thing. Maintaining the same schedule over the weekend will help avoid re-disrupting the circadian rhythm, and help avoid the struggle of changing from a more relaxed weekend schedule to a more regular weekday schedule. This will make the waking hours more beneficial as well.
Return to learn precautions with concussions are intended to avoid maxing out the cognitive load. Sometimes we push a little beyond our capacity and end up exhausted at the end of the day. A short nap to give the brain a break is appropriate and sometimes necessary, but these naps should be limited to 30-45 minutes in duration. This helps prevent the onset of REM sleep, which will only confuse the circadian rhythm yet again.
Limiting screens and sleep distractions are part of creating an environment conducive to restful sleep. The actual environment of the room also plays an important role. The room should be kept relatively dark which means eliminating extra lights. Similar to limiting screen time, this decreases the stimulus load stressing the brain. A low-level nightlight for comfort is completely acceptable, just try to limit light from outside with curtains and remove or relocate electronics (computers, TVs, tablets, phones, etc) that give off an extra glow.
In addition to light, room temperature is also a factor for sleep quality. Warm rooms may make us feel drowsy, but for a better quality of sleep, its actually better if the room is a little on the cool side. 75 degrees is considered by most to be an ideal room temperature for quality sleep. While a cool room is good for sleep, you shouldn’t be shivering while you sleep either. Adding a pair of socks can help keep you warm while the room stays cool and helps you fall asleep faster.
Screen time is often a trigger for concussion symptoms, such as headaches and dizziness, and should be limited for patients with a concussion to avoid exacerbating symptoms. Make sure to limit the amount of screen time during the day, and particularly avoid screen time 1-2 hours before bed. By avoiding triggering symptoms, such as headache, sleep should be easier to initiate and maintain. Avoiding screens before bed also allows the brain to transition from stimulation to rest mode. Maintaining this pattern of avoiding screens will reinforce your body’s circadian rhythm and make falling asleep easier. Turn off TVs or tablets at least 30 minutes before sleep and keep them out of the sleeping area. Do not plug phones in next to the bed or do any last-minute Facebook updates or Instagram, or go on “Candy Crush sprees” before turning the lights out.
If sleep continues to be a struggle in your recovery despite taking measures to address proper sleep hygiene, talk to your doctor about what additional steps might be necessary for you to get the rest you need. Additional information about concussions, symptoms, and triggers to avoid can be found in the SPARCC patient handouts for children and adults.
By Christine Gage & Jon Minor, MD
Sleep Hygiene: Healthy Sleep Habits for Children and Adolescents; Owens K, Mindell J.; A Clinical Guide to Pediatric Sleep, 2nd edition
Sleep Disturbance and Neurocognitive Function During the Recovery from a Sport-Related Concussion in Adolescents; Kostyun, Matthew and Imran; The American Journal of Sports Medicine Vol 43 Issue 3 pp 633-640
Screen time and sleep among school-aged children and adolescents: A systematic literature review; Hale and Guan; Sleep Medicine Reviews Vol 21 pp 50-58
Light level and duration of exposure determine the impact of self-luminous tablets on melatonin suppression; Wood, Rea, Plitnick, and Figueiro; Applied Ergonomics Vol 44 Issue 2 pp 237-240
Sleep Disturbances in Athletic Concussion; Jaffee, Winter, Jones and Ling; Brain Injury Vol 29 Issue 2