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Insomnia following a mild traumatic brain injury: a missing piece to the work disability puzzle?
Accepted Manuscript Title: “Insomnia following a mild traumatic brain injury: a missing piece to the work disability puzzle?” Author: Nadia Gosselin, Catherine Duclos PII: DOI: Reference:
S1389-9457(15)02025-0 http://dx.doi.org/doi: 10.1016/j.sleep.2015.10.011 SLEEP 2931
To appear in:
Sleep Medicine
Please cite this article as: Nadia Gosselin, Catherine Duclos, “Insomnia following a mild traumatic brain injury: a missing piece to the work disability puzzle?”, Sleep Medicine (2015), http://dx.doi.org/doi: 10.1016/j.sleep.2015.10.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Editorial Title: “Insomnia following a mild traumatic brain injury: a missing piece to the work disability puzzle?” Nadia Gosselin1,2 and Catherine Duclos1,3 Affiliations: 1. Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada 2. Department of Psychology, Université de Montréal, Montreal, Canada 3. Department of Psychiatry, Université de Montréal, Montreal, Canada
Submitted to: Sleep Medicine Date: October 27th, 2015 Number of words: 993 Number of references: 17 Address for correspondence: Nadia Gosselin, Ph.D. Center for Advanced Research in Sleep Medicine Hôpital du Sacré-Cœur de Montréal 5400 boul. Gouin Ouest, local E-0330 Montréal, Québec H4J 1C5 Canada Tel: 514-338-2222 ext. 7717 Fax: 514-338-3893 [email protected]
Page 1 of 7
Sleep-wake disturbances are reported by approximately 50% of individuals after a traumatic brain injury (TBI), and insomnia is among the most common sleep disturbances observed in those who have sustained a mild TBI[1, 2]. Although the emergence and evolution of sleep-wake disturbances are still poorly understood, recent evidence has shown that they appear during the acute stage of the injury[3, 4]. Sleep-wake disturbances tend to persist over time[5] and 29% of individuals with TBI still fulfill the insomnia diagnostic criteria several years after their injury.[6] Little is known about how sleep-wake disturbances impact daytime functioning, but studies have pointed to the role of sleep-wake disturbances in predicting cognitive recovery, [4, 7] anxiety, depression and pain after a TBI [3, 8], suggesting a causal role of sleep disturbances in subsequent recovery. In the study by Mollayeva and colleagues published this month in Sleep Medicine [9], the authors investigated the relationship between insomnia and perceived disability among 92 individuals. They were all followed in a rehabilitation hospital after sustaining a mild TBI in the last three months to five years due to a work-related accident. The authors retrospectively analyzed data obtained form medical and insurer’s files as well as from employers’ reports of injury/illness. They also collected sleep and medical information directly from participants. Perceived disability levels regarding work, social life and family life responsibilities were measured by the Sheehan Disability Scale[10] and insomnia was evaluated using the Insomnia Severity Index[11]. At the time of assessment, 57% of participants were on work disability. The authors observed that participants with greater disability reported more insomnia, depression, anxiety, and pain than participants with lower disability. In the adjusted multivariate analysis, controlling for age, sex, depression, and anxiety, the odds of reporting marked/extreme global disability were greater with
Page 2 of 7
increasing insomnia and pain. The odds of perceiving greater disability for work responsibilities increased with insomnia only, independently of age, sex, pain, anxiety and depression. The role of insomnia in predicting disability was only observed for work but not for social or family domains. This well-conducted study brings new and key elements to improve our understanding of disability after a mild TBI. This study shows that insomnia might play a significant role in an individual’s perception of his ability to return to work. Insomnia is defined by dissatisfaction with sleep quantity/quality characterized by a report of difficulty initiating sleep, difficulty maintaining sleep or early morning awakening[12]. The diagnosis of insomnia necessarily implies that sleep disturbances are associated with marked distress or subjective impairment in daytime functioning including the social, occupational or behavioral domains. The behavioral diagnostic criterion is of high importance in our understanding of functional recovery after a TBI, since it specifically suggests that presenting insomnia after a TBI reduces daytime functioning and may impede the return to pre-injury level of functioning. This element is also of high importance for individuals with an injured brain who may be more sensitive to the cognitive consequences of insomnia. Considering that one-third of TBI patients have insomnia and that 60% of them are untreated[6], insomnia may be a missing factor that is vital in understanding chronic disability after TBI. Treating sleep-wake disturbances with individualized treatments including sleep hygiene, pharmacological and/or sleep apnea interventions has already been shown to be associated with a significant improvement in cognitive and communication abilities after TBI[13]. Moreover, in a preliminary study with 11 individuals with TBI, cognitive-behavioral therapy was found to be efficient to reduce insomnia[14].
Page 3 of 7
Future studies should examine whether treatment of sleep-wake disturbances reduces perceived disability and facilitates return to work. On the other hand, perceiving no or lower disability for work probably leads to enhanced psychological well-being, contributing to a lower risk of presenting insomnia. In a study by Ouellet and colleagues among 208 survivors of TBI, those who reported being active through work, studies, or volunteering had lower psychological distress, fatigue and sleep disturbances[15]. Although most studies cannot confirm a causal relationship between psychological well-being, sleep disturbances and disability, a multi-directional link probably exists. Therefore, treating insomnia and encouraging individuals with TBI to be active through work, studies, or volunteering may lower disability. Performing sleep studies among individuals with chronic TBI presents challenges. Many participants have co-morbid conditions including anxiety, depression, post-traumatic stress disorder, pain, orthopedic injury , and intake of medication. Studies generally point to the difficulty in weeding out the role of sleep disturbances when concomitant factors such as depression, anxiety and pain are present [6, 16-18]. Excluding individuals on the basis of these co-morbid conditions would lead to a non-representative sample of TBI participants. A large sample size is therefore required to conduct this type of study. In the study by Mollayeva and colleagues, 92 participants were included and the authors were able to show that, when all other factors were controlled, insomnia stands out as the only factor of significance in relation to perceived work disability, which represents a key finding. However, as discussed by the authors, the lack of significant association between insomnia and perceived disability for social and family life may be explained by an insufficient sample size.
Page 4 of 7
Another challenge encountered in TBI research is the homogeneity of the sample. All participants recruited in the study by Mollayeva and colleagues were workers at the time of their injury [9]. Their diagnosis was confirmed by a physician, and they were all referred to a rehabilitation center; hence, the homogeneity of this study sample represents a strength, enabling these factors to be controlled for. However, the participants were tested between three months and five years post-injury, and we can expect the perceived disability for work responsibilities and its association with psychological well-being to be less strongly related to the TBI as the post-injury delay increases. Nonetheless, the study by Mollayeva and colleagues adds to the growing literature showing that sleep-wake disturbances are associated with psychological, cognitive, and physical dysfunctions after TBI [9]. Treating sleep-wake disturbances may have the potential to improve recovery, work-related outcomes, and quality of life in the TBI population.
Page 5 of 7
References
[1] Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis. Sleep Med. 2012;13:898-905. [2] Ouellet MC, Beaulieu-Bonneau S, Morin CM. Sleep-wake disturbances after traumatic brain injury. Lancet Neurol. 2015;14:746-57. [3] Chaput G, Giguere JF, Chauny JM, Denis R, Lavigne G. Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury. Sleep Med. 2009;10:713-6. [4] Duclos C, Dumont M, Blais H, Paquet J, Laflamme E, de Beaumont L, et al. Rest-Activity Cycle Disturbances in the Acute Phase of Moderate to Severe Traumatic Brain Injury. Neurorehabilitation and neural repair. 2013;28:472-82. [5] Kempf J, Werth E, Kaiser PR, Bassetti CL, Baumann CR. Sleep-wake disturbances 3 years after traumatic brain injury. J Neurol Neurosurg Psychiatry. 2010;81:1402-5. [6] Ouellet MC, Beaulieu-Bonneau S, Morin CM. Insomnia in patients with traumatic brain injury: frequency, characteristics, and risk factors. J Head Trauma Rehabil. 2006;21:199212. [7] Makley MJ, Johnson-Greene L, Tarwater PM, Kreuz AJ, Spiro J, Rao V, et al. Return of memory and sleep efficiency following moderate to severe closed head injury. Neurorehabil Neural Repair. 2009;23:320-6. [8] Rao V, McCann U, Han D, Bergey A, Smith MT. Does acute TBI-related sleep disturbance predict subsequent neuropsychiatric disturbances? Brain injury : [BI]. 2014;28:20-6. [9] Mollayeva, Tatyana et al. The relationship between insomnia and disability in workers with mild traumatic brain injury/concussion. Sleep Med 2015.
[10] Leon AC, Shear MK, Portera L, Klerman GL. Assessing impairment in patients with panic disorder: the Sheehan Disability Scale. Social psychiatry and psychiatric epidemiology. 1992;27:78-82. [11] Gagnon C, Belanger L, Ivers H, Morin CM. Validation of the Insomnia Severity Index in primary care. Journal of the American Board of Family Medicine : JABFM. 2013;26:701-10. [12] Association AP. Diagnostic and statistical manual of mental disorders 5th ed. Arlington, VA: Amerian Psychiatric Publishing; 2013. [13] Wiseman-Hakes C, Murray B, Moineddin R, Rochon E, Cullen N, Gargaro J, et al. Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain injury : [BI]. 2013;27:1364-76. [14] Ouellet MC, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design. Arch Phys Med Rehabil. 2007;88:1581-92. [15] Ouellet MC, Morin CM, Lavoie A. Volunteer work and psychological health following traumatic brain injury. J Head Trauma Rehabil. 2009;24:262-71. [16] Fogelberg DJ, Hoffman JM, Dikmen S, Temkin NR, Bell KR. Association of sleep and cooccurring psychological conditions at 1 year after traumatic brain injury. Arch Phys Med Rehabil. 2012;93:1313-8. [17] Ouellet MC, Morin CM. Subjective and objective measures of insomnia in the context of traumatic brain injury: a preliminary study. Sleep Med. 2006;7:486-97.
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[18] Ponsford JL, Parcell DL, Sinclair KL, Roper M, Rajaratnam SM. Changes in sleep patterns following traumatic brain injury: a controlled study. Neurorehabilitation and neural repair. 2013;27:613-21.
Page 7 of 7
S1389-9457(15)02025-0 http://dx.doi.org/doi: 10.1016/j.sleep.2015.10.011 SLEEP 2931
To appear in:
Sleep Medicine
Please cite this article as: Nadia Gosselin, Catherine Duclos, “Insomnia following a mild traumatic brain injury: a missing piece to the work disability puzzle?”, Sleep Medicine (2015), http://dx.doi.org/doi: 10.1016/j.sleep.2015.10.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Editorial Title: “Insomnia following a mild traumatic brain injury: a missing piece to the work disability puzzle?” Nadia Gosselin1,2 and Catherine Duclos1,3 Affiliations: 1. Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada 2. Department of Psychology, Université de Montréal, Montreal, Canada 3. Department of Psychiatry, Université de Montréal, Montreal, Canada
Submitted to: Sleep Medicine Date: October 27th, 2015 Number of words: 993 Number of references: 17 Address for correspondence: Nadia Gosselin, Ph.D. Center for Advanced Research in Sleep Medicine Hôpital du Sacré-Cœur de Montréal 5400 boul. Gouin Ouest, local E-0330 Montréal, Québec H4J 1C5 Canada Tel: 514-338-2222 ext. 7717 Fax: 514-338-3893 [email protected]
Page 1 of 7
Sleep-wake disturbances are reported by approximately 50% of individuals after a traumatic brain injury (TBI), and insomnia is among the most common sleep disturbances observed in those who have sustained a mild TBI[1, 2]. Although the emergence and evolution of sleep-wake disturbances are still poorly understood, recent evidence has shown that they appear during the acute stage of the injury[3, 4]. Sleep-wake disturbances tend to persist over time[5] and 29% of individuals with TBI still fulfill the insomnia diagnostic criteria several years after their injury.[6] Little is known about how sleep-wake disturbances impact daytime functioning, but studies have pointed to the role of sleep-wake disturbances in predicting cognitive recovery, [4, 7] anxiety, depression and pain after a TBI [3, 8], suggesting a causal role of sleep disturbances in subsequent recovery. In the study by Mollayeva and colleagues published this month in Sleep Medicine [9], the authors investigated the relationship between insomnia and perceived disability among 92 individuals. They were all followed in a rehabilitation hospital after sustaining a mild TBI in the last three months to five years due to a work-related accident. The authors retrospectively analyzed data obtained form medical and insurer’s files as well as from employers’ reports of injury/illness. They also collected sleep and medical information directly from participants. Perceived disability levels regarding work, social life and family life responsibilities were measured by the Sheehan Disability Scale[10] and insomnia was evaluated using the Insomnia Severity Index[11]. At the time of assessment, 57% of participants were on work disability. The authors observed that participants with greater disability reported more insomnia, depression, anxiety, and pain than participants with lower disability. In the adjusted multivariate analysis, controlling for age, sex, depression, and anxiety, the odds of reporting marked/extreme global disability were greater with
Page 2 of 7
increasing insomnia and pain. The odds of perceiving greater disability for work responsibilities increased with insomnia only, independently of age, sex, pain, anxiety and depression. The role of insomnia in predicting disability was only observed for work but not for social or family domains. This well-conducted study brings new and key elements to improve our understanding of disability after a mild TBI. This study shows that insomnia might play a significant role in an individual’s perception of his ability to return to work. Insomnia is defined by dissatisfaction with sleep quantity/quality characterized by a report of difficulty initiating sleep, difficulty maintaining sleep or early morning awakening[12]. The diagnosis of insomnia necessarily implies that sleep disturbances are associated with marked distress or subjective impairment in daytime functioning including the social, occupational or behavioral domains. The behavioral diagnostic criterion is of high importance in our understanding of functional recovery after a TBI, since it specifically suggests that presenting insomnia after a TBI reduces daytime functioning and may impede the return to pre-injury level of functioning. This element is also of high importance for individuals with an injured brain who may be more sensitive to the cognitive consequences of insomnia. Considering that one-third of TBI patients have insomnia and that 60% of them are untreated[6], insomnia may be a missing factor that is vital in understanding chronic disability after TBI. Treating sleep-wake disturbances with individualized treatments including sleep hygiene, pharmacological and/or sleep apnea interventions has already been shown to be associated with a significant improvement in cognitive and communication abilities after TBI[13]. Moreover, in a preliminary study with 11 individuals with TBI, cognitive-behavioral therapy was found to be efficient to reduce insomnia[14].
Page 3 of 7
Future studies should examine whether treatment of sleep-wake disturbances reduces perceived disability and facilitates return to work. On the other hand, perceiving no or lower disability for work probably leads to enhanced psychological well-being, contributing to a lower risk of presenting insomnia. In a study by Ouellet and colleagues among 208 survivors of TBI, those who reported being active through work, studies, or volunteering had lower psychological distress, fatigue and sleep disturbances[15]. Although most studies cannot confirm a causal relationship between psychological well-being, sleep disturbances and disability, a multi-directional link probably exists. Therefore, treating insomnia and encouraging individuals with TBI to be active through work, studies, or volunteering may lower disability. Performing sleep studies among individuals with chronic TBI presents challenges. Many participants have co-morbid conditions including anxiety, depression, post-traumatic stress disorder, pain, orthopedic injury , and intake of medication. Studies generally point to the difficulty in weeding out the role of sleep disturbances when concomitant factors such as depression, anxiety and pain are present [6, 16-18]. Excluding individuals on the basis of these co-morbid conditions would lead to a non-representative sample of TBI participants. A large sample size is therefore required to conduct this type of study. In the study by Mollayeva and colleagues, 92 participants were included and the authors were able to show that, when all other factors were controlled, insomnia stands out as the only factor of significance in relation to perceived work disability, which represents a key finding. However, as discussed by the authors, the lack of significant association between insomnia and perceived disability for social and family life may be explained by an insufficient sample size.
Page 4 of 7
Another challenge encountered in TBI research is the homogeneity of the sample. All participants recruited in the study by Mollayeva and colleagues were workers at the time of their injury [9]. Their diagnosis was confirmed by a physician, and they were all referred to a rehabilitation center; hence, the homogeneity of this study sample represents a strength, enabling these factors to be controlled for. However, the participants were tested between three months and five years post-injury, and we can expect the perceived disability for work responsibilities and its association with psychological well-being to be less strongly related to the TBI as the post-injury delay increases. Nonetheless, the study by Mollayeva and colleagues adds to the growing literature showing that sleep-wake disturbances are associated with psychological, cognitive, and physical dysfunctions after TBI [9]. Treating sleep-wake disturbances may have the potential to improve recovery, work-related outcomes, and quality of life in the TBI population.
Page 5 of 7
References
[1] Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis. Sleep Med. 2012;13:898-905. [2] Ouellet MC, Beaulieu-Bonneau S, Morin CM. Sleep-wake disturbances after traumatic brain injury. Lancet Neurol. 2015;14:746-57. [3] Chaput G, Giguere JF, Chauny JM, Denis R, Lavigne G. Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury. Sleep Med. 2009;10:713-6. [4] Duclos C, Dumont M, Blais H, Paquet J, Laflamme E, de Beaumont L, et al. Rest-Activity Cycle Disturbances in the Acute Phase of Moderate to Severe Traumatic Brain Injury. Neurorehabilitation and neural repair. 2013;28:472-82. [5] Kempf J, Werth E, Kaiser PR, Bassetti CL, Baumann CR. Sleep-wake disturbances 3 years after traumatic brain injury. J Neurol Neurosurg Psychiatry. 2010;81:1402-5. [6] Ouellet MC, Beaulieu-Bonneau S, Morin CM. Insomnia in patients with traumatic brain injury: frequency, characteristics, and risk factors. J Head Trauma Rehabil. 2006;21:199212. [7] Makley MJ, Johnson-Greene L, Tarwater PM, Kreuz AJ, Spiro J, Rao V, et al. Return of memory and sleep efficiency following moderate to severe closed head injury. Neurorehabil Neural Repair. 2009;23:320-6. [8] Rao V, McCann U, Han D, Bergey A, Smith MT. Does acute TBI-related sleep disturbance predict subsequent neuropsychiatric disturbances? Brain injury : [BI]. 2014;28:20-6. [9] Mollayeva, Tatyana et al. The relationship between insomnia and disability in workers with mild traumatic brain injury/concussion. Sleep Med 2015.
[10] Leon AC, Shear MK, Portera L, Klerman GL. Assessing impairment in patients with panic disorder: the Sheehan Disability Scale. Social psychiatry and psychiatric epidemiology. 1992;27:78-82. [11] Gagnon C, Belanger L, Ivers H, Morin CM. Validation of the Insomnia Severity Index in primary care. Journal of the American Board of Family Medicine : JABFM. 2013;26:701-10. [12] Association AP. Diagnostic and statistical manual of mental disorders 5th ed. Arlington, VA: Amerian Psychiatric Publishing; 2013. [13] Wiseman-Hakes C, Murray B, Moineddin R, Rochon E, Cullen N, Gargaro J, et al. Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain injury : [BI]. 2013;27:1364-76. [14] Ouellet MC, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design. Arch Phys Med Rehabil. 2007;88:1581-92. [15] Ouellet MC, Morin CM, Lavoie A. Volunteer work and psychological health following traumatic brain injury. J Head Trauma Rehabil. 2009;24:262-71. [16] Fogelberg DJ, Hoffman JM, Dikmen S, Temkin NR, Bell KR. Association of sleep and cooccurring psychological conditions at 1 year after traumatic brain injury. Arch Phys Med Rehabil. 2012;93:1313-8. [17] Ouellet MC, Morin CM. Subjective and objective measures of insomnia in the context of traumatic brain injury: a preliminary study. Sleep Med. 2006;7:486-97.
Page 6 of 7
[18] Ponsford JL, Parcell DL, Sinclair KL, Roper M, Rajaratnam SM. Changes in sleep patterns following traumatic brain injury: a controlled study. Neurorehabilitation and neural repair. 2013;27:613-21.
Page 7 of 7