After Concussion: Alternative Treatments For Fatigue and Sleep Disorders
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Headache and dizziness after concussion: risk factors for problems with sleep

Headache and dizziness after concussion: risk factors for problems with sleep | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

Sleep disturbances are often overlooked after a concussion or TBI, taking a backseat to more dramatic problems such as cognitive and memory impairments and mood disorders like anxiety and depression. Yet without sleep, cognitive function can worsen, and mood disorders can spiral out of control. Determining who is most at risk for developing a  sleep disorder after TBI can help put this critical issue on the radar of treating physicians, who are often overwhelmed by the multitude of serious symptoms appearing after brain injury.

 

In this study, Chinese researchers investigated possible risk factors related to sleep disturbances following brain injury. While their patient numbers were strongly weighted towards mild traumatic brain injuries (70% of those studied),  they still found some interesting patterns:

 

•overall, 38% of victims of brain injury suffer from some kind of sleep disturbance. 

•Drilling down further, sleep problems increase as the severity of brain injury increases. 30% of mild TBI patients, 53% of moderate, and 57% of severe TBI patients experience sleep disturbances.

•The strongest risk factor for hypersomnia - excessive sleepiness - is severe brain injury,

•The predominant risk factors for sleep disturbance - seen in the graph above-- were headache, dizziness, and anxiety and depression. In fact, more than half of the patients with headache had sleep disturbances.

•Sleep disturbance did not seem associated with injury to any particular area or region of the brain.

 

Without more information, it's hard to know what common physiological basis links these risk factors and sleep problems. Headache and dizziness can have numerous causes after brain injury. However, one common thread to all three - headache, dizziness, and sleep disturbance - could be distortion of the brain's membranes, as described in an earlier article here. Distortion of the "tentorium cerebellum" or "tent", as described by other researchers, can press down on the brainstem and also  cause autonomic nervous system disruption (both linked to dizziness) and can pull on any number of structures in the head that are linked to headaches. The research doesn't address that possibility. The researchers also did not discuss whether sleep improved after dizziness and headache were treated.

 

Still, any information about the prevalence and risk factors for sleep disturbance is important. Sleep is the greatest healer of all, and it's crucial to keep that fact front and center when we treat our patients with traumatic brain injury.

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Fatigue following brain injury - International Brain Injury Association - Excellent Summary

Fatigue following brain injury - International Brain Injury Association - Excellent Summary | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
Fatigue following brain injury - Author: Jennie Ponsford IntroductionA significant proportion of people with brain injury (32-73%) reportedly experience fatigue (1, 2). Whereas fatigue resolves within days or weeks for most people with mild injuries, it can persist over many years following moderate to severe injuries and impact negatively on participation in numerous activities, including ... International Brain Injury Association - IBIA International Brain Injury Association - IBIA Houston, Texas USA
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

An excellent summary of the current state of thinking on fatigue and traumatic brain injury. Sadly, there is little research to date on this topic, so there are few answers in standard medicine for suffering patients.

 

I have been treating it in patients for 30 years. Fatigue can be a direct result of injury to the brain and the nervous system - what we call  "primary" fatigue, or it can be a result of other factors that accompany the injury, what we call "secondary" fatigue.  Here, I am going to discuss some of the most common causes I see of secondary fatigue.

 

1. As I mention in another commentary, injury to the pituitary can cause extreme fatigue, because it can  affect thyroid, growth hormone, and cortisol. A disruption of any of these by itself can cause fatigue; as a trio, the effects can be devastating. Cranial osteopathy has numerous ways of treating pituitary dysfunction. Hormone supplementation under the supervision of an endocrinologist can be also be helpful, though it may not be curative.

 

2. It's not uncommon for the thyroid gland to be injured in TBI. Head injury and neck injury often occur together, and the thyroid gland. perched on the outside of the windpipe, is very vulnerable to injury. The thyroid  controls metabolism and energy production, and thyroid injury can significantly depress energy levels. A test of thyroid levels can be diagnostic; however, there is disagreement about what levels constitute an "abnormal" reading. More about that in another post. Supplemental thyroid hormone is cheap and effective and can give the thyroid a little help while it recovers.

 

3. I find that a rarely considered cause of fatigue is allergies resulting from digestive and gut problems that often follow tbi.  We have all heard that TBI disrupts the "blood brain barrier" that protects the brain, but it can also cause disruptions in the "blood-gut" barrier. Undigested food leaks into the bloodstream. When that happens, the immune system goes into a frenzy trying to neutralize the undigested food.


In severe brain injury, this gut disruption can cause a massive and sometimes fatal inflammatory response called SIRS, or systemic inflammatory response syndrome. In a less severe brain injury, it can provoke an inflammatory and allergic response. People suddenly feel achy and terrible. They also become allergic to all kinds of foods, dusts, pollens, and chemicals. The inflammatory response has a direct effect on cognition. As a friend of mine once said, "allergies make you stupid". They also make you extremely tired. If you have digestive problems after TBI or concussion, consider this gut-brain disruption as a possible cause..


Probiotic supplementation is critical. But cranial treatment to address the neurological dysfunction that causes the leaking in the first place is absolutely critical.


More about treatment options as we go along.


 

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Veterans with blast traumatic brain injury may have a highly treatable but unrecognized condition - pituitary dysfunction

Veterans with blast traumatic brain injury may have a highly treatable but unrecognized condition - pituitary dysfunction | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
In soldiers who survive traumatic brain injury from blast exposure, pituitary dysfunction after their blast injury may be an important, under-recognized, and potentially treatable source of their symptoms, a new study finds. The results were presented Saturday at ICE/ENDO 2014, the joint meeting of ...
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

I am thrilled that finally injury to the pituitary is being recognized as a serious problem in traumatic brain injury. Between 30 to 50% of TBI sufferers have injury to the pituitary. This pea-sized gland in the middle of the brain, straight back from the nose, is the body's master gland, regulating sexual function, energy metabolism, sleep wake cycle, stress levels, kidney function, blood pressure, water balance, and temperature regulation. A good history is often the key to finding pituitary dysfunction - but you have to know to look for it!

 

I have frequently treated pituitary dysfunction in TBI victims. It manifests in many ways: sexual dysfunction, obesity, fatigue, bleeding kidneys, sleep disturbance, headache. This reflects the astonishing diversity of functions the pituitary regulates.

 

While hormone testing and treatment can be very helpful, I treat the pituitary with manual medicine. As a cranial osteopath, I am trained to use the connections among the  structures of the head –  membranes, bones, and the brain itself, to name a few – to treat the brain. Knowing the anatomy is the key to why my treatments are so successful. That, and many years of  experience in treating these structures with my hands.

 

In the case of the pituitary, I work to straighten out the bony pillars that surround it. The pituitary swings from a stalk of tissue and is surrounded by pillars of bone called the Turk's Saddle, or Sella Turcica. Trauma can bend the pillars and disrupt the pituitary’s functions. So, I work to straighten out the pillars.

 

Sometimes I use the connective tissue that is attached to the pillars to straighten them out. Because the dural membranes covering the pillars lie close to the coverings of the optic nerves, I can use the eyes to influence the pillars. The pillars are also tied to a large membranous tent that cover the back of the brain and anchors itself to the skull’s bones. I work with this bone-membrane complex the way a master model builder uses guy wires to straighten a  boat in a glass bottle. 

 

The pituitary sits in a bony nook in the large bone that forms part of the orbits. Falls on the face can distort that bone (the sphenoid bone) and the pituitary along with it. When a fall compresses the frontal (forehead) bone and its neighbors, it can also distort the pituitary complex. Then I manipulate the facial bones, including the frontal bone, to restore physiological function to the pituitary.

 

To read more about how osteopathic manual medicine can treat the pituitary gland, including the case of a child whose bleeding kidneys were successfully treated with cranial osteopathy, see my book, Healing Pain and Injury.

 

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Taichi exercise for self-rated sleep quality... [Int J Nurs Stud. 2014] - PubMed - NCBI

Taichi exercise for self-rated sleep quality... [Int J Nurs Stud. 2014] - PubMed - NCBI | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it

Tai Chi has a beneficial effect in improving self-rated sleep quality for older adults.

Dr. Maud Nerman, DO., CSPOMM, CA's insight:

This study took a hard lookk at previous studies about Tai Chi and insomnia. The conclusion?  Tai Chi "could be an effective alternative ... approach to existing therapies for older people with sleep problems."  Since insomnia is one of the most prevalent and devastating consequences of TBI and concussion, I hope that this study will spark a new awareness among medical practitioners and TBI victims  of how beneficial Tai Chi can be for sleep disorders.

 

The study did not go into why Tai Chi is so helpful, but I suspect it may be because of its balancing effect on the autonomic nervous system. Tai Chi has a well studied ability to reduce inflammatory markers. improve anti-oxidant status, and balance the autonomic nervous system. To me, this suggests that Tai Chi is helping to turn off the "injury shock" that keeps the "fight or flight" reaction in overdrive . My patients who practice Tai Chi - both TBI and non-TBI - have lower overall stress levels and better sleep.

 

There are a number of studies involving Tai Chi's benefits for TBI - improved mood and self esteem, improved balance and overall physical function. It would be good to see a study specifically dealing with sleep after TBI.

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Recovery from sleep disturbance precedes that of depression and anxiety following mild traumatic brain injury

Recovery from sleep disturbance precedes that of depression and anxiety following mild traumatic brain injury | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

In my clinical experience, sleep is one of the most important landmarks of recovery. When a person's sleep starts to improve, that is a deep sign that recovery is underway and the person is getting better.

 

So, though I am not a specialist in mood disorders, it is not surprising to me that improvement in sleep precedes improvement of mood disturbances. In my brain injured patients, I almost always see sleep improve first,  because it is in sleep that the brain does its primary healing. Mood almost always improves AFTER sleep starts to improve. This study also suggests that at least for some victims of MTBI, sleep disturbance is the primary cause of depression and anxiety, not the other way around.

 

So sleep is not only a "landmark" of healing, it is also one of healing's most critical components. Without sleep, you cannot heal. As physicians, we must tell our patients to worship sleep! It is the greatest healer of all.

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Blue light therapy helps relieves fatigue and daytime sleepiness after concussion

Blue light therapy helps relieves fatigue and daytime sleepiness after concussion | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it

Blue light therapy appears to be effective in alleviating fatigue and daytime sleepiness following TBI.

Dr. Maud Nerman, DO., CSPOMM, CA's insight:

This is a fascinating study about leveraging the body's natural healing ability after TBI.  As human beings, we are programmed to wake up when our eyes are exposed to morning daylight, which is rich in the blue wavelength of light. This light is a powerful suppressor of melatonin, which regulates our sleep-wake cycle.  Blue light receptors in the eye link to the part of the brain that releases melatonin. Blue light, in effect, wakes us up.


It makes sense that exposing people  to blue light for 45 minutes in the morning could help reset their biological clock. At the higher wavelengths used in this study, the light can penetrate more deeply into biological tissues.


Before you go running off to buy a blue light device, know that it is a two edged sword:  too much, the wrong kind, and at the wrong time can be counterproductive and actually harmful. Computer screens and phones radiate blue light, one of the reasons that if you work on your computer late at night you can have trouble sleeping. We are already getting exposed to a lot of blue light during the day because flourescent bulbs, unless they are specially treated, emit more blue light than incadescents. And blue light therapy can be contraindicated if you have macular degeneration, and too much can apparently be harmful.


As I digest this study I will have more comments, but it does open up a fascinating approach.  I have long advocated my patients taking a 10 minute walk in the morning to expose their retinas to natural light to help reset their biological clocks. I would be interested in feedback as to whether this works for you. The light therapy's help fades away over time, but properly used has few side effects and uses the body's own wakefulness monitors to control fatigue and excessive sleepiness during the day.

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Acupuncture for Treatment of Insomnia in Patients With Trauma : The Journal of Head Trauma Rehabilitation

Acupuncture for Treatment of Insomnia in Patients With Trauma : The Journal of Head Trauma Rehabilitation | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
Objectives: To assess the efficacy of acupuncture in treating insomnia in traumatic brain injury (TBI) survivors as compared to medication, to determine whether acupuncture has fewer cognitive and affective adverse effects than does medication.
Participants: Twenty-four adult TBI survivors, rand...
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

An exciting development in the literature, demonstrating that acupuncture is a valid modality for treating post TBI or post-concussion insomnia, and concomitantly, depression. Very important, particularly in the beginning of recovery, when the brain has the greatest power to heal.

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Sleep: More Important Than You Think

Sleep: More Important Than You Think | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
As a caregiver for a husband with traumatic brain injury (TBI), Rosemary Rawlins shares insights garnered from her own experiences along with insights from other caregivers and family members in her blog, “Learning by Accident,” on BrainLine. In this blog post, she talks about sleep — how poor sl...
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

This is an interesting perspective by Rosemary Rawlins, caregiver of a spouse with TBI who shares her insights about sleep problems.

 

It's also interesting that the proportion of tbi victims with sleep apnea, a devastating chronic disruption of restful sleep, is between 30 and 50 percent.

 

Without sleep, we cannot heal. You cannot make up for chronic deficits with an all out blitz once a week. Pay attention to Rosemary's simple tips.  I devote a whole chapter in my book, Healing Pain and Injury to sleep, why it's so disrupted after injury, surgery, or other trauma, and what you can do to fix it.

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How mindfulness changed my sleep: focus groups with chronic insomnia patients

How mindfulness changed my sleep: focus groups with chronic insomnia patients | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

While this study did not involve TBI victims, it does show that practices such as meditation, which calm the autonomic nervous system, can be extremely powerful in helping insomnia.I often recommend to my patients that they begin meditating for five to ten minutes per day once they do not feel stressed by adding a new task to their day. I also recommend alternate nostril breathing as an effective way for dropping into meditation. This is a treatment that is effective, easy to do, relatively quick, and free.


There are many resources on the web. UCLA's Mindful Awareness Research center is 's a good place to start:

http://marc.ucla.edu/body.cfm?id=22

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Distortion of the brain's membranes linked with sleep-wake disturbances after mild traumatic brain injury

Distortion of the brain's membranes linked with sleep-wake disturbances after mild traumatic brain injury | After Concussion: Alternative Treatments For Fatigue and Sleep Disorders | Scoop.it

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Abstract: OBJECTIVE: The purpose of this study was to determine if there is an association between tentorial length and angle and sleep-wake disturbances...
Dr. Maud Nerman, DO., CSPOMM, CA's insight:

Sleep disturbance is a universal problem for traumatic brain injury victims. In this study, radiologists analyzed the brain scans of MTBI victims suffering from insomnia. They  found a fascinating anatomical anomaly. The large membrane known as the "tent" in the back of the skull, which you can see in the picture above, was flattened out. Ordinarily the tent rises and falls like the wings of a bird. Patients who had this particular anomaly also had a longer course of recovery, something that is not surprising to me. Researchers have been looking for some structural reason for sleep disturbance after TBI, but I believe they haven't been looking in the right places. This is the first study I know of that actually found a structural abnormality associated with sleep-wake disturbance after TBI. What makes this doubly exciting is that  this anomaly is very treatable.


The authors speculate that this stuck membrane might upset the pineal gland, which is part of the brain's "sleep-wake" controls. The pineal gland produces melatonin, known as the "Dracula hormone" because its levels increase with darkness. Melatonin helps the body reset its sleep-wake cycle that can be disrupted in TBI. TBI causes levels of melatonin to drop, disrupting sleep rhythms.  If you find yourself sleeping at the wrong time, or the normal rhythm of your sleep is disrupted, you may have low melatonin levels.


 It's not surprising that a shortage of melatonin would also mean that the patients' course of healing was longer. Melatonin is  a powerful anti-oxidant with strong neuroprotective properties. Supplementing with melatonin immediately after brain injury has been shown to protect injured neurons and help repair spatial memory problems. It also reduces brain edema and helps reseal the blood brain barrier, critical to taming the neuroinflammation that ravages the brain after concussion or TBI. Melatonin is in fact one of the most powerful anti-oxidant and anti-inflammatory substances in the body. See my scoop.it! topic on TBI and cognitive impairment for more info on this amazing hormone.


A flattened "tent"  also continually activates the sympathetic or "fight-or-flight" nervous system, which can cause insomnia and disturbed sleep. The  "tent"  also has indirect anatomical connections to the hypothalamus, which is the main regulator of the sleep-wake cycle. Perhaps a flattened tent has an impact on the hypothalamus as well.


To me  a cranial osteopath, this is an exciting yet not-surprising finding. I frequently find abnormalities in the position of the tent during examination of the skull after TBI . Our profession has  been working with the membranes of the brain for over 80 years, utilizing sophisticated manual techniques to detect and remove abnormal strain patterns in the tent and her sister membranes. The tent is critical for pumping cerebral spinal fluid in the brain, and to do that job, the tent has to move. Freeing up the tent is part of what I do when I treat TBI. Perhaps that is part of why we are successful in treating TBI-related insomnia. 

 


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