Sleep disturbances and Sports Concussion- time to address the sleeping elephant in the room.
Meeta Singh MD (@athletesleepmd1)
A ‘sports concussion’ is a mild form of traumatic brain injury caused by a blow, a fall, a bump or a shake during play. Because our brains are essentially the consistency of gelatin and float in our skulls, any trauma that makes the brain move back and forth quickly, can lead to damage. The cells can stretch and tear, and this results in the symptoms of concussions. Usually, an athlete recovers from concussion relatively quickly (days to weeks), but some athletes have persistent symptoms that interfere with daily life. For most athletes who suffer a concussion, sleep disturbances are often an issue. In fact, the story of sleep and concussion is closely intertwined, and disturbances of sleep can occur both acutely and chronically after the concussion happens. Additionally, there is new data that shows sleep disturbances may in fact, increase an athlete’s risk of developing concussions. So, this relationship is bidirectional and it’s important for athletes, athletic trainers, coaches, to understand this better as it affects athlete performance and wellbeing.
For starters, the relationship between concussion and sleep is best understood by exploring what parts of the brain are affected by concussion. We know that sleep is produced in areas of the brain that lie deep under the surface and concussions often cause damage to those same areas, so it’s not surprising that disturbed sleep will occur in 30-80 percent of the concussion cases.
Immediately after the concussion, many athletes will complain of excessive sleepiness and will sleep longer. Research shows that this is a protective mechanism as most of the healing processes in the brain occur during sleep and so concussed athletes require more restorative sleep. Getting proper sleep during the initial recovery stage therefore, is beneficial to the concussed athlete as it restores the electrochemical balance in the brain and decreases the likelihood of the athletes experiencing prolonged symptoms. Thus, allowing athletes to rest and easing the athlete back to their full athletic schedule becomes important. Another complaint the concussed athlete may have acutely after concussion, is of variable sleep, with nights of poor sleep mixed with nights of “catch-up’ good sleep. The problem is that variability in sleep is associated with low mood, pain and feelings of restlessness. These factors interact to reduce the quality of life of a concussed athlete. Therefore, this complaint of variable sleep should serve as a cue to the athletic trainers to refer the athlete to the sports physician for an assessment.
The one important clarification that is needed here is regarding the advice that used to be given out immediately after concussion that seems to contradict the advice of letting concussed athletes rest. The advice was that “if you have a head injury or a sports related concussion, you may be warned to stay awake for several hours or to have someone wake you up every hour’.The reason for this advice was based on the idea that if you are asleep; your family or doctors will miss indications of serious brain damage (like seizures, loss of consciousness, weakness of one side of the body, etc. which can result if there is swelling the brain due to a bleed). This recommendation however is a myth. The new recommendation is that the concussed player should be observed for 3-6 hours and if they show any worsening, they should be sent to the emergency room immediately. If there are no such signs, the player should be allowed to sleep undisturbed.
In addition to acute sleep issues, changes in sleep quality and quantity, as well as new-onset of sleep disorders can also occur chronically (>1 month) after the concussion. As mentioned above, it becomes very important to address these, as the presence of sleep problems prolongs recovery time (3- to 4-fold increase) and negatively impacts quality of life in athletes. These sleep complaints range from players complaining of difficulty falling and staying asleep as well as changes in their sleep/wake pattern. They may be excessively sleepy during the day and complain of snoring or leg kicks at night. These complaints should alert the athletic trainers and coaches to refer these players to team doctors who can address these sleep issues. Additionally, the knowledge that sleep plays a starring role in athletic performance is only growing. We are learning more about its importance for optimal accuracy, speed, muscle growth and restoration, learning, and memory consolidation; so, it’s not surprising that sleep disturbances following concussion contribute to poorer athletic performance. Secondly, athletes with continuing sleep issues after concussion, feel that they have not recovered well, and this perception itself impacts performance. Finally, impaired athletic performance may add to the stress the athlete might feel. Thus, the bottom line is that sleep disturbances are often seen in athletes after a concussion. These should be identified and addressed as left untreated they tend to prolong the recovery time and affect athletic performance.
Now to come to the newer research findings that show that athletes who have poor and inadequate sleep may be at a higher risk for sports-related concussions. This study done in 190 NCAA Div 1 athletes found that athletes suffering moderate-to-severe insomnia saw concussion risk increased more than three times, and those suffering from excessive daytime sleepiness more than doubled their risk. Given what sleep scientists already know when it comes to the detrimental effects of poor and inadequate sleep on mental fatigue, attentional lapses, visual tracking, and reaction time, it is not surprising that the athlete’s capacity to minimize or avoid injuries is reduced. In addition, poor sleep will increase impulsivity, and risk-taking behaviors, both of which result in poorer in-the-moment decisions and may results in increased injury and concussion risk. Thus, it seems sleep disturbances may play a starring role in concussion causation, in addition to being caused by concussions.
Currently, concussions are a serious concern for athletes and a rising public health problem. For coaches and athletic trainers looking for modifiable factors that might improve athlete health and performance after concussion, identifying and addressing sleep concerns is key. Placing an emphasis on sleep education may potentially facilitate better sleep habits in athletes. Additionally, its important to be cognizant of the bidirectional relationship of sleep and concussion. Until recently the major risk factor for sustaining a sports concussion was a history of one of more prior concussions. Poor and disturbed sleep may hold the steps to developing the first and subsequent concussion. Assessing and proactively improving sleep issues may thus reduce sports-related concussion risk.
- Wickwire EM, Williams SG, Roth T, et al. Sleep, Sleep Disorders, and Mild Traumatic Brain Injury. What We Know and What We Need to Know: Findings from a National Working Group. Neurotherapeutics. 2016;13(2):403–417. doi:10.1007/s13311-016-0429-3
- Adam C. Raikes, Sydney Y. Schaefer, Sleep Quantity and Quality during Acute Concussion: A Pilot Study, Sleep, Volume 39, Issue 12, 1 December 2016, Pages 2141–2147,
- Michael S. Jaffee, W. Christopher Winter, Christine C. Jones & Geoffrey Ling (2015) Sleep disturbances in athletic concussion, Brain Injury, 29:2, 221-227, DOI:
- Raikes, Adam & Athey, Amy & Alfonso-Miller, Pamela & Killgore, William & Grandner, Michael. (2019). Insomnia and daytime sleepiness: risk factors for sports-related concussion. Sleep Medicine. 10.1016/j.sleep.2019.03.008.