This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.
This document summarizes a presentation on concussions and cervical injuries. It discusses how concussions are caused by rotational forces on the brain and shares similarities in symptoms with cervical injuries, which result from neck muscle strains. Tests are presented to differentiate between concussion and cervical injury. The risk of lower extremity injuries in the 6 months following a concussion is significantly higher than in non-concussed athletes, with the knee and ankle being most commonly injured. Ongoing balance and strength training is recommended for several months after concussion recovery to prevent future injuries.
This document discusses an approach to returning to play after a concussion. It begins by reviewing the neurological domains commonly affected - exercise tolerance, visual/vestibular function, mood, and cognition. It then outlines a systems-based approach to rehabilitation, addressing each domain through sub-symptom threshold exercise, vision therapy, managing cognitive load, and monitoring mood. Finally, it discusses return to play protocols and managing complex cases, emphasizing the need for a graduated, multi-disciplinary approach focusing on symptom resolution over timelines.
This document provides the schedule and objectives for a concussion symposium on September 12, 2020. The full-day virtual event will feature several speakers presenting on topics such as best practices in concussion care, return to learn and play protocols, post-concussion headaches and migraines, cervicogenic deficits, mood and sleep disorders, COVID-19 guidelines, and a multidisciplinary rehabilitation panel. The symposium aims to educate health care professionals, athletic trainers, and physical therapists on defining and managing different aspects of concussion care. It will offer up to 4 continuing education credits for physicians and athletic trainers.
This document provides guidelines for returning to sports during the COVID-19 pandemic. It outlines the risks of the disease, including symptoms, long term effects, and higher risk groups. Recommendations are made for prevention through distancing, hygiene, screening, and operating in phases based on community transmission rates. The phases gradually increase contact and activities from conditioning to practice to competition. Testing protocols and procedures for positive cases and exposures are also outlined, including isolation and cardiac screening before returning to play. The guidelines balance safety precautions with other health and behavioral factors.
Practical management of ataxia and balance impairment: Part 2MS Trust
This presentation by Dr Lisa Bunn looks at the practical management of ataxia and balance impairment among people with MS. It includes information on assessing ataxia, the rehabilitation of balance, and relevant research studies.
It was presented at the MS Trust Annual Conference in November 2013.
This document summarizes a presentation on concussions and cervical injuries. It discusses how concussions are caused by rotational forces on the brain and shares similarities in symptoms with cervical injuries, which result from neck muscle strains. Tests are presented to differentiate between concussion and cervical injury. The risk of lower extremity injuries in the 6 months following a concussion is significantly higher than in non-concussed athletes, with the knee and ankle being most commonly injured. Ongoing balance and strength training is recommended for several months after concussion recovery to prevent future injuries.
This document discusses an approach to returning to play after a concussion. It begins by reviewing the neurological domains commonly affected - exercise tolerance, visual/vestibular function, mood, and cognition. It then outlines a systems-based approach to rehabilitation, addressing each domain through sub-symptom threshold exercise, vision therapy, managing cognitive load, and monitoring mood. Finally, it discusses return to play protocols and managing complex cases, emphasizing the need for a graduated, multi-disciplinary approach focusing on symptom resolution over timelines.
This document provides the schedule and objectives for a concussion symposium on September 12, 2020. The full-day virtual event will feature several speakers presenting on topics such as best practices in concussion care, return to learn and play protocols, post-concussion headaches and migraines, cervicogenic deficits, mood and sleep disorders, COVID-19 guidelines, and a multidisciplinary rehabilitation panel. The symposium aims to educate health care professionals, athletic trainers, and physical therapists on defining and managing different aspects of concussion care. It will offer up to 4 continuing education credits for physicians and athletic trainers.
This document provides guidelines for returning to sports during the COVID-19 pandemic. It outlines the risks of the disease, including symptoms, long term effects, and higher risk groups. Recommendations are made for prevention through distancing, hygiene, screening, and operating in phases based on community transmission rates. The phases gradually increase contact and activities from conditioning to practice to competition. Testing protocols and procedures for positive cases and exposures are also outlined, including isolation and cardiac screening before returning to play. The guidelines balance safety precautions with other health and behavioral factors.
Practical management of ataxia and balance impairment: Part 2MS Trust
This presentation by Dr Lisa Bunn looks at the practical management of ataxia and balance impairment among people with MS. It includes information on assessing ataxia, the rehabilitation of balance, and relevant research studies.
It was presented at the MS Trust Annual Conference in November 2013.
The Chiro Hub is at the forefront of providing advanced treatment in the field of balance, dizziness and postural disorders. Physiosensing, using unparalleled accuracy in obtaining objective measures, is superior when it comes to the management of conditions such as concussion, whiplash, neurologic and orthopaedic conditions.
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
It's not just back pain... It's the big picture.
Some experts say as many as 80% of us will experience a back problem at some time in our lives
Unfortunately, we tend to think of back pain as something to be treated when it happens, instead of something that can be cared for and prevented through healthy lifestyle decisions and maintaining our spinal health
The document discusses new developments in the classification and treatment of spondyloarthropathies. It covers:
1) New classification criteria have been developed to classify axial spondyloarthritis, with "ankylosing spondylitis" being replaced by the broader term "axial spondyloarthritis".
2) New NICE guidance on the management of spondyloarthropathies provides recommendations on pharmacological treatments, non-pharmacological treatments like exercise and physical aids, and ensuring access to specialist care.
3) New therapies continue to be developed and approved for the treatment of psoriatic arthritis and ankylosing spondylitis, including drugs targeting tumor necrosis factor (TNF),
This document provides guidelines for managing occupational low back pain using a combined occupational medicine and physical therapy approach. It lists factors that indicate higher probabilities of success with various treatments like coordination/stabilization exercises, directional preference exercises, and manipulation plus exercise. It also discusses classifying patients into low, medium, and high risk of chronicity using tools like the STarT Back Tool and assessing red flags. The usual care of NSAIDs and encouraging normal activities is noted to have a high recurrence rate. A biopsychosocial approach including cognitive behavioral techniques and therapeutic neuroscience education is recommended for high risk patients.
The document discusses the challenges of managing back pain in an aging population. It notes that medical factors like tolerances for pharmacotherapy and operative fitness limit management options for back dysfunction in older patients. It also discusses challenges from attitudes and perceptions about back pain in older adults, including myths and legends about opioid use and dependence. Finally, it covers how lifestyle factors and priorities around independence, future activity, finances, and environment affect back pain management priorities for retirees.
Critical care rehabilitation is an important part of the recovery process for ICU patients. It begins with early mobilization like passive range of motion exercises and progresses to active transfers, sitting at the edge of the bed, and eventually ambulation. A multidisciplinary team approach that includes nurses, physiotherapists, and other allied health professionals comprehensively assesses patients and develops individualized rehabilitation plans and goals. Regular evaluation during the ICU stay, before discharge, and after discharge is important to optimize recovery outcomes and quality of life.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Avoiding tech neck: adverting biomechanical dysfunction from the use of techn...Chiropractic Economics
Tech Neck is the term used to describe the injuries and pain sustained from looking down at wireless devices.
Tech Neck Symptoms include:
Chronic Headaches
Upper Back Pain
Shoulder Pain
Neck Pain
Curvature of the Spine
This document summarizes a presentation on physiotherapy for non-cancer chronic pain. It discusses that physiotherapy aims to restore and promote optimal physical function and quality of life for those with persistent pain. It provides an overview of evaluation processes in physiotherapy and various treatment modalities. It also summarizes evidence on approaches for common persistent pain conditions like low back pain, whiplash associated disorder, and osteoarthritis. Screening tools for risk of long-term disability are also briefly covered.
1) The document provides an overview of falls prevention and treatment for older adults. It discusses epidemiology facts about falls and examines assessment strategies across four domains: medical, cognitive, functional, and environmental.
2) Key points covered include that 25% of community-dwelling older adults fall each year, with 5-10% of falls causing serious injuries like fractures. Falls are also the most common cause of traumatic brain injury in the elderly.
3) The document emphasizes the importance of assessing multiple risk factors across different domains to identify potentially treatable diagnoses. It provides examples of medical, cognitive, functional, and environmental risk factors and stresses that etiologies of falls are usually multifactorial.
1) Concussion education is needed for athletes, parents, coaches and medical professionals to improve recognition and management of concussions.
2) Studies show educational interventions can improve immediate knowledge but longer term effects on behavior change are unclear.
3) A public health framework including surveillance, identifying risk factors, developing interventions and evaluating outcomes may help increase reporting and proper management of concussions.
4) Effective education requires understanding barriers, tailoring messages and delivery to different audiences, and evaluating impact on behaviors over time.
‘Neurodynamics as a therapeutic intervention; the effectiveness and scientifi...NVMT-symposium
This document discusses the evidence for neural mobilization as a treatment for nerve disorders. It begins by reviewing animal studies showing that movement such as exercise prevents neuropathic pain development, aids nerve recovery after injury, and reduces neuropathic pain. However, the evidence for neural mobilization and nerve gliding exercises in humans is limited. A systematic review found limited evidence that neural mobilization is more effective than minimal interventions for pain and disability in carpal tunnel syndrome, but not more effective than other treatments. Another review found limited evidence for the effectiveness of nerve gliding exercises in carpal tunnel syndrome. The document concludes that while movement may be beneficial, the evidence does not clearly support neural mobilization over other conservative treatments, and more high-quality research is
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
Thriving, not just surviving after critical illnessCoda Change
1. Many ICU survivors experience long-term physical and mental disability after discharge, impacting their quality of life.
2. A study of 262 Australian ICU survivors found 57% experienced disability 6 months after discharge, with highest impairment in physical activity. Predictors included a history of anxiety/depression, separated/divorced marital status, and more days on mechanical ventilation.
3. Clinicians believe strategies like early mobilization, improved sedation practices, nutrition protocols, and enhancing family support could help ICU survivors recover and thrive after discharge.
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Properties of the brain's emotional learning circuitry predict the transition to chronic pain. In a longitudinal study, individuals with acute back pain were scanned over a year-long period. The strength of functional connectivity between the medial prefrontal cortex and nucleus accumbens at the initial scan predicted whether the individual would transition to chronic pain with over 80% accuracy. Future studies are needed to understand the mechanisms driving pain chronicity, with the goal of developing novel therapies to prevent the transition to chronic pain.
Professor Andrew Davies is an Intensivist working at Peninsula Health in Melbourne. He has performed clinical research in the field of critical care for 20 years, as a participating investigator in over 50 studies (mostly clinical trials), predominantly in the areas of critical care nutrition, mechanical ventilation and acute lung injury and severe sepsis. He is a past Vice Chair of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) with a special interest in nutrition in the ICU, and is a past Chair of the Australian and New Zealand Society of Parenteral and Enteral Nutrition (AuSPEN).
In this talk, Professor Davies tackles the often overlooked aspect of nutrition in the ICU and it’s potential benefits for our patients.
Evaluation and Treatment of Children and Adolescents With Sleep DisordersStephen Grcevich, MD
In this presentation from Child and Adolescent Behavior Health in Canton OH, Dr. Stephen Grcevich discusses evaluation and treatment of insomnia in children and teens in an outpatient psychiatric treatment setting. Viewers will review guidelines describing “normal” sleep in children and teens, explore common causes of sleep disturbance in the pediatric population, address treatment of sleep issues associated with common psychiatric conditions in children and teens and be presented with an approach to addressing concerns with insomnia in clinical practice.
Link to video: https://www.slideshare.net/drgrcevich/evaluation-and-treatment-of-children-and-adolescents-with-sleep-disorders
This slideshare is a summary of a study on patient beliefs about low back pain in an outpatient physical therapy clinic in Trinidad. The study is a retrospective analysis of survey data using the Back-PAQ measure. Results show a high proportion of negative beliefs particularly around protection of the back. The study highlights the need to address these unhelpful beliefs with appropriate interventions that decrease fear and protection of the back.
The Chiro Hub is at the forefront of providing advanced treatment in the field of balance, dizziness and postural disorders. Physiosensing, using unparalleled accuracy in obtaining objective measures, is superior when it comes to the management of conditions such as concussion, whiplash, neurologic and orthopaedic conditions.
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
It's not just back pain... It's the big picture.
Some experts say as many as 80% of us will experience a back problem at some time in our lives
Unfortunately, we tend to think of back pain as something to be treated when it happens, instead of something that can be cared for and prevented through healthy lifestyle decisions and maintaining our spinal health
The document discusses new developments in the classification and treatment of spondyloarthropathies. It covers:
1) New classification criteria have been developed to classify axial spondyloarthritis, with "ankylosing spondylitis" being replaced by the broader term "axial spondyloarthritis".
2) New NICE guidance on the management of spondyloarthropathies provides recommendations on pharmacological treatments, non-pharmacological treatments like exercise and physical aids, and ensuring access to specialist care.
3) New therapies continue to be developed and approved for the treatment of psoriatic arthritis and ankylosing spondylitis, including drugs targeting tumor necrosis factor (TNF),
This document provides guidelines for managing occupational low back pain using a combined occupational medicine and physical therapy approach. It lists factors that indicate higher probabilities of success with various treatments like coordination/stabilization exercises, directional preference exercises, and manipulation plus exercise. It also discusses classifying patients into low, medium, and high risk of chronicity using tools like the STarT Back Tool and assessing red flags. The usual care of NSAIDs and encouraging normal activities is noted to have a high recurrence rate. A biopsychosocial approach including cognitive behavioral techniques and therapeutic neuroscience education is recommended for high risk patients.
The document discusses the challenges of managing back pain in an aging population. It notes that medical factors like tolerances for pharmacotherapy and operative fitness limit management options for back dysfunction in older patients. It also discusses challenges from attitudes and perceptions about back pain in older adults, including myths and legends about opioid use and dependence. Finally, it covers how lifestyle factors and priorities around independence, future activity, finances, and environment affect back pain management priorities for retirees.
Critical care rehabilitation is an important part of the recovery process for ICU patients. It begins with early mobilization like passive range of motion exercises and progresses to active transfers, sitting at the edge of the bed, and eventually ambulation. A multidisciplinary team approach that includes nurses, physiotherapists, and other allied health professionals comprehensively assesses patients and develops individualized rehabilitation plans and goals. Regular evaluation during the ICU stay, before discharge, and after discharge is important to optimize recovery outcomes and quality of life.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Avoiding tech neck: adverting biomechanical dysfunction from the use of techn...Chiropractic Economics
Tech Neck is the term used to describe the injuries and pain sustained from looking down at wireless devices.
Tech Neck Symptoms include:
Chronic Headaches
Upper Back Pain
Shoulder Pain
Neck Pain
Curvature of the Spine
This document summarizes a presentation on physiotherapy for non-cancer chronic pain. It discusses that physiotherapy aims to restore and promote optimal physical function and quality of life for those with persistent pain. It provides an overview of evaluation processes in physiotherapy and various treatment modalities. It also summarizes evidence on approaches for common persistent pain conditions like low back pain, whiplash associated disorder, and osteoarthritis. Screening tools for risk of long-term disability are also briefly covered.
1) The document provides an overview of falls prevention and treatment for older adults. It discusses epidemiology facts about falls and examines assessment strategies across four domains: medical, cognitive, functional, and environmental.
2) Key points covered include that 25% of community-dwelling older adults fall each year, with 5-10% of falls causing serious injuries like fractures. Falls are also the most common cause of traumatic brain injury in the elderly.
3) The document emphasizes the importance of assessing multiple risk factors across different domains to identify potentially treatable diagnoses. It provides examples of medical, cognitive, functional, and environmental risk factors and stresses that etiologies of falls are usually multifactorial.
1) Concussion education is needed for athletes, parents, coaches and medical professionals to improve recognition and management of concussions.
2) Studies show educational interventions can improve immediate knowledge but longer term effects on behavior change are unclear.
3) A public health framework including surveillance, identifying risk factors, developing interventions and evaluating outcomes may help increase reporting and proper management of concussions.
4) Effective education requires understanding barriers, tailoring messages and delivery to different audiences, and evaluating impact on behaviors over time.
‘Neurodynamics as a therapeutic intervention; the effectiveness and scientifi...NVMT-symposium
This document discusses the evidence for neural mobilization as a treatment for nerve disorders. It begins by reviewing animal studies showing that movement such as exercise prevents neuropathic pain development, aids nerve recovery after injury, and reduces neuropathic pain. However, the evidence for neural mobilization and nerve gliding exercises in humans is limited. A systematic review found limited evidence that neural mobilization is more effective than minimal interventions for pain and disability in carpal tunnel syndrome, but not more effective than other treatments. Another review found limited evidence for the effectiveness of nerve gliding exercises in carpal tunnel syndrome. The document concludes that while movement may be beneficial, the evidence does not clearly support neural mobilization over other conservative treatments, and more high-quality research is
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
Thriving, not just surviving after critical illnessCoda Change
1. Many ICU survivors experience long-term physical and mental disability after discharge, impacting their quality of life.
2. A study of 262 Australian ICU survivors found 57% experienced disability 6 months after discharge, with highest impairment in physical activity. Predictors included a history of anxiety/depression, separated/divorced marital status, and more days on mechanical ventilation.
3. Clinicians believe strategies like early mobilization, improved sedation practices, nutrition protocols, and enhancing family support could help ICU survivors recover and thrive after discharge.
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Properties of the brain's emotional learning circuitry predict the transition to chronic pain. In a longitudinal study, individuals with acute back pain were scanned over a year-long period. The strength of functional connectivity between the medial prefrontal cortex and nucleus accumbens at the initial scan predicted whether the individual would transition to chronic pain with over 80% accuracy. Future studies are needed to understand the mechanisms driving pain chronicity, with the goal of developing novel therapies to prevent the transition to chronic pain.
Professor Andrew Davies is an Intensivist working at Peninsula Health in Melbourne. He has performed clinical research in the field of critical care for 20 years, as a participating investigator in over 50 studies (mostly clinical trials), predominantly in the areas of critical care nutrition, mechanical ventilation and acute lung injury and severe sepsis. He is a past Vice Chair of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) with a special interest in nutrition in the ICU, and is a past Chair of the Australian and New Zealand Society of Parenteral and Enteral Nutrition (AuSPEN).
In this talk, Professor Davies tackles the often overlooked aspect of nutrition in the ICU and it’s potential benefits for our patients.
Evaluation and Treatment of Children and Adolescents With Sleep DisordersStephen Grcevich, MD
In this presentation from Child and Adolescent Behavior Health in Canton OH, Dr. Stephen Grcevich discusses evaluation and treatment of insomnia in children and teens in an outpatient psychiatric treatment setting. Viewers will review guidelines describing “normal” sleep in children and teens, explore common causes of sleep disturbance in the pediatric population, address treatment of sleep issues associated with common psychiatric conditions in children and teens and be presented with an approach to addressing concerns with insomnia in clinical practice.
Link to video: https://www.slideshare.net/drgrcevich/evaluation-and-treatment-of-children-and-adolescents-with-sleep-disorders
This slideshare is a summary of a study on patient beliefs about low back pain in an outpatient physical therapy clinic in Trinidad. The study is a retrospective analysis of survey data using the Back-PAQ measure. Results show a high proportion of negative beliefs particularly around protection of the back. The study highlights the need to address these unhelpful beliefs with appropriate interventions that decrease fear and protection of the back.
This document discusses the evidence that resident work hours should be reformed to improve resident and patient well-being. It summarizes research showing that sleep deprivation impairs clinical performance and increases medical errors. Studies found residents had high rates of depression, motor vehicle accidents, and obstetric complications due to long work hours and lack of sleep. The document advocates for collaborative efforts between medical schools, hospitals, and unions to implement work hour limits and enforce policies to promote resident and student health and safety.
Predicting Subjective Sleep Quality Using Objective Measurements in Older AdultsReza Sadeghi
This document summarizes Reza Sadeghi's dissertation defense on predicting subjective sleep quality using objective measurements in older adults. The document outlines the importance of sleep quality prediction, a brief review of sleep physiology including sleep stages, existing challenges in sleep assessment, and the proposed methods. The proposed methods involve using machine learning techniques and extracting features from physiological signals collected by wearable sensors to predict sleep quality, with a focus on predicting sleep quality in caregivers of people with dementia and enhancing prediction models using electronic health records and heart rate variability data.
Presentation by Jen Unwin at the SFCT research conference Orienting Solutions 2013, University of Hertfordshire.
For more resources like this, go to http://herts.ac.uk/hesian.
This document summarizes an ongoing study examining risk stratification of mild traumatic brain injuries. The study utilizes a prospective observational cohort called HeadSMART that collects clinical data, serum, plasma, mRNA, and DNA samples from patients with head injuries. Advanced imaging and 'omics techniques like proteomics, genomics and metabolomics are used along with clinical data to characterize patients and injuries to improve risk stratification. Preliminary results show certain serum biomarkers like BDNF measured on the day of injury can predict recovery risks. Ongoing work involves examining more biomarkers and developing machine learning models to better prognosticate recovery outcomes after mild traumatic brain injury.
Treating Insomnia in Depression Insomnia Related Factors Pred.docxturveycharlyn
Treating Insomnia in Depression: Insomnia Related Factors Predict
Long-Term Depression Trajectories
Bei Bei
Monash University and Royal Women’s Hospital, University of
Melbourne
Lauren D. Asarnow
Stanford University
Andrew Krystal
University of California, San Francisco
Jack D. Edinger
National Jewish Health, Denver, Colorado, and Duke University
Medical Center
Daniel J. Buysse
University of Pittsburgh
Rachel Manber
Stanford University
Objective: Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has
been associated with poorer outcomes for both conditions. However, individual differences in depressive
symptom trajectories during and after treatment are poorly understood in comorbid insomnia and
depression. This study explored the heterogeneity in long-term depression change trajectories, and
examined their correlates, particularly insomnia-related characteristics. Method: Participants were 148
adults (age M � SD � 46.6 � 12.6, 73.0% female) with insomnia and MDD who received antidepressant
pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or
control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were
assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs
about sleep were also assessed. Results: Growth mixture modeling revealed three trajectories: (a)
Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value � .001)
and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom
reduction during treatment (p values � .001) and low depression severity at posttreatment, but increased
severity over follow-up (p value � .001). (c) Optimal-Responders (13.5%) achieved most gains during
early treatment (p value � .001), continued to improve (p value � .01) and maintained minimal
depression during follow-ups. The classes did not differ significantly on baseline measures or treatment
received, but differed on insomnia-related measures after treatment began (p values � .05): Optimal-
Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about
sleep. Conclusions: Three depression symptom trajectories were observed among patients with comorbid
insomnia and MDD. These trajectories were associated with insomnia-related constructs after commenc-
ing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes.
What is the public health significance of this article?
This study identified three distinct depression trajectories in patients with comorbid major depression
and insomnia disorders during treatment and 2-year follow-up. Those with the largest and most
sustained improvements in depression consistently scored the lowest on postbaseline insomnia and
insomnia-related cognitions. Early changes in insomnia symptoms and insomnia-related character ...
1. The document discusses a study on treatment options for insomnia in primary care settings in New Zealand. It examines how patients view available treatments and the relationship between sleep beliefs, treatment choices, and insomnia symptoms.
2. The study found that patients were not accessing effective non-medication treatments and those using prescription medication had greater sleep difficulties. Greater endorsement of unhelpful sleep beliefs was related to longer term medication use.
3. The conclusions suggest cognitive behavioral therapy could help patients improve sleep and reduce medication use by addressing unhelpful sleep beliefs.
Dennis Rosen - Harvard Medical School and Boston Children's Hospital, USA. Fundación Ramón Areces
El jueves y viernes 18 y 19 de enero del 2018 se organizó en la Fundación Ramón Areces un Simposio Internacional: Patología del Sueño: de la Neurobiología a las manifestaciones sistémicas. En colaboración con la Sociedad Española de Sueño.
This document summarizes research on hope and its relationship to well-being and health outcomes. It discusses how hope has been defined, including as a belief in one's ability to achieve goals and find pathways to do so. Studies cited found that higher hope is associated with greater well-being, life satisfaction, positive mood, and longevity. Brief solution-focused therapy aims to enhance hope by focusing on clients' strengths and setting small, achievable goals. A pilot study found that a solution-focused well-being intervention increased participants' hope, positive mood, and subjective well-being. The document concludes by discussing the importance of hope for human flourishing and suggesting that solution-focused brief therapy could be considered a form of "hope
Sexology and lifestyle medicine - a multidisciplinary approach (NACS 2018, Tu...Vilho Ahola
- Sexual dysfunction is often multifactorial, with somatic components highly dependent on lifestyle. Effective clinical care requires a multidisciplinary approach.
- Lifestyle factors like poor diet, lack of exercise, stress, and substance abuse can lead to pathologies like obesity, diabetes, vascular disease, and depression that impact sexual function.
- Exercise, diet, sleep, mindfulness and stress management can promote neuroplasticity to improve sexual response through effects on hormones, vascular health, and cognition. A multidisciplinary lifestyle approach is usually most effective for treating sexual dysfunction.
This document provides information about a case study involving a 75-year-old patient named Clare who suffered a traumatic brain injury and now lives alone. She has poor physical and mental health as well as depression, anxiety, and obsessive compulsive disorder. The document outlines her health issues, needs assessment, and proposed interventions including installing non-slip flooring, exposure therapy for OCD, and cognitive behavioral therapy. It discusses skills like communication, teamwork, and information sharing needed by nurses to effectively promote patient health and conduct interventions.
Case An elderly widow who just lost her spouse. Subjective.docxcowinhelen
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
• Metformin 500mg BID
• Januvia 100mg daily
• Losartan 100mg daily
• HCTZ 25mg daily
• Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Insomnia is a disorder linked with difficulty in sleep quality, initiating or maintaining sleep, along with substantial distress and impairments of daytime functioning. Its prevalence ranges from 10 to 15% among the general population, with higher rates seen among females, divorced or separated individuals, those with loss of loved ones, and older people (Bollu & Kaur, 2019). Insomnia can simply be defined as a sleep disorder where the patient has trouble falling asleep or staying asleep. According to Krystal et al (2019), it is a common condition that is linked with noticeable deterioration in function and quality of life, mental and physical morbidity. The complaints of insomnia are present in 60–90% of patients with major depression, Complaints of disrupted sleep are very common in patients suffering from depression, (Wichniak, etal., 2017).
Questions you might ask the patient and rationale
The diagnosis and treatment of insomnia rely mainly on a thorough sleep history to address the precipitating factors as well as maladaptive behaviors resulting in poor sleep (Bollu & Kaur, 2019).
What is your sleep pattern including how many hours of sleep do you get at night prior to your husband’s demise and what it has been in the 10 months since his death? Does she perform certain rituals or do something special before she sleeps. This assesses if the insomnia started before or after the husband’s death. This provides a clue to insomnia that may be related to bereavement.
What time do you go to bed every night and what is your normal routine before going to bed? This is to check if the patient is doing something differently which has disrupted her normal routine and caused insomnia.
How often do you wake up to urinate at night? This question is asked to assess for nocturia due to diabetes that may lead to insomnia. Nocturia can prevent the patient from having a good night’s sleep. , changes in blood glucose levels at night causesto hypoglycemic and hyperglycemic episodes, nocturia and associated .
Respond of your colleagues who were assigned to a different.docxwilfredoa1
Respond
of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings as a Psychiatric Nurse Practitioner.
NOTE: Positive comment
Main Post
The three questions this writer would as the patient are:
Did your depressive symptoms worsen after the death of your husband?
How many hours per night do you sleep on average?
Do you sleep throughout those hours of sleep or do you wake constantly?
Do you ingest any stimulants like coffee or chocolate before bed?
Do you sleep during the daytime?
The rationale behind question one is to gauge the timeline of the patient’s depression. She appears to have been suffering with untreated depression for a long time, however the additional symptoms of insomnia and tearfulness seemed to worsen after his death. With this information the nurse practitioner will know if her depression is in an acute state and the severity of her illness.The patient is reporting sleeplessness; however the nurse practitioner needs to gauge if the patient is participating in restful sleep. Sleep of two hours or less may only consist of REM sleep (Boland et al., 2020). If the patient is not getting restful sleep, she is not benefiting from the bodily repair that takes place during sleep (Fitzgerald et al., 2017). This can place her at an increased risk for other illnesses and heighten depressive symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps consistently throughout those hours of sleep will provide information to the nurse about the kind and amount of sleep the patient is getting. Ingesting certain stimulants like caffeinated drinks, coffee or chocolate can affects the client’s sleep by providing wakefulness (Ulke et al., 2017). If the patient is sleeping during the daytime, her circadian rhythm could have been reversed where she will need less sleep during the night time hours (Fitzgerald et al., 2017).
The people this writer would interview are:
The patient’s aide
The patient’s son
The patient aide may be able to provide more information about observed sleepiness during the daytime. In addition, she will be able to provide information on the patient’s dietary patterns and physical activity. The questions to the aide would be:
Does she easily nod off during the daytime?
Does she easily become fatigued?
Does she consume a well-balanced diet?
Question one would illicit answers about her getting sleep.
It appears that she in fact getting sleep but because of a revered circadian rhythm she is not able to get the sleep at the night which is the desired time. Question two will help the nurse practitioner gauge the extent of the effects that non sleep has taken on the patient’s life. The patient, if constantly fatigued throughout the day has a life that has been highly impacted by the .
This document proposes a randomized controlled study to investigate the effects of bright light therapy on sleep and mood disorders in Parkinson's disease. 80 Parkinson's patients will be included and randomized to either real or placebo light therapy groups. Primary outcomes will be mood measures, and sleep parameters, motor symptoms, physiological markers, and biological rhythms will also be assessed if additional funding is obtained. The goal is to develop an effective non-pharmacological therapy to improve sleep, mood, and quality of life for Parkinson's patients.
Respond of your colleagues who were assigned to a different .docxwilfredoa1
Respond
of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
NOTE: Positive comment
Main Post
The three questions this writer would as the patient are:
Did your depressive symptoms worsen after the death of your husband?
How many hours per night do you sleep on average?
Do you sleep throughout those hours of sleep or do you wake constantly?
Do you ingest any stimulants like coffee or chocolate before bed?
Do you sleep during the daytime?
The rationale behind question one is to gauge the timeline of the patient’s depression. She appears to have been suffering with untreated depression for a long time, however the additional symptoms of insomnia and tearfulness seemed to worsen after his death. With this information the nurse practitioner will know if her depression is in an acute state and the severity of her illness.The patient is reporting sleeplessness; however the nurse practitioner needs to gauge if the patient is participating in restful sleep. Sleep of two hours or less may only consist of REM sleep (Boland et al., 2020). If the patient is not getting restful sleep, she is not benefiting from the bodily repair that takes place during sleep (Fitzgerald et al., 2017). This can place her at an increased risk for other illnesses and heighten depressive symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps consistently throughout those hours of sleep will provide information to the nurse about the kind and amount of sleep the patient is getting. Ingesting certain stimulants like caffeinated drinks, coffee or chocolate can affects the client’s sleep by providing wakefulness (Ulke et al., 2017). If the patient is sleeping during the daytime, her circadian rhythm could have been reversed where she will need less sleep during the night time hours (Fitzgerald et al., 2017).
The people this writer would interview are:
The patient’s aide
The patient’s son
The patient aide may be able to provide more information about observed sleepiness during the daytime. In addition, she will be able to provide information on the patient’s dietary patterns and physical activity. The questions to the aide would be:
Does she easily nod off during the daytime?
Does she easily become fatigued?
Does she consume a well-balanced diet?
Question one would illicit answers about her getting sleep.
It appears that she in fact getting sleep but because of a revered circadian rhythm she is not able to get the sleep at the night which is the desired time. Question two will help the nurse practitioner gauge the extent of the effects that non sleep has taken on the patient’s life. The patient, if constantly fatigued throughout the day has a life that has been highly impacted by the lack of sleep. The aide would be able to provide a clear, picture of the patient’s diet. The aide would be .
Shafali Spurling Jeste, MD: “Medical and Neurological Considerations in ASD: ...Semel Admin
(1) The document discusses medical comorbidities that are commonly seen in autism spectrum disorder, including genetics, epilepsy, and insomnia.
(2) It provides information on recommended genetic testing and screening for epilepsy and seizures. Rates of epilepsy are higher in ASD and can be related to genetic mutations or developmental regression.
(3) Insomnia is also very common in ASD, affecting up to 80% of children, and is characterized by difficulties with sleep initiation, maintenance, and duration. Screening and behavioral/pharmacological interventions are recommended for treating insomnia.
This document discusses delirium in the ICU, including:
1) Delirium is a common syndrome in ICU patients characterized by inattention and cognitive dysfunction. It is associated with increased mortality, length of stay, and long-term cognitive impairment.
2) Implementing an ABCDE bundle including awakening trials, breathing coordination, delirium monitoring/management, and early mobility can reduce delirium incidence and improve outcomes.
3) Non-pharmacological interventions like reorientation, mobility, and minimizing sedative exposure are important for preventing and treating delirium.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
3. Objectives
• Identify common sleep disturbances after concussion
• Identify risk factors for development of mood symptoms after
concussion
• Recognize treatment strategies to reduce sleep and mood
symptoms after concussion
8. Consequences of Decreased Sleep
• Decreased endurance and sprint sport performance
• Decreased accuracy in sports
• Increased injury and illness risk
• Increased depression risk
Also found increase in accuracy, reaction time and sprint performance after increased
sleep duration (Watson 2017)
9. Frequency of Sleep Symptoms
• 34% of patients reported sleep disturbance (Bramley 2017, n- 367)
• 50% of patients had some form of sleep disturbance (Mathias 2012)
• 70% of patients experienced sleep disturbance (Paniak 2002, n- 118)
10. Concussion Leading to Sleep Problems
• Higher level of sleep related problems at 5 weeks in concussed patients
(Barlow 2020)
• Increased rate of sleep disturbances in individuals who have recovered
from concussion (Blake 2019)
11. Sleep Issues Prolong Concussion Symptoms
• Poor sleep vs good sleep
groups
– higher symptom scores at initial
visit and at 3 months post injury
in poor sleep
– Poor sleep group took 2 weeks
longer to recover (Chung 2019)
• Sleep disturbance associated
with almost 4 fold increase in
recovery time (Bramley 2017)
12. Is Poor Sleep A Risk Factor For Concussion?
Athletes with a history of moderate to severe insomnia
have a 2-3x higher risk of concussion (Raikes 2019)
15. Ways To Treat Sleep Symptoms
• Sleep hygiene
• Melatonin
• Prescription medications
• CBT-I
• Blue light therapy?
• Active rehab
16. Sleep Hygiene
• Regular bedtime and wake
time
• Use bed for sleep only
• Cool, quiet, dark room
• No electronics before bed
• Avoid caffeine
• Daily exercise
• Avoid naps if not able to
sleep through the night
17. Melatonin
• Helps with sleep onset, some neuroprotective and antioxidant
properties (Zizhen 2017)
• Favorable safety profile
• AASM does not advocate for melatonin given weak evidence of
efficacy
18. Melatonin In Concussion
• RCT of melatonin vs placebo
showed improvement in sleep
onset time (Sletten 2018)
• 67% of concussed patients reported
improved sleep with melatonin
(Bramley 2017)
• RCT of melatonin vs placebo in
children with PPCS showed no
benefit (Barlow 2020)
19. Medications For Sleep
• Trazodone
• Zolpidem (Ambien)
• Amitriptyline
• Benzodiazepines and Diphenhydramine
are not recommended (Driver 2018)
20. Therapy For Sleep
• CBT-I (cognitive behavioral
therapy for insomnia)
• Has been shown to treat
insomnia in adults, limited
data in pediatrics
• RCT of CBT-I vs treatment as
usual in adolescents with
PPCS shows improvement
(Tomfohr-Madsen 2020)
21. Therapy For Sleep
• Blue light therapy
• RCT of blue vs amber light each morning
in patients with sleep problems after
mTBI showed improvement of
symptoms (Killgore 2020)
– Phase advanced sleep onset, but no
change in overall sleep duration
– Reduced daytime sleepiness
– Improved executive functioning
– Improved interconnectivity in brain
on DTI MRI
24. Frequency of Mood Symptoms With Concussion
• 23% of youth had psychological distress at 4 and 12
weeks post concussion (Brooks 2019)
• 22% of children recovering from concussion had
depression symptoms (Stazyk 2017)
• 49.4% of patients recovering from concussion had at
least 1 emotional symptom (Ellis 2015)
25. Mood Symptoms and Duration of Concussion
• Children with depressive symptoms had higher post
concussion symptom scores (Stayzk 2017, Ellis 2015)
• Pre concussion depression or anxiety disorder are
markers for prolonged concussion symptoms (Meares
2011)
26. Concussion Leading to Mood Issues
• Dose response relationship between amount of prior
concussions and risk for future diagnosis of depression
in retired NFL players (Kerr 2012)
• History of concussion was associated with a 3.3x greater
risk of diagnosis of depression in adolescents (Chrisman
2014)
27. Concussion and Elevated Anxiety
• Athletes may be worried about losing position on the
team, future scholarships and relationships with
teammates
• Adults may be worried about loss of income and
inability to support family
• Pandemics don’t help either
28. Concussion and ADHD
• Higher rate of concussion in adolescents with ADHD (Iverson 2016)
• Systematic review: Those with ADHD or LD do not appear to be at
substantially greater risk of concussion (Iverson 2017)
• Higher prevalence of prior concussion in adolescents with ADHD and/or LD
(Iverson 2020)
• 50% of adolescents with concussion had predating ADHD (Iaccarino 2018)
• Higher post concussion symptom score in patients with ADHD (Iaccarino 2018)
30. Ways to Treat Mood Symptoms With Concussion
• Reassurance, education, support
• Mindfulness and relaxation
• CBT
• Medication (SSRI etc.)
• Active rehab
31. Reassurance and Relaxation in Concussion
• Reassurance and education
– 10 randomized studies reviewed-
mixed results
• Relaxation and mindfulness-
– 2 randomized studies reviewed-
mixed results (Al Sayegh 2010)
32. Therapy for Mood Symptoms
• CBT
– 3 RCTs - all showing some benefit
• Reduced frequency, intensity and
duration of symptoms at 6 mo
• Improved anxiety and depression
symptoms at 1 mo
• Improvement in psychosocial
functioning (anxiety and depression)
– 7 non randomized studies- all showed
some benefit (Al Sayegh 2010)
33. Medication for Mood Symptoms
• SSRIs (Fluoxetine, Sertraline, etc)- first line
• SNRIs (Duloxetine, Venlafaxine, etc)- second line
– 2018 meta analysis shows no benefit for SSRI/SNRI vs placebo
– Included study with questionable mTBI
– Silverberg et al suggest treating mTBI with SSRIs (Silverberg 2019)
34. Relationship Between Sleep and Mood Symptoms
• In a cohort of pediatric patients with anxiety
disorder, 88% also had sleep related problems
(Chorney 2007)
• In a cohort of pediatric patients with depression
disorder, 74% also had significant insomnia
(Chorney 2007)
• Levels of anxiety and depression were found to
correlate with changes in sleep in TBI patients
(Parcell 2008)
36. Take Home Points
• There is a bi directional relationship between
– Concussion and sleep
– Concussion and mood
• Early recognition and treatment of sleep and mood
issues is important in concussion
37. References
• Bramley H, Henson A, Lewis MM, Kong L, Stetter C, Silvis M. Sleep Disturbance Following Concussion Is a Risk Factor for a Prolonged Recovery. Clin Pediatr (Phila).
2017;56(14):1280-1285. doi:10.1177/0009922816681603
• Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis. Sleep Med. 2012;13(7):898-905.
doi:10.1016/j.sleep.2012.04.006
• Paniak C, Reynolds S, Phillips K, Toller-Lobe G, Melnyk A, Nagy J. Patient complaints within 1 month of mild traumatic brain injury: a controlled study. Arch Clin
Neuropsychol. 2002;17(4):319-334.
• Blake AL, McVicar CL, Retino M, Hall EE, Ketcham CJ. Concussion history influences sleep disturbances, symptoms, and quality of life in collegiate student-athletes. Sleep
Health. 2019;5(1):72-77. doi:10.1016/j.sleh.2018.10.011
• Barlow KM, Girgulis KA, Goldstein G, et al. Sleep Parameters and Overnight Urinary Melatonin Production in Children With Persistent Post-concussion Symptoms. Pediatr
Neurol. 2020;105:27-34. doi:10.1016/j.pediatrneurol.2019.11.006
• Barlow KM, Brooks BL, Esser MJ, et al. Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial. Pediatrics. 2020;145(4):e20192812.
doi:10.1542/peds.2019-2812
• Watson AM. Sleep and Athletic Performance. Curr Sports Med Rep. 2017;16(6):413-418. doi:10.1249/JSR.0000000000000418
• Raikes AC, Athey A, Alfonso-Miller P, Killgore WDS, Grandner MA. Insomnia and daytime sleepiness: risk factors for sports-related concussion. Sleep Med. 2019;58:66-74.
doi:10.1016/j.sleep.2019.03.008
• Zizhen Xie, Fei Chen, William A. Li, Xiaokun Geng, Changhong Li, Xiaomei Meng, Yan Feng, Wei Liu & Fengchun Yu (2017) A review of sleep disorders and melatonin,
Neurological Research, 39:6, 559-565, DOI: 10.1080/01616412.2017.1315864
• Sletten TL, Magee M, Murray JM, et al. Efficacy of melatonin with behavioural sleep-wake scheduling for delayed sleep-wake phase disorder: A double-blind, randomised
clinical trial. PLoS Med. 2018;15(6):e1002587. Published 2018 Jun 18.
• Driver S, Stork R. Pharmacological management of sleep after traumatic brain injury. NeuroRehabilitation. 2018;43(3):347-353. doi:10.3233/NRE-182536
• Tomfohr-Madsen L, Madsen JW, Bonneville D, et al. A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Insomnia in Adolescents With Persistent
Postconcussion Symptoms. J Head Trauma Rehabil. 2020;35(2):E103-E112. doi:10.1097/HTR.0000000000000504
38. References
• Killgore WDS, Vanuk JR, Shane BR, Weber M, Bajaj S. A randomized, double-blind, placebo-controlled trial of blue wavelength light exposure on sleep and recovery of brain structure, function, and cognition
following mild traumatic brain injury. Neurobiol Dis. 2020;134:104679. doi:10.1016/j.nbd.2019.104679
• Stazyk K, DeMatteo C, Moll S, Missiuna C. Depression in youth recovering from concussion: Correlates and predictors. Brain Inj. 2017;31(5):631-638. doi:10.1080/02699052.2017.1283533
• Brooks BL, Plourde V, Beauchamp MH, et al. Predicting Psychological Distress after Pediatric Concussion. J Neurotrauma. 2019;36(5):679-685. doi:10.1089/neu.2018.5792
• Ellis MJ, Ritchie LJ, Koltek M, et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015;16(6):709-718. doi:10.3171/2015.5.PEDS15220
• Meares S, Shores EA, Taylor AJ, et al. The prospective course of postconcussion syndrome: the role of mild traumatic brain injury. Neuropsychology. 2011;25(4):454-465. doi:10.1037/a0022580
• Chrisman SP, Richardson LP. Prevalence of diagnosed depression in adolescents with history of concussion. J Adolesc Health. 2014;54(5):582-586. doi:10.1016/j.jadohealth.2013.10.006
• Kerr ZY, Marshall SW, Harding HP Jr, Guskiewicz KM. Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. Am J Sports Med.
2012;40(10):2206-2212. doi:10.1177/0363546512456193
• Iverson GL, Atkins JE, Zafonte R, Berkner PD. Concussion History in Adolescent Athletes with Attention-Deficit Hyperactivity Disorder. J Neurotrauma. 2016;33(23):2077-2080. doi:10.1089/neu.2014.3424
• Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941-948. doi:10.1136/bjsports-2017-097729
• Iverson GL, Wojtowicz M, Brooks BL, et al. High School Athletes With ADHD and Learning Difficulties Have a Greater Lifetime Concussion History. J Atten Disord. 2020;24(8):1095-1101.
doi:10.1177/1087054716657410
• Iaccarino MA, Fitzgerald M, Pulli A, et al. Sport concussion and attention deficit hyperactivity disorder in student athletes: A cohort study. Neurol Clin Pract. 2018;8(5):403-411.
doi:10.1212/CPJ.0000000000000525
• Al Sayegh A, Sandford D, Carson AJ. Psychological approaches to treatment of postconcussion syndrome: a systematic review. J Neurol Neurosurg Psychiatry. 2010;81(10):1128-1134.
doi:10.1136/jnnp.2008.170092
• Silverberg ND, Panenka WJ. Antidepressants for depression after concussion and traumatic brain injury are still best practice. BMC Psychiatry. 2019;19(1):100. Published 2019 Mar 27. doi:10.1186/s12888-019-
2076-9
• Chorney DB, Detweiler MF, Morris TL, Kuhn BR. The interplay of sleep disturbance, anxiety, and depression in children. J Pediatr Psychol. 2008;33(4):339-348. doi:10.1093/jpepsy/jsm105
• Parcell DL, Ponsford JL, Redman JR, Rajaratnam SM. Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study. Arch Phys Med Rehabil. 2008;89(5):843-850.
doi:10.1016/j.apmr.2007.09.05
Trouble getting to sleep
Trouble staying asleep
Sleeping more/less
Needing more naps, trouble focusing
Not enough REM sleep
Single night of 5 hrs of sleep was shown to decrease serving accuracy up to 53% in tennis players
-Collegiate male basketball players, increased sleep by 1.9 hrs per night over 5-7 week was associated with 9% increase in free throw percentage and 9.2% increase in 3-point percentage and improvements in reaction time
-Collegiate tennis players, 1.6 hr increase in sleep was associated with 36-41% increase in serving accuracy
-Bramley 2017, N-367, 13-18 yo after concussion
-Mathias 2012, meta analysis of after TBI
-Paniak 2002, N-118
-Barlow 2020, Higher level of SRP in children with Persistent PostConcussive Symptoms (PPCS) at 5 weeks following injury compared to recovered and healthy individuals, of note objective measures found no differences
-Blake 2019, 82 collegiate athletes surveyed, not currently recovering from concussion, found that those with a history of concussion were more likely to have sleep disturbances vs those without concussion, also found graded response, more previous concussion the more sleep disturbances
-Chung 2019, Participants were from the north Texas concussion network prospective registry and were 18yo or less with concussion, used Pittsburg sleep quality index (PSQI) at initial visit and 3mo f/u, good sleep group 5 or less and bad sleep group >5 on PSQI, N: 517
Poor sleep group reported higher total concussion symptoms scores at initial visit and 3 months post injury and took avg 2 weeks longer to recover compared to good sleep group
Poor sleep group also had higher levels of anxiety and depression symptoms
-Bramley 2017, n 367, retrospective chart review, adolescents with concussion, 34% with sleep disturbance, those with sleep disturbance recovered in 111 days vs 29 days in those without sleep disturbance (asked if they had trouble falling or staying asleep)
Raikes 2019- N 190, survey of UofA atheltes, Insomnia severity index ISI and Pittsburg sleep quality index PSQI given and then followed to see who had a concussion
-keep a good schedule
-avoid blue light for 2 hrs prior to bed (screen filters/glasses)
-if going to have caffeine avoid after lunch
-Get sub symptom threshold exercise daily but avoid exercise right before bed
-Released by pineal gland at night corresponding with circadian rhythm, generally starts to increase 2 hrs before sleep onset and peaks 5 hours later (Zizhen 2017)
-Concerns over product quality and regulation
-American Academy of Sleep Medicine does not advocate for melatonin given weak evidence of efficacy
Sletten 2018, RCT of melatonin vs placebo showed improvement in sleep onset time by 34 min and improvement of subjective sleep parameters
Bramley 2017, n 367, Of patients with sleep disturbance after concussion 67% who took melatonin reported improved sleep (Bramley 2017)
Barlow 2020, 3mg vs 10mg vs Placebo, RCT, n92, treated for 28 days, no significant difference, everyone got better
Didn’t differentiate between those with sleep problems, no control without placebo
Trazodone- antidepressant, at low doses acts as a hypnotic agent, can decrease number of early awakenings
Zolpidem (Ambien)- nonbenzo GABA receptor agonist, hypnotics, less cognitive side effects and lower risk for dependence
Amitriptyline- tricyclic antidepressant, used for migraines in mTBI, side effect of sedation can be used for sleep
Benzodiazepines and Diphenhydramine are not recommended (Driver 2018)
-Helps to identify, challenge and alter maladaptive beliefs, attitudes and practices related to sleep
-Tomfohr-Madsen 2020, n 24 RCT of CBT-I vs treatment as usual in adolescents with PPCS
Improved insomnia ratings
Fewer dysfunctional beliefs about sleep
Better sleep efficiency
Shorter sleep onset latency
Longer sleep time
-Retinal ganglion cells are sensitive to blue light, they then project to the SCN which then suppresses melatonin secretion from the pineal gland
-Killgore 2020, n 32, RCT 6 weeks of 30 min of blue vs amber light in the am
Phase advanced sleep onset, but no change in overall sleep duration
Reduced daytime sleepiness
Improved executive functioning
Improved interconnectivity in brain on DTI MRI
Brooks 2019, N 311, 6-17 yo seen at injury, 4 weeks and 12 weeks
Stazyk 2017, N 92, children with concussion
Ellis 2015, N 174, avg 14.2yo
-Kerr 2012, 9 yr risk of depression, n 1044 ex NFL players surveyed in 2001 and again in 2010
-Chrisman 2014, N 36,060, retrospective phone survey, 12-17yo without active concussion, only included those with current depression in depressed group
-Iverson 2016, In adolescents with ADHD, 26.1% had a history of concussion. Whereas in those without ADHD, 17.1% had a history of concussion. N 6529, 13-19yo, baseline impact testing, Kids with ADHD are at increased risk for injuries in general, perhaps owing to being less attentive, more impulsive, and more prone to risk taking?
-Iverson 2020, N 32,487, adolescents with baseline impacts
-Iaccarino 2018, N 79, 12-24yo with concussion in last 10 yrs, 50% of adolescents with concussion had ADHD where as the overall rate of ADHD in children is 9.4% per CDC
Al Sayegh 2010, systematic review of 42 papers
Reassurance and education(3 showing benefit, 7 showing no benefit or inconclusive)
Relaxation and mindfulness -1 study showing improvement of symptoms with relaxation techniques
1 study showing no improvement with mindfulness based intervention
Silverberg 2019, questionable study had more likely moderate to severe TBI than mTBI, Also note that even if there is benefit from placebo it may still be worth giving the medication.