Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury

Adam R Kinney; Xiang-Dong Yan; Alexandra L Schneider; Samuel King; Jeri E Forster; Nazanin Bahraini; Lisa A Brenner

doi:10.3389/fresc.2022.964420

Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury

Front Rehabil Sci. 2022 Oct 12:3:964420. doi: 10.3389/fresc.2022.964420. eCollection 2022.

Authors

Adam R Kinney^{1

2}, Xiang-Dong Yan¹, Alexandra L Schneider¹, Samuel King¹, Jeri E Forster^{1

2}, Nazanin Bahraini^{1

3}, Lisa A Brenner^{1

4}

Affiliations

¹ Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States.
² Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
³ Departments of Physical Medicine and Rehabilitation and Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
⁴ Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

Abstract

Background: Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.

Materials and methods: This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).

Results: 87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).

Discussion: Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.

Keywords: concussion; mild traumatic brain injury (mTBI); neurobehavioral symptoms; participation; postconcussive symptoms; sleep; veterans.

This work is authored by Adam R. Kinney, Xiang-Dong Yan, Alexandra Lindsay Schneider, Samuel King, Jeri E. Forster, Nazanin Bahraini and Lisa Anne Brenner on behalf of the U.S. Government and as regards Dr. Kinney, Dr. Yan, Dr. Schneider, Dr. King, Dr. Forster, Dr. Bahraini and Dr. Brenner, and the U.S. Government, is not subject to copyright protection in the United States. Foreign and other copyrights may apply.