Post-Concussion Dizziness: An Integrated Approach to Treatment and Recovery
Concussion injuries can trigger a multitude of symptoms, each unique and complex in its own right. The severity of these symptoms can vary considerably, ranging from barely noticeable to exceptionally…
Quick! What’s the one thing most people would give their right arm to get more of?
Nope, it’s not money…
No, it’s not sex or beer or chocolate, although, those are all fine guesses.
The answer is SLEEP!
According to a report by Statistics Canada, one in three Canadians aren’t getting enough sleep. The study, which followed 10,000 Canadians between the ages of 18 to 79 over a six-year period, also found that Canadians are getting even less sleep than they were in 2005!
Things aren’t much rosier south of the border. According to the American Sleep Association, 50-70 million Americans suffer from a sleep disorder, and 37.9% have reported that they unintentionally fell asleep during the day at least once in the preceding month. 4.7% of these were while driving!
Getting quality sleep is important for everyone’s health. But when it comes to treating concussion patients, sleep is the primary tool to uncover what may really be going on inside them.
Chicken or the Egg?
When a person is not sleeping well, they are going to present with a certain set of symptoms. They will feel fatigued during the day and a little foggy. They will also most likely have mood issues and difficulty focusing and concentrating. And this is someone without a concussion!
And that’s the point.
If you take an otherwise healthy person and deprive them of sleep for just two or three days, they will develop cognitive impairment similar to a concussion patient.
This is one of the reasons sleep is so incredibly important to concussion recovery. Because if a patient is also reporting fatigue, fogginess, trouble concentrating, difficulty remembering, dizziness etc., their healthcare provider has to wonder, “Are these symptoms because of the concussion or because they’re not sleeping properly?”
It’s the chicken or the egg syndrome.
It becomes incredibly hard to monitor a concussion patient who is also not sleeping well because the symptoms are so similar.
Another example of this is anxiety. Anxiety is a common side effect of a head injury. And anxiety by itself can also cause someone to not be able to fall asleep. And sleep deprivation can bring on anxiety in a healthy person.
So, you see, all of these symptoms are intertwined, which makes it difficult to know exactly what is going on with a concussion patient who also isn’t sleeping well. Often if we, as healthcare providers, we can determine the patient is having trouble sleeping and tackle that issue first, the outcomes are far better.
Your Body Needs Sleep to Heal
Sleep is also extremely important and critical for healing following a brain injury or injury in general. Not only is sleep required to flush out neurotoxins, it also helps to restore damaged DNA and neurons.
Sleep is also necessary for the production of oligodendrocyte precursors, which are needed for the production of myelin, which helps with signal transmission of the brain.
Sleep is vitally important to regeneration, repair and neuroplasticity. According to a study by Howell in 2019(1), 45% of adolescents report having sleep difficulties in the first 10 days after a concussion and, no surprise, this was also correlated with having worse symptoms and increased symptom burden.
When you start looking at chronic patients in the Post-Concussion Syndrome (PCS) stages, these numbers climb even higher. Brooks and colleagues in 2019(2) found that 62% of adolescents who were an average of six months post injury had clinically significant insomnia. This was associated with higher concussion symptoms, higher anxiety and higher depression.
Now again, we have the ol’ chicken or the egg syndrome. Are these kids depressed and anxious because they’re not sleeping? Or are they not sleeping because they’re depressed and anxious? Or is it the head injury itself causing the depression, anxiety and insomnia?
How Does a Concussion Affect Your Sleep Cycle?
It’s no surprise that a brain injury would disrupt your sleep. But what exactly is going on? There are three ways a concussion affects the quality and amount of sleep a patient gets each night.
1. Reduced Melatonin
There is evidence that a concussion can cause reduced melatonin production. Melatonin is the sleep hormone released by the pineal gland in full darkness. If your body produces less melatonin for whatever reason, the result is going to be trouble falling asleep each night. Light stimulation can also suppress melatonin production, but we’ll get to this particular subject in just a little bit.
2. Glutamate Release
The second way a concussion can wreak havoc on sleep is through the actual concussion injury itself. Concussion injury results in millions of brain cells firing and discharging immediately after impact. This causes your brain to release glutamate, a neurotransmitter, and high glutamate release can affect your circadian rhythm.
Your circadian rhythm is your sleep-wake cycle. You’re awake in the day, you’re asleep at night – that is your normal circadian rhythm. But a concussive injury is believed to throw off this delicate circadian rhythm and leave patient’s sleepy all day and alert at night.
3. Hormonal Imbalances
The third way a concussion can negatively impact the quality and quantity of your sleep is by causing a hormonal imbalance in your body. While melatonin is probably the most well-known hormone associated with sleep, there are other hormones that are involved in sleep and wakefulness.
Recent evidence demonstrates it is common for concussion patients to suffer hormonal imbalances following a head injury(3,4). In fact, as many as 30% of patients six months or more after the initial injury have shown different imbalances in hormones. And some of these hormones are involved in sleep and wakefulness.
How Your Body Puts Itself to Sleep
You may think a math class, a documentary on paper towel production, or one of your uncle’s stories about his first Buick is what triggers your body to fall asleep. But the actual mechanics of sleep are a bit more involved. Though certainly boredom does seem to have a way of making us sleepy!
Basically, throughout your day, you get a buildup of substances in your body that make you feel nice and sleepy by the end of the day. One of those substances is adenosine, which is a byproduct of energy use. ATP (adenosine triphosphate) is the energy molecule that we use for our bodily processes.
Over the course of a day, as you’re burning energy by doing chores, running errands and working, you have an increase in buildup of adenosine. You also have an increased buildup of cytokines, which are your immune cells. This buildup of adenosine and cytokines creates “sleep debt”, and as your sleep debt builds, you start to feel more tired.
This is often why, when you’re fighting a cold or infection, you feel the urge to sleep more. It’s because of the increased inflammatory and immune response, a response that is also present following a concussion. As these chemicals build up in your body you get more and more fatigued. See more about the TOP CAUSES of prolonged concussion symptoms here!
Now, during a good night’s sleep, particularly during periods of deep or “slow wave sleep”, your body resets and restores your adenosine and cytokine levels so that you are ready to tackle the day. This is why after a good night’s sleep you feel so awake and alert in the morning.
This is the wake-sleep cycle in a nutshell: your body builds up stuff over the course of the day, you restore levels at night, and then you build up more stuff the next day. It’s a never-ending fluctuation. Understanding this concept, it becomes clear how a couple nights of bad sleep and not clearing inflammation or restoring your energy levels can leave you feeling foggy, fatigued, and anxious.
The other component to this sleep-wake cycle is that hormone we discussed earlier called melatonin. Darkness is what signals your body to produce more melatonin, which helps your body become nice and drowsy. In the old days, when our ancestors scheduled their day around sunrise and sunset, there were far less sleep issues.
But modern humans must now contend not only with lightbulbs but with myriad digital screens, all of which are emitting a blue light. And it is this blue light that your body is very sensitive to in terms of your production of melatonin.
Essentially when light hits the retina, it stimulates melanopsin-based intrinsically photosensitive retinal ganglion cells. Whew, say that a few times fast! These cells are sensitive to light in the blue spectrum of the range. When these cells are stimulated, they suppress the production of melatonin.
Essentially, blue light tells your body it’s time to wake up. So when you stay on your phone playing Candy Crush for hours before bed and then wonder why you can’t fall asleep, it’s because you have been staring into blue light, and this light has told your pineal gland to avoid secreting any melatonin. Good luck catching Zzzzz’s now – you’d have better luck catching a taxi on a rainy day in the middle of Times Square.
This is why so many people wear those funny-looking blue light-blocking glasses in the evening. Especially people who do a lot of work on the computer. Some people wear these glasses at night while watching television so the blue light emitted from the TV won’t keep them from falling asleep.
In general, it’s a good idea to avoid blue light at nighttime, so stay off your phone or computer and don’t watch TV in bed. Better to read a book or listen to music.
Can Something Bad for You be Good for You, Too?
Unless you’re a glutton for punishment, you wouldn’t drink copious amounts of coffee right before bedtime. But how many of us can’t seem to get going in the morning without a cup or three of our favorite brew?
Coffee: bad at night, great in the morning.
Similarly, you don’t want to subject your eyes to blue light right before bed because it suppresses melatonin production. But, blue light in the morning can be a very good thing.
Blue light at the right time of day can actually help regulate and kickstart your circadian rhythm. Because blue light tells your body to stop producing melatonin, it helps your body to become more awake and alert.
Blue light therapy has become an interest in concussion patients because it has been found to reduce daytime fatigue, reduce daytime sleepiness and improve alertness throughout the day. Blue light therapy has also been shown to be effective in treating some forms of depression, which often overlap some of these sleep difficulties.
Concussion researchers are now looking into how blue light can potentially be used to bio hack and reset a patient’s circadian rhythm, which has become disrupted by a concussion injury.
One study(5) that has shown promising results with blue light therapy treated 34 adult patients with persistent concussion symptoms. These adult patients were randomized into two groups: one group received daily blue light therapy. The second group did the exact same protocol, but their light was amber.
Both groups did 30 minutes of daily light exposure within two hours of waking up and they kept track of their results in a journal, noting any daytime sleepiness they may have felt. They also wore wrist-watch-type-thingies called “actinographs” that measured how well they were sleeping at night and how long they were in each space cycle of their sleep.
After six weeks of treatment, the blue light group had a significant phase advancement in sleep onset. Meaning they fell asleep significantly earlier after blue light therapy than they had been before blue light therapy. One hour earlier was the average. However, the group using the amber light was falling asleep 15 minutes later by the end of the six weeks. It had basically no effect!
Interestingly the blue light group was also waking up one hour earlier. The blue light effectively phase shifted their entire sleep cycle to be one hour earlier. The amber light group, on the other hand was waking up 16 minutes earlier. So, they were falling asleep 15 minutes later and waking up 16 minutes earlier! Their overall sleep cycle had actually contracted whereas the blue light group’s overall sleep had just shifted over.
87.5% of the blue light group also showed reduced sleepiness scores from pre-intervention to post-intervention. The authors of the study concluded, “Our findings are consistent with well-established evidence that blue light exposure affects the timing of sleep-wake cycles through stimulation of the retinohypothalamic system.” That’s the system where your eyes are connected with your hypothalamus to release certain chemicals and compounds to allow you to sleep or be awake.
While more research will be needed, 30 minutes of morning blue light therapy may prove to be an easy and inexpensive way to potentially “biohack” your way to a better night’s sleep. Concussion or not..
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