Conservative Interventions May Improve Sleep Quality for Patients After TBI, Stroke

Conservative interventions, such as cognitive behavioral therapy and intradermal acupuncture, may improve the sleep of adults with a history of stroke or traumatic brain injury.

Psychotherapy-based approaches and acupuncture may enable some patients with acquired brain injury to sleep better, according to study results published in Disability and Rehabilitation. Additionally, patients who have history of stroke may experience less insomnia after acupuncture.

Researchers in the United Kingdom examined published experimental studies to determine which conservative interventions might improve the sleep of adults with a history of stroke or traumatic brain injury (TBI), the most common causes of acquired brain injury in Europe.

The research team used Embase, PubMed, and the Cochrane Library to find peer-reviewed published original experimental studies published up to March 28, 2020, on the use of conservative interventions to improve the sleep or sleep disorders of patients aged 16 years or over with a history of stroke (ischemic or hemorrhagic of the brain) or TBI (any severity), in either a hospital or community setting.

The studies had to assess sleep objectively or via a formal sleep questionnaire or sleep-wake diary. They excluded case reports, studies that used pharmacologic or ventilatory treatments to improve sleep or sleep disorders, and articles that only assessed daytime sleepiness (unless hypersomnia was formally diagnosed).

Of the 23 studies they identified, 19 were original randomized controlled trials (RCTs) and 4 were pre-post designs. The neurologic diagnosis was stroke in 7 studies and TBI in 16 studies. 5 studies were performed during an early hospital or inpatient rehabilitation admission whereas the majority were conducted in a community or outpatient setting.

Compared to baseline in studies of psychotherapy-based interventions for adults with history of TBI, patients experienced improved sleep efficiency after 8 weekly sessions of cognitive behavioral therapy (CBT) for insomnia (77.2% vs 88%, respectively; P <.017) and a reduction in Insomnia Severity Index (ISI) (17.6 vs 8.8, respectively; P <.017) in an outpatient setting, according to sleep-wake diaries and the ISI, and at a 3-month follow-up (sleep efficiency, 90.9%; ISI, 10.3;P <.017 for both).

In another study that followed 8 weekly sessions of CBT, Pittsburgh Sleep Quality Index (PSQI) (standardized mean difference, 3.1; 95% CI, 1.5-4.7) and ISI scores (standardized mean difference, 3.12; 95% CI, 1.29-4.95) also improved significantly and maintained at the 2-month follow-up (standardized mean difference, 4.85 [95% CI, 2.56–7.14] and 5.96 [95% CI, 3–8.93], respectively).

In 2 studies involving patients with a history of stroke, intradermal acupuncture for 2 days improved sleep latency (126.7±128.7 vs 186±141.3 minutes), sleep quality on the Morning Questionnaire (57.3±24.6 vs 22.7±18.3), improved ISI (14.9±5.5), and Athens Insomnia Scale scores (10.6±5.1 vs 15.6±3.8) compared with a placebo group. When patients received intradermal acupuncture compared to placebo for 3 days, ISI scores (mean difference, 5.4 vs 1.6; P <.001) and Athens Insomnia Scale scores (mean difference 4.6 vs 1.2; P <.001) also improved.

In a pilot study of adults with a history of TBI and reported insomnia, the adults who received acupuncture had a significant reduction in ISI score after treatment (Z=-3.07, P <.01) and at 1-month follow-up (Z=-3.07, P <.01).

Limitations of the study included only 1 author performing the initial literature searches and primary screening of articles, the inclusion of only English publications, and the reporting of secondary outcome measures.

Study researchers concluded that “psychotherapy-based approaches might be useful for sleep disturbance after TBI and acupuncture may help improve insomnia or sleep disturbance following stroke or TBI, respectively,” Further studies, however, “may also wish to investigate interventions earlier after injury and use a combination of subjective and objective measures to assess sleep disturbance and specific sleep disorders.”


Lowe A, Bailey M, O’Shaughnessy T, Macavei V. Treatment of sleep disturbance following stroke and traumatic brain injury: a systematic review of conservative interventions. Disabil Rehabil. Published online December 11, 2020. doi:10.1080/09638288.2020.1856948