Injured by TBI and suffer from insomnia? This USU study could help you catch some ZZZs

BETHESDA, MD, UNITED STATES

03.03.2022

Story by Ian Neligh 

Uniformed Services University

A potential solution for a good night’s sleep for military members struggling with insomnia is currently being studied by the Uniformed Services University’s Center for Neuroscience and Regenerative Medicine (CNRM).

Helping military members with a history of traumatic brain injuries (TBI) treat their insomnia symptoms is tricky and deployments make in-person visits with trained providers challenging. This virtual study hopes to give service members and veterans a convenient, more effective, and drug-free solution.

To make that happen, the study uses a remote version of cognitive-behavioral therapy, a proven technique for treating insomnia, within the Military Healthcare System.

The study, “A Randomized, Controlled, Blinded Study of Internet-guided Cognitive Behavioral Therapy for Insomnia in Military Service Members with History of Traumatic Brain Injury” is completely online and requires no in-person visits. Service members and veterans can simply utilize the program from their smartphone or computer, anywhere and at any time.

The USU study is nearly halfway through its two-year plan and aims to enroll 200 participants total in a six- to nine-week, internet-guided program to examine virtual cognitive-behavioral therapies in the military populations. Funded by CNRM, the project is using a modified version for the military of a web-based program called SHUTi or “Sleep Healthy Using the Internet.”

“The need is really what kicked it off,” says the study’s associated investigator Navy Lt. Cmdr. (Dr.) Kent Werner, assistant professor in the Department of Neurology at USU and director of Research at Walter Reed National Military Medical Center. “Cognitive behavioral therapy for insomnia, or CBT-i, is established as the most promising therapy for insomnia, above medication, even though most people are started on medication when they have insomnia.”

However, Werner says it is difficult to get access to someone able to deliver that care, it is often demanding on one’s schedule, and so the ability to do it online without traveling is an attractive option.

“When the data came out that the online version works about as well as the in-person version, then it seemed like a natural question ‘well, how well does the online version work on TBI patients?’” Werner asked.

He adds, in the military, there are high levels of insomnia, and nearly all TBI patients, even with mild cases including concussions, complain of suffering from sleep issues.

“If you look at the numbers, it can be anywhere from 50 percent to over 90 percent,” Werner says. “So it’s pretty common after the injury. We wanted to know if we were able to offer it, if it would give them some relief.”

Causes of Insomnia

Werner says it is not entirely clear how TBI might increase the risk of insomnia or other sleep disorders, such as sleep apnea and narcolepsy.

“We presume that after TBI, circuits are disrupted — some of them could play a role in the sleep regulatory process?” Werner says. “TBI is also related to inflammation — insomnia is also related to inflammation. Could this link be important or useful in understanding insomnia in TBI patients?”

Werner says his research team conducted a recent study that shows the chronic sleep complaints of concussion patients have elevated inflammatory markers. The worse their sleep quality was, the more inflammatory markers they had.

“We’re also looking at brain images of TBI patients and comparing different features, such as their network activity in the functional brain scans or their brain volume measurements, to their sleep polysomnogram studies and their sleep complaints,” Werner says. “We don’t know the answer — but we’re looking for it.”


How the Treatment Works

Werner says the cognitive therapy, in part, works like a Sleep 101 course, teaching participants the components of sleep hygiene, which can include, avoiding blue light caused by TV or smartphones before bed, creating the right sleep environment (the ideal temperature is 65 degrees), complete darkness, using earplugs or white noise if necessary, and to keep pets out of the bedroom.

“There’s also a component of cognitive restructuring,” Werner says. “So if you suffer from insomnia, just the act of going to bed can be stressful. You can create a self-perpetuating cycle where you are struggling to fall asleep, you are angry about that, and you fear it every time you lay down again. So the idea of going to sleep becomes a stress response and keeps you awake.”

Part of this sleep therapy includes using an algorithm to determine what time a patient needs to go to sleep and wake up in the morning to maximize “sleep efficiency.” The program may instruct the participant to go to bed later than they’d like in order to build up what Werner calls “sleep drive.”

“Sleep drive is a homeostatic signal that collects over time and the desire to sleep gets stronger and stronger. CBT-i trains you to build up that desire and that propensity to sleep,” Werner says.

Molly Malarkey, the Henry M. Jackson Foundation for the Advancement of Military Medicine clinical research coordinator for the USU SHUTi study, says they’re looking into testing how well a completely remote digital therapeutic tool like SHUTi will work with a military population vs. civilians.

“What we’re looking at is how cognition, our thoughts, affect behavior and vice versa,” Malarkey says. “We home in on specifically what insomnia-related symptoms each service member is experiencing — and then we try to figure out how to change their cognition about that specific symptom, and then that inherently changes their behavior. Everyone is different.”

She adds the future of digital therapeutics could look into avenues for service members to receive access to applications remotely, even offline and in deployment situations where military personnel wouldn’t have an internet connection otherwise.

“We want to make it as accessible to the patients as possible, regardless of where they are, geographically,” Malarkey says.

The study is currently looking for additional patients with a history of TBI struggling with insomnia until the end of June 2022.

“I think it is important when dealing with TBI patients to ask about sleep and provide some reassurance that there are resources — because a lot of people don’t think to ask for help,” Werner says.

For more information on the study, contact the CNRM study team at:
[e-mail] or [phone].

• Date Taken: 03.03.2022
• Date Posted: 03.03.2022 12:13
• Story ID: 415697
• Location: BETHESDA, MD, US