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. Author manuscript; available in PMC: 2026 Jul 12.
Published in final edited form as: Br J Sports Med. 2025 May 2;59(10):698–705. doi: 10.1136/bjsports-2024-109058

Sleep quantity and quality during the first week postinjury and time to symptom resolution in youth with concussion

Olivia VonDeylen 1,2, Enas Alshaikh 1, Krista Wheeler 1, Robyn Recker 3, Paola Malerba 4,5, Amy Valasek 5,6, Keith Owen Yeates 7, Jingzhen Yang 1,5
PMCID: PMC13355237  NIHMSID: NIHMS2170663  PMID: 40011013

Abstract

Objective

To examine bidirectional associations between objective measures of sleep quantity and quality with postconcussion symptoms (PCS) scores in concussed youth during the first week postinjury and to explore the associations between sleep measures and time to symptom resolution.

Study design

We conducted a secondary analysis of a prospectively enrolled cohort of youth (11–17 years) with a physician diagnosed concussion within 72 hours of injury. During the first week postconcussion, sleep quantity (time in bed, total sleep time and daytime sleep) and sleep quality (sleep efficiency, WASO and number of awakenings) were measured using an ActiGraph. We evaluated bidirectional temporal associations between the sleep measures and PCS during the first week postinjury using cross-lagged panel models. We assessed the associations between sleep measures and time to symptom resolution using Cox proportional hazard models.

Results

Participants included 78 concussed youth, 34.6% females, mean age of 14.2 years (SD=2.1). Significant bidirectional associations were observed between PCS and both total sleep time and daytime total sleep in the first week postinjury. Increased daytime sleep was also associated with a decreased likelihood of symptom resolution, adjusted HR (aHR)=0.88, 95% CI=0.78, 0.999. An optimal total sleep time of 418 min per day was associated with a 2.1-fold increased likelihood of symptom resolution (aHR=2.1, 95% CI=1.3, 3.2).

Conclusions

Clinicians should provide guidance on sleep hygiene, including limiting daytime sleep/naps and getting the appropriate amount of nighttime sleep acutely postconcussion to aid recovery in youth.

INTRODUCTION

Concussions, a form of mild traumatic brain injury (TBI) that affects approximately two million children under 18 annually in the USA,1 2 can have adverse effects on physical, cognitive, emotional and sleep health.3–5 Postconcussion sleep disturbances are commonly reported among children and adolescents. Recent studies show that following concussion, 27%–34% of youth self-report excessive sleep, loss of sleep and/or trouble falling asleep.6 7 Youth with postconcussion sleep-related symptoms may experience subsequent alterations in sleep patterns, circadian rhythms and sleep timing, impairing overall sleep quality.8–10 Furthermore, poor sleep quality following a concussion is associated with more symptom exacerbation, longer recovery time6 7 11 and greater risks of executive dysfunction and reinjury.9 12

Sleep is crucial in memory, learning and neural plasticity, especially in children and adolescents.13 Understanding postconcussion sleep patterns and their associations with concussion recovery is a vital first step to prevent and mitigate postconcussion sleep disturbances.13 14 Currently, studies examining postconcussion sleep disturbances rely primarily on self-reported data, with few using objective measures.15–21 Furthermore, the clinical course of paediatric postconcussion sleep disturbances is not well elucidated in current literature. Though a growing number of studies have objectively measured sleep quantity and quality following concussion and have found sleep disturbances may persist in some youth long after the injury,10 11 18 20 21 sleep quantity and quality during the first week postconcussion and their impact on overall concussion recovery in youth remains an area of ongoing investigation.

This study examined bidirectional associations between objective measures of sleep quantity and quality and postconcussion symptoms (PCS) scores in concussed youth during the first week postinjury and explored the associations between sleep measures and time to symptom resolution. We hypothesised that the relationships between sleep quantity and quality and PCS within 1 week of postinjury would be bidirectional. We also hypothesised that sleep quantity and quality during the first week postinjury would have non-linear associations with time to symptom resolution in youth with concussion.

METHODS

Study design

We conducted a secondary analysis of a prospectively enrolled cohort of 83 youth (11–17 years) with a physician diagnosed concussion (83.3% sport related) within 72 hours of injury.22 23 Concussion was defined as a mild TBI induced by a direct or indirect blow to the head, neck, face or other part of the body, resulting in transient neurological deficits.24 Eligible youth, recruited from local schools preinjury or in the emergency department and concussion clinics at Nationwide Children’s Hospital postinjury, were enrolled following the completion of written assent and consent (details about the original study published elsewhere).22 23 For this study, 78 participants were included, excluding five with incomplete sleep data (missing or less than 3 days).

Enrolled youth wore an ActiGraph (Model: wGT3X-BT) on their wrist to measure 24-hour activity and sleep patterns daily for 1 week following enrolment. Participants were then followed until symptom resolution (symptom-free or symptoms returned to preinjury level) or 45 days postinjury, whichever occurred first. Youth completed daily surveys throughout their recovery to assess self-reported PC S and sleep. Study data were collected between November 2016 and February 2019. The Institutional Review Board of the participating institutions approved this study (IRB16–00613). This report follows STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) reporting guidelines.25

Study participants

Youth were eligible if they were 11–17 years old, received a physician-confirmed concussion diagnosis and could complete the first assessment within 72 hours of injury. Youth were excluded if their concussion (1) was accompanied by other trauma (eg, face or neck injury, broken bone), (2) involved a penetrating injury, (3) required neurosurgical intervention or hospital admission or (4) resulted in a condition(s) that prevented them from wearing study devices or completing study assessments (eg, eye injury).22

Equity, diversity and inclusion

Sex and race/ethnicity exclusions were not used in this study. No specific effort was made to include or exclude minorities. All eligible patients aged 11–17 with a physician-confirmed concussion during the study period were approached. Seven listed authors, including the lead author, are women. We included authors from a variety of career stages and clinical disciplines.

Study variables and measures

Sleep quantity and quality were measured using actigraphy,26 a non-invasive method of monitoring human rest/activity cycles (ActiGraph wrist band) during the first 7 days following enrolment (‘the first week postinjury’). Using ActiLife software, we extracted, examined and validated the sleep data collected by the ActiGraph. Sleep quantity variables included time in bed (TIB), total sleep time (TST) over 24 hours and daytime total sleep (DTS). TST includes daytime and nighttime sleep, and DTS is defined as sleep time from 9:00 am to 9:00 pm. Sleep quality variables were sleep efficiency, wake after sleep onset (WASO) and number of awakenings. For participants with the first and/or last day’s ActiGraph wear-time below 75% of their average wear-time on the other days, we imputed their wear - time for that day using the average wear-time of the other days.

PCS were assessed daily using the Postconcussive Symptom Scale.27 Participants were also asked to retrospectively rate their symptoms at the time of injury during their initial clinical visit. The Postconcussive Symptom Scale consists of 22 items, each rated from 0 (no symptom) to 6 (severe symptom) (possible score range=0–132). The scale is a commonly used concussion assessment tool with established reliability and normative data.27 Four of the 22 symptoms are specifically sleep-related: ex cessive sleep, loss of sleep, trouble falling asleep and drowsiness. Reported scores of 1 or higher for any of these sleep symptoms were coded as the presence of sleep-related symptoms. A PCS cut-off score of 44, based on the median score at the time of injury, was used to indicate symptom severity in the analysis.

Other variables included participant demographics, concussion history, whether the injury was sports-related, number of days with daytime naps during the first week postinjury and date of symptom resolution.

Statistical analysis

We described participant demographics and daily sleep characteristics. We plotted the changes in daily sleep quantity and quality measures across the first week postinjury. To examine the bidirectional temporal associations between the daily sleep measures and daily PCS during the first week postinjury, we used cross-lagged panel models (CLPMs).28 We averaged daily sleep measures and PCS for the first 3 days postinjury in the CLPM model because participants were enrolled within 72 hours of injury.

To assess the associations between the sleep measures and time to symptom resolution, we employed Cox proportional hazards models to estimate the corresponding HRs with 95% CIs. We defined the event of interest as symptom resolution and the survival time as the number of days from injury to symptom resolution or to 45 days postinjury (censored), whichever came first. We fit the Cox models with sleep as a continuous variable with a quadratic distribution, adjusting for sex, age group, sport-related injury, sleep-related PCS and daily PCS score (as a time-varying covariate). To assess the linearity and proportional hazards assumption for each predictor identified, we plotted the cumulative martingale residuals against time and calculated the Kolmogorov-type supremum test based on a sample of 500 simulated residual patterns.29 Furthermore, when the proportional hazards assumption was not met, we used a restricted cubic spline function to investigate the non-linear relationship between TST and time to symptom resolution in the Cox model.30 31 Finally, we calculated the study power using current sample size and conducted sensitivity analysis using bootstrapping with 500 simulated samples for the sleep variables of interest (eg, TST, DTS and sleep efficiency) (online supplemental appendix 1). All analyses were conducted between January and December 2023 using SAS, V.9.4.

RESULTS

Participant demographics and postconcussion symptoms

Of the 78 participants, the average age was 14.2 years (SD=2.1), 65.4% were male and 71.8% were White (table 1). Most concussions occurred during a sports activity (83.3%), and 26.9% of participants had a prior concussion. The average PCS score at injury was 44 (max 132, SD=18.9), with a median score of 44. The average number of symptoms at injury was 13 of 22 possible symptoms (SD=4.2), and the average PCS duration was 20 days (SD=17.1). Sixty-four (82.1%) participants reported experiencing one or more sleep-related PCS at injury, with average sleep-related symptom scores of 5.6, ranging from 1 to 16 (data not shown). Forty-three (55.1%) participants were still experiencing one or more sleep-related PCS at the end of the first week postinjury. The most common sleep-related PCS was drowsiness, reported by 48 participants at the beginning of the first week postinjury.

Table 1.

Quantity and quality sleep measure daily averages by demographic and concussion clinical characteristics

Sleep quantity measures Sleep quality measures
Time in bed (TIB, min) Total sleep time (TST, min) Daytime total sleep (DTS, min) Efficiency (%) Wake after sleep onset (WASO, min) Awakenings (number)
N (%) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Overall 78 453.1 144.2 415.8 142.3 37.8 86.1 91.4 5.3 37.3 24.2 16.4 9.8
Sex
 Male 51 (65.4) 451.2 11.1 412.2 11.2 35.5 7.5 90.9 0.5 38.7 2.3 16.9 0.9
 Female 27 (34.6) 456.8 11.2 422.8 11.8 44.2 9.8 92.4 0.6 34.0 2.5 15.2 1.1
 P value 0.72 0.51 0.48 0.06 0.16 0.25
Age group
 11–14 years 39 (50.0) 452.0 10.1 417.4 10.9 25.0 6.8 91.9 0.6 34.8 2.3 15.4 1.0
 15–17 years 39 (50.0) 454.6 13.2 414.8 13.0 53.3 9.4 91.0 0.5 39.3 2.5 17.2 1.0
 P value 0.88 0.88 0.02 0.26 0.19 0.21
Race
 White 56 (71.8) 456.6 9.5 418.5 9.4 36.3 6.5 91.5 0.4 37.8 1.9 16.6 0.8
 Black 15 (19.2) 465.4 21.1 435.3 22.7 53.5 18.0 92.6 1.0 29.9 3.6 13.6 1.6
 Other 7 (9.0) 404.2 15.3 360.7 19.1 28.4 15.2 88.7 1.9 44.3 6.4 19.1 2.4
 P value 0.1 0.1 0.6 0.2 0.1 0.2
Injured in sport
 No 13 (16.7) 482.1 19.5 446.3 20.5 45.7 14.9 92.3 0.9 36.1 3.8 16.0 1.7
 Yes 65 (83.3) 447.4 8.9 410.0 9.0 37.3 6.5 91.3 0.4 37.1 1.9 16.3 0.8
 P value 0.14 0.14 0.60 0.32 0.81 0.86
Prior concussion
 No 57 (73.2) 456.3 9.3 419.7 10.0 37.1 6.7 91.5 0.5 36.7 1.8 16.0 0.8
 Yes 21 (26.9) 444.9 17.2 406.6 15.5 43.0 12.5 91.4 0.8 37.6 4.0 17.0 1.6
 P value 0.56 0.48 0.68 0.97 0.83 0.60
PCS at injury*
 PCS<44 37 (47.4) 447.6 12.0 408.0 12.2 27.2 4.8 90.8 0.5 39.3 2.1 17.5 0.9
 PCS≥44 41 (52.6) 458.5 11.2 423.6 11.5 49.3 8.9 92.1 0.6 34.8 2.7 15.1 1.1
 P value 0.51 0.35 0.01 0.11 0.18 0.09
Sleep-related PCS at injury†
 No 14 (17.9) 456.2 25.0 424.5 26.0 30.3 13.4 92.4 1.0 31.7 4.0 13.5 1.7
 Yes 64 (82.1) 452.8 8.6 414.7 8.8 40.1 6.6 91.3 0.4 37.9 1.9 16.7 0.8
 P value 0.90 0.72 0.51 0.33 0.16 0.08
Sleep-related PCS at the end of the week†
 No 35 (44.9) 454.2 10.7 417.3 10.9 21.1 4.7 91.6 0.5 36.5 2.0 16.6 0.8
 Yes 43 (55.1) 448.9 12.1 411.4 12.3 44.8 9.1 91.2 0.6 37.5 2.7 16.1 1.1
 P value 0.74 0.72 0.04 0.61 0.76 0.73
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Significant p-values are bolded. Statistical significance was defined as α=0.05.

*

Median PCS was 44 in the sample.

†

Reported scores of 1 or higher for any sleep symptoms were coded as the presence of sleep-related symptoms at injury and at the end of the first week postinjury. PCS, postconcussion symptoms.

Sleep quantity and quality

During the first week postinjury, average daily TIB, TST and DTS were 453.1 min (SD=144.2), 415.8 min (SD=142.3) and 37.8 min (SD=86.1), respectively (table 1). Average daily sleep efficiency was 91.4% (SD=5.3). Average WASO and number of awakenings were 37.3 min (SD=24.2) and 16.4 times (SD=9.8) per day, respectively.

Most sleep quantity and quality measures did not differ across the categories of sex, age, race, previous concussion or sports injury. However, older participants (15–17 years) had longer average DTS than the younger group (11–14 years) (53.3 vs 25.0min per day). Average DTS during the first week postinjury also differed by PCS score; participants with PCS at injury ≥44 slept 49.3 min per day versus 27.2 min per day for those with PCS<44.

Changes in sleep quantity and quality

During the first week postinjury, the average daily minutes of TIB fluctuated slightly, ranging from an average 427 to 465 min per day (figure 1a). TST mirrored the fluctuation of TIB, with daily averages ranging from 394 to 430 min per day (figure 1b). However, the average daily minutes of DTS showed a gradual increase from day 1 to day 3, a decrease from day 3 to day 5 and an increase afterward (figure 1c).

Figure 1.

Figure 1

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(a–f) Sleep quantity and quality measures daily averages (solid lines) with 95% CI (dotted lines).

Sleep efficiency, one of three sleep quality variables, showed a stable trend during the first week postinjury, ranging from 90.6% to 91.9% (figure 1d). Conversely, mean WASO decreased slightly from a high of 41.5 min on day 3 to a low of 33.5 min on day 6 (figure 1e). The average number of awakenings followed a similar pattern as WASO, with the highest average of 18 times observed on day 3 (figure 1f).

Bidirectional associations between sleep and postconcussion symptoms

In the CLPM, TST and PCS (figure 2a) and DTS and PCS (figure 2b), all showed significant positive autoregressive associations across the first week postinjury except for the TST path from days 1–3 to day 4 postinjury, reflecting stability across time in both sleep measures and PCS. Additionally, four cross-lagged paths were statistically significant. Specifically, higher PCS at days 1–3 postinjury was associated with both longer TST (β=0.17, 95% CI=0.01, 0.32) and longer DTS (β=0.21, 95% CI=0.01, 0.40) at day 4 postinjury. Longer TST (β=−0.09, 95% CI=−0.18 to –0.002) and longer DTS (β=−0.08, 95% CI=−0.16 to –0.01) at day 6 postinjury were both associated with lower PCS at day 7 postinjury. No other cross-lagged paths were statistically significant.

Figure 2.

Figure 2

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(a and b) Bidirectional associations between sleep measures and postconcussion symptoms (PCS) during the first week postinjury.

Adjusted HRs of time to symptom resolution

After adjusting for other covariates (sex, age group, sport-related injury, sleep-related PCSs and daily PCS score), TIB and TST were not significantly associated with the risk of delayed symptom resolution (table 2). However, for every additional 60 min increase in DTS, there was a 12% decreased likelihood of symptom resolution (adjusted HR (aHR)=0.88, 95% CI=0.78, 0.999). None of the sleep quality variables were significantly associated with time to symptom resolution.

Table 2.

Adjusted HRs for time to symptom resolution with 95% CIs

Adjusted HRs (aHRs) 95% Wald Robust CIs P value
Sleep quantity
 Time in bed (TIB, unit=60 min) 0.94 0.87 1.03 0.17
 Total sleep time (TST, unit=60 min) 0.94 0.86 1.03 0.16
 Daytime total sleep (DTS, unit=60 min) 0.88 0.78 0.999 0.05
Sleep quality
 Efficiency (unit=10% points) 0.77 0.47 1.25 0.28
 Wake after sleep onset (WASO, unit=60 min) 1.13 0.60 2.13 0.67
 Number of awakenings (unit=10) 0.90 0.70 1.16 0.42
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The Cox proportional hazard models, with the sleep measures as continuous variables with quadratic distributions, were adjusted by sex, age group, sports injury, sleep-related symptoms at injury and daily postconcussive symptoms as a time-varying variable.

Bolded value is statistically significant.

Additional analyses, accounting for the non-linear relationship between TST and time to symptom resolution, revealed that compared with youth who slept 300 min or less (reference group), those with 300<TST<500 min per day experienced a significantly increased likelihood of symptom resolution (figure 3). An optimal TST of 418 min per day was associated with a 2.1-fold increased likelihood of symptom resolution (aHR=2.1, 95% CI=1.3, 3.2).

Figure 3.

Figure 3

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Non-linear relationship between total sleep time (TST) and time to symptom resolution (HR with 95% CI in grey). Cox model, adjusted for sex, age group, sports injury, sleep symptoms at injury, TST reference ≤300 min. aHR, adjusted HR.

DISCUSSION

We monitored 78 youth (11–17 years) using an ActiGraph wrist-band for 1 week to measure sleep quality and quantity after a diagnosed concussion. Our results indicate that during the first week postconcussion, significant bidirectional associations were observed between TST and PCS and between DTS and PCS. Furthermore, for every additional hour of daytime sleep during the first week postinjury, a 12% decreased likelihood of symptom resolution was observed. Finally, compared with youth who slept 300 min or less per day, those who slept between 300 and 500 min per day experienced earlier symptom resolution; an optimal TST of 418 min per day was associated with a 2.1 times increased likelihood of symptom resolution. Our findings contribute to the existing literature on the association of sleep quantity and quality with youth concussion recovery12 18 32 and suggest that a potential Goldilocks effect may exist between sleep quantity and concussion recovery.

Previous research on sleep and concussion recovery in youth has predominantly relied on self-reported sleep duration,16 33 with few studies using objective data and even fewer explicitly examining daily sleep patterns during the acute postinjury phase.11 12 18 20 Consequently, many investigations cannot differentiate total TIB and TST,7 34 35 resulting in a limited understanding of the clinical trajectory of paediatric postconcussion sleep disturbances. Findings from a small number of studies that objectively measure sleep quantity and quality following paediatric concussions suggest that sleep issues may persist in some youth well beyond the initial injury.10 18

Our findings indicate that most of the examined sleep measures remained relatively stable and did not exhibit significant changes during the first week postconcussion. This consistency in sleep patterns may be attributed, in part, to the possibility of similar medical advice given to young concussion patients; all study participants received some level of concussion care at our hospital.22 23 Our findings align with prior research on actigraphy parameters in children with acute and subacute concussion, indicating no sleep quality abnormalities.11 19 36 However, our findings diverge from other studies where evidence points to sleep disturbance after a concussion, including poor sleep efficiency, increased WASO and shorter sleep durations.8 10 18 Further research involving a larger, more diverse sample and a longer objective data collection period is necessary to validate these results.

Our study reveals higher PCS on days 1–3 postinjury was linked to significantly longer TST and longer DTS during day 4 postinjury, while both longer TST and DTS during day 6 postinjury was associated with lower PCS on day 7 postinjury. These results add to previous studies highlighting the bidirectional association between sleep quantity and PCS.37 38 In a prospective study by Trbovich et al, sleep was negatively associated with next-day symptoms, particularly later in the day and with regard to emotional symptoms and cognitive-migraine fatigue.18 From a mechanistic perspective, postconcussion sleep disturbances have been linked to disruptions in brain homeostatic processes, resulting in impaired neuronal function and delayed recovery.39 Conversely, improvements in PCS correlate with better sleep quality and quantity.40 To comprehensively evaluate sleep’s influence on concussion recovery in youth, additional research employing randomised controlled trial designs is needed.41

Our findings indicate that every additional hour of daytime sleep during the first week postinjury was associated with a 12% decreased likelihood of symptom resolution. Most existing studies do not distinguish between daytime and nighttime sleep. However, evidence suggests that disturbances in sleep are often marked by heightened overall sleep need and daytime sleepiness.42 While the relationship between daytime sleep and concussion recovery in youth remains complex and not fully elucidated, several possible explanations exist. Youth with postconcussion sleep disturbances may undergo subsequent changes in sleep patterns, circadian rhythms and sleep timing. These disruptions in sleep activity can impact regular sleep cycles.10 43 Considering that sleep and wakefulness disorders can be effectively treated, early monitoring of sleep using objective measures and enhancing the management of persistent PCS using multimodal sleep and circadian assessments could be a helpful approach in expediting recovery from paediatric concussions.20 43 44

Our results suggest that the relationship between TST and PCS is not linear. Delayed symptom resolution was observed in youth who slept less than 300 min per day or more than 500 min per day. An optimal TST of 418 min per day was associated with more than twofold of earlier symptom resolution. These findings align with a previous longitudinal study investigating the trajectory of sleep and concussion symptoms in a prospective cohort of youth 6–18 years.42 One explanation is that despite increased sleep time, the sleep architecture is disrupted in youth experiencing daytime sleepiness, thus impairing the restorative processes that occur during sleep.37 Clinically, after a concussion, there is a period of hypersomnolence lasting approximately 2 weeks.45 Sleep disturbances serve as an independent risk factor for poor recovery. Notably, in most young patients, as their sleep patterns improve, other PCS also tend to ameliorate. Conversely, those whose sleep remains disturbed often experience protracted symptoms.33 Future studies are needed to further disentangle this relationship.

Clinical implications

Our results have important clinical implications for managing acute paediatric concussions. Having the appropriate amount of TST during the first week postconcussion, not too much nor too.little, could hasten timelines for recovery. Paediatricians should promote good sleep hygiene among youth immediately after concussion, including limiting daytime sleep/naps to help speed recovery. Youth with concussion may benefit from monitoring sleep quantity and quality acutely postinjury using a wearable device to aid in recovery. Clinical trials are necessary to determine the optimal timing, duration and quality of sleep that support concussion recovery among youth.

Limitations

This study has several limitations. First, the small sample size reduced the study’s power for at least one sleep outcome. Second, the study predominantly included male and White participants with sports injuries, limiting the generalisability to other concussed youth populations. Third, we only collected continuous actigraphy for 1 week postinjury and did not gather preinjury sleep data, which could affect postconcussion sleep patterns. Additionally, sleep patterns during the first week postinjury may not fully represent the entire recovery process. Fourth, the study lacked a comparison group (eg, orthopaedic injured patients), preventing us from determining if the observed sleep disturbances were due to concussion. Fifth, actigraphy estimates sleep and wake based on activity levels. While it has high accuracy and sensitivity for evaluating sleep disorders, it has lower specificity,46 47 potentially leading to overestimation or underestimation of TST, WASO and sleep efficiency.48 Finally, our analyses considered limited covariates due to the small sample size. Confounding factors, such as daily physical activity, may have influenced recovery outcomes but were not adjusted for in our models.

CONCLUSIONS

This study examines associations between sleep quality and quantity measures and concussion recovery outcomes in youth ages 11–17. A bidirectional association between sleep quantity and PCS score is observed during the first week postinjury, highlighting the importance of objectively measured sleep in this area of research. Furthermore, youth who sleep more during the day or who sleep too much or too little per day may be at risk for a decreased likelihood of symptom resolution. It is vital for clinicians to actively engage in counselling paediatric patients and provide guidance on appropriate sleep hygiene, including limiting daytime sleep/naps and getting the appropriate amount of nighttime sleep acutely postinjury to aid in concussion recovery among youth.

Supplementary Material

Supplement 1

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Additional supplemental material is published online only. To view, please visit the journal online (https://doi.org/10.1136/bjsports-2024-109058).

WHAT IS ALREADY KNOWN ON THIS TOPIC

  • About a third of youth exhibit sleep-related symptoms after a concussion. However, existing research on sleep and concussion recovery in youth has predominantly relied on self-reported sleep duration, with few studies using objective data and even fewer explicitly examining daily sleep patterns during the acute postinjury phase. The quantity and quality of sleep during the first week postconcussion and its impact on overall recovery in youth remains an area of ongoing investigation.

WHAT THIS STUDY ADDS

  • During the first week after concussion, a significant bidirectional association was observed between total sleep time and postconcussion symptoms (PCS) and between daytime total sleep and PCS. Specifically, higher PCS scores on days 1–3 postinjury were linked to an increase in total sleep time and daytime total sleep during the fourth day postinjury. Also, longer total sleep time and longer daytime total sleep on the sixth day postinjury were both associated with a reduction of PCS on the seventh day postinjury.

  • For every additional hour of daytime total sleep during the first week postinjury, there was a 12% decreased likelihood of symptom resolution.

  • Compared with youth who slept 300 min or less per day, those who slept between 300 and 500 min experienced an increased likelihood of symptom resolution; an optimal total sleep time of approximately 7 hours per day was associated with a 2.1 times increased likelihood of symptom resolution.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Clinical trials are needed to determine the optimal total sleep time acutely postinjury to promote recovery from concussion in youth. This study informs advice on proper sleep hygiene to assist in postconcussion recovery among youth.

Acknowledgements

The authors thank the ReAct Clinical Study Group and Certified Athletic Trainers and Clinical Research Coordinators at Nationwide Children’s Hospital who assisted in participant recruitment and data collection for this project. They also want to express appreciation to Donna Hull and Lisa Kluchurosky who helped coordinate various study activities. Finally, they want to acknowledge the invaluable contributions of the families who were involved in this project.

Funding

Research reported in this publication was partially supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (R21HD086451) and The Ohio State University Chronic Brain Injury (CBI) Programme Summer Undergraduate Research Fellowship. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the CBI Programme.

Footnotes

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

Patient consent for publication Consent obtained from parent(s)/guardian(s).

Ethics approval This study involves human participants and was approved by Nationwide Children’s Hospital Institutional Review Board Study IRB16–00613.Participants gave informed consent to participate in the study before taking part.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement

Data are available upon reasonable request. Dr Yang has full access to all of the study data and takes responsibility for the integrity of the data and the accuracy of the data analysis. The data sets generated and/ or analysed during the current study are available from Dr Yang upon reasonable request. Raw data are not available due to parameters indicated in the participant consent materials.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1
NIHMS2170663-supplement-Supplement_1.pdf (171.5KB, pdf)

Data Availability Statement

Data are available upon reasonable request. Dr Yang has full access to all of the study data and takes responsibility for the integrity of the data and the accuracy of the data analysis. The data sets generated and/ or analysed during the current study are available from Dr Yang upon reasonable request. Raw data are not available due to parameters indicated in the participant consent materials.

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