The Silent Struggle: Traumatic Brain Injuries and the Battle for a Good Night’s Sleep

0:00:08 - Shane Smith
Hey, Shane here from Shane Smith Law. I'm here today on Mind Matters: Navigating Head Injuries and Concussions, our podcast, and Thomas is here with us. He's one of the attorneys from the concussion and brain injury group at Shane Smith Law, and today we're going to be talking about traumatic brain injuries, but a specific part of that and how it impacts sleep disturbances. So, Thomas, before we dig into all of that, what is a traumatic brain injury?

0:00:29 - Thomas Ozbolt
Yeah, a traumatic brain injury occurs when there's a direct bump, blow, or jolt to the head, or when there's blunt force or a hit to the body that causes the head or brain to move quickly back and forth or just quickly back, quickly forth. This causes the brain to bounce around or even twist inside of the skull and also causes chemical changes in the brain and stretching or damaging brain cells.

0:00:55 - Shane Smith
So it sounds to me like you know, when I was a kid I had one of those balls and inside of it was another ball and you could hit it against the wall and obviously that's an impact, but you could also just shake the thing and you could hear the ball inside bouncing around. Same thing with brain?

0:01:08 - Thomas Ozbolt
Similar concept with skull and the brain inside. Yeah, and you know, when you do that, when you shake that ball, or when you know that skull gets shaked around, that can lead to changes in the brain which leads to symptoms that might affect how you think, learn, act, feel, smell or even sleep.

0:01:28 - Shane Smith
Wow, all right. So, and sleep's what we're going to talk about today, and sleep is not really something I think about when I'm talking about injuries, you know, and what's going on in life. Rarely, since I don't do brain injuries all the time, do I think, okay, tell me about your sleep? Not like, I know you hurt your back and you're pain, it can be hard to sleep, but how does how does having a TBI affect sleep normally?

0:01:49 - Thomas Ozbolt
Yeah, that's a great question. They become a crucial part of the narrative and you know the true story that we tell about what's happened to our clients. These are things, you know, when we talk about sleep disturbances, they not only impact your daily life, as anybody who has ever had any difficulty getting sleep can tell you. You know the importance of a good night's sleep, like a new mom, for instance?

Right yeah, a new mom, new dad, any of those things. You know sleep, it's crucial, and if you can establish a clear connection between the TBI and those sleep disturbances, you've established a pivotal step in building a strong case.

0:02:26 - Shane Smith
What does sleep disturbances mean, right? Is that like I wake up all the time? Is that I never get into deep sleep? Is it, I can't fall asleep? What is sleep disturbances in the context of a TBI?

0:02:36 - Thomas Ozbolt
Yeah, so sleep disturbance, it falls under, they've kind of got several different categories underneath it. This is something you commonly see in TBIs. They're caused by multiple different reasons, though, so you need some kind of correlations, clinical correlation.

0:02:50 - Shane Smith
Now, if I get a concussion, does that mean I'm going to have a sleep issue? Is that what you're saying is pretty common?

0:02:54 - Thomas Ozbolt
It's pretty common. It's not necessarily going to be the case, but when you have a TBI, some of the related sleep disturbances that you might have. They include insomnia, obstructive sleep apnea, excessive sleepiness that's called hypersomnia, 50 cent word there, that's what my dad used to say, and narcolepsy.

0:03:14 - Shane Smith
Now, Thomas, before we go into what each of these types of sleep disturbances are, how common are they? Because we've talked a little bit about before, it's pretty common. But what does that mean? Like you know, am I like 90% likely to have a sleep disturbance? Is it like 10%? What, what does that mean?

0:03:30 - Thomas Ozbolt
Yeah, that's a great question. So there's been a lot of different studies done on these. One, in one of these studies, of 100 different patients one year after TBI, 50% of them continue to have difficulty with sleep, even after a year, and 64% of that 50% reported waking up too soon. 25% of them reported prolonged sleep and 45% of that reported difficulty with falling asleep.

0:03:58 - Shane Smith
Okay so, a little mix of everything basically right your sleepers nightmare kind of deal.

0:04:03 - Thomas Ozbolt
Yeah, and you know we talked about hey one year, even one year, in another study three years after the TBI 67% of individuals reported persistent sleep disturbance. That's even worse, even worse, and of those 27% had difficulty with excessive sleep. So you know, oversleeping their alarm going way too long, disrupting their life and work. 12% had excessive daytime sleepiness and 10% had insomnia. Okay now, the scary fact about this at least for me, I value my sleep is that insomnia occurs in 30 to 50 percent of TBI cases and might not appear until weeks to months after the injury.

0:04:49 - Shane Smith
So you may, if you're not knowledgeable in TBIs, you might not even associate it with it because it didn't appear for for several weeks right?

0:04:58 - Thomas Ozbolt
Right, and you know you can obviously see where that can create difficulties in speaking with an adjuster who has very limited experience on on some things, probably brain injuries in particular you know, and it's like, hey, you know, this didn't, this might not have shown up until a month after the crash, but that doesn't mean it's not related. There are different causes that are responsible for insomnia, you know, that's something certainly to acknowledge, but one of those causes is damage to the brain structure.

0:05:27 - Shane Smith
Let me ask you this too. So if I have one type of sleep disturbance, am I not gonna have the others, or these all mixed together, like if I've got insomnia, it would seem to me when I think about it, I could also have the sleepiness during the day because I didn't sleep right, or hyper-sleepiness. So do people have insomnia then the next week they're so tired they oversleep and do all this? It impacts, you can have all types of them?

0:05:50 - Thomas Ozbolt
Yeah, I think you could have a mix, certainly have a mix. You know we talked about insomnia being present in 30 to 50 percent. Sleep apnea, that was found in 30 to 40 percent of TBI patients who experience daytime sleepiness. So you see a lot of crossover. It's not just like you're gonna have sleep apnea, you're gonna have insomnia. You can definitely see that mix over. Whether there's been specific studies that will go beyond isolating one, I'm not exactly sure of that. But there's a multitude of studies that look at these kind of in isolation, you know, studying for one factor, controlling for one factor.

0:06:24 - Shane Smith
Yeah, I know the effects of messed up sleep compound. Yeah, day after day after day, it just keeps getting worse and worse and worse. I mean it can make everything difficult, right?

0:06:34 - Thomas Ozbolt
Right. Sleep, we're finding more and more out, is just one of the most crucial parts of your life. You know your sleep, your diet, your physical activity. These are essentially the building blocks to having a healthy lifestyle and healthy well-being. If one of those goes off here, sleep disturbance being one of the things that's affected by TBI you can disrupt your entire life. You know the healing of your body, your metabolism. Scary fact that you know, learned and researching this issue is that TBI can essentially cause a flip-flopping of your waking and sleeping cycle. So if you think about, wow, daylight savings time and how that throws havoc on you and that's just one hour.

Yeah, this can flip flop your entire days and nights, where you're awake at night and asleep during the day. That's called circadian rhythm sleep disorder. That can happen with TBI.

0:07:25 - Shane Smith
And I, I've seen the effects that can have on somebody who works night shift for a long time. It starts bleeding over into everything, it's not uncommon for it to impact their metabolism, their weight, their emotional aspect, I mean their moods, everything. And that's something, I don't want to say you can control, but you know you have a little bit of control there, whereas this you've got no control.

0:07:44 - Thomas Ozbolt
Yeah, it's like being forced into a third shift lifestyle, which studies have shown it's really harmful to your body, is working that type of lifestyle. So if that is forced upon you by the negligence of someone else and causing you a traumatic brain injury, that's a life-changing sort of incident.

0:08:00 - Shane Smith
Yeah, because most higher paying jobs for one are daytime jobs. I mean, I'm not gonna say they're no great nighttime jobs, but the vast majority of the high-income jobs are daytime. A lot of times the nighttime jobs are there but they don't pay as well, right.

0:08:15 - Thomas Ozbolt
Yeah, and you think about kind of being an attorney or being a doctor or being somebody who runs a restaurant or or any of these things where you do what you have to do during the day, because that's when your clientele is out and about. If you have something like that happen for someone like that, or a teacher, you know even a mother, you know a full-time mom staying at home watching the kids.

Kids are up there the day right? Kids are up during the day and you're, you can't get off the couch. Like that's terrible.

0:08:40 - Shane Smith
I mean even even non economically, but just socially. Yeah, I mean interacting with everybody would be so much harder as well, because while everybody else is up moving around, you're asleep and while everybody I mean, and they want to wind down at 9 o'clock, they're settling in for bed and you're like it's 8 in the morning. It has a ripple effect on your social life and your psychological health, and just everything that makes us human beings. What evidence do we need for the, for this right? I mean, how do I prove I've got sleep disturbances?

0:09:07 - Thomas Ozbolt
Yeah, so, as in any case, documentation is key. We're looking for medical records, we're seeking expert opinions, and we might even involve sleep specialists to provide a comprehensive picture. One of the goals that we have is is showing to a jury how TBI has directly led to those observed sleep disturbances, and strengthening our case in that process. There's some diagnostic measures that you can use for this. Some of these involve self reporting, others involve you know what you call objective testing those, those self reporting mechanisms. You could use a sleep diary just to report your sleep night by night. There's questionnaires, one of those called the Pittsburgh sleep quality index. There's an insomnia, insomnia severity index and the Epworth sleepiness scale. Sleepiness scale, yeah, not exactly sure what that looks like, but it is a clinical way that they use to assess the degree and the severity of sleep disturbances.

0:10:03 - Shane Smith
And I'm sure, I mean, you know, we sort of joke when you talk about a sleep journal or whatever. You know, wake up in the morning, how was your sleep? But I'm sure it's more detailed than that. I mean they ask some questions that you know, they get more detailed.

So it is a little more objective than just hey, I slept great or I slept bad. Yeah and nowadays with technology I think your phones and your watches and all that can't they tell you how many times you woke up and they could start measuring the quality of your sleep, and I'm sure that would be evidence we could use to prove that you woke up 47 times in the night.

0:10:34 - Thomas Ozbolt
Right, yeah, I've got one on right now it's called a Whoop. Plug for Whoop right now.

0:10:43 - Shane Smith
You know, but we laugh, but but that would be a great way to measure your sleep disturbances, because they're- it tracks, it records that for weeks, I think right?

0:10:52 - Thomas Ozbolt
Right, for months. I have a six month picture of what it looks like and it provided a report for me to show to the doctor what the, that sleep study we refer to. It's called a nighttime polysomnography. That measures a lot of the same information that the Whoop will capture. That would include you go into a sleep laboratory. They're assessing your brainwave activity while you sleep, eye movements, muscle movements, heart rate, your respiratory rate, your blood oxygen content and your limb movements. Now Whoop only covers your heart rate, respiratory rate, blood oxygen content and heart rate variability. But those are all things you can see a change, like you could look at that information.

If you have a sleep study done, you can kind of see how that evolves over time to show that it's happening.

0:11:34 - Shane Smith
And I like the, the home method of the Whoop and, and maybe some of the other stuff, just because I know people who've went and had sleep studies and they're like, look, this is not an accurate reflection. I sleep because who has a lot of fun going to a place sleeping with all these things, tape all over your body, and sometimes the lights are on or they come in and check on you and then you know, I mean ever, yeah, I think a lot of jurors to look at that and go, well, maybe it's probably not that bad, because I've had those and it's, nobody can sleep there. Right, whereas the Whoop, that's just on your arm and your home right?

0:12:04 - Thomas Ozbolt
Yeah, it's charging, or it's recording what is your, your baseline, so you have a picture of what it looks like and so if something happened to me, you could look at my data and see the impact that it had over time. Now, not everybody has that, but it is a measure.

0:12:13 - Shane Smith
Even if I put it on today and mine was crazy, you could certainly say this is atypical, doesn't fit the norm, right? And Whoop then would tell you, hey, you're, you've got a lot of stuff going on. You need to relax or you need to do whatever.

0:12:26 - Thomas Ozbolt
Yeah, it measures your kind of stress level and it told me that my body temperature was a little over last night. It was a little bit warm in our house. So it'll, it'll let you know those factors that will affect your sleep.

0:12:37 - Shane Smith
Obviously, sleep issues leads to tiredness, fatigue, just not being your hundred percent self. How's that intersect with with TBI? Or is TBI directly linked to the fatigue? Or is the insomnia linked to the fatigue? How's all that work?

0:12:53 - Thomas Ozbolt
Yeah. So I think, starting by defining fatigue in terms of how they do it medically, it's the state of chronically feeling tired and exhausted. Now, to be clear, I mean there are a lot of things that cause fatigue. It's a common symptom, you know. Anything from being out of shape to significant medical problems like anemia, multiple sclerosis or cancer could cause fatigue. But post traumatic fatigue affects at least 50% of individuals with TBI. Wow. And in those cases it's often debilitating. There's been long longitudinal studies that have been done on TBI patients, and in those studies fatigue was present in 68% percent after the first post trauma week, 38% after the third month and 34% after even the six month of that longitudinal study.

0:13:40 - Shane Smith
So it seems to get, once you cross the six month mark, you're, I don't want to say stuck with this in your life, but I mean it's very difficult to overcome those sleep issues and the insomnia and the fatigue and everything wrapped into place if you're still having it six months out.

0:13:53 - Thomas Ozbolt
Yeah, you know it can definitely be there even after half a year. And if it's there after half a year, you know you, you got to assume that's gonna continue to some extent, or you might be able to assume that's gonna continue to some extent.

0:14:09 - Shane Smith
And I think it's important to realize there's no break. Frequently, you know, you have a mom with a new baby or dad who's taking care of a new baby.

You know they go for five days on, which is difficult and challenging, but then dad may be at home or mom may be at home for the weekend, so they get that break. Or even grandma comes into town and takes care of the baby for a night, sort of give a reset, you know what I mean? Yeah. A lot of people talk about that, right, like my mom came into town, took the baby for a weekend, finally got eight good hours asleep. Or I went on vacation and got, I went to bed early on Saturday and woke up super late on Sunday, so I'm sort of recharged pretty good, but there's no break for these guys, right?

0:14:41 - Thomas Ozbolt
Yeah, it's when you're, all those examples you're talking about, that's something external that's causing the fatigue. In these instances, where it's traumatic, post traumatic fatigue, it's caused by something inside of you, you, that you can't control. You know many, in many cases there's, there's different ways to treat this, but it's, it's something that affects an injured person's daily life and there's really no escape from it. It affects their ability to work, engage in activities, be a mom or dad, maintain a certain quality of life and, you know, establishing that connection between the TBI and the fatigue and sorting out, hey, it's not all these other confounding variables, it's the TBI that's causing it. That's crucial.

And you know, post traumatic fatigue is caused by a lot of different factors. What are some of the factors that cause it? So there's, you know, at least six different kind of factors that will cause it. There's anatomical, there's behavioral, there's biochemical, there's endocrine factors, there's medications and there's sleep disruption, as we just kind of talked about. Now for anatomical, traumatic injury to specific structures within your brain, like the brain stem, the basal ganglia, that can affect your a level of alertness as well as your drive and motivation.

0:15:53 - Shane Smith
So that's gonna, that's when the brain, there's an actual injury to that part of the brain, boom. That's what's causing the issue, the injury itself.

0:15:59 - Thomas Ozbolt
Yeah, it's, it's, it's creating, you know it's, it's causing the fatigue in the way, by affecting your level of alertness as well as your drive and motivation, you know, triggering those, you know, internal effects upon you. And then you've got behavioral, you know, depression, which is something that's particularly prevalent with TBI. That can also be related to fatigue development. When you're under that stress of just feeling like the world is ending or just life is terrible and that's maybe oversimplifying depression, that can develop fatigue in your-

0:16:32 - Shane Smith
So the TBI caused me to have depression, and the depression is what's creating the fatigue issue.

0:16:39 - Thomas Ozbolt
Right, it leads to fatigue. So all these things kind of, it's a web.

0:16:42 - Shane Smith
So it's a path together.

0:16:44 - Thomas Ozbolt
Okay, then you've got biochemical changes, like, traumatic injury to the brain can cause alteration in your amino acids that are produced that can affect the production of neurotransmitters within your brain, the signals that are being sent for your body to act and react to certain stimuli. So the chemicals are off inside? Right, yeah, okay, much simpler. Endocrine dysfunction, particularly related to pituitary gland injury. This can cause fatigue due to deficiencies in your growth hormones, your thyroid, your cortisol, all the things that make you go, the things that build your muscle, the things that control your stress level. Injury to the pituitary gland, that's the endocrine we'll talk about there. Wow. And then medications, these have fatigue as a side effect. In a lot of cases, medications are prescribed to deal with TBI, and then sleep disruption and all.

0:17:37 - Shane Smith
So the medication, that's one of those things where everybody's evaluating is a cure worse than the disease kind of thing. You've got some injury, some traumatic brain injury issue you're trying to treat. You take the medication, but the medication, like one of the side effects is weight gain. So it makes you gain a bunch of weight, or it just makes you overly fatigued, or it makes it so you can't sleep, right.

0:17:55 - Thomas Ozbolt
Yeah, it gives you weight gain, which gives you depression, which gives you fatigue, which makes you have drugs to, you know, deal with that, but it's not like you can just not take the medicine, right, that's not a choice for a client. And there's rarely other alternatives. With a lot of these sorts of injuries to the brain, there's limited ways we have to deal with them, right now at least.

0:18:16 - Shane Smith
So it's not like Tylenol, where there's a whole bunch of different types of Tylenol out there. There may only be one type of medication for this specific injury to your brain, or two right, of which both may have the side effect fatigue, right?

0:18:27 - Thomas Ozbolt
Right yeah. And at that point you're locked in. You know, do I deal with this debilitating issue or do I have the secondary, you know also debilitating fatigue, that comes with it. Right, and that's catch, I don't know, that's catch 22.

0:18:42 - Shane Smith
So yeah, catch everything I mean kind of deal. And it makes, and you know, when we look at fatigue as a symptom, you know, I know personally, like when I'm super tired I'm not myself.

0:18:53 - Thomas Ozbolt
Right.

0:18:55 - Shane Smith
You know, I don't want to, if I've had a super hard day at work or two super hard days at work, I'm not going home and being as active and doing all the things I'm doing. That's just two days yeah.

Right, and that assumes I can get sleep. I mean part our clients and other people who suffer from the fatigue symptom or the insomnia. It just compounds and compounds, I mean. So, like we said, it totally takes over your life because dad's still, dad's too tired to do anything, or mom's too tired to do anything right, which, if you look at mom was a homemaker and she can no longer get up and clean the house and do all those things. That's going to fall apart, her relationship with her husband's gonna fall apart.

Probably affects the resent you know, I mean spouses begin to resent, now they got another kid right, instead of their partner. How much people lose for this? And part of our job is as on the, now we'll switch the legal aspect of it. Part of our job is to say I mean almost basically say what would you give up, what would you pay to have this part of your life taken away? Right?

0:19:48 - Thomas Ozbolt
Yeah, and you know we don't live in a time where you know, you go take away what was taken from you. It's not an eye for an eye anymore.

We live in a world and a constitutional system that says the mechanism that we have by law to give you justice is to give you compensation. So we're not asking for someone to just be given money.

0:20:08 - Shane Smith
If I had to do a study and I put up there and said, hey, we're running this study, we're running this contest. Here's what's going to happen to you. You're going to get hit in the head and you're not going to be able to sleep for two, more than you know, for two weeks at a time. Who would sign up for that study? Right, and if I said, your sleep is going to be messed up for six months, who's going to sign up for that? And how much would I have to pay to get volunteers to come in and do this? Or we talk about the circadian rhythm flipping. How much would I have to pay for somebody to say, hey, I'll take that job. Yeah, and that's probably the right amount. I mean, because that's what I would have to pay for somebody to voluntarily do it, is at least equivalent to somebody who didn't have a choice, right?

0:20:49 - Thomas Ozbolt
Right, so what's the value of what was taken from you? And it's like, if you can't sleep anymore, if you can't function well with your family anymore, it's like what are those relationships worth to you? I don't see how anybody would give that up for anything really, but I mean you gotta start in the millions of dollars.

0:21:06 - Shane Smith
And I was gonna say, and that's what we gotta talk about, right, and that's part of the difficult part of our job is what is that worth, right? What's the question for that? And off the cuff, like you say, you say a million dollars. Sounds like a huge amount of money, but if you've got a 30 year old man who's now, he sleeps all during the day and is up all night and you can't have the accountant or a doctor, now he can't do that anymore. Now he's gonna have to take a night shift job at a fact, you know what I mean or where the income is in half, or he's not gonna be able to see his kids at the family picnic anymore.

You know what I mean, cause I remember when I knew people who worked night shift, they, when they had to come to do stuff during the day, they were there cause it's a family event, but a lot of times they were barely there. You know what I mean. They're in the corner, propped up against the wall, trying to be awake, but they're also asleep because they just worked an eight hour shift and they got two hours of sleep in their back. I think about years ago when I had two children, you know, and my wife taking care of them during the day. You know, by the end of the week she was pretty wiped out.

0:22:05 - Thomas Ozbolt
I had a client describe it to me one time. You know he had suffered a traumatic brain injury. He said I feel like I'm a ghost caught between two worlds and he said I wish God would just take me to the next one. It's like that's how bad it had gotten for him. He just felt like he wasn't here in either world.

0:22:18 - Shane Smith
Wow, and that's one of the things we're gonna talk about on a topic later on is at one of our other episodes we're gonna talk about the impact of traumatic brain injuries on suicide and early you know, early death, where people just feel like there's no options and they're hopeless. Another topic we wanna talk about is we wanna go a little bit deeper into these sleep disturbances and talk about you know what exactly each one means, right, and some of them are pretty self-explanatory.

Insomnia everybody knows that means you can't sleep, but what really does that mean, right? Does that mean I can't sleep one or two nights, or does that mean forever, or you know? So we're gonna delve into those topics. So, for our listeners, if this is a topic that interests you, please hit like and subscribe down below and remember the bell well, lets you know when a new episode of Mind Matters comes out. We should be getting an episode out every single week, so just stay tuned and get regular updates and find out what's going on and always remember if you got a TBI or some kind of injury like that from an accident and you wanna talk to one of our attorneys Thomas, who's here, or one of the other attorneys in the Brain Injury and Concussion Group, please give us a call at 980-999-9999. And remember if you're in pain, call Shane.