Monash University

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Cognitive Behaviour Therapy to Treat Sleep Disturbance and Fatigue Following Acquired Brain Injury

posted on 2017-04-10, 00:33 authored by Sylvia Nguyen
Sleep disturbance and fatigue are common phenomena following acquired brain injury (ABI). Prevention and management of these symptoms are important targets in rehabilitation yet there is limited empirical investigation into effective interventions. Although local, consensus-based guidelines have been put forward, there are no universally established, evidence-based guidelines to treat poor sleep and fatigue following traumatic brain injury (TBI) or stroke. Sleep disturbance and fatigue are inter-related and have bidirectional relationships with cognitive deficits, depression, anxiety and pain. Cognitive behaviour therapy (CBT) is a promising treatment given its success in treating these symptoms in non-neurological populations. A small number of studies have implemented CBT to treat insomnia and fatigue in ABI cohorts but further research is needed to draw stronger conclusions regarding treatment efficacy.
   The primary aims of the current research were to conduct a pilot randomised controlled trial (RCT) to 1) evaluate the effectiveness of an adapted CBT intervention for sleep disturbance and fatigue in a TBI sample, 2) investigate the efficacy of the same CBT intervention in a stroke sample and 3) identify predictors of positive response to CBT for sleep in both TBI and stroke participants.
   Eligible participants (n=36) with history of mild to severe TBI or stroke with clinically significant fatigue and/or sleep complaints completed baseline assessment and were randomly allocated to intervention (CBT) or treatment as usual (TAU). The intervention consisted of eight weekly therapy sessions with a neuropsychologist. CBT was delivered according to a manualised protocol and adapted to accommodate cognitive impairments. Participants were reassessed at two months (post-therapy) and four months from baseline (two-month follow-up) on primary outcome measures: the Pittsburgh Sleep Quality Index (PSQI) and the Fatigue Severity Scale (FSS). Secondary measures assessed insomnia severity, daily fatigue levels, daytime sleepiness, mood and quality of life.
   The first study with a TBI sample revealed significantly greater improvements for CBT recipients on the primary measure of sleep quality (PSQI) and in insomnia (Insomnia Severity Index) than TAU. While there was no change on the primary fatigue measure (FSS), daily fatigue levels (Brief Fatigue Inventory) were reduced following CBT. Secondary improvements were also noted in depression (Hospital Anxiety and Depression Scale). Gains were maintained at two-month follow-up with large treatment effects by the end of the study.
   In the second study with a stroke cohort, there was a significant reduction on the primary fatigue measure (FSS) following CBT. Improvements in sleep quality and insomnia were significant post-treatment but were attenuated at follow-up. CBT participants further reported significant decline in depression and increased physical quality of life (SF-36). Treatment gains were maintained up to two months after therapy cessation with large effect sizes.
   The third study examined characteristics of treatment responders using classification and regression tree (CART) analyses. As a combined ABI sample, better memory, younger age and higher baseline depression were associated with greater improvements in sleep quality following CBT.    
   This research illustrates the feasibility of delivering adapted CBT to treat sleep disturbance and fatigue following ABI, but larger RCTs are required to extend and replicate these pilot findings.


Principal supervisor

Jennie Ponsford

Additional supervisor 1

Adam McKay

Additional supervisor 2

Dana Wong

Additional supervisor 3

Shantha Rajaratnam

Year of Award


Department, School or Centre

Psychological Sciences

Campus location



Doctor of Philosophy

Degree Type



Faculty of Medicine Nursing and Health Sciences

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