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Cited by 2Traumatic Brain Injury ResearchSleep and related disordersTraumatic Brain Injury and Neurovascular Disturbances

The DOI matches its Crossref record; 65 of the 65 references it cites were found in a registry or an index; none of the 51 sources its claims cite is checked for support yet.

Concussion Disrupts Sleep in Adolescents: A Systematic Review and Meta-Analysis

Open access
Noordeen, Suleyman, Wang, Poh, Strazda, Anna E., Arany, Eszter Sara, Ergisi, Mehmet, Yeo, Linghui Janice, Popovic, Rebeka, Mahendran, Abinayan, Khawaja, Mikail, Grover, Kritika, Memon, Mohammed, Hegde, Saahil, Qiu, Connor S., Oulton, Charles, Yu, Yizhou·2025·Clocks & Sleep
DOI 10.3390/clockssleep7030046PMC PMC12452595
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Abstract

Concussions significantly impact sleep quality among adolescents. Despite increasing recognition of these effects, the complex relationship between adolescent concussions and sleep disturbances is still not fully understood and presents mixed findings. Here, we conducted a systematic review and meta-analysis to assess how concussions affect sleep-related symptoms in adolescents. We included papers presenting Pittsburgh Sleep Quality Index (PSQI) differences following concussion in high school and collegiate patients, with sleep measures recorded following concussion. Animal studies, research on participants with conditions other than concussion, non-English articles and papers failing to present PSQI data were excluded. We searched MEDLINE®, Embase®, CINAHL, Web of Science™, PsycINFO®, Google Scholar, and Cochrane Central Register of Controlled Trials databases until 23 August 2024. In addition, we performed hand-searching of relevant reference lists and conference proceedings to identify further studies. Risk of bias was assessed using the Newcastle–Ottawa scale. In total, we considered 4477 studies, with nine meeting the inclusion criteria. Our analysis involved 796 participants, 340 of whom had experienced a concussion. Analysis was carried out using the meta and metafor packages in R (version 4.0.0). We showed a deterioration in sleep quality post-concussion, as evidenced by increased PSQI (standardised mean difference 0.84; 95% CI 0.53–1.16; p < 0.0001). Subgroup and quality assessments confirmed the consistency of these findings. Since poor sleep quality impacts daytime activities, we analysed the relationship between concussion and daytime dysfunction. We showed that concussion is associated with a significant worsening of the daytime dysfunction score by 0.55 (95% CI 0.24–0.70; p = 0.006). We conclude that concussions impair both sleep quality and daytime functioning in adolescents. Our research underscores the need for systematic inclusion of sleep quality assessments in post-concussion protocols and calls for targeted interventions to manage sleep disturbances post-concussion to mitigate their broader impacts on daily functioning.

Overview

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TL;DR

This systematic review and meta-analysis found that concussion in adolescents and collegiate-aged individuals is associated with worse sleep quality and greater daytime dysfunction. Across nine studies and 796 participants, PSQI scores were significantly higher post-concussion, and daytime dysfunction scores were also significantly worse.

Key findings

  • Pooled analysis of 9 studies (796 participants; 340 concussed) found concussion associated with increased PSQI, indicating worse sleep quality: standardised mean difference 0.84 (95% CI 0.53–1.16; p < 0.0001); the paper reports this corresponds to a 4.24% decrease in sleep quality.
  • Daytime dysfunction subscore analysis (3 studies, 404 participants, 35.6% concussed) found significant worsening: standardised effect size 0.55 (95% CI 0.24–0.70; p = 0.006), corresponding to an approximate 9.2% increase in daytime dysfunction.
  • Three included studies found non-statistically significant differences in overall PSQI between concussed and non-concussed participants, but some reported significant worsening in specific components such as daytime dysfunction, sleep efficiency, sleep quality, and sleep disturbances.
  • No moderating effect was found for sex or average age on PSQI, and study quality on the Newcastle–Ottawa scale did not influence the estimated effect of concussion on sleep quality.

Methods

  • Systematic review and meta-analysis following PRISMA guidelines, registered with PROSPERO (CRD42021290208); searched MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Google Scholar, and Cochrane Central Register of Controlled Trials until 23 August 2024, plus hand-searching of reference lists and conference proceedings.
  • Included RCTs, abstracts, cross-sectional, and case–control studies published between 1988 and August 2024 that evaluated concussion/mild traumatic brain injury and PSQI in ages 12–30; excluded animal studies, other neurological conditions, non-English articles, duplicates, and articles without full text or results. From 4477 records, 9 studies met inclusion criteria.
  • Random-effects models (DerSimonian and Laird method) and mixed-effect models were run in R using the meta and metafor packages; reported weighted standardised mean differences with 95% CIs, assessed heterogeneity with I², publication bias with funnel plots, and study quality with the Newcastle–Ottawa scale.

Limitations

  • Stated: the authors were unable to perform moderator analysis for specific confounding factors such as mental health differences or sleep hygiene awareness; future research is needed across diverse populations to understand age, sex, and ethnic differences, and concussions may have sexually dimorphic outcomes.
  • Evident from the text: only 9 studies were included, two of which were abstracts not subject to peer review; the primary analysis had heterogeneity, with one study (Albicini et al.) most distinct; Newcastle–Ottawa scores ranged from 2 to 8 out of 9; three studies were drawn from an adolescent population aged 12–18 years while others used student populations; all studies were recruited from English-speaking countries, indicating a homogeneous population.

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Integrity signals

Registry

Crossref · 10.3390/clockssleep7030046

Cites

65 of 65 references verified0 citation errors · 0 not checkable

Statistics

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Figures

Figure 1 Data filtering methodology flowchart. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020) workflow was followed.
Figure 1 Data filtering methodology flowchart. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020) workflow was followed.CC BY · PubMed Central
Figure 2 Adolescent sleep quality is significantly worse after concussion events. The individual and pooled standardised mean differences (abbreviated as SMD in the figure) are shown. The pooled SMD was a PSQI of 0.84 (95% CI 0.53–1.16; p < 0.0001) in adolescents who sustained a concussion compared to controls (random effect model). The size of the box representing the point estimate for each study in the forest plot is proportional to the contributing weight of that study estimate to the summary estimate. There is a presence of considerable heterogeneity as indicated by the 74% I2 score and p < 0.01 [9,43,44,45,46,47,48,49,50].
Figure 2 Adolescent sleep quality is significantly worse after concussion events. The individual and pooled standardised mean differences (abbreviated as SMD in the figure) are shown. The pooled SMD was a PSQI of 0.84 (95% CI 0.53–1.16; p < 0.0001) in adolescents who sustained a concussion compared to controls (random effect model). The size of the box representing the point estimate for each study in the forest plot is proportional to the contributing weight of that study estimate to the summary estimate. There is a presence of considerable heterogeneity as indicated by the 74% I2 score and p < 0.01 [9,43,44,45,46,47,48,49,50].CC BY · PubMed Central
Figure 3 Publication bias and confounder analysis. (a) Funnel plot indicating the possible heterogeneity in the analysis. The standard error in the y-axis is a measure of study precision, and the standardised mean difference in the x-axis indicates the study results. Each dot represents an individual study, and the outlier is labelled. The outer dashed lines indicate the triangular region within which 95% of studies are expected to lie in the absence of both biases and heterogeneity. The middle dashed line indicates the overall standardised effect size determined via a common effect model, and the vertical dotted line represents the overall standardised effect size determined via a random effect model. (b–d) Confounder analysis of gender ratio (b), age (c), and Newcastle–Ottawa scores (d). The gender ratio, average age, and Newcastle–Ottawa scores of each study are plotted against the observed outcome and modelled in a meta-regression analysis. The size of each dot represents the weight of each study. All p-values of these confounders are above 0.05 [49].
Figure 3 Publication bias and confounder analysis. (a) Funnel plot indicating the possible heterogeneity in the analysis. The standard error in the y-axis is a measure of study precision, and the standardised mean difference in the x-axis indicates the study results. Each dot represents an individual study, and the outlier is labelled. The outer dashed lines indicate the triangular region within which 95% of studies are expected to lie in the absence of both biases and heterogeneity. The middle dashed line indicates the overall standardised effect size determined via a common effect model, and the vertical dotted line represents the overall standardised effect size determined via a random effect model. (b–d) Confounder analysis of gender ratio (b), age (c), and Newcastle–Ottawa scores (d). The gender ratio, average age, and Newcastle–Ottawa scores of each study are plotted against the observed outcome and modelled in a meta-regression analysis. The size of each dot represents the weight of each study. All p-values of these confounders are above 0.05 [49].CC BY · PubMed Central
Figure 4 Relationship between concussion and daytime dysfunction. (a) The individual and pooled standardised mean difference (abbreviated as SMD in the figure) are shown. The pooled SMD was 0.55 (95% CI 0.24–0.70; p = 0.006) in adolescents who sustained a concussion compared to controls (random effect model). (b) Heterogeneity analysis. The standard error in the y-axis is a measure of study precision, and the standardised mean difference in the x-axis indicates the study results. Each dot represents an individual study. (c–e) Confounder analysis of gender ratio (c), age (d), and Newcastle–Ottawa scores (e). The gender ratio, average age, and Newcastle–Ottawa scores of each study are plotted against the observed outcome and modelled in a meta-regression analysis. The size of each dot represents the weight of each study. All p-values of these confounders are above 0.05 [9,49,50].
Figure 4 Relationship between concussion and daytime dysfunction. (a) The individual and pooled standardised mean difference (abbreviated as SMD in the figure) are shown. The pooled SMD was 0.55 (95% CI 0.24–0.70; p = 0.006) in adolescents who sustained a concussion compared to controls (random effect model). (b) Heterogeneity analysis. The standard error in the y-axis is a measure of study precision, and the standardised mean difference in the x-axis indicates the study results. Each dot represents an individual study. (c–e) Confounder analysis of gender ratio (c), age (d), and Newcastle–Ottawa scores (e). The gender ratio, average age, and Newcastle–Ottawa scores of each study are plotted against the observed outcome and modelled in a meta-regression analysis. The size of each dot represents the weight of each study. All p-values of these confounders are above 0.05 [9,49,50].CC BY · PubMed Central

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Cites

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  1. Wells, G. (2000, January 3–5). The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Proceedings of the 3rd Symposium on Systemic Review Basics, Oxford, UK.

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Metadata

Authors
Noordeen, S., Wang, P., Strazda, A. E., Arany, E. S., Ergisi, M., Yeo, L. J., Popovic, R., Mahendran, A., Khawaja, M., Grover, K., Memon, M., Hegde, S., Qiu, C. S., Oulton, C., & Yu, Y.
Affiliations
  • University of Cambridge (GB)
  • Imperial College London (GB)
  • International Sleep Charity, Shedfield, Southampton SO32 2HQ, UK
  • Norfolk and Norwich University Hospital (GB)
  • Leeds Teaching Hospitals NHS Trust (GB)
  • Eastbourne District General Hospital (GB)
Corresponding author
Yu, Yizhou
ORCID
Venue
Clocks & Sleep
Publisher
MDPI AG
Published
2025-08-29
Volume
7
Issue
3
Pages
46
ISSN
2624-5175 (ISSN-L)
DOI
10.3390/clockssleep7030046
PMC
PMC12452595
OpenAlex
W4413807623
Cited by
2
References
65
Citations by year
2026: 2
FWCI
0.29
Type
journal article
Language
en
Open access
Licence
Locations
  • Clocks & Sleep (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • PubMed Central (publishedVersion, cc-by)
  • Apollo (University of Cambridge) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
International Sleep Charity (1123736)
Topics
  • Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury and Neurovascular Disturbances
Keywords
concussion, sleep quality, adolescents, Pittsburgh Sleep Quality Index, daytime dysfunction, sleep disorders, post-concussion syndrome, high school athletes, collegiate athletes

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