Improving

the significance and direc3on of

sleep research in TBI rehabilita3on: A
research transla3on journey.

Risa Nakase-Richardson, Ph.D., FACRM, FNAN

Mental Health and Behavioral Sciences, Defense Health Agency TBI Center of
Excellence, James A. Haley Veterans Hospital, Tampa, FL
Professor, Division of Pulmonary and Sleep Medicine, College of Medicine,
University of South Florida, Tampa, Florida
 Disclosures
•  Presenter(s) has no financial conflict of interest relevant to this acPvity.
•  This work is supported by the following:
Pa3ent Centered Outcomes Research Ins3tute
PCORI – CER-1511-33005
Defense Health Agency’s Defense and Veterans Brain Injury Center and Subcontractor
General Dynamics Health SoluPon DVBIC-W91YTZ-13-C-0015
U.S. Army Medical Research and Material Command and from the U.S. Department of Veterans
Affairs
Chronic Effects of Neurotrauma ConsorPum under Award No. W81XWH-13-2-0095.
Na3onal Ins3tute on Disability, Independent Living, and Rehabilita3on Research TBI Model
Systems
Grant # 90DPTB00070, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02, 90DP0084

This material is also the result of work supported with resources and the use of faciliPes at the
James A. Haley Veterans’ Hospital, Tampa, FL and the Department of Veterans Affairs TBI Model
Systems Program of Research
 Disclaimer

–  The statements presented in this publicaPon are

solely the responsibility of the author(s) and do
not necessarily represent the views of the PaPent-
Centered Outcomes Research InsPtute® (PCORI®),
its Board of Governors or Methodology
Commihee.
–  Contents may not represent the views of the
Department of Veterans Affairs, Defense Health
Agency or the United States Government
 Objectives

•  Describe mechanisms by which sleep problems

may contribute to neurologic recovery and
accelerated aging aier TBI
•  List the five components of a framework for
management of sleep problems post-TBI
•  Discuss common barriers to implemenPng
evidence-based care for treaPng sleep apnea
earlier in neurologic recovery following TBI.

 Case 1 – Fully SC Veteran

CC: Worsening cogniPon -43 yo MWM

(focusing his ahenPon, mulP-tasking, mistakes on job, noPced by coworkers/family)
•  Civilian Job in Senior Management
•  Had both civilian and VA providers
(with Significant CogniPve Demands)
•  Recently seen by VA Psychiatry Service
•  18yrs educaPon / Superior IQ (referred for Npsych & PNS)
•  MulPple young children (under age 5)
•  History of •  MedicaPons
–  TBI (mulPple) –  Minimized Pain MedicaPon Use
–  SPmulant (ADHD)
–  Sleep Apnea (>15 years)
–  Insomnia •  Pihsburgh Sleep Quality Index = 13
–  Chronic Pain (Back, Head) (severe)
–  Hypertension / Diabetes •  Epworth Sleepiness Scale = 12
–  “ADHD” (Newly Diagnosed in 4th (Abnormal)
decade of life - based on abnormal •  Mood Assessment Scale = 16
SPECT) (Mild)
–  Possible Depression / Anxiety
–  Nightmares
 Case 1
Treatment RecommendaPons

•  Neuropsychology •  Refer to PNS SLP for

–  TBI EducaPon (Npsych) cogniPve strategies to
–  ComorbidiPes EducaPon
–  Defer comprehensive tesPng unPl
increase workplace
comorbidiPes affecPng cogniPon efficiency (despite ePology)
addressed



•  Refer to RehabilitaPon Psychologist •  Referred to PNS TBI
(Pain/Sleep/Mood Specialist)

Physician for management
–  Evaluate Candidacy for InpaPent of ongoing rehabilitaPon
Comprehensive Pain RehabilitaPon needs
Program
–  Evaluate for anxiety/mood disorders


–  Address Sleep Issues

UNCLASSIFIED (U)

STAGES OF RESEARCH TRANSLATION

Implementa3on Research:
Effec3veness Research: Promo3on of Evidence-Based Care
Efficacy Pragma3c, Real-World Se`ngs AcPve data collecPon (mixed methods common)
Studies
What works best in read world
seungs
ObservaPon of
ImplementaPon Outcome of ImplementaPon:
Bench Research Effec3veness •  Systems Outcomes
Research •  PaPent Outcomes
•  Both PaPent and System
IntervenPon to
Outcomes
Clinical Research Overcome Barriers to
ImplementaPon
Prac3ce Guidelines of Evidence IntervenPon Examples: health literacy
& Consensus Statements intervenPon; developing champions, ongoing
Health Services trainings, learning collaboraPve.
Research
Knowledge synthesis Barrier Examples: lack of provider knowledge, missing necessary
resources to implement the best pracPce

Opportunity for a Learning Healthcare System

•  14% of research from RCT takes an average of 17 years to reach the pa3ent’s bedside1
•  Publica3ons alone do not get providers to adopt evidence-based interven3ons
•  Guidelines alone do not get providers to adopt evidence-based interven3ons
•  Partnerships between scien3sts across clinical sciences, health services & implementa3on
research are needed to promote adop3on of new knowledge into prac3ce
1. Commihee on Quality of Health Care in America, InsPtute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: NaPonal Academies Press; 2001.

7
UNCLASSIFIED (U)
 Background

•  The IOM concluded moderate to severe TBI is associated with

many chronic health condiPons and disabiliPes and need for
life-long care.1

•  Meta-analyses support higher incidence of sleep disturbances

and sleep disorders in TBI2
–  LimitaPon of exisPng studies include
•  mixed severity
•  mixed Pme post-injury
•  mixed seungs

1Rutherford GW, Corrigan JD. (2011). Long-term consequences of traumaPc brain injury. J Head Trauma Rehabil. 2009: 24, 421-423.
2Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumaPc brain injury: A meta-analysis. Sleep

Med. 2012;13:898-905.

 Sleep & Neuroplas3city

q  NeuroplasPcity
q  The ability of the brain to reorganize itself in
both structure and funcPon.
q  Sleep Promotes Brain Repair (healing/
neuroplasPcity)
q RestricPon of sleep alters several
endogenous brain repair mechanisms
including1
q Axonal sprouPng, synaptogenesis,
neurogenesis, angiogenesis

•  Sleep is associated with a 60% •  Sleep and NeurodegeneraPon
increase in intersPPal space (Chronic ConsideraPons)
and influx of CSF mixing with
intersPPal fluid
•  Waste products including
beta-amyloid were cleared
with the efflux of CSF from
Pssue in space surrounding
venous system (glymphaPc
system)
•  One of the restoraPve
funcPons of sleep is to clear
neurotoxins accumulated
during waking h ours
Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult brain. Science 2013; 342:373-7.

Sleep Sequence 1 Sequence 2 Sequence 3
Disturbance (ini3al (second (third
Ra3ng (DelRS- evalua3on) evalua3on) evalua3on)
R98)

TSI 24 days 29 days 33 days

No Sleep Dist. 25 (14.5%) 40 (23%) 65 (38%)

Mild 37 (21.5%) 52 (30%) 51 (30%)

85% 63%
Moderate 84 (49%) 73(42%) 46 (27%)
64% 33%
Severe 26 (15%) 7 (4%) 10 (6%)
 Examples of Mod-Severe SWCD using
AcPgraphy (ObjecPve Measure) in Acute TBI
Algorithm-Determined Sleep Interval

Blue = sleep interval

Midnight Yellow- white light
Black = movement
 Examples of Mod-Severe SWCD using
AcPgraphy (ObjecPve Measure) in Acute TBI

Midnight Midnight

Algorithm-Determined Sleep Interval

 Is Sleep Temporally Related to Acute
Confusion/PTA aier TBI?
Others think so…. Acute
Sleep Confusion
& PTA
TBI Outcome
–  Makley et al, 2009
•  Sleep efficiency improved with PTA resoluPon Other Predictors

–  Sherer et al 2009
•  Sleep Improvement Preceded ResoluPon of Other Confusion Symptoms
–  Nakase-Richardson et al 2013
•  Severity of sleep disturbance at 1 month post-injury predicPve of PTA duraPon and hospital length of
stay
–  Duclos et al, 2014
•  Earlier improvement associated with earlier PTA and clearance and lower disability
–  Holcomb et al, 2016
•  Severity of sleep disturbance predicPve of cogniPve recovery (CogniPve Test for Delirium) in acute
rehabilitaPon

–  Duclos et al, 2017

•  DAR, Sleep, FragmentaPon Improve in Parallel with recovery of consciousness/cogniPon
 The Sleep Cycle

NREM and REM Sleep occur cyclically, in varying amounts through the sleep period; each
have their own specific biochemical signatures, generated in completely different parts of
the brain, and each likely serve different funcDons.

* Slide courtesy of National Sleep Foundation

 Architecture
SLEEP BRAIN
CHARACTERISTICS
STAGE WAVES
•  Brief transiPon from wakefulness to light sleep
Stage
Slowing •  Slowing of heartbeat, breathing, eye movements
N1
•  Muscles relax, occasional twitches
3-7%
•  Light sleep
Slower with •  Further slowing of heartbeat and breathing
Stage brief bursts •  Further relaxaPon of muscles 45-50%
N2 of electrical •  Body temperature drops
80% acPvity •  Eye movements stop
•  More Pme in repeated sleep cycles here than any other stage
•  Need to feel refreshed in the morning
Stage Even slower •  Occurs more in first half of sleep 15-20%
N3 brain waves •  Heartbeat and breathing slow to lowest levels
•  Muscles relax; difficult to awaken
•  First occurs 90 min aier falling asleep
Mixed •  Rapid eye movement from side to side
frequency •  Breathing is faster and irregular
REM
brain wave •  Heart rate and blood pressure increase near waking levels
acPvity •  Most (not all) dreaming
•  Temporary paralysis of arms/legs
 Is there an opPmal duraPon of sleep?

•  “Sleeping less than 7 hours

per night on a regular basis is
associated with adverse
health outcomes including
weight gain and obesity,
diabetes, hypertension, heart
disease, stroke, depression,
and increased risk of
death….impairs immune
funcPon, increased pain,
impaired performance,
increased errors, and greater
risk of accidents.”

Purported Purposes of Sleep
“facilitates brain health”

q  RestoraDon of Biochemical / Cellular substrate
§  Depleted substrate are replenished during sleep.
§  SWS is associated with the release of Growth Hormone promoPng protein synthesis, anabolism, and cell repair.
§  PotenPal Immune System Enhancement : Sleep is associated with an increased WBC

q  RestoraDon of SynapDc Integrity and Responsiveness
§  RestoraPon of neurotransmihers (replePon of depleted aminergic and cholinergic substrate),
§  RestoraPon of synapPc integrity (receptor sensiPvity)

q  Sleep Facilitates the Process of Memory / Learning

InformaPon storage, organizaPon and coordinaPon for future recall, and integraPon with other stored data

Proposed Associa3ons of Sleep Stages with Memory and Recall

N3/SWS -> Specific ordered replay of day’s events (Hippocampus -> Cortex)
Hippocampus (short term memory) -> Cortex (long term memory)
This potenPally facilitates the capacity for recall, and thus for later use

REM -> Random Replay of events… this may enhance new associaPons, new soluPons,
…. Increasing creaPvity, innovaPon, problem solving skills
 5-Finger Model to Sleep Management

Environment/Circadian
Psychiatric Pharmacologic Misalignment
•  Mental Disorders •  Prescribed
•  Shii Work Light
•  Psychological •  Non-prescribed
Distress •  Noise Stress
•  Stress Blindness

Medical Disorders
•  Pain GERD Primary Sleep Disorders
•  Asthma Asthma •  Insomnia SRBD
•  Allergic RhiniPs •  Hypersomnia CRSD
•  Renal, Liver Failure •  Sleep Apnea
•  Cardiac Ischemia

McCarty DE. Beyond Ockham’s Razor: Redefining Problem-Solving in Clinical Sleep

Medicine using a “Five-Finger” Approach. 2010. Journal of Clinical Sleep Medicine; 6 (3).
 Framework for Considering Sleep Disturbance Aier
TBI (Moderate to Severe Illustrated Below)
Is Post-TBI sleep Acute Sub-Acute Chronic
disturbance the (ICU/Ward) (Rehab) (Community)
same thing over
Pme? TBI TBI TBI
TBI (Improves) TBI (Improves)

Sleep Sleep
Domains Impac3ng Sleep Disturbance Sleep Disturbance Sleep
Changes Changes
Sleep Quality (Improves) (Improves)

“Five Fingers”
• Environment
• Medical Disorder
• Formal Sleep
Disorders
• Medica3ons
• Psychological Health
 Categories Of Primary Sleep
Disorders

q  Sleep-Related Breathing Disorders

ObstrucPve Sleep Apnea; Central Sleep Apnea

q  Circadian Rhythm Sleep Disorders

Shii Work; Jet Lag

q  Insomnia
Inadequate or poor quality of sleep

q  Hypersomnia
Excessive dayPme sleepiness; not beher accounted for by
other sleep disorder, or inadequate sleep

q  Narcolepsy
Sudden and uncontrollable, though oien brief, ahacks of deep sleep.
SomePmes is accompanied by paralysis and hallucinaPons
 Sleep Treatment Prac3ce Guidelines & Consensus Statements
hhps://aasm.org/clinical-resources/pracPce-standards/pracPce-guidelines/
 Why Sleep Apnea?
a=er TBI

•  The Clinical Dilemma

–  Assessment for specific sleep disorders is criPcal to the delivery of evidence based
treatments.
–  Poor characterizaPon of the sleep disturbance can lead to delivery of the wrong treatment.
–  Lihle guidance exists to inform clinicians’ (TBI physicians, sleep medicine) approach to
assessment of specific sleep disorders in the acute rehabilitaPon seung for moderate to
severe TBI.

•  Stakeholder Input
–  Clinicians/ScienPsts
•  GBC Think Tank MeePng-PrioriPzed earlier diagnosis of OSA

–  PaPents/Families (focus groups/surveys)
•  “[I] can’t imagine another issue more important than helping TBI persons regain the
ability to regulate their normal sleep paherns.”

–  Non-TBI Stakeholder Input (Agency for Healthcare Research and Quality)
•  Future Research Needs Papers 11&12 - Sleep Apnea Diagnosis & Treatment
 Sleep-Related Breathing Disorders:
Sleep Apnea

•  ObstrucPve Sleep Apnea:

–  Reduced/absent airflow despite conPnued effort to
breathe
•  Central Sleep Apnea:
–  Reduced/absent airflow due to reduced/absent
effort to breathe
Hypoxemia in Sleep Apnea
•  Caused by apneas/hypoapneas
•  Drops in oxygen levels due to decreased air geung to
lungs while asleep
•  Increases risk of heart ahack, stroke, death
Total AHI=71.21
 Treatment of Sleep Apneas with CPAP
Split-Night Study: mTBI pa3ent with Severe Sleep Apnea
Start of CPAP Therapy

Pre-CPAP (No REM observed) CPAP Ini3ated – REM returns

 Two Consequences of OSA
The frequent disrupPon of sleep
The low oxygen level while asleep
Cause or exacerbate:
•  Hypertension (High blood pressure)
•  Hyperglycemia (Elevated Blood Sugars) making control of Diabetes more difficult
•  Heart problems: Atrial Fibrilla3on, Worsening Conges3ve Heart Failure, Heart Aoacks
•  Strokes
•  Headaches (par3cularly awakening with a headache)
•  GERD (Gastric / Acid Reflux)
•  Impotence / Sexual Dysfunc3on (males and females)
•  Depression
•  Sleepiness / Fa3gue during the day
Increasing the risk of accidents (driving accidents and others)

•  Cogni3ve Dysfunc3on (inability to focus on task and learn new things)

•  Inaoen3veness


•  First study to use advanced diagnosPcs during inpaPent
rehabilitaPon to formally diagnose sleep apnea in
consecuPve admissions (N=86, unbiased sample)

•  1 in 2 of admissions were diagnosed with primarily
obstrucPve sleep apnea –primarily mild in TBI sample

•  TradiPonal risk factors were not predicPve of sleep apnea
status except age (median age 37) and hypertension or
hypertensive episodes
 OBSTRUCTIVE SLEEP APNEA RISK IS
ASSOCIATED WITH COGNITIVE IMPAIRMENT
AFTER CONTROLLING FOR MILD TBI:
A CHRONIC EFFECTS OF NEUROTRAUMA
CONSORTIUM STUDY
Garcia A, Reljic T, Pogoda TK, Kenney K, Agyemang A, Belanger H, Troyanskaya M,
Wilde L, Walker WC, Nakase-Richardson R .

Dept of Defense, Chronic Effects of Neurotrauma ConsorPum (CENC) Award W81XWH-13-2-0095
Dept of Veterans Affairs CENC Award I01 CX001135, & Subcontract from General Dynamics
InformaPon Technology (W91YTZ-13-C-0015)- I-MAP. No COI. The views, opinions, and/or findings
should not be construed from the Department of Veterans Affairs.



 Secondary Analysis of CENC Longitudinal Data
•  N=375 of 470 (83% mTBI, 17% control; 88% male) with complete, reliable OSA risk, cogniPve and self-report data
•  62% STOPBANG Risk >3; (64% TBI vs 50% Control, p<.05) 41% STOPBANG Risk > 4 (44% TBI vs 25% Control, p<.001)

Aoen3on and Execu3ve Func3oning Speed of Processing Memory Self-Repored

Cogni3on

TMT-B Digits BWD Flanker TMT-A Coding CVLT LDFR BVMT-DR NSI
(3med (speed of (self-reported
mul3tasking processing) cogni3on)
and
sequencing)

Age 0.25** -0.21** -0.37** 0.31** -0.29** -0.32** -0.34** -0.19**

Gender 0.01 -0.02 0.03 0.01 -0.21** -0.09 0.02 -0.16**

Race -0.16** 0.10 0.04 -0.13** 0.08 0.14** 0.10 -0.17

Educa3on -0.08 0.06 -0.08 -0.17** 0.16** 0.01 0.06 -0.4

TBI 0.10 -0.07 -0.48 0.06 -0.11* 0.07 -0.08 0.21**

Apnea Risk 0.13* -0.06† -0.01† 0.01 -0.15** -0.03 -0.05 0.25**

* p < .05, ** p < .01

•  AccounPng for TBI history, OSA risk independently predicts poorer performance on

execuPve funcPoning tasks, processing speed tasks, and self-reported cogniPve

impairment. This offers an avenue for treatment of the most common complaints for
Veterans/Service members with mTBI.

 Secondary Analysis of CENC Longitudinal Data
Being female and having higher OSA risk associated with number
of white maher hyperintensiPes for those with lesions present
Variable Beta p-value
•  N=1017 with complete,
TBI Exposure No reliable OSA risk,
Yes -0.464 0.067
cogniPve and self-report
Age 0.017 0.090
data
Sex Male
•  80% mTBI
Female 0.651 0.023
Hypertension No
•  20% control

Yes 0.103 0.648 •  87% male
Diabetes No •  61% STOPBANG Risk >3;
Yes -0.171 0.582
•  WMH in 31%
STOPBANG 0.169 0.016

ObstrucPve Sleep Apnea Risk is Associated with

Number of White Maher HyperintensiPes,
But History of Mild TBI Exposure is Not:
Long-Term Impact of Military-Relevant Brain Injury ConsorPum –
Chronic Effects of Neurotrauma ConsorPum (LIMBIC-CENC) Study
 Sleep Apnea and Moderate to Severe
TBI Associated Outcomes

•  Opioid Use
–  MarPn et al., J. Head Trauma Rehabil, 2021
•  Cogni3on
–  Steward et al., Under Review
•  Func3onal Independence
–  Nakase-Richardson R, et al. In preparaPon.
•  Chronic Pain
–  MarPn et al, in preparaPon
•  PTSD Severity
–  Miles et al., Rehab Psychol, In press
•  Psychological Health (SWLS, Depression)
–  Noyes et al., Rehab Psychol, In press
•  Par3cipa3on/Produc3vity
–  Ching DMK et al., Under Review
 Economic Impact of Sleep Apnea

•  12.4 billion (in 2015)

–  Cost of diagnosing and treaPng OSA (U.S.)
•  $149.6 billion (in 2015)
–  Cost of undiagnosed OSA
•  $49.5 billion (in 2015)
–  Cost of diagnosing and treaPng every American adult
who has OSA
•  $100.1 billion (in 2015)
–  Projected savings in a single year in the U.S.
1.  Watson NF. Health Care Savings: The economic value of diagnosPc and therapeuPc care for obstrucPve sleep apnea. J Clin Sleep Med 12:
1075-6.
2.  Cost jusPficaPon for diagnosis and treatment of obstrucPve sleep apnea. PosiPon statement of the American Academy of Sleep
Medicine. Sleep 2000;23:1017–8.

Now Back to Case 1
 Case 1 Polysomnography
•  1st Polysomnography
AHI = 20**
18 Central Apneas
2 ObstrucPve Apneas
18 Hypopneas
O2 Nadir (85%)

•  2nd Polysomnography (CPAP Titra3on Study)
CPAP=8
ObstrucPve Events Eliminated with CPAP
Central Events Persisted
 Our Pa3ent - Case 1


1. ObstrucPve Sleep Apnea – treated with CPAP

2. Central Sleep Apnea – Why does our pa3ent have CSA?


---------------------------------------

3. Circadian Sleep Wake Cycle Disorder

Irregular Sleep-Wake schedule due to his untreated OSA and CSA

4. Insomnia
Ahributable in part to maladapPve behaviors for problems #1-3
 UDS related to CPRP
---- DRUGS OF ABUSE ----

URINE Jun 22 Jun 08 Apr 14 Reference
Units Ranges
-------------------------------------------------------------------------------

AMPHET 1474 H 1637 H 959 ng/mL 0 - 1000

BARBIT <10.0 <10.0 <10.0 ng/mL 0 - 200

BENZO <10.0 <10.0 <10.0 ng/mL 0 - 200

THC <10.0 <10.0 <10.0 ng/mL 0 - 50

COCAINE <10.0 22 <10.0 ng/mL 0 - 300

OPIATES <10.0 468 H 297 ng/mL 0 - 300

 Treatment Outcomes
•  PaPent successfully •  Obstruc3ve Sleep Apnea –
completed full course of treated successfully with
CPAP
Prolonged Exposure
Therapy for PTSD. •  Central Sleep Apnea –
treated successfully with
•  PaPent successfully weaned eliminaPon of Opioid
off opioids during inpaPent medicaPons
CPRP.
•  Insomnia – treated
•  PaPent parPcipated in Pme successfully with CBT-I
limited SLP to develop
•  Circadian Sleep Wake
cogniPve strategies Cycle Disorder - resolved
(organizaPonal in nature) with treatment of the above
•  Has q 6 month FU with TBI
 Comparison of Sleep Apnea Assessment Strategies
to Maximize TBI Rehabilita3on
Par3cipa3on and Outcome
Clinicaltrial.gov Registra3on Number: NCT03033901

Risa Nakase-Richardson, Ph.D., FACRM

Mental Health and Behavioral Sciences, Defense and Veterans Brain Injury Center,
James A. Haley Veterans Hospital, Tampa, FL
Professor, Morsani College of Medicine, University of South Florida, Tampa, FL
UNCLASSIFIED (U)

STAGES OF RESEARCH TRANSLATION

Implementa3on Research:
Effec3veness Research: Promo3on of Evidence-Based Care
Efficacy Pragma3c, Real-World Se`ngs AcPve data collecPon (mixed methods common)
Studies
What works best in read world
seungs
ObservaPon of
ImplementaPon Outcome of ImplementaPon:
Bench Research Effec3veness •  Systems Outcomes
Research •  PaPent Outcomes
•  Both PaPent and System
IntervenPon to
Outcomes
Clinical Research Overcome Barriers to
ImplementaPon
Prac3ce Guidelines of Evidence IntervenPon Examples: health literacy
& Consensus Statements intervenPon; developing champions, ongoing
Health Services trainings, learning collaboraPve.
Research
Knowledge synthesis Barrier Examples: lack of provider knowledge, missing necessary
resources to implement the best pracPce

Opportunity for a Learning Healthcare System

•  14% of research from RCT takes an average of 17 years to reach the pa3ent’s bedside1
•  Publica3ons alone do not get providers to adopt evidence-based interven3ons
•  Guidelines alone do not get providers to adopt evidence-based interven3ons
•  Partnerships between scien3sts across clinical sciences, health services & implementa3on
research are needed to promote adop3on of new knowledge into prac3ce
1. Commihee on Quality of Health Care in America, InsPtute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: NaPonal Academies Press; 2001.

41
UNCLASSIFIED (U)
•  Aim 1: OSA Screening during inpaPent rehabilitaPon (n=248)
–  STOPBANG QuesPonnaire and MAPI QuesPonnaire are comparable
–  Berlin QuesPonnaire is significantly less predicPve of OSA

•  Aim 2: OSA Diagnosis during inpaPent rehabilitaPon (n=214)
–  Portable Tests are Not as SensiPve to OSA thus they are NOT Non-
Inferior
•  If the test is negaPve or mild, may sPll have significant disease
–  Portable Tests Have Good Specificity
•  If idenPfied as having OSA, likely have OSA but may be more
severe
UNCLASSIFIED (U)

STAGES OF RESEARCH TRANSLATION

Implementa3on Research:
Effec3veness Research: Promo3on of Evidence-Based Care
Efficacy Pragma3c, Real-World Se`ngs AcPve data collecPon (mixed methods common)
Studies
What works best in read world
seungs
ObservaPon of
ImplementaPon Outcome of ImplementaPon:
Bench Research Effec3veness •  Systems Outcomes
Research •  PaPent Outcomes
•  Both PaPent and System
IntervenPon to
Outcomes
Clinical Research Overcome Barriers to
ImplementaPon
Prac3ce Guidelines of Evidence IntervenPon Examples: health literacy
& Consensus Statements intervenPon; developing champions, ongoing
Health Services trainings, learning collaboraPve.
Research
Knowledge synthesis Barrier Examples: lack of provider knowledge, missing
necessary resources to implement the best prac3ce

Opportunity for a Learning Healthcare System

•  14% of research from RCT takes an average of 17 years to reach the pa3ent’s bedside1
•  Publica3ons alone do not get providers to adopt evidence-based interven3ons
•  Guidelines alone do not get providers to adopt evidence-based interven3ons
•  Partnerships between scien3sts across clinical sciences, health services & implementa3on
research are needed to promote adop3on of new knowledge into prac3ce
1. Commihee on Quality of Health Care in America, InsPtute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: NaPonal Academies Press; 2001.

43
UNCLASSIFIED (U)
ImplementaPon Facilitators and Barriers
IdenPfied by Stakeholders
Including End-Users of the Science

•  Stakeholder engagement
–  Clinicians
•  Physiatrists, Sleep Medicine,
Neurology, Therapists,
Psychologists,
–  TBI PaPents and Caregivers
–  Research Personnel
–  Policymakers
 ImplementaPon Facilitators and •  Two-Day Guided Review of State of
Barriers Science and Discussion of Gaps
IdenPfied by Stakeholders
•  GraffiP Wall
Including End-Users of the Science
 Stakeholder IdenPfied
Barriers
Consumer Demand for Services Infrastructure to Support
Services
•  Pa3ent and family belief that
OSA is important as a health •  Provider belief that OSA is
comorbidity (health literacy) important and that treatment
•  PaPent’s belief that treatment may make a difference in
will make a difference in outcome
outcome •  Funding policies for
reimbursement
“Of the 12 appointments that I had •  Availability of staff on
after discharge, someone needed to inpaPent units to support
tell me why it was important to follow- services
up with sleep medicine for the test” •  Technology adaptaPon and
Caregiver of Person with Severe TBI
ease of use for TBI
 Barriers helped to prioriPze
secondary analyses
•  Cost and lack of reimbursement barrier:
–  Cost Benefit and Cost EffecPveness Analyses
•  Nakase-Richardson R, Hoffman JM, Magalang U, Almeida E, Drasher-Phillips L, Ketchum JM, Whyte J, Bogner522 J, Dismuke-Greer CE. Cost
benefit analysis from the payor’s perspecPve to screening and diagnosing OSA during inpaPent rehabilitaPon for moderate to severe TBI. Arch
Phys Med Rehabil, 2020; 101:1497-508. PMID: 32376325
•  Tsalatsanis A, Dismuke-Greer C, Kumar A, Hoffman J, Monden K, Magalang U, Schwartz D, Nakase-Richardson R. Cost effecPveness of sleep
apnea diagnosis and treatment in hospitalized persons with moderate to severe traumaPc brain injury. Under Review 09/2020

•  Consumer beliefs barrier

–  TBI Model System Factsheet on OSA and TBI

•  Provider beliefs barrier

–  Expand Outcome Studies
–  Develop RCT of PAP vs Usual Care during InpaPent RehabilitaPon

Sleep Deprived Staff
 Collaborators
Sleep Medicine- University of South Florida & Moss Rehabilita3on and Research Ins3tute,
Tampa VAMC Philadelphia, PA
Daniel J. Schwartz, M.D. John Whyte, M.D., Ph.D.
William M. Anderson, M.D. Thomas Watanable, M.D.
Karol Calero, M.D.
Carlos Diez-Sien, RSPGT University of Washington, Seaole, WA
Marc Silva, Ph.D. Jeanne Hoffman, Ph.D.
Leah Phillips, M.P.H.
Danielle O’Conner, MPH Craig Hospital, Denver, CO
Amanda Garcia, Ph.D. Cindy Harrison-Felix, Ph.D.
Deveney Ching, M.S. Kim Monden, Ph.D.
Jessica Ketcum, Ph.D.
Physical Medicine and Rehabilita3on, Tampa Emily Almeida, M.S.
VAMC
Steven Scoh, D.O. University of Texas Southwestern, Dallas, TX
Marissa McCarthy, M.D. Kathleen Bell, M.D.
Faiza Humayan, M.D.
Rafael Mascarinas, M.D. Baylor Scoo & White Rehabilita3on, Dallas, TX
Marie DahDah, Ph.D.
Sleep Physiology, Stanford University & Palo Alto
VAMC Ohio State University, Columbus, OH
Jamie Zeitzer, Ph.D. Jennifer Bogner, Ph.D.
Ulysses Magalang, M.D.