Sleep Participation After a Neurological Injury

After a neurological injury, such as a stroke or TBI, sleep changes are common. Approximately 40% of individuals with chronic stroke and 70% of individuals with acute stroke have sleep-wake disorders, including insomnia, excessive daytime sleepiness, hypersomnia, fatigue, and sleep-disordered breathing, such as obstructive sleep apnea (Frange et al., 2023). Sleep disturbances such as insomnia,  fatigue, and sleepiness affect approximately 30-70% of individuals after a traumatic brain injury (Viola-Saltzman & Musleh, 2016).  

Issues with sleep can affect your health, quality of life and rehabilitation outcomes and should be addressed as early as possible. Balancing activity and rest, and prioritizing sleep are crucial for neurological recovery. 

Sleep disturbances may be due to a variety of factors and it is important to collaborate with a variety of providers such as neurologists, sleep specialists, mental health therapists, and your therapy team. It is especially important to rule out underlying sleep disorders, such as sleep apnea or restless leg syndrome. Sleep changes may also be due to changes in your bladder and bowel function and may benefit from a referral to a urologist, gastroenterologist and/or pelvic-floor therapist. Pain, anxiety and depression may also factor into your sleep quality.

​

Importance of Sleep for Brain Recovery 

After a neurological injury, you may experience insomnia (difficulty falling or staying asleep), sleep apnea (interrupted breathing during sleep, often associated with snoring and gasping for breath), light sleep, frequent waking, and persistent daytime fatigue. As mentioned above, additional challenges that can impact sleep include pain, muscle tightness or spasms, stress or anxiety, nighttime bathroom trips, or medication side effects.

Sleep is crucial for rewiring the brain to support consolidation of new memories and skills, repair of damaged tissues, reducing inflammation, and emotional regulation and stress management (The Stroke Foundation, 2025)

Sleep Hygiene 

The first step in improving your sleep quality is creating a consistent routine that sets you up for a good night’s sleep. It is important to associate the bed with sleep and sex only, avoiding activities like reading, watching TV, or other wakeful activities in this same space. 

If you are experiencing pain at night, especially if this is the primary factor impacting your sleep quality, talk to your healthcare providers regarding pain management techniques. 

Below is a list of additional tips to improve your sleep hygiene. If all the below are new to you, consider incorporating one strategy at a time and monitor for success before trying additional strategies. 

• Create a Consistent Sleep Schedule
  
  • Go to bed and wake up at the same time every day, including the weekends. 
    
• Set Up a Comfortable Sleep Environment
  
  • Ensure your bedroom is dark, quiet, and cool (between 65-68 degrees Fahrenheit). You may also benefit from black out curtains and/or an eye mask to make it darker, as well as the use of white noise, such as a fan or a white noise machine or app. 
    
  • Ensure your pillows and bedding are comfortable, including those you may use to position your arm or leg if you are impacted by muscle tightness or pain. 
    
• Find Ways to Relax Before Bedtime 
  
  • When possible, avoid stimulating activities before bedtime such as watching TV or scrolling on your phone to allow your body to down regulate in preparation for sleep. Instead, try activities such as gentle stretching, listening to music, or aromatherapy to wind down. Gentle stretching with the use of a heating pad can be especially helpful if you have any tension or pain in your limbs. 
    
• Consider Foods and Drinks Consumed Before Bed 
  
  • Avoid caffeine, including coffee, tea, and chocolate, as well as nicotine in the hours leading up to bedtime.
    
  • Avoid food with high sugar content that can impact sleep onset.
    
  • Limit large meals within two hours of bedtime.
    
  • Stay hydrated, but avoid large amounts of liquid right before bed. When possible, cease liquids 2-3 hours before bed especially if you tend to wake up to use the bathroom in the middle of the night. 
    
• Manage Anxiety and Negative Thoughts 
  
  • If you tend to stress and overthink at night, try scheduling a time before bed to identify concerns, thoughts, or a to-do list to avoid getting into a cycle of doing this at bedtime. This can be completed internally or written down, depending on your preference. 
    
  • Reframe thoughts around sleep. For example, it is actually normal to wake up (briefly) a couple of times at night and your sleep quality can still be good even with these awakenings. Remember that there is a wide range of sleep needs, and quality is more important than quantity. 
    
  • If it is still hard to manage anxiety and negative thoughts, consider working with a mental health counselor or therapist to address further. 
    
• Incorporate Relaxation Techniques 
  
  • There are a variety of relaxation techniques such as visualization, progressive muscle relaxation, meditation, and deep breathing that can quiet your mind and prepare your body for sleep. Everyone has different preferences, so if one technique isn’t effective after consistent effort, try experimenting with another until one fits. 
    
• Limit Naps 
  
  • If you are going to nap during the day, aim for 20-30 minutes to help you feel refreshed instead of groggy. Anything more can negatively impact your ability to fall asleep at night.  
    
• Exercise During the Day 
  
  • Exercise regularly to promote better sleep. 
    
    • The exercise recommendations for healthy adults from The American College of Sports Medicine and CDC are 150 minutes of moderate-intensity aerobic activity every week (30 mins on 5 days of the week), as well as muscle strengthening activities at least 2 times per week (American College of Sports Medicine, 2025).
      
  • As a bonus, try to get outside in daylight. Natural light helps to regulate your internal clock which can help improve sleep. 
    

Additional Recommendations

If you have difficulty with falling asleep (taking more than 20 minutes), it is recommended to leave the sleep space to avoid a conditioned response that results in activities like tossing, turning, or stress. If it is not safe or feasible to get out of bed, you can also prop yourself up during periods of wakefulness to train your brain that wakefulness is associated with being upright, while laying down is associated with sleep. You can use this wakeful time to complete a pleasant and calming activity such as those mentioned above. 

You may also consider creating a sleep journal for a minimum of 1 week if you’re having consistent difficulties with sleep. Include information such as when you went to bed and when you woke up, how often you woke up (if applicable) and why (e.g., to use the toilet, noise, anxiety), sleep quality, and other relevant information to uncover potential patterns. 



Pharmacological interventions and Further Assessments 

Pharmacological interventions may be required if non-pharmacological strategies have not been effective. It is important to consider the potential side effects and interactions with other medications you are taking. Always talk to your doctor before making any adjustments to your medications. 

Additional assessments, such as a sleep study to rule out sleep disorders like sleep apnea, may also be required if the sleep hygiene strategies alone have not been successful. 

Remember that adequate sleep is key to your recovery and should be prioritized and addressed as early as possible to optimize your health, quality of life and rehabilitation. 




References 

American College of Sports Medicine (ACSM). 2025. Physical Activity Guidelines. American College of Sports Medicine(ACSM).https://acsm.org/education-resources/trending-topics-resources/physical-activity-guidelines/  

Flint Rehab. (December 2025). 9 Ways to Fall Asleep Faster and Improve Sleep Quality After Stroke. Flint Rehab. https://www.flintrehab.com/improve-sleep-after-stroke/ 

Frange, C., Brian James Murray, & Morgadinho, F. (2023). The Importance of Sleep for Successful Neurorehabilitation after Stroke. Sleep Science, 16(03), e335–e343. https://doi.org/10.1055/s-0043-1772805

Lee, Sarah. (May 2025). Rehabilitating Sleep in Neurological Disorders. Number Analytics. https://www.numberanalytics.com/blog/rehabilitating-sleep-neurological-disorders 

The Stroke Foundation. (January 2025). Rest Right, Recover Better: The Role of Sleep in Stroke Rehabilitation. The Stroke Foundation. https://www.thestrokefoundation.org/news/rest-right-recover-better-the-role-of-sleep-in-stroke-rehabilitation 

Viola-Saltzman, M., & Musleh, C. (2016). Traumatic brain injury-induced sleep disorders. Neuropsychiatric Disease and Treatment, 339. https://doi.org/10.2147/ndt.s69105