Non-pharmacologic therapies for sleep disturbances after traumatic brain injury: a systematic review and meta-analysis

Abstract

Background: Sleep disturbances are common after traumatic brain injury (TBI), yet there are no guidelines specific to non-pharmacologic management in this population.

Objective: To evaluate whether adults with post-TBI sleep disturbances benefit from commonly described non-pharmacologic therapies - cognitive behavioural therapy (CBT) (including for insomnia, CBT-I), hyperbaric oxygen (HBO2), blue-wavelength light therapy (BWLT) and repetitive transcranial magnetic stimulation (rTMS) - with attention to both statistical and minimally clinically important differences (MCIDs).

Methods: A systematic review (registered with the International Prospective Register of Systematic Reviews) and meta-analysis of randomised controlled trials (RCTs) were used. Databases (PubMed, APA PsycInfo and PsychArticles, Medline Complete, CINAHL Plus) were originally searched in October 2023 and updated in PubMed on 14 March 2026. The searches were conducted separately for each intervention. Outcomes included sleep quality and duration (Pittsburgh Sleep Quality Index, PSQI; Insomnia Severity Index, ISI; actigraphy), daytime sleepiness (Epworth Sleepiness Scale, ESS) and daytime dysfunction. The quality of evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

Results: Twelve RCTs met inclusion criteria. CBT significantly improved PSQI (MD: -3.44), ISI at 6-8 weeks (mean difference, MD: -2.23) and 12-16 weeks (MD: -0.91) and ESS (MD: -1.45) at 16 weeks. Only the change in PSQI reached the MCID. Evidence for HBO2, BWLT and rTMS remained very low, with small samples and heterogeneity precluding definitive conclusions regarding sleep outcomes; HBO2 showed a higher risk of mild ear barotrauma v. sham (relative risk: 2.66).

Conclusions: CBT/CBT-I appears to improve sleep quality and daytime sleepiness in adults with TBI; online CBT-I (eCBT-I) may expand access. The paucity and heterogeneity of trials for HBO2, BWLT and rTMS precludes definitive conclusions for proposed outcomes. Larger RCTs with standardised protocols are needed.

Keywords: Grading of Recommendations, Assessment, Development, and Evaluation approach; blue-wavelength light; cognitive behaviour therapy; hyperbaric oxygen; repetitive transcranial magnetic stimulation; sleep disturbance; systematic review; traumatic brain injury.