Results Summary

What was the research about?

People who have a traumatic brain injury, or TBI, often have sleep apnea. Sleep apnea causes the upper airway to become blocked during sleep. It can make TBI symptoms worse and make recovery difficult. Screening helps identify who is at risk for sleep apnea. Then, doctors use tests to diagnose sleep apnea.

In this study, the research team compared ways to screen for and diagnose sleep apnea in people receiving hospital rehabilitation for moderate or severe TBI. For screening, the team compared

  • The STOP-Bang survey
  • The MAPI survey
  • The Berlin survey
  • A wristband that tracked total sleep time

To diagnose sleep apnea, the research team compared

  • A standard sleep test with a trained technician monitoring the patient in a sleep lab, which doctors consider the gold standard, or most reliable, test
  • A sleep test using portable equipment, which is easier to do and costs less

The research team wanted to learn if using portable equipment wasn’t worse at diagnosing sleep apnea than the standard test.

What were the results?

Screening. To identify people with TBI who were at risk for moderate to severe sleep apnea, the STOP-Bang and MAPI surveys worked about the same. STOP-Bang and MAPI worked better than the Berlin survey or wristband. To identify people with TBI who were at risk for mild sleep apnea, all three surveys worked about the same and better than the wristband.

Diagnosis. Portable equipment wasn’t as good as the standard test to diagnose sleep apnea. It was less likely to detect mild sleep apnea, and it was less accurate in diagnosing sleep apnea severity for people with moderate or severe sleep apnea.

Who was in the study?

The comparison of diagnostic tests included 214 people receiving inpatient treatment for TBI at one of six rehabilitation centers across the country. The screening study included 248 people at these centers. Of these patients, 74 percent were White, 20 percent were Black, 13 percent were Hispanic, 3 percent were Asian, and 2 percent were another race or ethnicity. The average age was 44, and 82 percent were men; 61 percent had severe TBI.

What did the research team do?

The research team gave people both tests to diagnose sleep apnea on the same night. People also wore the screening wristband. Within three days, people with TBI, family members, and doctors filled out the STOP-Bang, MAPI, and Berlin surveys. Each survey asked about slightly different risk factors for sleep apnea.

The research team compared the diagnostic tests. They also looked at how well the surveys and wristband worked to screen for sleep apnea.

A person with TBI, a caregiver, nurses, doctors, and therapists helped to plan the study.

What were the limits of the study?

The study didn’t include people with very mild or very severe TBI who were unable to undergo testing. Results may differ for these people.

Future research could continue to explore ways to diagnose mild sleep apnea in people with TBI.

How can people use the results?

Hospitals can use the results when considering ways to screen for and diagnose sleep apnea in people with TBI.

Final Research Report

View this project's final research report.

Journal Citations

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • The reviewers noted that the researchers referred to their study as a clinical trial, but the study was actually a prospective observational cohort study. The reviewers acknowledged that the technical definition of clinical trial might include this study but that most researchers would not classify it as a clinical trial. The researchers therefore replaced instances of clinical trial in the report with cohort study.
  • Reviewers asked how the researchers accounted for missing Glasgow Coma Scale scores for participants who were “chemically paralyzed, sedated, or intubated.” The researchers stated that they imputed scores on the Glasgow Coma Scale by replacing the missing scale scores the same way that previous researchers had done. The researchers also stated that  when the Glasgow Coma Scale scores were missing for all other reasons, those participants’ data were excluded from sensitivity analyses.
  • Reviewers questioned why the researchers reported their results for cohorts with Apnea-Hypopnea Index scores greater than or equal to 5, as well as greater than or equal to 15, when the lower scores typically did not warrant treatment. The researchers explained that they were following common practices in the field by reporting on both cutoff scores. In addition, they added information in the discussion section referencing evidence that even mild obstructive sleep apnea had cardiovascular consequences for individuals receiving inpatient rehabilitation for a traumatic brain injury.

Conflict of Interest Disclosures

Project Information

Risa Nakase-Richardson, PhD, FACRM, FNAN
Tampa VA Research and Education Foundation
$2,606,321
10.25302/09.2021.CER.151133005
Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome

Key Dates

July 2016
July 2021
2016
2021

Study Registration Information

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Last updated: March 14, 2024