Brain Injury, May 2010; 24(5): 748754

Actigraphy for assessment of sleep in traumatic brain injury:

Case series, review of the literature and proposed criteria for use

FELISE S. ZOLLMAN, CHERINA CYBORSKI, & SYLVIA A. DURASKI

Rehabilitation Institute of Chicago, Chicago, IL, USA

(Received 18 October 2009; revised 26 January 2010; accepted 4 February 2010)

Abstract
Primary objective: To demonstrate that actigraphy is an appropriate means of measuring sleep in patients with TBI and to
define parameters for its use in this population.
Research design: Case series and review of the literature.
Methods and procedures: Subjects participating in one of two externally funded studies addressing the role of acupuncture in
treating insomnia in TBI underwent actigraphy for the purpose of quantifying sleep time. Cases selected for presentation
illustrate challenges in use of this modality in this population.
Main outcomes and results: Caution should be exercised in interpreting actigraphy data in patients with TBI and (1) motor
impairment or (2) cognitive and behavioural impairments which include agitation and impulsivity.
Conclusions: Guidelines for use of actigraphy in patients with TBI are proposed: (1) Patients should be at Rancho Los
Amigos cognitive level of III or above; (2) Patients with paresis, significant spasticity or contractures of one or more limbs
should have the device placed on the least affected limb; and (3) For patients with tetraparesis, the device may not be an
appropriate instrument for measurement of sleep; if it is to be used, consideration should be given to placing it on the head,
rather than limbs or torso.

Keywords: Actigraphy, insomnia, sleep, traumatic brain injury, TBI

Introduction maintaining sleep (i.e. more than 30 minutes of

In the US, an estimated 1.4 million people sustain a
traumatic brain injury (TBI) each year [1]. Survivors
of these injuries typically exhibit a number of cogni-
tive, physical and behavioural impairments, including
the disturbance of sleep. Sleep disturbances can
appear as soon as 24 hours following injury and
may continue for several years after TBI [2]. Several
studies conducted among different samples of indi-
viduals with TBI, in both inpatient and outpatient
settings, suggest that between 3081% of survivors
experience sleep difficulties [28].
Insomnia can be clinically defined as the occur-
rence of trouble sleeping characterized by (1) diffi-
culty falling asleep (i.e. requiring more than
30 minutes to get to sleep) and/or difficulty
nocturnal awakening) which (2) occurs at least
3 nights per week and (3) results in impairment in
daytime functioning [9, 10]. Defining insomnia in an
inpatient setting is a less precise process; no univer-
sally accepted criteria for the diagnosis of insomnia in
the early post-acute (i.e. first 3 months post-injury
onset) inpatient TBI population has been estab-
lished. This is particularly important because it is
likely that the mechanisms and/or factors involved in
the development of insomnia are different in the early
post-acute TBI setting than in outpatient popula-
tions. According to Thaxton and Patel [7], During
the acute stage, dysregulation of sleep seems to be a
function of the diffuse disruption of cerebral func-
tioning in the wake of both direct physical damage to

Correspondence: Felise S. Zollman, MD, Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine,
Rehabilitation Institute of Chicago, 345 East Superior St., Chicago, IL 60611, USA. Tel: 312-238-4087. Fax: 312-238-8405. E-mail: fzollman@ric.org
ISSN 02699052 print/ISSN 1362301X online 2010 Informa Healthcare Ltd.
DOI: 10.3109/02699051003692167

the brain and secondary neuropathological events
(p. 566). As the brain undergoes repair and recovery,
the neuroanatomical mechanisms underlying insom-
nia in the early post-acute stage probably become less
significant; however behavioural and affective factors
are likely to become more prominent.
The presence of sleep disturbance in TBI patients
is under-reported. This phenomenon is believed to
be due to the fact that the problem is likely
minimized by patients and rehabilitation profes-
sionals, given the presence of other cognitive and
behavioural problems brought about by TBI [2]. At
the same time, there is clearly a need to address sleep
disturbance, given its potential to have a significant
impact on the course of recovery from TBI. In
particular, fatigue, mood disturbance and cognitive
deficits (speed of processing, attention, concentra-
tion, learning, memory and executive functions), all
impairments typically seen in patients with TBI, are
also recognized consequences of insomnia [2, 3, 11].
One can readily appreciate the need to effectively
identify those with a sleep disturbance so that
appropriate treatment can be instituted.
Mechanisms for assessing sleep vary from subjec-
tive tools (i.e. self-assessment) to the use of sophis-
ticated equipment which records physical changes
during sleep (e.g. polysomnography). Subjective
sleep assessments consist of sleep logs/diaries and
questionnaires such as the Insomnia Severity Index,
Epworth Sleepiness Scale or the Pittsburgh Sleep
Quality Index. This method of sleep assessment is
simple, inexpensive and can be done by the patient
or caregiver; however, several concerns about accu-
racy exist. Numerous studies have shown that
individuals have difficulties assessing their own
sleep [12]. Additionally, studies performed in a
hospital setting where specially trained staff observe
sleeping patients and document the quantity of
sleep (e.g. via Sleep Logs) have shown that
over-estimation of sleep duration is common [13].
With respect to measurement via instrumentation,
polysomnography (PSG) continues to be the gold
standard method to assess sleep. PSG provides a
comprehensive recording of the physiological
changes that occur during sleep. The PSG monitors
many body functions through electroencephalogram
(EEG), electrooculogram (EOG), electromyogram
(EMG) and electrocardiogram (ECG) during sleep.
However, due to the complexity of the equipment
required, PSG is costly, labour intensive and not
convenient for routine use.
Recently, use of actigraphy has become an
accepted means of measuring sleep because of its
convenience, relatively low cost and ease of use. An
actigraph is a small portable device that can be
attached to the wearers arm, leg or waist to monitor
activity or movement by miniaturized acceleration
Actigraphy for assessment of sleep in TBI 749
sensors which translate physical motion into a
numeric representation (Figure 1).
This representation is sampled every tenth of a
second and aggregated at a constant interval referred
to as an epoch. These epoch-by-epoch samples are
stored in the internal memory of the device until the
information is downloaded to a computer [14]. The
raw data can then be analysed to determine sleep
latency, quantity of sleep, number and duration of
awakenings and overall sleep efficiency.
Actigraphy has been shown to be significantly
correlated to the total sleep time as measured by
PSG in normal subjects [15]. In subjects with
rudimentary motor abilities, however, this is not
necessarily the case: actigraphy tends to over-
estimate total sleep time [16]. In guidelines on the
clinical use of actigraphy, the American Academy of
Sleep Medicine Standard of Practice Committee
concluded that actigraphy is a valid way to assist in
determining sleep patterns in normal, healthy adult
populations and in patients suspected of certain
sleep disorders, i.e. insomnia, sleep schedule
disorders and breathing related disorders.
Little has been written about the use of the
actigraph in assessing the sleep of individuals with
TBI. Ayalon et al. [17] used the actigraph to study
circadian rhythm sleep disorders following mild TBI
in a sample of 42 patients. In this study, the
researchers were able to distinguish delayed sleep
phase syndrome from irregular sleepwake pattern
with the use of the actigraph and other measures
including the PSG, melatonin levels, oral tempera-
ture and Morningness-Eveningness Questionnaire.
In another study, the actigraph was used to assess
reduced daytime activity in a group of ambulatory
acquired brain injury survivors, to test the hypothesis
Figure 1. Actigraph unit.
750 F. S. Zollman et al.
that those with apathy had reduced activity when
compared to healthy controls without apathy [18].
In this study, the actigraph was used to measure
movement during daytime hours. MAkley et al. [19]
used the actigraph to measure sleep disturbances in
survivors of moderate-to-severe closed head injury.
They followed 27 brain injury survivors admitted to
a rehabilitation unit, but they excluded those with
significant tetraparesis or immobility because of the
effect on actigraph placement. No researcher has
documented parameters for actigraph use with
moderate-to-severe TBI survivors manifesting
cognitive and physical impairments.
Methods
Subjects participating in one of two externally
funded and IRB-approved studies addressing the
role of acupuncture in treating insomnia in TBI
underwent actigraphy for the purpose of quantifying
sleep time. One of these studies (funding source:
NIDRR) addresses this matter in inpatients with
moderate-to-severe TBI, the other (funded by
CDMRP) in outpatients with chronic TBI. The
authors selected cases for presentation in this pub-
lication because the recordings obtained illustrated
challenges in use of this modality in this population.
For the purpose of each study, insomnia was
defined based on the following criteria: (1) Insomnia
Severity Index score of 15 or greater [20]; and
(2) sleeping for an average of 6.5 hours per night for
3 consecutive nights as documented in nursing Sleep
Logs (for inpatients) or self-report of perceived
insufficient sleep (for outpatients). Eligible patients
who consented to participate in either of these two
studies underwent further assessment, including
baseline and post-intervention period actigraphy.
The actigraph devices used at the institution are
manufactured by ActiGraph (Pensacola, FL). The
cost of an individual actigraph unit ranges from
$300500, depending on the specific model,
functions desired and memory capacity. The soft-
ware program used to analyse the raw data and
provide graphs and tables quantifying sleep can also
be purchased directly from the company, at a cost of
$500. One desktop application can be used to
collect and analyse data from multiple units. The
actigraphy tracings generated by the computer
analysis are the basis for the data presented herein.
Case studies
The following are six cases of individuals with TBI.
Five were inpatients and one was an outpatient in a
free-standing brain injury rehabilitation programme.
Actigraphy was utilized to assess sleep disturbances.
For inpatients, a sleep log was also recorded by
the healthcare team. The actigraph was used not
only in those with cognitive deficits but also in
those with physical impairments. In all cases,
actigraphs were programmed for sleep between
8 pm and 8 am.
Case 1
MD was a 40-year-old man who suffered an assault.
His initial Glasgow Coma Scale (GCS) was 5 and he
required an emergent right frontotemporoparietal
craniotomy for evacuation of a subdural haematoma.
Imaging also showed a right-to-left midline shift,
right occipital epidural haematoma, left tempo-
ral and frontal punctuate haemorrhages and
subarachnoid haemorrhage. The patient had an
actigraph sensor placed during his inpatient rehabil-
itation stay, 4 weeks after his injury, at which time he
was in post-traumatic amnesia and was assessed at a
Rancho Los Amigos (RLA) Cognitive Functioning
level IV. On the day of actigraphy use, MD was
walking 400 feet, ascending and descending four
stairs and tossing a ball with minimum assistance,
while needing maximum verbal cues for attention.
The Sleep Log recorded 7 hours of sleep, while the
actigraph showed a sleep time of 5 hours and
51 minutes with 23 awakenings averaging 16 minutes
(Figure 2).
Case 2
MZ was a 63-year-old male who was an unhelmeted
operator of a motorcycle involved in a motor vehicle
accident. GCS at the emergency department (ED)
was 8; he was airlifted to a second ED where his
GCS was 3. Imaging revealed a left occipital
fracture, pneumocephalus, effacement of the fourth
ventricle, right intracerebral haemorrhage and a
subarachnoid haemorrhage. Neurosurgical interven-
tion consisted of placement of an external ventricular
drain (EVD). On admission to acute inpatient
rehabilitation, he was tetraparetic with the left side
more involved. An actigraph was placed on his right
leg 1 month after his injury at which time he needed
Figure 2. Case 1.

Figure 3. Case 2.
maximum assistance with transfers, was limited by
restlessness and needed maximum assistance to
stand for 45 seconds. He was deemed to be a RLA
level IV. The Sleep Log reported 2 hours of sleep,
while the actigraph showed a sleep time of 3 hours
and 21 minutes with 37 awakenings averaging
14 minutes (Figure 3).
Case 3
IG was a 43-year-old man who was involved in a
motorcycle vs. semi-truck motor vehicle crash. He
sustained a TBI with unknown GCS and initial
imaging and C3 American Spinal Injury Association
(ASIA) A spinal cord injury. His injury was 2.5 years
prior to outpatient actigraph placement for evalua-
tion of persistent insomnia. At the time of actigraph
placement, he was independent with a power
wheelchair and communication and otherwise
dependent for all other activities of daily living
(ADLs) and was a RLA level VII. On the day of
actigraph use, he was able to maintain sitting balance
with bilateral upper extremities support in his lap for
9 minutes, maximum assistance to recover loss of
balance. The actigraph was placed on his left arm,
which he uses to control his power wheelchair. It
showed sleep time of 11 hours and 12 minutes with
seven awakenings averaging 7 minutes each
(Figure 4).
Case 4
RS was a 21-year-old male who was the helmeted
driver of a snow-mobile that collided with a tree; he
was down for an unknown period of time. Brain
imaging showed subarachnoid haemorrhage, diffuse
axonal injury and subdural haemorrhage; all of
which were managed conservatively. He developed
myositis ossificans in his bilateral quadriceps and
spasticity with contractures in all four limbs. He had
an actigraph sensor placed on his left lower extremity
as an inpatient, 3.5 months after injury, at which
time he was assessed as a RLA level V. At the time
of actigraphy, he had unsupported short sit for
35 minutes with contact guard assistance after set-up
Actigraphy for assessment of sleep in TBI 751
Figure 4. Case 3.
Figure 5. Case 4.
and maximum assistance for drinking from cup.
Actigraphy showed a sleep time of 11 hours and
9 minutes with nine awakenings averaging
6 minutes while the Sleep Log documented
5 hours of sleep over the same period (Figure 5).
Case 5
EC was a 41-year-old man who suffered a TBI
secondary to a fall while carrying furniture upstairs.
He had an 8 minute loss of consciousness and when
he awoke was confused and agitated. In the emer-
gency room he had a GCS of 13 and was moving all
four extremities. He was found to have a left
frontotemporal intracranial haemorrhage and bilat-
eral subdual haemorrhages necessitating an emer-
gent left craniectomy. The following day he was
found to have a right cerebellar haemorrhage
needing an evacuation. A ventriculo-peritoneal
shunt was placed 1 month post-injury. He under-
went a cranioplasty 4 months after his injury.
Actigraph sensors were placed 5.5 months after
initial injury during an inpatient rehabilitation stay,
at which time he had little spontaneous movement of
all four extremities and was not following com-
mands. He was assessed as a RLA level III. During
his therapies, EC grasped grooming items with his
right hand with maximum assistance and maximum
verbal cues and showed improved head control in a
neutral position; otherwise, he was dependent in all
functional areas. On observation, he spontaneously
752 F. S. Zollman et al.
Figure 6. Case 5.
moved his right side more than the left. Actigraph
sensors were placed on both his right leg and arm
(below) because it was unclear which limb was more
active. Review of these tracings shows that all of the
movements detected on the leg actigraph sensor
correlated with movements on the arm actigraph
sensor. More movement was noted, however, by the
actigraph on his arm, which translated to identifying
40 minutes less sleep time than his leg (11 hours
23 minutes vs. 10 hours 47 minutes) and three more
awakenings seen (10 vs. 7). Note that, during this
same period, the Sleep Log recorded only 5 hours of
sleep (Figures 6(a) and (b)).
Case 6
JT was a 48-year-old female who fell off of a ladder
and hit her head on a granite countertop. She was
down for 3 days prior to being found. Imaging
showed a non-displaced right occipital bone fracture
and left subdural haematoma with mid-line shift
necessitating evacuation. An actigraph was placed in
the inpatient rehabilitation setting, 18 days after
injury. In therapy, she was walking 200 feet with a
walker and performed lower extremity dressing with
minimal assistance. She was a RLA IV and, because
of her impulsivity, it was difficult to keep the
actigraph sensor in place. In this instance, the
Sleep Log documentation reflected no sleep all
night, while the actigraph recorded a sleep time of
7 hours and 58 minutes and 21 awakenings with an
average of 11.5 minutes each: per nursing staff verbal
communication, the actigraph sensor was found in
bed off the patients body during this recording
period (Figure 7).
Discussion
In patients with moderate-to-severe TBI who have
physical impairments (including spasticity, contrac-
tures and paresis) and who exhibit cognitive and
behavioural impairments, the appropriateness of
Figure 7. Case 6.
actigraph use has not been established.
Determination of the threshold for its use and
appropriate placement of the device is all the more
uncertain. In fact, with respect to the latter issue, the
American Sleep Disorder Association, in reviewing
the role of actigraphy in the evaluation of sleep
disorders, has asserted that the issue of standard
placement of the actigraph device, even in normal
subjects, has not been addressed [14]. The cases
presented in this paper highlight some of the
potential challenges in using actigraphy in patients
with TBI, leading to a rationale for setting para-
meters for its use, and suggested further areas of
research in the assessment of sleep in TBI patients.
More specifically, two clinical circumstances are
discussed further: (1) those patients with TBI and
motor impairment and (2) those patients with TBI
whose cognitive and behavioural impairments
include agitation and impulsivity. The discussion
which follows illuminates some of these issues in the
context of the cases presented above.
The patient in Case 2 demonstrated an accurate
sleep recording, as compared to direct observation,
despite the patients hemiparesis. It is likely that this
is because the actigraph was placed on the most
active limb, on the non-hemiparetic side. However,
for the patient in Case 3, who has tetraparesis, the
actigraph was also placed on his most active limb,

i.e. the one in which he controls his motorized
wheelchair, but even the active limb had limited
motion. In this instance, the actigraph recording was
significantly disparate from the patients self-report
(which was deemed to be reasonably accurate, given
his relatively high cognitive functional level). In
Case 4 the actigraph was once again placed on the
patients most active limb; however, the recording
showed 11 hours of sleepmuch more than was
recorded on the Sleep Log by nursing staff. This can
be explained by the patients severely limited range
of motion from his spasticity and contractures. The
patient in Case 5 had such severe motor involvement
that no more active limb was distinguishable, so
actigraph sensors were placed on both the right
upper and lower limbs. The recording demonstrated
that the upper extremity identified 40 minutes
more awake/active time than the lower extremity.
At the time of actigraph use, family stayed with the
patient in his hospital room and reported far less
than the 1011 hour sleep time recorded; the Sleep
Log concurred with family observation, showing
only 5 hours of sleep.
With respect to cognitive and behavioural impair-
ment and the use of actigraphy, Cases 1 and 6 offer a
meaningful comparison: both patients were RLA
level IV. The patient in Case 1 was not particularly
impulsive or agitated and tolerated wearing the
actigraph throughout the assessment period. This
patient demonstrated a sleep time via actigraphy
which was consistent with all other reports (self and
staff/Sleep Log). In contrast, the patient in Case 6
had no motoric limitations and was quite impulsive,
thus was readily able to remove the actigraph sensor.
While the sensor recorded 7 hours of sleep, this is
clearly an inaccurate over-estimate, given that the
staff found the actigraph sensor off the patient
during the presumed recording period.
Very little has been written about the use of
actigraphy in physically and/or cognitively impaired
patients. Most studies utilizing actigraphy to docu-
ment quantity of sleep have excluded patients with
physical and cognitive impairments, such as those
described above, because proper placement of the
actigraph sensor to optimize accurate recording can
be challenging. Further, inherent limitations of the
computer paradigm used for interpretation of raw
data limit use in a cognitively or physically impaired
population: periods of rest during the day do not
register as sleep on the actigraph, though the patient
may be sleeping; conversely inactivity during the
defined sleep period (8 pm to 8 am in this study)
is identified as sleep because no movement is
taking place.
In one study which did examine the issue of
actigraph placement in a population with motor (but
not cognitive) impairment, Spivak et al. [21]
Actigraphy for assessment of sleep in TBI 753
evaluated the use of actigraphy in spinal cord
injury patients with tetraplegia. In this study, the
actigraph sensor was placed on a head mount as an
alternative. The authors concluded that wrist place-
ment of the actigraph should occur in patients with
C57 tetraplegia and head mounted actigraphy
should be an alternative for patients with higher
level cervical spine injuries. This option could have
been considered for the patients in Cases 3, 4 and 5,
i.e. for those TBI patients with significant tetrapar-
esis, spasticity and/or contractures.
Conclusions
As outlined in the introduction, assessing sleep in
those with a TBI is a significant clinical issue. In the
inpatient rehabilitation setting, there is no gold
standard of sleep measurement that is convenient
and readily accessible. For outpatients and inpati-
ents alike, subjective reporting of sleep disturbances
in a population with cognitive deficits secondary to a
TBI results in unreliable information: patients often
times do not remember the quantity or quality of
sleep. Family members or friends who stay with
these patients are typically not awake the entire night
monitoring the patient and, therefore, cannot pro-
vide a fully accurate picture of quantity or quality of
sleep. For hospitalized patients, staff typically only
report sleep during a brief period of assessment each
hour. This can lead to gross inaccuracies: e.g. a
patient may be sleeping at the time of assessment but
then wake up a short period later and may not return
to sleep for some time. Alternatively, the assessor
may unintentionally awaken the patient, causing the
documentation to incorrectly reflect that the patient
was awake.
The use of the actigraph is a convenient and, when
used in the appropriate population, potentially
accurate tool in sleep evaluation for those who
have suffered TBIs. Appropriate parameters for use
have yet to be established, however. Based upon this
case series study, a few guidelines may be offered.
First, the RLA cognitive scale may be considered:
those individuals with a RLA level of III have little
purposeful movement which would likely not be
sufficient to register on the actigraph sensor. RLA
levels of III and above begin to demonstrate more
apparent physical reactions to external and internal
stimuli which would be more likely to register on the
actigraph. Secondly, patients with paresis of one or
more limbs or significant spasticity or contractures
should have the device placed on the least affected
limb to ensure that all wakeful movement is being
captured. Finally, for patients with tetraparesis, the
device may not be an appropriate instrument for
measurement of sleep; if it is to be used,
754 F. S. Zollman et al.
consideration may be given to placing it on the head,
rather than limbs or torso.
Further research should be undertaken to hone
these guidelines. For example, for those patients
with quadriparesis, hemiparesis and spasticity, direct
comparison of placement of the actigraph sensor on
the head, torso and limbs and comparing this data
with Sleep Logs or similar direct observational
findings, as well as with PSG, may aid in identifying
the most accurate site for recording of sleep data in
this population. In those individuals with cognitive
deficits or agitation, placement of the actigraph
sensor on a site on the body not readily accessible/
noticeable to the patient may reduce the likelihood
of removal. Further research should also be under-
taken to determine whether the paradigm used by
the actigraph software to identify sleep could be
modified to aid in more accurately distinguishing the
diminished motor activity which characterizes sleep
from complete lack of activity due to removal if the
device. Finally, head-to-head comparison of patient/
caregiver report vs. Sleep Log vs. actigraphy may aid
in identifying the circumstances in which each might
most appropriately be employed in this population.
Addressing these questions will help guide the
accurate assessment of sleep in TBI survivors,
ultimately improving clinical care and ideally leading
to improved outcomes.
Acknowledgements
The authors wish to thank Laura Wasek, MPH for
her assistance in preparation of this manuscript.
Supported by grants from NIDRR
(#H133A080045) and CDMRP (US Army
Medical Research and Material Command
#W81XWH-08-1-0752).
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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