In 2021, David Howell, PhD, submitted a pilot grant proposal to the Colorado Clinical and Translational Sciences Institute (CCTSI) to study post-concussion sleep problems in adolescent athletes. When he found out that he was going to receive the CCTSI’S Child and Maternal Health Junior Faculty Pilot Award, he was ecstatic.
“This award represented the missing link of the existing science and clinical impact that we wanted to address,” said Howell, associate professor, Orthopedics, CU Anschutz School of Medicine. “The reason I was so excited is that the pilot project was going to set us up with a new line of both scientific and clinical discovery.”
Howell worked with Stacey Simon, PhD, co-medical director of sleep medicine at Children’s Hospital Colorado, and Julie Wilson, MD, medical director of concussion care at Children's Colorado to study post-concussion sleep problems in adolescents. “Through this grant, we were able to test out what we thought would be useful technology to measure in the real world what was happening to sleep after concussion.”
To study adolescents’ sleep habits and quality after a concussion, participants used one of the following methods: a headband that measures brain waves during sleep, two different wrist-worn products that measure activity during sleep, and an online sleep diary. The researchers used trial and error to see what worked and what did not, and how to scale into the next study.
The data from this pilot project allowed Howell and his team to challenge existing clinical knowledge regarding how to classify sleep quality disruptions among adolescents with concussion. They used this data in their submission for a larger R21 clinical trial grant from the National Institutes of Health (NIH) in 2023. They were successful. And to date, Howell has received three NIH grants worth $4 million.
First of its kind behavioral sleep intervention
Once Howell and his team completed the feasibility study, they published three papers from the CCTSI pilot study. Using the data from adolescents with and without concussion, Howell and team developed an intervention for adolescent athletes that targets five key areas 1) reduced time asleep, 2) inconsistent sleep/wake time, 3) more bed use for non-night-sleep purposes (e.g., napping), 4) excessive screen time before bed, and 5) night-time anxiety. With this intervention, Howell and his collaborators applied to NIH and were awarded a two-year R21 grant.
“It is first-of-its-kind behavioral sleep intervention for adolescents with concussion,” Howell said. The study compares what is currently standard-of-care for post-concussion treatment for sleep issues, which is fairly generic, to the individualized sleep intervention Howell and team developed.
If a participant is placed in the intervention, they receive a 45-minute session with a sleep expert. They discuss their particular habits, preferences, and their schedule, then the sleep psychologist develops an individualized sleep plan for them. This strategy is a move away from blanket recommendations toward guidance that takes patient habits and preferences into account.
Tools for clinicians and patients alike
Howell also received an R01 grant from the NIH, which is the gold standard for independent investigators. The study, Modulating Exercise Dosage to Improve Concussion Rehabilitation: A Randomized Clinical Trial is testing the use of aerobic exercise as an effective treatment to reduce symptom severity in sports-related concussion. He and his team are examining if a high dose exercise program (higher volume than currently prescribed at an individualized, safe intensity level) initiated within the first several weeks of concussion will result in faster symptom resolution.
The study is ongoing and will wrap up in 2027. Findings from the research should lead to more rigorous and precise rehabilitation guidelines and improved understanding about how exercise affects neurophysiological function among adolescents with concussion.
Howell says the goal is to develop a standard of care, the practical guidance you can give to clinicians who have a patient with concussion.
“Dr. Howell’s research study has the potential to completely change the paradigm for post-concussion treatment of children,” said Ron Sokol, MD, director of the CCTSI and Chief Scientific Officer, Child Health, Children’s Colorado and CU Anschutz.
Neuromuscular training smartphone app
Another outgrowth of the CCTSI pilot grant was Howell’s development of an eight-week virtual neuromuscular training (NMT) program that individuals may access through a smartphone application.
“We thought, if somebody sustained a concussion, how could they download an app and have rehabilitation information at their fingertips? We worked with a collaborator, Vipul Lugade, PhD, who helped us develop each step of this novel smartphone app,” said Howell.
Not only did Howell and Lugade develop the app, they studied the initial feasibility aspects for participants who used it and published the results in 2024, finding that the program was easy to navigate and use. From here, they are working to finalize findings with this approach now tested among patients with a concussion.
Impact on the research enterprise
When Howell applied for the CCTSI pilot grant, he was an assistant professor. Today he is an associate professor of Orthopedics, Director of Clinical Research for the CU Department of Orthopedics, and Director of Research, Sports Medicine Center at the Children’s Colorado. He also leads the Colorado Concussion Research Laboratory with Julie Wilson, MD. Together they mentor a team of eight: post-doctoral researchers, doctoral students, research professionals along with medical and physical therapy students.
“Dr. Howell is the example of the early-stage investigator who needs early career support to blossom into a successful researcher who will eventually lead a larger research team, as Dr. Howell does now, and make important impacts on the health of children and adults,” said Sokol. “This is a win-win for Dr. Howell and his research team as well as the children and families for whom his research is going make an important difference in their lives.”
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