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Fatigue and traumatic brain injury

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8th September 2018
Dr. Elvina Tay (Senior Resident, Department of Rehabilitation Medicine, Tan Tock Seng Hospital)

Published in: Healthcare
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Fatigue and traumatic brain injury

  1. 1. Fatigue and Traumatic Brain Injury 8th September 2018
  2. 2. Overview • What is Fatigue? ▫ Definition • How common is fatigue post traumatic brain injury (TBI)? ▫ Background, epidemiology, impact of fatigue • What are the potential causes and associations with fatigue? ▫ Sleep and traumatic brain injury (TBI) • What can I do? ▫ Management of fatigue • Take home message
  3. 3. What is fatigue in TBI?
  4. 4. Definition (1) • The awareness of a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization and/or restoration of resources needed to perform activity1 • Feeling of exhaustion, tiredness, weariness or lack of energy2 1. Aaronson LS, Teel CS,Cassmeyer V, et al. Defining and measuring fatigue. Image J Nurs Sch. 1999;31:45–50. 2. Kathleen R. Bell. Fatigue and Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 2015;96:567-8
  5. 5. Definition (2) • Conceptualized more broadly as multidimensional, including psychological, motivational, situational, physical and activity related components.1 1. Joshua B. Cantor; Teresa Ashman; Tamara Bushnik Xinsheng Cai; Leah Farrell-Carnahan; Shinakee Gumber; Tessa Hart; Joseph Rosenthal; Marcel P. Dijkers. Systematic Review of Interventions for Fatigue After Traumatic Brain Injury: A NIDRR Traumatic Brain Injury Model Systems Study. J Head Trauma Rehabil 2014 Vol. 29, No. 6, pp. 490–497
  6. 6. Definition (3) • Physiological fatigue: state of general tiredness due to physical or mental exertion, which can be ameliorated by rest.1 ▫ Usually time limited • Pathological fatigue: weariness unrelated previous exertion level, and not ameliorated by rest.1 1. Tatyana Mollayevaa, Tetyana Kendzerskad, Shirin Mollayevae, Colin M. Shapirog, Angela Colantonioc, J David Cassidy j. A systematic review of fatigue in patients with traumatic brain injury: The course, predictors and consequences. Neuroscience and Biobehavioral Reviews 47 (2014) 684–716
  7. 7. Definition (4) • Physical fatigue: “I’m tired and I need to rest. I’m dragging today.” • Psychological fatigue: “I just can’t get motivated to do anything. Being depressed wears me out; I just don’t feel like doing anything.” • Mental fatigue: “After a while, I just can’t concentrate anymore. It’s hard to stay focused. My mind goes blank” 1. Kathleen R. Bell. Fatigue and Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 2015;96:567-8
  8. 8. Definition (5) • Primary fatigue caused by diseases or disorders.1 • Secondary fatigue result from exacerbation of primary fatigue in circumstances such as physiological distress, sleep disturbance and pain.1 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  9. 9. How common is fatigue and sleep problems post TBI?
  10. 10. Epidemiology (1) • More than 60% of patients with TBI report experiencing fatigue1 • Estimates of incidence of fatigue after TBI vary from 21% to 73%2 • Can occur during acute and chronic phases of recovery3 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233 2. Tatyana Mollayevaa, Tetyana Kendzerskad, Shirin Mollayevae, Colin M. Shapirog, Angela Colantonioc, J David Cassidy j. A systematic review of fatigue in patients with traumatic brain injury: The course, predictors and consequences. Neuroscience and Biobehavioral Reviews 47 (2014) 684–716 3. Joshua B. Cantor; Teresa Ashman; Tamara Bushnik Xinsheng Cai; Leah Farrell-Carnahan; Shinakee Gumber; Tessa Hart; Joseph Rosenthal; Marcel P. Dijkers. Systematic Review of Interventions for Fatigue After Traumatic Brain Injury: A NIDRR Traumatic Brain Injury Model Systems Study. J Head Trauma Rehabil 2014 Vol. 29, No. 6, pp. 490– 497
  11. 11. Epidemiology (2) • 64% of TBI patients showed clinically significant fatigue as compared with 35.1% of healthy controls. • Patients with TBI showed higher levels of anxiety and depression symptoms • Those with anxiety and depressive symptoms more likely to show clinically significant fatigue. 1.Zinno C, Ponsford J. Measurement and prediction of subjective fatigue following traumatic brain injury. J Int Neuropsychol Soc. 2005;11:416–425.
  12. 12. Epidemiology (3) • Sleep disturbance may occur in 30-70% of TBI patients1  Sleep initiation (trouble falling sleep) and sleep maintenance (staying asleep) most common features of TBI related insomnia.  Approximately 3 times prevalence of insomnia in TBI patients compared to general population 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  13. 13. How does fatigue affect individuals?
  14. 14. Impact of Fatigue in TBI (1) • Self-reports reported fatigue as the worst or one of the worst symptoms by 50% of TBI patients.1 • Fatigue can have negative effects on social, physical and cognitive function and participation in everyday activities, and role in increased work-related and other disabilities2 1.Ulrichsen KM, Kaufmann T, Dørum ES, Kolskår KK, Richard G, Alnæs D, Arneberg TJ, Westlye LT and Nordvik JE , Clinical Utility of Mindfulness Training in the Treatment of Fatigue After Stroke, Traumatic Brain Injury and Multiple Sclerosis: A Systematic Literature Review and Meta-analysis. Front. Psychol. 2016, 7:912. 2.Tatyana Mollayevaa, Tetyana Kendzerskad, Shirin Mollayevae, Colin M. Shapirog, Angela Colantonioc, J David Cassidy j. A systematic review of fatigue in patients with traumatic brain injury: The course, predictors and consequences. Neuroscience and Biobehavioral Reviews 47 (2014) 684–716
  15. 15. Impact of Fatigue in TBI (2) •Associated with lower levels of functioning, reduced quality of life and increased institutionalization and mortality1 •Can make resuming work and daily roles difficult. Can potentially lead to social isolation 1. Ulrichsen KM, Kaufmann T, Dørum ES, Kolskår KK, Richard G, Alnæs D, Arneberg TJ, Westlye LT and Nordvik JE (2016) Clinical Utility of Mindfulness Training in the Treatment of Fatigue After Stroke, Traumatic Brain Injury and Multiple Sclerosis: A Systematic Literature Review and Meta-analysis. Front. Psychol. 7:912.
  16. 16. Impact of Fatigue in TBI (3) •Insomnia and fatigue may exacerbate existing cognitive difficulties such as poor concentration, memory and difficulties accomplishing tasks1 •Can worsen memory and attention deficits, cause irritability 1.Marie-Christine Ouellet, Josée Savard, and Charles M. Morin. Insomnia following Traumatic Brain Injury: A Review Neurorehabilitation and Neural Repair 18(4); 2004
  17. 17. What are the associations and potential causes of TBI?
  18. 18. Etiology/Associations- Fatigue (1) • Physical fatigue: muscle weakness/deconditioning.  Usually worse in the evening and will improve after a good night’s sleep.  Often will improve with improvement of physical function. • Psychological fatigue: depression, anxiety and other psychological conditions.  Can worsen with stress.  Sleep may not help and fatigue often worse when waking up in the morning. 1. Kathleen R. Bell. Fatigue and Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 2015;96:567-8
  19. 19. Etiology/Associations- Fatigue (2) • Mental fatigue: extra effort needed for cognition/thinking.  Many common tasks take more concentration than previously.  Working hard to think and stay focused worsen fatigue. 1. Kathleen R. Bell. Fatigue and Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 2015;96:567-8
  20. 20. Etiology/Associations- Fatigue (3) • Primary fatigue post TBI could be related to mechanical brain changes after TBI1 • Secondary fatigue post TBI could be related sleep disorders, pain and depression.1 • Result from additional compensatory effort expended in meeting the demands of everyday life in presence of cognitive deficits.1 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  21. 21. Etiology/Associations- Fatigue (4) • Conditions known to increase fatigue  Depression  Sleep problems such as sleep apnea  Hypothyroidism or other endocrine gland disorders  Respiratory or cardiac problems  Lack of physical exercise  Vitamin deficiency or poor nutrition  Stress  Anemia  Medications 1. Kathleen R. Bell. Fatigue and Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 2015;96:567-8
  22. 22. Etiology/Associations- Fatigue (5) • Sleep disturbance ▫ Insomnia, hypersomnia, excessive daytime sleepiness and altered sleep-wake cycles1 ▫ Significant association found between fatigue and sleep disturbance.1 ▫ Fatigue can be a consequence of insomnia and vice- versa.2 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233 2. Marie-Christine Ouellet, Josée Savard, and Charles M. Morin. Insomnia following Traumatic Brain Injury: A Review Neurorehabilitation and Neural Repair 18(4); 2004
  23. 23. Etiology/Associations- Fatigue (6) • Sleep disturbance ▫ Sleep disturbance can be associated with depression and anxiety.1 ▫ Prevalence rates of depressive and anxiety disorders in TBI patients as high as 57% and 77% respectively.2 ▫ Still remains unclear whether insomnia from physiological effects of injury or from difficulties adjusting to physical or psychological disturbances from TBI2 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233 2. Marie-Christine Ouellet, Josée Savard, and Charles M. Morin. Insomnia following Traumatic Brain Injury: A Review Neurorehabilitation and Neural Repair 18(4); 2004
  24. 24. Etiology/Associations- Fatigue (7) • Can be difficult to elucidate in TBI population due to numerous plausible biological causes of fatigue1 • More research will be needed to determine to the specific clinical, behavior and physiological factors and predictors associated with occurrence of fatigue1 1. Tatyana Mollayevaa, Tetyana Kendzerskad, Shirin Mollayevae, Colin M. Shapirog, Angela Colantonioc, J David Cassidy j. A systematic review of fatigue in patients with traumatic brain injury: The course, predictors and consequences. Neuroscience and Biobehavioral Reviews 47 (2014) 684–716
  25. 25. How can fatigue be managed post TBI?
  26. 26. Management (1) Interdisciplinary team: PT/OT/Psychologist
  27. 27. Management (2) • Recognizing fatigue ▫ Poor concentration ▫ Irritability ▫ Yawning, daytime sleepiness ▫ Reduced energy levels ▫ Non specific muscle aches/pain • Recognizing triggers ▫ Busy/noisy environment ▫ Multi-tasking ▫ Driving/public transport • Which activities are more tiring than others? How can I plan and prioritize my daily routine? Managing fatigue after brain injury from https://headway.org.uk
  28. 28. Management (3) • Set treatment goals ▫ Help accomplish daily routine, activities of daily living ▫ Help maintain and establish interpersonal relations ▫ Return to work
  29. 29. Management (4) • Assess all possible contributing factors: review medications, pain, mood and sleep changes1 ▫ Consider seeing a doctor especially if debilitating/worsening symptoms  Discuss physical problems that may be causing fatigue  Review current medications  Inform your doctor if you are feeling depressed ▫ Treatment of contributing factors 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  30. 30. Management (5) • Work-up and treatment contributing conditions ▫ Assess for potentially treatable conditions  Psychological: anxiety, depression ▫ History, physical examination, relevant basic blood tests, updated health screening
  31. 31. Management (6) • Examples of some medications that can potentially aggravate fatigue ▫ Hypnotics, benzodiazepines ▫ Certain psychiatric medications ▫ Anti-histamines ▫ Muscle relaxants ▫ Opioids • Insufficient evidence of using medications to manage fatigue post TBI ▫ However, potential drugs for treatment of sleep and anxiety/depression.
  32. 32. Management (7) • Interdisciplinary team: ▫ Psychologist: cognitive behavior therapy techniques1  Understanding chronic fatigue  Awareness of fatigue  Achievement of activity goals and personal goals  Help patient attain control over symptoms 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224– 233
  33. 33. Management (8) • Interdisciplinary team: ▫ Occupational therapist/ Psychologist:  Management of information overload and associated social difficulties such as time pressure management.  Referral to return to work services if required  Cognitive Rehabilitation ▫ Physiotherapist:  Physical conditioning programs to reduce physical fatigue and promote well-being 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  34. 34. Management (9) • Activities scheduling/modification ▫ Modifying pace and demands of activities including work hours, if possible1 ▫ Understand triggers and work within resources ▫ Be realistic in planning of activities ▫ Acknowledge that you may not be able to do as much as previously ▫ Prioritize energy ▫ Do not be overwhelmed on things not achieved: focus on things done well. Reschedule activity when you feel less fatigued. ▫ Reducing distraction and need for multi-tasking1 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  35. 35. Management (10) • Activities scheduling/modification ▫ Plan time to do pleasurable activities- rewards, relaxation. ▫ Recognize signs of fatigue. Taking necessary rest breaks1 ▫ Short and simple tasks and gradually build up to complex tasks with varying time intervals ▫ Allow sufficient time to complete activities 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  36. 36. Management (11) • Activities scheduling/modification ▫ Regular working routine, daily schedule ▫ Allow adequate time to plan and organize prior to tasks ▫ Use of memory aids: hand phone reminders, calendars, diary, note books, checklists, alarms, post-its, cue cards /
  37. 37. Management (12) • Activities scheduling/modification ▫ Power naps have been found useful (avoid >30 mins), ideally before 4pm. ▫ Avoid compensatory strategies such as spending extended time in bed, excessive daytime napping and restricting participation in activities1 1. Joshua B. Cantor; Teresa Ashman; Tamara Bushnik Xinsheng Cai; Leah Farrell-Carnahan; Shinakee Gumber; Tessa Hart; Joseph Rosenthal; Marcel P. Dijkers. Systematic Review of Interventions for Fatigue After Traumatic Brain Injury: A NIDRR Traumatic Brain Injury Model Systems Study. J Head Trauma Rehabil 2014 Vol. 29, No. 6, pp. 490–497
  38. 38. Management (13) • Energy conservation techniques ▫ Especially for physical fatigue. ▫ Examples: having regularly used items within reach, slide items. ▫ Organize workplace, use labels/signs to locate items ▫ Good lighting to prevent eye strain. ▫ Good work desk ergonomics Managing fatigue after brain injury from https://headway.org.uk
  39. 39. Management (14) ▫ Sleep hygiene1  Avoiding long daytime naps if interferes with night time sleep  Regular sleep schedule  Avoiding time spent in bed awake  Avoid stimulant around bedtime: caffeine, nicotine, alcohol. 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  40. 40. Management (15) ▫ Sleep hygiene1  Avoid heavy or spicy meals too close to bedtime  Exercise regularly but not too late in evening  Dark, quiet and comfortable sleep environment  Avoid use of electronic devices just before sleep 1. Jennie L. Ponsford; Carlo Ziino; Diane L. Parcell; Julia A. Shekleton; Monique Roper; Jennifer R. Redman;Jo Phipps-Nelson; Shantha M. W. Rajaratnam. Fatigue and Sleep Disturbance Following Traumatic Brain Injury— Their Nature, Causes, and Potential Treatments. J Head Trauma Rehabil 2012. Vol. 27, No. 3, pp. 224–233
  41. 41. Management (16) • Sleep Management - Relaxation therapy: Progressive muscle relaxation, imagery training, thought stopping1 - Cognitive therapy: identify sleep cognitive distortions, reframe dysfunctional cognitions into more adaptive thoughts1 1. Marie-Christine Ouellet, Josée Savard, and Charles M. Morin. Insomnia following Traumatic Brain Injury: A Review Neurorehabilitation and Neural Repair 18(4); 2004
  42. 42. Management (17) • Mindfulness Training • Consciously aware of present moment and to focus on own feelings, thoughts and surroundings. • Name thoughts and feelings • Sitting silently and paying attention to thoughts, breathing and parts of body Managing fatigue after brain injury from https://headway.org.uk
  43. 43. Management (18) • Exercise/Activities: - Can benefit some patients especially those with physical deconditioning - Can improve physical functioning and fatigue - Positive effect on mood - Graded exercise therapy: structured progressive levels of activity - 30 mins moderate intensity exercise, 5 times a week - Walking, cycling - Consider consulting physician on recommendations and precautions - Group activities/support groups Managing fatigue after brain injury from https://headway.org.uk
  44. 44. Management (19) • Nutrition and Hydration - My Healthy Plate - Eat in moderation - Avoid foods high in glycaemic index (GI) - Chips, processed food, cakes - Take complex carbohydrates, low GI index food - Brown rice, wholegrain, vegetables, fruits, protein- chicken/fish, nuts. - Avoid alcohol - Keep well hydrated. Avoid too much caffeine, soft drinks Managing fatigue after brain injury from https://headway.org.uk
  45. 45. Take Home Message (1) • Fatigue is a personal experience that is different for everyone. • Fatigue and sleep disorders can be relatively common post TBI and these can negatively impact on quality of life, functioning and employment. • Importance of recognizing fatigue and its triggers • Understanding the impact of sleep on fatigue, and fatigue on sleep. • Understanding the association with mood disorders like anxiety and depression.
  46. 46. Take Home Message (2) • Consider consulting your doctor especially when symptoms are debilitating and worsening. Role of the interdisciplinary team. • Management of fatigue post TBI includes treatment of medical conditions, medication review, activity modification, mindfulness training, sleep hygiene, exercise and nutrition. • Prognosis can be varied and there is currently limited evidence on this. • Managing fatigue is not about taking it away completely but understanding how to control it- which is possible.
  47. 47. Thank You Any Questions?

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