Fatigue and traumatic brain injury

Fatigue and Traumatic Brain
Injury
8th September 2018

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

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

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

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

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

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

How common is fatigue and
sleep problems post TBI?

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
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

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.

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

How does fatigue affect
individuals?

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

•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.

•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

What are the associations and
potential causes of TBI?

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.

• 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.

• 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

• 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

• 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

• 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

• 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

How can fatigue be managed
post TBI?

Management (1)
Interdisciplinary
team:
PT/OT/Psychologist

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

Management (3)
• Set treatment goals
▫ Help accomplish daily routine, activities of daily
living
▫ Help maintain and establish interpersonal
relations
▫ Return to work

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

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

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.

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

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

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

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

Management (11)
▫ 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
/

Management (12)
▫ 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

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

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.

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

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

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

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

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

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.

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.

Fatigue and traumatic brain injury

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Fatigue and traumatic brain injury

Similar to Fatigue and traumatic brain injury (20)

Recently uploaded

Recently uploaded (20)

Fatigue and traumatic brain injury