Fatigue After Brain Injury

By Katherine Dumsa, OTR/L, CBIS and Angela Spears, MA, CCC-SLP, DPNS, CBIS, Rainbow Rehabilitation Centers

Fatigue is a part of life that is experienced by everyone. Whether it is from a busy day at work, a demanding workout, or after paying attention to a long lecture, the term “I’m tired” is exceedingly common.

Fatigue and Traumatic Brain Injuries
For individuals with brain injuries, fatigue (sometimes referred to as cognitive fatigue, mental fatigue, or neurofatigue), is one of the most common and debilitating symptoms experienced during the recovery process. It can become a significant barrier to one’s ability to participate in the activities they want and need to do in daily life. It is reported that as many as 98% of people who have experienced a traumatic brain injury have some form of fatigue. Many report that fatigue is their most challenging symptom after brain injury. Reasons for the fatigue are not well understood but may include endocrine abnormalities, the need for the brain to work harder to compensate for brain injury deficits (in other words, inefficiency), or changes to brain structures.

Assessment Tools to Determine Fatigue Levels
Fatigue can be difficult to identify because it is not always reported by the patient or obvious to others. Clinicians use various self-report assessment tools to gain further information on a patient’s fatigue levels and the impact it has on their overall daily functioning. Two of the scales specifically designed for individual patients with brain injuries include the Barrow Neurological Institute Fatigue Scale (BNI) and the Cause of Fatigue Questionnaire (COF). Clinicians must also evaluate physical and mental changes, which can lead to depression and other psychiatric conditions following brain injury. The changes can commonly present as overwhelming fatigue.

Symptoms
Generally, those who have sustained brain injuries have described fatigue as a sense of mental or physical tiredness, exhaustion, lack of energy, and/or low vitality. Physical observations of fatigue include yawning, an appearance of confusion or “brain fog,” or easily losing attention and concentration. In more severe cases, it may present as forgetfulness, irritability, slurred speech, or dizziness. Emotions can become raw at this level of fatigue, affecting mood, motivation, and interaction with one’s social network. To manage fatigue effectively, individuals must learn to identify the symptoms of fatigue and how to modify activities that may trigger fatigue. Managing fatigue effectively will help decrease stress levels and improve overall performance for both work and home activities. Some fatigue-inducing activities include:

Working at a computer

Watching television excessively

Having a stimulating sensory environment

Concentrating on paperwork

Reading for long periods of time

Physically demanding tasks

Cognitively demanding tasks

Emotionally draining tasks

Symptoms of fatigue can include:

Physical Symptoms: a pale or greyish pallor, glazed eyes, headaches, tension in muscles, shortness of breath, slower movement and speech, decreased coordination, or difficulty staying awake.

Cognitive Symptoms: increased forgetfulness, distractibility, decreased ability to follow directions, making an increased number of mistakes, decreased awareness of surroundings, or increased response time or lack of response.

Social/Emotional Symptoms: decreased ability to communicate effectively, decreased ability to engage in social activities, irritability, restlessness, emotional lability, increased negative thoughts, withdrawal, short answers, dull tone of voice, lack of motivation and interest, or difficulty engaging in activities of daily living.

Fatigue Is Not Laziness
In today’s multi-media society, we take in, absorb, and process large amounts of information every day. It can be difficult for family members or peers to understand the limitations caused by fatigue following a brain injury. Unfortunately, it can be mistaken for laziness or an unwillingness to participate in therapies and daily activities. It is important to understand that lacking the mental energy needed to complete tasks does not equate to lacking the desire to complete those tasks. Many individuals struggling with fatigue have motivation but lack the energy to keep up with daily demands.

Coping Strategies Used to Ease Symptoms
When managing fatigue, it is important to identify and treat physical factors that may be contributing to the fatigue. Recognizing early signs of fatigue and working with the patient so they understand how to respond to these is beneficial. By learning to recognize these triggers, one can learn coping strategies to successfully meet daily demands, ultimately increasing quality of life. These strategies include:

Having a Healthy Sleep Routine – This can be done by setting a sleep schedule of when to go to bed and when to wake, regardless of the day of the week. Establishing a strict routine using an alarm clock allows the brain proper rest. When rest is needed, aim for a “power nap” of 30 minutes maximum to avoid feeling over tired for the remainder of the day. Lack of sleep has a negative effect on our cognition, mood, energy levels, and appetite. The American Academy of Neurology reports that as many as 40% to 65% of people with mild traumatic brain injury complain of insomnia, so maintaining a sleep hygiene program is essential to recovery and to managing fatigue.

Practicing Energy Conservation – Pacing yourself each day, or prioritizing daily tasks to avoid becoming over-tired, can help with balancing out a busy schedule. Complete tasks that require the most mental effort earlier in the day with planned rest breaks in the afternoon or evening.
Organizing daily activities – Utilize a checklist or planner to set a to-do list. Break up complex projects into manageable tasks. When completing these tasks, minimize environmental stimulation as much as possible.

Improving Health and Wellness – Increased overall health and wellness has been described as “energizing,” and research suggests that it can improve mood. Aim to exercise three to five times per week for a minimum of 30 minutes per session. Maintain a well-balanced diet rich in protein, fiber, and carbohydrates to help the brain and body stay fully energized.

Keeping a Fatigue Diary – This kind of diary can assist in monitoring changes and energy levels before and after daily activities. This tracking of fatigue can be used with your treatment team to help mitigate what may be increasing neurofatigue. Assessment and treatment of fatigue continues to be a challenge for clinicians and researchers. While there is no cure for fatigue, there are many ways to manage and overcome the symptom. Awareness and an open mind towards coping strategies will lessen the negative effects of fatigue and allow for meaningful participation in life.

REFERENCES

Keough, A. 2016. Strategies to manage neuro-fatigue.

Cantor, J.H., Ashman, T., Gordon, W., Ginsberg, A., Engmann, C., Egan, M., Spielman, L., Dijkers, M., & Flanagan, S. (2008). Fatigue after traumatic brain injury and its impact on participation and quality of life. Journal of Head Trauma Rehabilitation. 23(1), 41-51.

Jang, S., & Kwon, H. (2016). Injury of the ascending reticular activating system in patients with fatigue and hypersomnia following mild traumatic brain injury. Medicine. 95(6). e2628.

Belmont, A., Agar, N., Hugeron, B. Gallais, C. & Azouvi, P., Fatigue and traumatic brain injury. Annales de Réadaptation et de Médecine Physique. 49(6). 370-374.

Johnson, G. (2000). Traumatic brain injury survival guide. Traverse City, MI.

Heins, J., Sevat, R., Werkhoven, C. (n.d.) Neurofatigue. Brain Injury Explanation.

This article first appeared in the Summer 2018 issue of Rainbow Visions Magazine available at www.rainbowrehab.com.

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Caring for Your Vision with So Much Screen-Time!

Avoid “Computer Vision Syndrome”

By Carl Hillier, OD FCOVD

Most of us are engaged in “screen time” more than ever before—using Zoom/Skype/FaceTime as a tele-therapy platform. For many, this can be very successful, but also potentially very visually stressful.

We recommend the following guidelines to help minimize the following problems associated with excess screen-time—collectively known as “Computer Vision Syndrome”:

Cognitive Fatigue
Visual Fatigue/Eye Strain
Dry Eye Symptoms
Blurred Distance Vision

Headache
Neck and Shoulder Pain
Poor-Quality Sleep

Things to do to alleviate the symptoms above:

Take scheduled breaks from screen time at least every 30 minutes, walking away from the computer for at least 2 minutes.
During these 2 minutes, stand or sit in a very relaxed way and rotate your body without moving your feet—try to look behind you one way, then back to the other way as far as you are able.
Check each eye individually during these 2-minute breaks to ensure you are not losing distance vision from either eye.
Acquire optical quality lenses that deflect the harmful blue light that emanates from screens. Your optometrist can get the proper protective lenses for you.
Research-proven nutritional supplementation solutions:

Lutein (10 mg), Zeaxanthin (2 mg) and Mesozeaxanthin (10 mg)—to improve visual performance, sleep quality and decrease adverse physical symptoms
Omega-3—Minimum EPA: 400 mg; Minimum DHA: 960 mg

Stop screen time 2 hours before going to sleep.
Get outside as much as possible!

If you would like more advice on how to establish a strong visual foundation for the demands of online learning, just let us know. We can provide activities for you to do off-line that will help you maintain good vision while you are on-line!

Carl G. Hillier, OD FCOVD
Melissa C. Hillier, OD FCOVD
San Diego Center For Vision Care
SanDiegoCenterForVisionCare.com

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