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Cognitive
Fatigue in the
TBI Population
and a Self-Rated
Scale During
Rehabilitation
Author: Alison Stewart
ReMed
– Provides brain injury rehabilitation services and programs to
patients with mild, moderate, and severe brain injuries
– Client Demographics:
– 31% Female and 67% Male
– Average age (at time of injury): 34 years
– Average Years Post-Injury: 4.7 years
ReMed
– Types of Injury Sustained:
– 69% Closed, 8% Disease, 5% Open, 15% Other
– Specialized Rehabilitation Team:
– Medical Director, Neuropsychologist, Case Manager, Physical
Therapist, Occupational Therapist, Speech Therapist, Behavioral
Analysist, Drug and Alcohol Counselor, Therapeutic Recreationist,
Brain Injury Specialist, Vocational Services
Rationale
“Fatigue is one of the most pervasive symptoms following TBI
and has been found to significantly impact well-being and
quality of life. Fatigue is multidimensional and can affect
physical, cognitive, and subjective aspects. Due to its
prevalence and effects, it is recommended that all patients
with TBI be assessed for fatigue”
(Ontario Neurotrauma Foundation, 2013)
Method/Procedure
– Clinical experience and observation at ReMed
– Obtained research articles and reviewed subjective rating scales
with the following criteria:
– Peer reviewed & published within last 10 years
– Feedback from ReMed staff
Objectives
– Traumatic Brain Injury
– Fatigue
– Clinical implications
– Impact on Cognitive Skills, Quality of Life, Rehabilitation Setting
– Fatigue assessment
– Treatment Strategies
– Cognitive Fatigue Rating Scale for ReMed
– Questions???
Traumatic Brain Injury
– TBI: form of nondegenerative acquired brain injury resulting
from external physical force to the head or other mechanisms
of displacement inside the skull
– Consequences of TBI: physical, cognitive-communication,
sensory, swallowing and behavioral issues
– SLP role: assessment, planning, treatment, prevention,
advocacy, education, administration, and research
(ASHA, 2015)
Statistics: TBI
– Every year at least 1.7 million Traumatic Brain Injuries (TBI)
occur in the United States across all age groups
– 3.2 million-5.3 million persons in the United states are living
with a TBI-related disability
– Factors associated with TBI can affect a person long after
acute medical treatment and rehabilitation
(Centers for Disease Control and Prevention, 2015)
What is Fatigue in TBI?
– Mental exhaustion becomes pronounced during sensory
stimulation or when cognitive tasks are performed for extended
periods without breaks
– Person may feel their brain is “overloaded” after a tiny load of
work
– Dependent on total activity level as well as the nature of the
demands of daily activities
(Mollayeva et al., 2015)
What is Fatigue in TBI?
– Types of fatigue in TBI:
– Physical fatigue: due to muscle weakness, balance, vision, endurance
– Psychological fatigue: associated with depression, anxiety, and other conditions
– Mental fatigue: comes from extra effort it takes to think after brain is injured
(Model System Knowledge Translation Center, 2009)
Statistics: Fatigue
– General population:
– Problematic fatigue in 10-20%
– Much higher for those with TBI:
– self-reported and observed in 45-73%
– prevalent during post-acute stages of rehabilitation
– Subjects still reported significant levels of fatigue 5 years postinjury
(Khol et al., 2009; Schiehser, 2015)
Characteristics of Fatigue
–
–
–
–
–
–
–
–
–
Poor concentration
Slowness of thinking and slow information processing speed
Impaired memory
Stress
Emotional liability and irritability
Sleeping problems
Noise and light sensitivity
Impaired ability to take initiative
Headaches
(Mollayeva et al., 2015)
Clinical Implications
“Understanding the facets of fatigue in TBI can guide in differential
diagnosis and follow up on treatments. Moreover, identifying the
most important contributors to post-traumatic fatigue can change
the view on the interventions necessary to deal with this
significant symptom”
(Mollayeva et al., 2015)
Impact on Cognitive Skills
– Theoretical Model of Cognitive Fatigue in TBI:
– “Coping hypothesis”: Cognitive fatigue is due to constant
(mental) effort individuals with TBI need to exert to compensate
for cognitive impairments (attentional problems and slower
processing) in order to maintain adequate task performance
(Belmont et. al., 2009)
(van Zomeren et al., 1984)
Impact on Quality of Life
– Loss of enjoyment during social interactions
– Sensitivity to stress
– Shameful/ Embarrassed
– Difficult for relatives and employers to understand
(Johansson and Rönnbäck, 2012)
Impact during Rehabilitation
– Difficult to assess, and is dependent on the professional
approach
– “As mental fatigue has such a great impact on many functions, it
is important to consider the problem from a wide perspective
and to look at the issue with an open mind, in order to develop
an understanding of the cause of the problem”
(Johansson and Rönnbäck, 2012)
Assessment
– Easy to misunderstand symptoms of fatigue (e.g. apathy)
– Consider medications commonly associated with fatigue
– Usually assessed as a subjective problem with self-report
questionnaires
– Recommended all patients be assessed for fatigue by using
relevant items on the Rivermead Post Concussion Symptoms
Questionnaire and/or a specific measure of fatigue
(Ontario Neurotrauma Foundation, 2013)
Clinical Applications: Assessment for TBI
population
Assessment
Description
Visual Analogue Scale For Fatigue (VAS-F)
Subjectively quantifies of fatigue and energy levels
The Fatigue Severity Scale (FSS)
A 9-item general fatigue scale used to assess the
consequences of fatigue and its impact on daily functioning
Global Fatigue Index (GFI)
Derived from the Multidimensional Assessment of Fatigue
Barrow Neurological Institute Fatigue Scale (BNI)
Items relating to daily levels of energy and alertness
Brain Injury Fatigue Scale (BIFS)
Self-report & independent rater; differentiates ‘normal’ and
pathological fatigue
Mental Fatigue Scale (MFS)
15 questions that cover most common symptoms occurring
after brain injury
(Rose, n.d.)
Strategies for Fatigue
Contingency plans: using specific strategies or call in extra support
Assess the environment: provide environment that is easy to work in
Schedule rest periods: set a timer
Break down activities: provide smaller opportunities to rest while
allowing patient to complete task
– Set priorities: focus on things that need to be done
– Medications: be aware of changes throughout day related to
medication
– Sleep and Fitness: encourage a regular sleeping and exercise pattern
–
–
–
–
Fatigue Rating Scale
– Based on questions from the Mental Fatigue Scale (MFS)
– Include symptoms reported early on, as well as long time after
brain injury
– To be assessed by patient or read by clinician before and after
therapy session
– Purpose: track fatigue and increase client awareness
Name: ___________________
Date: _____________
Session: __________________
Session Focus: ____________________
Fatigue Rating Scale
Fatigue is a feeling of exhaustion, weariness, or lack of energy due to physical or mental effort
Each statement is followed by four numbers that indicate:
(0)No Fatigue (1) Mild Fatigued: can still work (2) Moderate Fatigue: need a break (3) Severe Fatigue: need to stop the task and a long break
Place a circle around the number that best describes your present condition.
Beginning of Session
Time:
Total Score:
No
Mild
Mod
Severe
1. What is your current level of fatigue?
0
1
2
3
2. Do you have difficulty with attention?
0
1
2
3
3. Do you find it difficult to gather your thoughts and concentrate?
0
1
2
3
4. Are you forgetting things more often?
0
1
2
3
5. Are you more slow or sluggish when you think about something?
0
1
2
3
6. What is your current level of anxiety?
0
1
2
3
7. Are you sensitive to light or noise?
0
1
2
3
8. Are you short tempered or irritable?
0
1
2
3
9. Are you experiencing difficulty with balance?
0
1
2
3
10. What is your current level of pain?
0
1
2
3
Breaks taken throughout session:
End of Session
Time:
1.
2.
3.
4.
5.
6.
What is your level of fatigue following session/activity?
Are you having difficulty sustaining attention?
Do you find it difficult to gather your thoughts and concentrate?
Did you forget more as the session went on?
Are you more slow or sluggish when you think about something?
What is your level of anxiety following the session/activity?
No
0
0
0
0
0
0
7.
8.
9.
10.
Are you sensitive to light or noise?
Are you more short tempered or irritable after the session/activity?
Are you experiencing difficulty with balance?
What is your current level of pain?
0
0
0
0
Mild
1
1
1
1
1
1
1
1
1
1
Derived from: Mental Fatigue Scale (MFS) http://www.mf.gu.se/digitalAssets/1346/1346171_sj--lvskattning-engelska-modifierad.pdf
Total Score:
Mod
2
2
2
2
2
2
2
2
2
2
Severe
3
3
3
3
3
3
3
3
3
3
References
ASHA, Traumatic Brain Injury (TB), 2016.
Bay E, de Leon M. Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury. Journal of
Head Trauma Rehabilitation. 2011;26(5):355-363.
Belmont, A., Agara, N., & Axouvia, P. (2009). Subjective fatigue, mental effort, and attention deficits after severe traumatic
brain injury. Neurorehabil Nueral Repair, 23 (9), 939-944.
Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the
United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and
Control; Division of Unintentional Injury Prevention. Atlanta, GA.
Diagnosis, Mechanism and Management of Fatigue in Traumatic Brain Injury. Dawn Schiehser, PhD ,
Neuropsychologist, June 24, 2014
Dijkers MPJM, Bushnik T. Assessing Fatigue After Traumatic Brain Injury: An Evaluation of the Barroso
Fatigue Scale. Journal of Head Trauma Rehabilitation. 2008;23:3-16.
Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms: Persistent Fatigue. Ontario Neurotrauma
Foundation. September, 2013.
References
Birgitta Johansson and Lars Rönnbäck (2012). Mental Fatigue; A Common Long Term Consequence After a
Brain Injury, Brain Injury - Functional Aspects, Rehabilitation and Prevention, Prof. Amit Agrawal
(Ed.), ISBN:978-953-51-0121-5,
Kohl, A. D., Wylie, G. R., Genova, H. M., Hillary, F. G., & Deluca, J. (2009). The neural correlates of
cognitive fatigue in traumatic brain injury using functional MRI. Brain injury, 23(5), 420-432.
Krupp LB, Larocca NG, Muir-Nash J, et al. The Fatigue Severity Scale: application to patients with
Multiple Sclerosis and Systemic Lupus Erythematosus. Archives of Neurology. 1989;46:1121-1123.
Model System Knowledge Translation Center, 2009
Mollayeva, T., Kendzerska, T., Mollayeva, S., Shapiro, C. M., Colantonio, A., & Cassidy, J. D. (2014). A
systematic
review of fatigue in patients with traumatic brain injury: the course, predictors and consequences. Neuroscience
& Biobehavioral Reviews, 47, 684-716. Chicago.