“A good laugh and a long sleep are the two best cures for anything.” Irish Proverb
“I’m dead on my feet.”
“I’ve got nothing in the tank.”
Dog-tired, dead tired, wiped, spent, exhausted, worn out, cashed…
The English language is replete with ways to simply say, “I’m tired,” perhaps because fatigue is a nearly universal phenomenon that we have all experienced at one time or another. Whether it is rubbing tired eyes and yawning while trying to pay attention to a long lecture, or finishing an exercise routine and your legs feeling “like jello”, we have all experienced the inconvenience and irritation of feeling fatigued. But for brain injury survivors, fatigue is one of the most common and sometimes most debilitating symptoms during the recovery process, becoming a barrier to doing the things they need and want to do in their day to day lives.
Generally speaking, fatigue can be described as a lack of energy, feelings of tiredness, or exhaustion. More specifically, fatigue can be categorized into several types:
Physical fatigue: this type of fatigue can come from muscle weakness, and usually occurs after strenuous or extended physical activity. Typically, physical fatigue gets worse in the evening or after a busy day, but typically gets better after a good night’s sleep. Physical fatigue sounds like: “I’m tired and I need to rest. I’m dragging today.”
Psychological fatigue: comes with depression and other psychological conditions. This type of fatigue gets worse with stress. Many times, sleep does not help and for many it is worse in the morning. Psychological fatigue sounds like: “I just can’t get motivated to do anything. Being depressed wears me out; I just don’t feel like doing anything.”
Neurofatigue: also called mental fatigue or cognitive fatigue, this is a special kind of fatigue that can happen after brain injury. Neurofatigue is characterized by pronounced mental fatigue after mental activity. This is what is referred to when someone states, “My brain is tired.” Neurofatigue sounds like: “After a while, I just can’t concentrate anymore. It’s hard to stay focused. My mind goes blank.” (www.msktc.org)
NEUROFATIGUE AND BRAIN INJURY
As many as 98% of people with traumatic brain injuries (TBIs) have some kind of fatigue, and as many as 70% complain specifically of neurofatigue. Researchers propose that neurofatigue occurs in many locations within the brain, which is partly why it affects so many brain injury survivors. After injury, the brain is devoting a large amount of its energy reserves to heal itself, which leaves less mental energy for thinking and concentrating. Also during this healing time, the brain is less efficient in sending electrical signals, which causes more energy to be used for each signal sent. This phenomenon can occur anytime a brain has to work to heal itself, which is why neurofatigue affects so many brain injury survivors in such a powerful way. Researchers found that the severity of fatigue seems to have no relation to the severity of trauma, time since injury, or the area of the brain that is primarily affected. Therefore, neurofatigue is important to understand for the recovery of survivors of mild to severe brain injury, in the acute stages and many years after injury. (http://cdn.intechopen.com/pdfs-wm/46126.pdf)
Neurofatigue is sometimes referred to as a “silent” or “hidden” symptom because it is not obvious to the observer, like bleeding for example.
Recognizing neurofatigue requires a keener attention and awareness to subtle symptoms:
1) An unusually rapid drain of mental energy upon mental activity
2) Impaired attention and concentration over time
3) Following over-exertion, a long recovery time disproportionate to the exertion level
4) Fatigue often being better in the mornings and worse in the afternoons and evenings
With usually one or more associated symptoms:
5) Mood swings, irritability, and stress intolerance
6) Trouble with memory
7) Sleep problems
8) Sensitivity to, or intolerance of light and loud noise
9) Headaches following over-exertion
(http://cdn.intechopen.com/pdfs/30498/InTech-Mental_fatigue_a_ common_long_term_ consequence_after_a_brain_injury.pdf)
A typical characteristic of neurofatigue after brain injury is that the mental tiredness becomes more apparent during sensory stimulation or while performing cognitive tasks for long periods without breaks. Mental energy is drained during mental activity in situations where there is a high amount of sensory stimulation, such as noisy or hectic environments.
Another typical feature is that it takes a disproportionately long time to recover mental energy levels after being mentally exhausted. Neurofatigue is affected by the total activity level as well as the nature of the demands of the activity. The fatigue can arise quickly, and when it does, make it very difficult for the person to continue the ongoing activity. (http://cdn.intechopen.com/pdfs-wm/46126.pdf)
NEUROFATIGUE AND AFFECTS ON DAILY FUNCTION
Neurofatigue symptoms often occur in the following situations:
Situations when there is increased sensory stimulation, especially noisy and hectic environments such as crowded events, busy shopping centers, travelling by bus, etc.
- Reading books and newspapers
- Conversations with people; this becomes more difficult when more people are involved
- Unexpected events
The appearance of neurofatigue symptoms can interrupt daily activities in work, school, home management, and leisure:
Work: neurofatigue can make it difficult to complete work tasks such as prolonged activities on the computer, prolonged reading, listening to many people talking in a meeting, or tasks that require focusing for an extended period of time.
School: neurofatigue can impact one’s ability to listen to a lengthy lecture, focus for long periods to take a test, read textbooks, and study notes.
Home management: neurofatigue can make it challenging to complete grocery shopping in a busy shopping center, staying mentally focused to sort mail and pay bills, or tolerate unexpected events such as sudden need for home repairs.
Leisure: neurofatigue symptoms can interrupt one’s ability to read novels, complete puzzles, attend sporting events in a crowded stadium, go out to eat in busy restaurant, or socialize in a group situation.
STRATEGIES TO COPE WITH NEUROFATIGUE
While there is not yet a magic pill for curing neurofatigue, there are several strategies and tools available that can help to cope with neurofatigue symptoms and lessen the degree that it interrupts daily function.
Pay attention to what triggers your fatigue, and learn to identify the early signs of fatigue, such as becoming more irritable or distracted; Ask for help when needed; Keep yourself mentally stimulated, but find a balance between getting overtired and being under-stimulated or bored. http://www.bcftbi.org/about-tbi/fatigue.asp
Get good sleep. Set a regular schedule of going to bed and awakening the same time every day, aiming for 8-10 hours of sleep. In your schedule, include some regular rest breaks or naps. Be careful to limit naps to 30 minutes and avoid evening naps http://www.msktc.org/tbi/factsheets/Fatigue-And-Traumatic-Brain-Injury
Exercise. Research has shown that survivors of brain injury who exercise have better mental function and alertness. Over time, exercise and being more active helps lessen physical and mental fatigue and builds stamina. It also may decrease depression and improve sleep. http://www.msktc.org/tbi/factsheets/Fatigue-And-Traumatic-Brain-Injury
Diet. Eat a nutritious diet will also help fuel your brain. Try to have a good mix of fruit and vegetables, as well as lean proteins (beans, poultry, ground beef) in your diet. Alcohol and marijuana will generally make fatigue worse. Caffeine (coffee, cola products, energy drinks) should be avoided after lunch if sleeping is a problem http://www.bcftbi.org/about-tbi/fatigue.asp
Scheduling and Time Management. Follow a daily schedule. Using a calendar or planner can help manage neurofatigue; Schedule those tasks that require the most mental effort earlier in the day when you are fresher. Don’t save grocery shopping or balancing the checkbook for the evening when you are tired; Alternate high demand thinking tasks with some low energy activities and build regular relaxation time for rests into the day; Break activities into several steps (“chunking”) through scheduling activities; Avoid over-scheduling by prioritizing activities. Finish what is most important first. http://cdn.intechopen.com/pdfs/30498/InTech-Mental_fatigue_a_common_long_term_consequence_after_a_brain_injury.pdf
Pace Yourself. Encourage rest before becoming over-tired; Try to work at a steady pace, taking one task at a time with short working periods, and prioritize the tasks; Plan the days’ activities or the activities for the week in a diary or journal. Avoid overexertion. http://cdn.intechopen.com/pdfs-wm/46126.pdf
Avoid taking on more activities over longer periods in an attempt to improve mental endurance as this does not work. When the limits of mental activity are pushed, mental fatigue increases and there is a decrease in performance, including a higher chance for mistakes to be made. http://cdn.intechopen.com/pdfs/30498/InTech-Mental_fatigue_a_common_long_term_consequence_after_a_brain_injury.pdf
Relaxation. Avoid stress; Do one thing at a time, take more time for each activity; Avoid planning too many activities in a short period to ensure rest breaks are included; Try to do cognitive tasks in an environment where it is possible to rest and keep a slower pace. Going for walks in natural environments or doing calm and relaxing activities can provide mental rest http://cdn.intechopen.com/pdfs/30498/InTech-Mental_fatigue_a_common_long_term_consequence_after_a_brain_injury.pdf
Mindfulness- Based Stress Reduction (MBSR): The core of this approach is focusing only on things happening in the present moment. MBSR has a growing body of research that suggests it is effective in treating a variety of illnesses (Brantley, 2005). Most recently, researchers have found MBSR to be highly effective in managing cognitive fatigue after stoke and traumatic brain injury (Johansson B, Bjuhr H, & Ronnback L; 2012).
Follow this link for a free online MBSR training course that is self-paced and taught by a fully certified MBSR instructor from the University of Massachusetts Medical School http://palousemindfulness.com
COMMUNICATING ABOUT NEUROFATIGUE
In today’s multi-media society, we have to take in and process a lot of information, which can be exhausting for someone experiencing neurofatigue. Unfortunately, neurofatigue is often mistaken for laziness, unwillingness, or apathy. Upon careful examination, most people will be shown to have levels of high motivation, but lack the energy to keep up with activity demands.
It can be very difficult for family, friends, or coworkers to understand the limitations caused by neurofatigue after brain injury. Careful communication with loved ones and employers can help provide understanding that lacking mental energy to complete tasks does not equivocate to lacking desire to complete those tasks. Changing strategies (like finding a quiet place to do cognitive work, or taking breaks to take a short walk around the office) and reducing demands for time, efficiency, or productivity can help reduce stress and improve overall performance for work or home management activities. Sometimes coworkers and employers will expect the brain injured individual to quickly become “normal” again, when realistically recovery time can be prolonged and extended. Careful conversation regarding time needed for the brain to heal can increase understanding of the experience of the person recovering from brain injury. http://cdn.intechopen.com/pdfs/30498/InTech-Mental_fatigue_a_common_long_term_consequence_after_a_brain_injury.pdf
Written by guest author Anna Keough. This blog is modified from a presentation that I provided as a volunteer for the Lansing Chapter Support Group of the Brain Injury Association March 4, 2016. Anna Keough is a current student at Eastern Michigan University, in pursuit of a Master of Occupational Therapy degree. She has previously attained minors in Human Biology and Human Nutrition from Eastern Michigan University as well.
Anna has been involved in the field of neuro rehabilitation since 2011, first as a volunteer, and then as a Residential Teaching Assistant in a residential traumatic brain injury program. In addition, she has a variety of clinical OT fieldwork experiences across the lifespan and care continuum, including: preschool, acute care, inpatient rehabilitation, outpatient neuro rehabilitation, and geriatric psychiatry. Most recently, she has worked as a Graduate Assistant at EMU and volunteered at Camp Jump-In, providing Occupational Therapy services for children with developmental disabilities.
Anna’s professional development includes achievement of research study: “Determining the Needs of Family Caregivers during Older Adult Care Transitions: An Interprofessional Perspective”, to be featured at the 2016 American Occupational Therapy Association Conference & Expo, and previously presented at the 2015 Lyla M. Spelbring Endowed Lectureship and Conference. Anna maintains professional affiliation and membership with the national OT association and with EMU’s chapter of the OT honors society, for which she has served as president in 2014-2015.