Fatigue

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Fatigue is one of the most pervasive symptoms following concussion, with 27.8% of individuals experiencing persistent fatigue at 3 months post-injury.1 The perception of fatigue can be out of proportion to exertion or may even occur without any exertion.2 Fatigue is multidimensional and can affect physical, cognitive, motivational and psychological (i.e., depression, anxiety) spheres.3 Individuals with fatigue can experience poorer problem-solving and coping skills, which then increases stress, depression which creates an ongoing cycle that contributes to disability.4 

Due to its prevalence and effects, it is recommended that all patients be assessed for fatigue through a personal history with the patient and/or support person. 

As certain medications can cause fatigue, the practitioner should conduct a thorough review of the patient’s medications. If the patient has been prescribed a medication that is associated with fatigue, alternatives that produce the same treatment effect without inducing fatigue should be considered. As persistent fatigue may cause other symptoms to worsen, early intervention is required in order to prevent interference with the patient’s ability to participate in rehabilitation therapies.4,5 

Some non-pharmacological treatments such as exercise, mindfulness-based stress reduction, cognitive behavioural therapy and blue-light therapy could potentially be helpful in treating fatigue. Methylphenidate has been found in some studies to improve mental fatigue and processing speed in patients with persistent post-concussion symptoms,6,7 8 Caution is recommended in the use of stimulants off-label as clinical experience has identified that some individuals report stimulants provide a burst of energy followed by increased fatigue. 

References supporting introduction:

  1. Mollayeva T, Kendzerska T, Mollayeva S, Shapiro CM, Colantonio A, Cassidy JD. A systematic review of fatigue in patients with traumatic brain injury: the course, predictors and consequences. Neurosci Biobehav Rev. 2014;47:684-716.
  2. Dijkers MP, Bushnik T. Assessing fatigue after traumatic brain injury: an evaluation of the HIV-Related Fatigue Scale [corrected]. J Head Trauma Rehabil. 2008;23(1):3-16.
  3. Cantor JB, Ashman T, Gordon W, et al. Fatigue after traumatic brain injury and its impact on participation and quality of life. J Head Trauma Rehabil. 2008;23(1):41-51. 
  4. Juengst S, Skidmore E, Arenth PM, Niyonkuru C, Raina KD. Unique contribution of fatigue to disability in community-dwelling adults with traumatic brain injury. Arch Phys Med Rehabil. 2013;94(1):74-79.
  5. Norrie J, Heitger M, Leathem J, Anderson T, Jones R, Flett R. Mild traumatic brain injury and fatigue: a prospective longitudinal study. Brain Inj. 2010;24(13-14):1528-1538.
  6. Johansson B, Wentzel AP, Andréll P, Mannheimer C, Rönnbäck L. Methylphenidate reduces mental fatigue and improves processing speed in persons suffered a traumatic brain injury. Brain Inj. 2015;29(6):758-765.
  7. Johansson B, Wentzel AP, Andréll P, Odenstedt J, Mannheimer C, Rönnbäck L. Evaluation of dosage, safety and effects of methylphenidate on post-traumatic brain injury symptoms with a focus on mental fatigue and pain. Brain Inj. 2014;28(3):304-310.
  8. Johansson B, Wentzel AP, Andréll P, Rönnbäck L, Mannheimer C. Long-term treatment with methylphenidate for fatigue after traumatic brain injury. Acta Neurol Scand. 2017;135(1):100-107.
11.1

Determine whether cognitive and/or physical fatigue is a significant symptom by taking a focused history and reviewing the relevant items from administered questionnaires (see Appendix 11.1 and Fatigue Severity Scale).

Fatigue may be perceived as a lack of mental or physical energy which may impair daily functional activities. When symptoms of fatigue are suspected, they should be assessed using a standardized scale. Symptoms of fatigue following concussion are common and are associated with a constellation of disabling symptoms which may lead to poor outcomes post-injury.  

References supporting context:

  1. Schiehser DM, Delano-Wood L, Jak AJ, et al. Predictors of cognitive and physical fatigue in post-acute mild-moderate traumatic brain injury. Neuropsychol Rehabil. 2017;27(7):1031-1046.  
  2. Wylie GR, Flashman LA. Understanding the interplay between mild traumatic brain injury and cognitive fatigue: models and treatments. Concussion. 2017;2(4):CNC50.  
Level of Evidence C
Last updated  
11.2

Characterize the dimensions of fatigue (e.g., physical, mental, impact on motivation) and consider alternative or contributing causes that may not be directly related to the injury. Please refer to Table 11.1 for further information about contributing causes of fatigue, as well as to determine appropriate management strategies.

Due to the complex interplay of concurrent symptoms, fatigue may persist and be exacerbated by an array of other contributing factors. These may include mood disorders, sleep disturbances, metabolic diseases, electrolyte abnormalities, consequences of adverse effects of medications, polypharmacy, and/or nutritional deficiencies. 

Level of Evidence B
( Pain )
Level of Evidence C
( Mood )
Level of Evidence C
( Sleep )
Level of Evidence C
( Remaining )
Last updated  
11.3

After a brief period of rest during the acute phase (e.g., 24-48 hours) after injury, patients with concussion should be encouraged to gradually resume normal activity (e.g., activities of daily living, work, school, duty, leisure) based upon their tolerance, as long as the activity does not pose a risk for concussion. 

*NOT AN ORIGINAL RECOMMENDATION- REPEAT OF 12.2a

Evidence suggests that while an initial period of rest following injury (24-48 hours) may be of benefit, there is currently insufficient evidence that prescribing complete rest may ease discomfort or promote recovery during the post-acute period. Prolonged inactivity during the post-acute period following injury has been shown to slow recovery, while a progressive and gradual return to normal activity promotes recovery. 

References supporting context:

  1. Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabil. 2016;31(4):233-241.
  2. Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-264.
  3. Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.
  4. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
Level of Evidence A
Last updated  
11.4

Patients with significant symptoms of fatigue should be provided with written, verbal and/or pictorial education about key behavioral management strategies including:

  • Cognitive and physical activity pacing and planning
  • Sleep management strategies (see Appendix 7.4 and 7.5) 
  • Management of contributing factors (See Table 11.1) 

Various behavioural management strategies may be employed to reduce symptoms of fatigue in patients with concussion. Patients should be encouraged to distribute activities and breaks across the day to achieve more without exceeding tolerance levels. This may be facilitated with the use of a notebook or diary to plan and record activities. Self-monitoring and planning may also aid in identifying patterns of fatigue and contributing factors. Practitioners may also recommend that patients practice good sleep management strategies, such as regular sleep-wake schedules. Patients may also be advised to avoid stimulants and alcohol. 

References supporting context:

  1. Caldwell JA, Caldwell JL, Thompson LA, Lieberman HR. Fatigue and its management in the workplace. Neurosci Biobehav Rev. 2019;96:272-289.
Level of Evidence C
( Cognitive and physical activity pacing )
Level of Evidence C
( Sleep management strategies )
Level of Evidence A
( Management of contributing factors (CBT) )
Level of Evidence C
( Management of contributing factors (remaining) )
Last updated  
11.5

Mindfulness-based stress reduction may be recommended to manage fatigue.

There is evidence that mindfulness-based stress reduction may improve chronic symptoms following mild traumatic brain injury, particularly for fatigue and mood. Mindfulness-based stress reduction is an evidence-based program, with the practice of mindfulness embedded within it. Mindfulness itself involves regulating one’s attention to the present moment rather than to stressful thoughts, and non-judgmental awareness of one’s stream of consciousness. Patients may be provided with education about mindfulness in video and written formats. 

Consider the following resource for mindfulness-based stress reduction: https://palousemindfulness.com/

References supporting context:

  1. Acabchuk RL, Brisson JM, Park CL, Babbott-Bryan N, Parmelee OA, Johnson BT. Therapeutic Effects of Meditation, Yoga, and Mindfulness-Based Interventions for Chronic Symptoms of Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Appl Psychol Health Well Being. 2021;13(1):34-62.
  2. Bishop SR, Lau M, Shapiro S, et al. Mindfulness: A proposed operational definition: Science and practice. Clinical psychology. 2004;11(3):230-241. 
Level of Evidence A
Last updated  
11.6

Blue light therapy may be considered to reduce symptoms of fatigue and excessive daytime sleepiness.

Light is responsible for synchronizing circadian rhythms through the activation of photosensitive retinal ganglion cells synapsing with the superchiasmatic nucleus, also known as the brain’s biological clock. Melanopsin, a photopigment located in retinal ganglion cells, appears to be particularly sensitive to wavelengths of light in the blue colour range (λ ∼ 460 to 480 nm). This results in melatonin suppression, which may stimulate alertness. Evidence suggests that daily morning blue light therapy may reduce daytime sleepiness following concussion. These reductions in symptoms have been associated with corresponding increases in grey matter volume and functional connectivity in sleep-related brain regions. Two high quality systematic reviews have indicated that 30 minutes of blue light therapy per day in the morning over the course of 6 weeks may be effective for daytime sleepiness. In addition, one systematic review suggests that blue light therapy at varying doses may also reduce fatigue and depression when compared to no light therapy. Individuals presenting with excessive daytime sleepiness may report feeling as though they could sleep throughout the day, which may be differentiated from fatigue often described as simply feeling tired.

References supporting context:

  1. Berson DM, Dunn FA, Takao M. Phototransduction by retinal ganglion cells that set the circadian clock. Science. 2002;295(5557):1070-1073. 
  2. Brainard GC, Hanifin JP, Greeson JM, et al. Action spectrum for melatonin regulation in humans: evidence for a novel circadian photoreceptor. J Neurosci. 2001;21(16):6405-6412.
  3. Cajochen C, Münch M, Kobialka S, et al. High sensitivity of human melatonin, alertness, thermoregulation, and heart rate to short wavelength light. J Clin Endocrinol Metab. 2005;90(3):1311-1316.
  4. Raikes AC, Dailey NS, Forbeck B, Alkozei A, Killgore WDS. Daily Morning Blue Light Therapy for Post-mTBI Sleep Disruption: Effects on Brain Structure and Function. Front Neurol. 2021;12:625431.
  5. Raikes AC, Dailey NS, Shane BR, Forbeck B, Alkozei A, Killgore WDS. Daily Morning Blue Light Therapy Improves Daytime Sleepiness, Sleep Quality, and Quality of Life Following a Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2020;35(5):E405-E421.
  6. Singareddy R, Bixler EO, Vgontzas AN. Fatigue or daytime sleepiness?. J Clin Sleep Med. 2010;6(4):405.
  7. Srisurapanont K, Samakarn Y, Kamklong B, et al. Blue-wavelength light therapy for post-traumatic brain injury sleepiness, sleep disturbance, depression, and fatigue: A systematic review and network meta-analysis. PLoS One. 2021;16(2):e0246172.
Level of Evidence A
Last updated  
11.7

Other non-prescription treatment options that have been found to be useful in the treatment of fatigue include:  

  • Melatonin (taken 2 hours before bedtime in conjunction with reduced evening light exposure and light therapy in the morning)

Slow or quick release melatonin may be prescribed to aid with fatigue or sleep disturbances in patients with concussion. Melatonin is a natural hormone supplement that is used to help regulate the body's internal clock, or circadian rhythm. Taking 2-5mg of melatonin 2 hours before bedtime can help restore sleep and improve daytime alertness.

Level of Evidence A
( Melatonin )
Last updated  
11.8

Methylphenidate may be considered as a treatment option if:

  • Non-pharmacological treatment options have not been effective
  • The patient is experiencing functionally limiting cognitive fatigue for more than 3 months post-concussion

Methylphenidate is a central nervous system stimulant considered as a second-line treatment for narcolepsy in adults. This substance may stimulate alertness and improve cognitive function (i.e., processing speed, attention, working memory). However, prescription should be considered on an individual patient basis, as it may negatively impact anxiety, irritability and sleep and thus should not be offered if the patient has issues with the latter. In terms of dosing, the patient should initially be prescribed with the short-acting form to determine how well they respond. They should start at 5mg every morning, so not to affect sleep, for 1 week then increase to 5mg every morning and 5mg daily at noon and continue at this dose. It should be taken 30-45 minutes before meals. Patients should notice it helping with focus and concentration as well as fatigue almost right away. They should be advised to not stop suddenly without speaking with their health care provider.

References supporting context:

  1. Johansson B, Wentzel AP, Andréll P, Rönnbäck L, Mannheimer C. Long-term treatment with methylphenidate for fatigue after traumatic brain injury. Acta Neurol Scand. 2017;135(1):100-107.
  2. Verghese C, Abdijadid S. Methylphenidate. In: StatPearls. Treasure Island (FL): StatPearls Publishing; January 12, 2022.
Level of Evidence A
Last updated  
11.9

The use of Modafinil and Armodafinil can be considered in patients with excessive daytime sleepiness.

Level of Evidence A
( Armodafinil )
Level of Evidence A
( Modafinil )
Last updated  
11.10

Referral to interdisciplinary concussion services/clinics should be considered if fatigue persists for more than one month.

There is evidence that interdisciplinary approaches to concussion treatment may be effective. Patients with fatigue may benefit from referral to an interdisciplinary concussion clinic wherein practitioners from multiple disciplines coordinate care by providing diagnostic, educational, physical, cognitive, functional and emotional support. Interventions which may be effective in individuals with symptoms of fatigue include cognitive behavioral therapy, psychoeducation, psychotherapy, and exercise.

References supporting context:

  1. Caplain, S., Chenuc, G., Blancho, S., Marque, S., & Aghakhani, N. Efficacy of Psychoeducation and Cognitive Rehabilitation After Mild Traumatic Brain Injury for Preventing Post-concussional Syndrome in Individuals With High Risk of Poor Prognosis: A Randomized Clinical Trial. Frontiers in neurology. 2019;10, 929.
  2. DeGraba, T. J., Williams, K., Koffman, R., Bell, J. L., Pettit, W., Kelly, J. P., Dittmer, T. A., Nussbaum, G., Grammer, G., Bleiberg, J., French, L. M., & Pickett, T. C. Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions. Frontiers in neurology. 2021;11, 580182.
  3. Howe, E. I., Fure, S., Løvstad, M., Enehaug, H., Sagstad, K., Hellstrøm, T., Brunborg, C., Røe, C., Nordenmark, T. H., Søberg, H. L., Twamley, E., Lu, J., & Andelic, N. Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Frontiers in neurology. 2020;11, 561400.
  4. Rytter, H. M., Westenbaek, K., Henriksen, H., Christiansen, P., & Humle, F. Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial. Brain injury. 2019;33(3), 266–281.
  5. Thastum, M. M., Rask, C. U., Næss-Schmidt, E. T., Tuborgh, A., Jensen, J. S., Svendsen, S. W., Nielsen, J. F., & Schröder, A. Novel interdisciplinary intervention, GAIN, vs. enhanced usual care to reduce high levels of post-concussion symptoms in adolescents and young adults 2-6 months post-injury: A randomised trial. EClinicalMedicine. 2019;17, 100214.
Level of Evidence A
Last updated  
Appendix 1.5
Rivermead Post Concussion Symptoms Questionnaire
appendix-1-5.pdf
 

EVALUATION

Title of Resource: Rivermead Post-Concussion Symptom Questionnaire (RPQ)

Reference: King NS, Crawford S, Wenden FJ, Moss NE, Wade DT. The Rivermead Post Concussion Symptoms Questionnaire: A measure of symptoms commonly experienced after head injury and its reliability". J. Neurol. 1995; 242(9):587–92.  

Description: A questionnaire that can be administered to someone who sustains a concussion or other form of traumatic brain injury to measure the severity of symptoms. The RPQ is used to determine the presence and severity of post-concussion syndrome symptoms (i.e., a set of somatic, cognitive, and emotional symptoms).

Resource Criteria:

Population
Traumatic Brain Injury (Mild or Moderate)

Reliability/ Validity
High reliability was found for the total PCS scores for both test-retest (+ 0.91) and inter-rater (+ 0.87) experimental conditions.1

Factor analysis supports the existence of separate cognitive, emotional and somatic factors, although there was a high degree of co-variation between the three factors.2

As currently used, the RPQ does not meet modern psychometric standards. Its 16 items do not tap into the same underlying construct and should not be summated in a single score. When the RPQ is split into two separate scales, the RPQ-13 and the RPQ-3, each set of items forms a unidimensional construct for people with head injury at three months post injury. These scales show good test-retest reliability and adequate external construct validity.3

Proprietary?
Yes (Varied)

Time to Administer
3-5 minutes

Method to Administer
Self-administered or given by an interviewer (in-person or over the phone).

Formal Instructions (Mention if special environment/ equipment is needed)
Asks patients to rate the severity of 16 different symptoms commonly found after a mild traumatic brain injury (MTBI). Patients are asked to rate how severe each of the 16 symptoms has been over the past 24 hours. In each case, the symptom is compared with how severe it was before the injury occurred (premorbid). These symptoms are reported by severity on a scale from 0 to 4: not experienced at all, no more of a problem, mild problem, moderate problem, and severe problem.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None


1 King NS, Crawford S, Wenden FJ, Moss NE, Wade DT. The Rivermead Post Concussion Symptoms Questionnaire: A measure of symptoms commonly experienced after head injury and its reliability". J. Neurol. 1995; 242(9):587–92. 
2 Potter S, Leigh E, Wade D, Fleminger S. The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis. J Neurol. 2006 Dec;253(12):1603-14. Epub 2006 Oct 24.
3 Eyres S, Carey A, Gilworth G, Neumann V, Tennant A. Construct validity and reliability of the Rivermead Post-Concussion Symptoms Questionnaire. Clin Rehabil. 2005 Dec;19(8):878-87.

Appendix 11.1
Barrow Neurological Institute (BNI) Fatigue Scale
 

EVALUATION

Title of Resource: Barrow Neurological Institute (BNI) Fatigue Scale

Reference: Borgaro SR, Gierok S, Caples H, Kwasnica C. Fatigue after brain injury: Initial reliability study of the BNI Fatigue Scale. Brain Injury 2004;18:685–690. 

Description:  An 11-item self-report questionnaire designed to assess fatigue in brain injured patients during the early stages of recovery – focuses more on the difficulty of fatigue (e.g., staying alert, maintaining energy). 

Resource Criteria:

Population
Traumatic Brain Injury (Mild or Moderate)

Reliability/ Validity

Preliminary findings of the BNI Fatigue Scale revealed acceptable 1-day test–re-test reliability on a heterogeneous sample (n=30) of neurologic patients (r=0.96).1 Principle components factor analysis yielded a one-factor solution. Acceptable internal consistency was calculated for the scale items. Overall index of fatigue correlated significantly with the total scale score. 1

In another recent study, mTBI patients had significantly greater total scores on the BNI-FS than the control group (p<0.005, Cohen’s d=0.40). The internal consistency reliability for the BNI-FS, as measured by Cronbach’s alpha, was 0.96 for the mTBI
group and 0.87 for the control group.2 

Proprietary?
Yes (Varied)

Time to Administer
3-5 minutes

Method to Administer
Self-administered or given by an interviewer (in-person or over the phone).

Formal Instructions (Mention if special environment/ equipment is needed)

The BNI Fatigue Scale asks patients to describe their level of difficulty on 10 fatigue-related items (e.g. staying awake during the day; staying alert during activities) (see
Appendix). The scale ranges from 0–1 (rarely a problem), 2–3 (occasional problem, but not frequent), 4–5 (frequent problem) and 6–7 (a problem most of the time). A final item (item 11) asks patients more generally to provide an overall rating of their level of fatigue.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1 Borgaro SR, Gierok S, Caples H, Kwasnica C. Fatigue after brain injury: Initial reliability study of the BNI Fatigue Scale. Brain Injury 2004;18:685–690. 

2 Wäljas M, Iverson G, Hartikainen KM, Liimatainen S, Dastidar P, Soimakallio S, et al. Reliability, validity and clinical usefulness of the BNI fatigue scale in mild traumatic brain injury. Brain Injury 2012;26(7–8):972–978.

Appendix 11.2
List of Medications Associated with Fatigue, Asthenia, Somnolence, and Lethargy from the Multiple Sclerosis Council (MSC) Guideline
Appendix 11.3
Patient Advice Sheet on Coping Strategies for Fatigue
Appendix 11.4
Increasing Physical Activity to Better Manage Fatigue
Appendix 2.2
Parkwood Pacing Graphs
appendix-2-2.pdf
Table 11.1
Fatigue: Assessment and Management Factors for Consideration
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Popov N, Mercier LJ, King R, Fung T, Debert CT. Factors Associated with Quality of Life in Adults with Persistent Post-Concussion Symptoms. Can J Neurol Sci. 2022;49(1):109-117.

STROBE: 16/23

Associated with recommendation 11.1

Andelic N, Røe C, Brunborg C, et al. Frequency of fatigue and its changes in the first 6 months after traumatic brain injury: results from the CENTER-TBI study [published correction appears in J Neurol. 2020 Sep 10. J Neurol. 2021;268(1):61-73.   

STROBE: 18/23

Associated with recommendation 11.2 (pain, mood, and sleep)

Meltzer KJ, Juengst SB. Associations between frequent pain or headaches and neurobehavioral symptoms by gender and TBI severity. Brain Inj. 2021;35(1):41-47. 

STROBE: 16/23

Associated with recommendation 11.2 (pain)

Rakers SE, Timmerman ME, Scheenen ME, et al. Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study. Arch Phys Med Rehabil. 2021;102(10):1965-1971.e2.   

STROBE: 20/23

Associated with recommendation 11.2 (pain, mood, and sleep)

Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabil Res Pract. 2012;2012:705309.  

DOWNS & BLACK: 14/32

Associated with recommendation 11.3

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.  

PRISMA: 10/27

Associated with recommendation 11.3

Chin LM, Chan L, Woolstenhulme JG, Christensen EJ, Shenouda CN, Keyser RE. Improved Cardiorespiratory Fitness With Aerobic Exercise Training in Individuals With Traumatic Brain Injury. J Head Trauma Rehabil. 2015;30(6):382-390.  

DOWNS & BLACK: 14/32

Associated with recommendation 11.3

Sullivan KA, Blaine H, Kaye SA, Theadom A, Haden C, Smith SS. A Systematic Review of Psychological Interventions for Sleep and Fatigue after Mild Traumatic Brain Injury. J Neurotrauma. 2018;35(2):195-209.

AMSTAR 2: 14/20

Associated with recommendation 11.4 (CBT)

Ali A, Morfin J, Mills J, et al. Fatigue After Traumatic Brain Injury: A Systematic Review. J Head Trauma Rehabil. 2022;37(4):E249-E257.

AMSTAR 2: 12/20

Associated with recommendation 11.4 (CBT), 11.7 (melatonin), 11.8, 11.9 (modafinil), and 11.10

Acabchuk RL, Brisson JM, Park CL, Babbott-Bryan N, Parmelee OA, Johnson BT. Therapeutic Effects of Meditation, Yoga, and Mindfulness-Based Interventions for Chronic Symptoms of Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Appl Psychol Health Well Being. 2021;13(1):34-62.  

AMSTAR 2: 13/20

Associated with recommendation 11.5

Shirvani S, Davoudi M, Shirvani M, et al. Comparison of the effects of transcranial direct current stimulation and mindfulness-based stress reduction on mental fatigue, quality of life and aggression in mild traumatic brain injury patients: a randomized clinical trial. Ann Gen Psychiatry. 2021;20(1):33.  

Downs & Black: 20/28

Associated with recommendation 11.5

Raikes AC, Dailey NS, Forbeck B, Alkozei A, Killgore WDS. Daily Morning Blue Light Therapy for Post-mTBI Sleep Disruption: Effects on Brain Structure and Function. Front Neurol. 2021;12:625431.  

Downs & Black: 19/28

Associated with recommendation 11.6

Raikes AC, Dailey NS, Shane BR, Forbeck B, Alkozei A, Killgore WDS. Daily Morning Blue Light Therapy Improves Daytime Sleepiness, Sleep Quality, and Quality of Life Following a Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2020;35(5):E405-E421.  

Downs & Black: 21/28

Associated with recommendation 11.6

Srisurapanont K, Samakarn Y, Kamklong B, et al. Blue-wavelength light therapy for post-traumatic brain injury sleepiness, sleep disturbance, depression, and fatigue: A systematic review and network meta-analysis. PLoS One. 2021;16(2):e0246172. 

AMSTAR 2: 16/20

Associated with recommendation 11.6

Johansson B, Andréll P, Rönnbäck L, Mannheimer C. Follow-up after 5.5 years of treatment with methylphenidate for mental fatigue and cognitive function after a mild traumatic brain injury. Brain Inj. 2020;34(2):229-235.   

Downs and Black: 17/28

Associated with recommendation 11.8

Menn SJ, Yang R, Lankford A. Armodafinil for the treatment of excessive sleepiness associated with mild or moderate closed traumatic brain injury: a 12-week, randomized, double-blind study followed by a 12-month open-label extension. J Clin Sleep Med. 2014;10(11):1181-1191.  

PEDro: 10/11

Associated with recommendation 11.9