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. 

Introduction-only references:

  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.
Assessment and Management of Fatigue
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).

Level of Evidence Not Applicable
Last updated  

11.2

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

Level of Evidence Not Applicable
Last updated  

11.3

After a brief period of rest during the acute phase (24–48 hours) after injury, patients can be encouraged to become gradually and progressively more active as tolerated (i.e., activity level should not bring on or worsen their symptoms).

*NOT AN ORIGINAL RECOMMENDATION - REPEAT OF 4.5

Level of Evidence Not Applicable
Last updated  

11.4

If identified as a significant symptom, some key considerations that may aid in the management of persistent fatigue can include:

  • Aiming for a gradual increase in activity levels (see Appendix 11.4) that will parallel improvement in energy levels, including exercise below symptom threshold. (B)
  • Reinforce strategies of cognitive and physical activity pacing (see Appendix 2.2) and fragmentation across the day to help patients achieve more without exceeding tolerance levels. (C)
  • Encouraging good sleep hygiene (especially regularity of sleep-wake schedules, and avoidance of stimulants and alcohol), and proper relaxation times. (C)
  • Using a notebook or a diary to plan meaningful goals, record activity achievement and identify patterns of fatigue. (C)
  • Acknowledging that fatigue can be exacerbated by low mood or stress. (C)
  • Provide patients with a pamphlet containing advice on coping strategies for fatigue (see Appendix 11.3). (C)
Level of Evidence Not Applicable
Last updated  

Appendix 1.5
Rivermead Post Concussion Symptoms Questionnaire
 

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

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.

Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259.
Country: Canada
Design: Discussion/Review Article
Quality Rating: N/A *No checklists were appropriate to score this article design


Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med. 2017;24(1):75-82.
Country: Canada
Design: Randomized Control Trial
Quality Rating: PEDro: 8/11


Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278.
Country: USA
Design: Pilot Randomized Control Trial
Quality Rating: PEDro: 6/11


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.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 10/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable


Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Arch Phys Med Rehabil. 2015;96(4):754-759.
Country: USA
Design: Case Series
Quality Rating: DOWNS & BLACK: 14/32 *4 of the sections were not applicable


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.
Country: USA
Design: Case Series
Quality Rating: DOWNS & BLACK: 14/32 *4 of the sections were not applicable


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.
Country: USA
Design: Retrospective Chart Review
Quality Rating: DOWNS & BLACK: 14/32 *4 of the sections were not applicable


 

Leddy J, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion Management. PM R. 2016;8(3 Suppl):S91-S100.
Country: USA
Design: Discussion/Review Article
Quality Rating: N/A *No checklists were appropriate to score this article design