Taking Control of TBI Fatigue

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Shon Rice
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1 Taking Control of TBI Fatigue Sarah Lillas Occupational Therapist Acknowledgements Jean Hay-Smith and William Levack

2 Traumatic Brain Injury (TBI) Common i.e. rate in Waikato of 790 per 100,000 population per year 1 95% of TBI mild, 5% moderate/severe Highest incidence in ages 0-4 and years 1 Men times more likely (depending on severity) 1 Higher rates in Maori - 33% of TBI s vs 22% of general population 1

3 Fatigue and TBI Common TBI symptom % incidence 2 No correlation - severity and fatigue levels 5,6,7 Fatigue continues long after injury: At 1 month 66%, at 1 year 42% 5 Significant correlation - greater levels of fatigue and poorer performance in complex selective attention tasks.

4 Fatigue and TBI Contributors to severity of fatigue include: Vitamin D deficiency Poor sleep Anxiety 4 Variables associated with fatigue include: Early fatigue severity Active mental health input pre-injury Medical disability Depression 3

5 Fatigue Impact Fatigue associated with poorer outcomes in motor, cognitive and general functioning 8 Also impacts on Personal hygiene (25%) Cognitive ability (58%) Social and leisure (43%) Mood (44%) Work (45%) Rehabilitation activities (33%) 9

6 Fatigue Management There is no quality evidence to support any intervention to manage fatigue after sustaining a TBI 10

7 Fatigue Management at Work My Study Question: How do people manage fatigue, that they attribute to TBI, to enable them to conduct paid work?.

8 Fatigue Management at Work My Study Qualitative descriptive. Recruited via community based therapists. Semi-structured interviews, transcribed and thematically analysed. 8 Waikato based participants of working age. Mix of men and women that had mild to moderate TBI s. Time since injury 6 months to 21 months. Returned to their pre-injury employment.

9 Results Fatigue management strategies that were utilised at work formed a continuum. Movement to the left indicated greater productivity Movement to the right indicated a need for more recovery with lower productivity.

10 Continuum

Productivity and Drivers Green indicates engagement in the work tasks Purple indicates recovery to allow engagement in work tasks Individuals were seen to be pulled to left to

11 Productivity and Drivers Green indicates engagement in the work tasks Purple indicates recovery to allow engagement in work tasks Individuals were seen to be pulled to left to achieve productivity But to recover from TBI fatigue they were pulled to the right with resulting less productivity. Both essential in maximising productivity over the day/week

12 Intensity of Tasks

13 High Intensity Tasks Computers High levels of thinking Lots of noise or light Multi-tasking High social demands.

Low Intensity Tasks Choosing easier tasks Implementing cognitive strategies. Alter environment (noise/light). Move environment -reduce noise/light/ social.

14 Low Intensity Tasks Choosing easier tasks Implementing cognitive strategies. Alter environment (noise/light). Move environment -reduce noise/light/ social. Use equipment. because clearly the computer just drives me crazy, and the alternative task may not require so much, may not be taxing on my mind, my brain

15 Types of Breaks

16 Super Mini Break Very short break (few minutes). Occurs within the work task. Occurs in the same environment. I just sit there and not look at the screen for a couple of minutes

17 Mini Break Obvious stop from task. Away from core task Still in work environment. From 2 to 10 minutes. I had a few minutes between each patient as well. Just to kind of switch off

18 Long Break Obvious stop from task. Away from core task Often away from work environment. From 15 minutes to 1 hour. Often involved going for a walk. sometimes I could do a longer walk, sometimes I go for minute s walk

19 Sleep / Day Off Sleep Point of leaving work to sleep at home. Increase sleep at night Day Off When weekends aren t enough to recover

20 Activities Outside Work and Balancing

21 Activities Outside of Work Activities Reduce social, leisure and domestic tasks Avoid computers, alcohol and coffee. Exercise Light to moderate. After work, weekends and in long break Preferably outside Relaxation

22 Balancing Balance tasks over week. Prioritising tasks over week (work and self-care tasks priority). Alternating between high and low intensity over day So I schedule it as well as I can and I know that there s low concentration stuff there or high concentration stuff in the morning and a low stuff in the afternoon usually

23 Change Points Utilising fatigue symptoms to determine the need to change Symptoms included headaches, cognitive difficulties, increased sensitivity and irritability Fatigue symptoms were used to determine the level of break needed. Early recognition was ideal to reduce impact of break (keep to left on diagram)

24 Pushing Through Pushing through occurred when individuals continued with high intensity tasks, ignoring or choosing to ignore change points Consequence - extreme fatigue, temporary disability, 2-3 days to recovery Pushing through with resulting extreme fatigue was an essential factor into learning about the need to implement fatigue strategies and accepting this.

25 Decision of Change Point Implementation The decision on the timing of the change point was complex. Common factor in all a self defined fatigue symptom Motivator overdoing it crashing and related symptom exacerbation

26 Factors considered at change point Factors influencing the decision on what strategy to implement at change point Level of fatigue (primary) Own expectations or self identity Others expectations Priority of the task

27 Learning process Essential to successful fatigue management was a process of trial and error learning about own symptoms and the appropriate strategy to implement at the change point Further refinement of the timing of change points also occurred with a trial and error approach once at work utilising reflection.

28 Clinical Application - Symptoms Possible clinical applications may include: Supporting a process of learning about fatigue, and personalised fatigue symptoms. Encouraging trial and error and not externally preventing pushing through behaviours Encourage fatigue symptom identification through reflection and self discovery Use of diaries to help determine symptoms. Possible use of ranking fatigue symptoms to establish first symptoms

29 Clinical Application - Strategies Discuss strategies and use of altering tasks and different types of breaks Utilise fatigue diaries as learning tools - matching fatigue symptoms and/or activities to strategies Continue supporting trial and error learning to refine strategies.

30 References 1. Feigin, V. L., Theadom, A., Barker-Collo, S., Starkey, N. J., McPherson, K., Kahan, M.,... Ameratunga, S. (2013). Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurology, 12(1), Cantor, J. B., Gordon, W., & Gumber, S. (2013). What is post TBI fatigue? NeuroRehabilitation, 32(4), 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, Schnieders, J., Willemsen, D., & de Boer, H. (2012). Factors contributing to chronic fatigue after traumatic brain injury. The Journal of head trauma rehabilitation, 27(6), Dikmen, S., Machamer, J., Fann, J. R., & Temkin, N. R. (2010). Rates of symptom reporting following traumatic brain injury. Journal of the International Neuropsychological Society : JINS, 16(3), 401.

31 References 6. Borgaro, S. R., Baker, J., Wethe, J. V., Prigatano, G. P., & Kwasnica, C. (2005). Subjective reports of fatigue during early recovery from traumatic brain injury. The Journal of head trauma rehabilitation, 20(5), Cantor, J. B., Ashman, T., Gordon, W., Ginsberg, A., Engmann, C., Egan, M.,... Flanagan, S. (2008). Fatigue after traumatic brain injury and its impact on participation and quality of life. The Journal of head trauma rehabilitation, 23(1), Bushnik, T., Englander, J., & Wright, J. (2008a). The experience of fatigue in the first 2 years after moderate-to-severe traumatic brain injury: a preliminary report. The Journal of head trauma rehabilitation, 23(1), Ouellet, M.-C., & Morin, C. M. (2006). Fatigue Following Traumatic Brain Injury: Frequency, Characteristics, and Associated Factors. Rehabilitation Psychology, 51(2), Cantor, J. B., Ashman, T., Bushnik, T., Cai, X., Farrell-Carnahan, L., Gumber, S.,... Dijkers, M. P. (2014). Systematic review of interventions for fatigue after traumatic brain injury: a NIDRR traumatic brain injury model systems study.(national Institute on Disability and Rehabilitation Research)(Report). 29(6), 490.

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