Ontario Neurotrauma Foundation

Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms

3rd Edition, for Adults over 18 years of age

Ontario Neurotrauma Foundation

Fatigue

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Fatigue has been conceptualized as an experience of weariness or tiredness following mental or physical exertion, often resulting in a reduced capacity for work and limited efficiency to respond to stimuli. Fatigue can be caused by psychological or physiological forces1 and can be central or peripheral, which in lay terms is experienced as cognitive fatigue and physical fatigue or weariness.2-4 Fatigue is one of the most pervasive symptoms following concussion/mTBI, with 27.8% of individuals experiencing persistent fatigue at 3 months post-injury.5 The perception of fatigue can be out of proportion to exertion or may even occur without any exertion.6 One study reported a level of fatigue in patients with concussion/mTBI comparable to that of individuals with multiple sclerosis, a condition which is known to be associated with clinically-significant diseaserelated fatigue levels.7 Fatigue is multidimensional and can affect physical, cognitive, motivational and psychological (i.e., depression, anxiety) spheres.8 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.7 For instance, a state of chronic stress may be present following mTBI, which compromises the biological stress system and increases the likelihood for fatigue and stress-related disorders.9 Fatigue following TBI has also been found to significantly impact well-being and quality of life, and is strongly associated with somatic symptoms and perceived situational stress.8,9

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. A review of the relevant items from the Rivermead Post Concussion Symptoms Scale (Appendix 1.5) and/or a specific measure of fatigue, such as the Barrow Neurological Institute (BNI) Fatigue Scale10 (Appendix 11.1). The Fatigue Severity Scale11 (Appendix F), the Fatigue Impact Scale12 (Appendix F) or the Mental Fatigue Scale13 (Appendix F) can also assist with this.

Post-concussion/mTBI fatigue can be persistent and has been shown to still be present up to five years post-injury.8 Those who experience fatigue at three months post-injury are increasingly likely to continue to experience fatigue beyond six months post-injury.11 Due to the relationship between pituitary dysfunction, specifically growth hormone deficiency, and fatigue some have suggested a relation between the two; however recent literature has not found a significant relationship.14-16 As certain medications can cause fatigue, the practitioner should also 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. A list of medications commonly associated with fatigue can be found in Appendix 11.2. 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.8,17 Patients should also be provided with advice on how to cope with fatigue (see Appendix 11.3), such as general stress management techniques.8 If debilitating fatigue persists, consider referral to an interdisciplinary concussion clinic.

Research into treating fatigue has revealed few studies varying from non-pharmacological to pharmacological treatment. Methylphenidate has been found to improve mental fatigue and processing speed in patients with persistent post-concussion symptoms,18,19 including up to 6 months post-treatment.20 Caution is recommended in the use of stimulants however; as clinical experience has identified that some individuals report that stimulants provide a burst of energy followed by increased fatigue. Some non-pharmacological treatments such as exercise (e.g., aquatic therapy), mindfulness-based stress reduction, cognitive behavioural therapy21 and blue-light therapy22 could potentially be helpful in treating fatigue however more research is needed.23

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Assessment and Management of Fatigue

New Key Section Level of evidence A B C Updated Evidence
11.1 C

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).

11.2 C

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.

11.3* A

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

11.4 B C

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 2.6) 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)

Appendix 1.5

Rivermead Post Concussion Symptoms Questionnaire

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Appendix 11.1

Barrow Neurological Institute (BNI) Fatigue Scale

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Appendix 11.2

List of Medications Associated with Fatigue, Asthenia, Somnolence, and Lethargy from the Multiple Sclerosis Council (MSC) Guideline

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Appendix 11.3

Patient Advice Sheet on Coping Strategies for Fatigue

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Appendix 11.4

Increasing Physical Activity to Better Manage Fatigue

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Appendix 2.6

Parkwood Pacing Graphs

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Appendix F

Other Useful Links/References for Resources to Consider

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Table 11.1

Fatigue: Assessment and Management Factors for Consideration

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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

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