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Fatigue After Brain Injury: BrainLine Talks With Dr. Nathan Zasler

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Victoria Tilney McDonough, BrainLine

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Fatigue After Brain Injury: BrainLine Talks with Dr. Nathan Zasler
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BrainLine sat down with Dr. Nathan Zasler to talk about the issues of fatigue after a traumatic brain injury. Dr. Zasler is an internationally respected neurorehabilitation physician who specializes in brain injury.

BrainLine: Describe fatigue. What exactly is traumatic brain injury-related fatigue?

Dr. Zasler: Think about a car. It needs gas to run. If your tank is low, your car will start sputtering and then stop once you have reached the end of your reserve. It’s the same way with fatigue after TBI. Fatigue is caused by a decrease in physiological reserve, which includes a person’s physical and mental reserves. When your brain is “tapped out,” you feel tired. Basically, when a person’s brain is overtaxed, fatigue will set in.

Although one formal definition of fatigue that has been proposed states that it is the failure to initiate or sustain attention or physical activity that requires self-motivation, there continues to be debate about how best to define "fatigue." In part, it’s difficult to define the term because fatigue is subjective — that is, it is solely based on patient report — and it is really more a symptom than a diagnosis. Just like it is difficult to tell if someone is in pain, it is also challenging to know if someone suffers from fatigue unless they tell you so. But generally, people with TBI have described fatigue as a sense of mental or physical tiredness, exhaustion, lack of energy, and/or low vitality. Unfortunately, we don’t have any definitive screening tools for fatigue, so there is no universal way to measure it.

Cognitive and physical fatigue can occur separately or together, but most people seem to have more problems with the mental side of fatigue after a brain injury. They say they are not as quick as they used to be, mental tasks that were once easy are much more difficult, and they tire far more easily even doing something that used to be simple like reading, studying, or working.

Although there are limited long-term studies, some research indicates that fatigue is usually short-lived after most mild TBIs. And in my experience as a physiatrist, fatigue in patients with mild TBI usually lasts no longer than three to six months. However, for some people with mild TBI, their fatigue is more persistent.

BrainLine: How common is fatigue after a brain injury?

Dr. Zasler: In the general population, fatigue is a common complaint with some studies citing an incidence of 10 percent. But for people with traumatic brain injury, it is one of the most common problems post-injury. Fatigue affects not only people with moderate to severe TBI, but also those with mild TBI. And we still need more research to better understand this issue.

BrainLine: What does fatigue look like after TBI?

Dr. Zasler: The spectrum of fatigue is as broad as the spectrum of traumatic brain injury, itself. Everyone’s brain injury is different and everyone’s symptoms will be different. There are also many variables when it comes to post-TBI fatigue — from levels of severity to pervasiveness. Some people may be very fatigued all the time and others may only be fatigued after mental or physical exertion.

Most people who have fatigue resulting from brain injury only experience the problem at certain times and not all the time. They have more energy in the morning and tend to be more tired later in the day. People’s levels of fatigue also depend on how much they are pushing themselves physically or cognitively, and whether they are making time to rest periodically during the day and pace themselves.

Depression, anxiety, or stress can also contribute to the degree of a person’s fatigue or, alternatively, may even be the cause of the fatigue. Not everyone with a TBI will experience fatigue due to their brain injury. So, each person’s levels of fatigue, if present, may change over time during their recovery, in terms of both cause and level of severity.

BrainLine: Why do these problems occur?

Dr. Zasler: Unfortunately, we don’t really know. There have not been a lot of conclusive studies conducted on fatigue after brain injury. Much of what we are discussing is experiential. Some have theorized that damage to the basal ganglia — which are structures deep in the brain — are the critical areas involved in the generation of fatigue. Others have noted that other areas of the brain may be involved as well.

BrainLine: What kind of information should people with brain injury give their doctor to help the doctor better understand their issues with fatigue?

Dr. Zasler: This is a two-way street, of course. People should give their doctor as much information as they can and, in turn, the doctor needs to ask the right questions and get as full a picture of the symptoms and situation as possible.

First of all, it’s important to establish the cause of fatigue; it may not be a result of the traumatic brain injury. It could be something else, and those other potential causes should first be ruled out. Other common contributing factors for fatigue can include:

  • lack of regular and restorative sleep
  • psychiatric issues like depression or anxiety
  • chronic pain
  • chronic stress

There are also less common causes for fatigue that should also be ruled out. They can include:

  • seizure-related fatigue
  • hydrocephalus
  • hormonal abnormalities, like hypothyroidism
  • nutritional deficiencies such as low B12, anemia, or blood cancers (i.e., leukemia)
  • renal failure
  • hepatitis

All of these causes, common and less common, should be considered and then ruled out as the sole or contributing cause of a person’s fatigue before considering TBI as the cause.

Once other causes of fatigue are ruled out and the fatigue is found to be neurogenic —related to the damage to the brain’s nerve cells — some of the topics and questions that need to be covered in the doctor’s evaluation include:

  • When did the symptoms of post-TBI fatigue start?
  • Did the onset of fatigue symptoms correlate with any other event such as starting a new medicine or getting depressed?
  • What helps make the fatigue go away, or decrease?
  • What aggravates it?
  • What triggers it?
  • In what ways are you fatigued physically, and when?
  • In what ways are you fatigued mentally, and when?
  • How is your sleep?
  • How is your mood?

BrainLine


Nathan D. Zasler, MD Nathan D. Zasler, MD, Nathan Zasler, MD is CEO and medical director for Concussion Care Centre of Virginia, Ltd. as well as CEO and medical director for Tree of Life Services, Inc.  He is board certified in physical medicine and rehabilitation and fellowship trained in brain injury.


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Specifically, with regards to medical issues, always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Web Site. If you think you may have a medical emergency, call your doctor or 911 immediately. The Web Site does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Web Site. Reliance on any information provided by the Web Site or by employees, volunteers or contractors or others associated with the Web Site and/or other visitors to the Web Site is solely at your own risk.

Comments [28]

This is helpful. I conked my head six weeks ago and am keen to resume exercise but walks wipe me out. I really can't figure out if I should rest up or resume regular light training. Sounds like resting too much can cause fatigue which is what I hoped but maybe I'm reading this as I want to. My doctor is ok with gentle exercise.

Dec 7th, 2014 2:24am

I'd be interested to know how exercise effects people? I'm post tbi 4 years and the after effects of exercise still causes stunted or slurred speech and difficulty retrieving words. Sometimes I feel agitated or annoyed about an hour post workout. I used to be a runner before my accident. Thanks.

Nov 3rd, 2014 10:59pm

I suffered a TBI in early 2013 and also developed post-traumatic epilepsy. I also am terribly fatigued and wonder if anyone else with a seizure disorder has tried any of the stimulants mentioned in this article? I'm not sure if it is an option in my situation. I will discuss with my MD but am curious about anyone else's experience.

Jul 30th, 2014 11:29pm

I just thought of someone else's comment I would like to respond to in regards to insomnia and being awake all night (even though tired) but not being able to "turn the thoughts off" and go to sleep.  My psychiatrist said she thinks it may be because during the day there is so much going on (stimulation) that sometimes makes it hard for us with TBI to concentrate and focus. So ... we seem to "try" to get more done during the night time when things are more calm and quiet and we can focus more without the additional stimulation of day to day life. Hope this helps ... it makes sense to me.

Jul 29th, 2014 2:57am

My TBI was in 1997 and I still to this very moment fight fatigue. I am on Social Security disability. There are two drugs I have taken (as needed) for energy if I have a day with alot going on and need "help" staying awake and focused. I was told that these drugs were originally for people with narcolepsy. They are called Provigil and Nuvigil ... they are pretty much the same.  They really do help but sometimes I'll take one and STILL get extremely tired and CANNOT sleep but most of the time they help alot. I do not take them daily because I do not want to become dependent on them. Good luck and hope this helps!

Jul 29th, 2014 2:49am

I work with individuals who have sustained TBI and I am also putting together my latest research idea. I have read tonnes of literature and have noticed diet changes can help. Eat lots of eggs and red meat is one of the things I have seen

Jul 23rd, 2014 9:17am

My 'injury' was the surgery performed to remove a glioblastoma. Lucky as hell and in generally very good condition, including virtually no loss in cognition, or so it seems most of the time. Depending on how well I've been feeling, I can push my brain 4,5, 6 hours or a little more before I'm outta gas and sleep is going to happen. I'd better at least sit down. Golf is a bit of mental exercise, but the physical side of that is enough to keep me awake. I can take up to three naps a day, but am usually awake, up and going between 5 and 7 every morning. My ability to sleep at night is interrupted by an aging male's prostate, too, eliminating my chances at a good night's sleep. More of my great luck is an ability to turn the euphoria enjoyed through the use of cannabis into an energy that motivates activity. It's why I walk 5-8 miles a day, depending on how well I hit the ball, 4-5 days a week. Fatigue is unbeatable, but we can still lead active and reasonably normal lives.

Apr 13th, 2014 12:40am

Anna here, I get 2-3 hours of sporadic sleep a night.  Was told I have Chronic Fatigue Syndrome.  I cannot takes meds because of my TBI, we've tried.  I'm so tired of being tired.  My TBI came about from an auto accident in 1993, so, for almost 20years I have been exhausted.  Sad because my son was 8months old and I couldn't do much with him that little boys are supposed to do.  I constantly worry about TBI's and Alzheimers.

Mar 20th, 2014 12:11pm

I am tired often. I need to sleep for 4-5 hours after a seizure. I sleep at least 8 hours a night. But force myself to stay awake often.

Mar 16th, 2014 7:02pm

Quite interesting, thanks for sharing. A large, and oft overlooked contributing factor to neurofatigue is diet. I sustained a TBI 10+ years ago and found that fatty, carbohydrate saturated foods dramatically increased the mid-day "brain drain" that so many survivors report. I found that modifying my diet and including regular cardio exercise into my daily routine drastically improved my fatigue.

I'd be interested to see what research exists on exercise and also nutrition on fatigue after a brain injury.

Mar 16th, 2014 9:35am

While I was fighting to get social security disability, the judge looked at the variability of my fatigue levels as reason to assume the problem was not disabling. He was not impressed that on the only day that I did not get regular naps, my daughter's wedding, that I was rushed to the hospital against my wishes because my lips were blue, in addition to other obvious signs that I was mostly not awake. When I heard my lips had been blue, I purchased an oximeter and checked my blood-oxygen saturation over three days. I took the evidence to my doctor. In spite of the doctor observing blue lips at the wedding himself, he did not believe I had low oxygen levels because staff in his own office misread their oximeter, swapping pulse and oxygen levels in her report. So I had to go through a CT scan to rule out that I might be hallucinating before the doctor actually used a third party to check my oxygen levels. Since my TBI fatigue was at least partly due to inadequate oxygen, I wonder how many other TBI survivors are also struggling with low oxygen levels?

Mar 16th, 2014 7:18am

i have lost my smell sensation to some extent, i in 90% cases dont feel smell what others can,but while and after exercising , smell sensation works well but for 30 minutes after exercise.

Mar 15th, 2014 10:31pm

and after passing stool , feel completely energy less.i need to eat a lot which helps me feel energetic and have no fatigur in the morning but again makes me fatigues in the afternoon,so even if i take a nap or eat food, i get fatigued.I need to take a nap and exercise to get back to work.

Mar 15th, 2014 10:29pm

i had forgotten to mention-  the real cause for my fatigue is constipation , i dont pass stool for 3-4 weeks or more if i dont exercise and if i exercise , i pass stoll but in a very less quantity, after passing stool , fatigue goes off.

my previous comment-

When did the symptoms of post-TBI fatigue start?before weight loss

Did the onset of fatigue symptoms correlate with any other event such as starting a new medicine or getting depressed?depression after accident

What helps make the fatigue go away, or decrease? exercise in the morning and evening and fitnessblender metabolism 5 minute exercise every 2 hours , speak a lot the whole day and keep thinking and repeating things in brain

What aggravates it?no exercise, little or excessive food, walking fast for around 10 minutes and not for an hour to get enough exercise(i lost wt by walkingfrom 7pm to 2 am in the 3rd month of wt loss)

What triggers it? lack of exercise, depression, negative thoughts, inability to focus,

In what ways are you fatigued physically, and when? afternoon or after heavy exercise for 10 minutes.After 9.30pm and 12.00pm , sleep is must and my body automatically sleeps and i cant think at all and i must sleep.TO work at night, i must take a nap at 9.30 pm for 30 minutes

In what ways are you fatigued mentally, and when?morning

one day no exercise, its all over

How is your sleep? 6-7 hours

How is your mood?depends

Do you suffer from significant chronic pain?back injury , otherwise, i do feel left front brain and sometimes right front brain paining a bit and at the rear of the left brain.Apart from this, i sometimes feel something wrong with my right side of the heart, some sort of choking.and sometimes, this heart pain becomes severe and i can feel the vein of that right part of the heart tapping some 4-5 times very heavily.

Apart from this, on monday i have signs of panic anxiety, as doctor says.Chest becomes real hot, brain stops working and pains a bit and i become nervous.

All my heart and brain reports are normal.ECG report was abnormal but doctor said its a machine error, there are p waves in the report which the machine isnt able to recognise and hence is generating wrong report

and  comment of the 52 kg loss

Mar 15th, 2014 10:23pm

When did the symptoms of post-TBI fatigue start?before weight loss

Did the onset of fatigue symptoms correlate with any other event such as starting a new medicine or getting depressed?depression after accident

What helps make the fatigue go away, or decrease? exercise in the morning and evening and fitnessblender metabolism 5 minute exercise every 2 hours , speak a lot the whole day and keep thinking and repeating things in brain

What aggravates it?no exercise, little or excessive food, walking fast for around 10 minutes and not for an hour to get enough exercise(i lost wt by walkingfrom 7pm to 2 am in the 3rd month of wt loss)

What triggers it? lack of exercise, depression, negative thoughts, inability to focus,

In what ways are you fatigued physically, and when? afternoon or after heavy exercise for 10 minutes.After 9.30pm and 12.00pm , sleep is must and my body automatically sleeps and i cant think at all and i must sleep.TO work at night, i must take a nap at 9.30 pm for 30 minutes

In what ways are you fatigued mentally, and when?morning

one day no exercise, its all over

How is your sleep? 6-7 hours

How is your mood?depends

Do you suffer from significant chronic pain?back injury , otherwise, i do feel left front brain and sometimes right front brain paining a bit and at the rear of the left brain.Apart from this, i sometimes feel something wrong with my right side of the heart, some sort of choking.and sometimes, this heart pain becomes severe and i can feel the vein of that right part of the heart tapping some 4-5 times very heavily.

Apart from this, on monday i have signs of panic anxiety, as doctor says.Chest becomes real hot, brain stops working and pains a bit and i become nervous.

All my heart and brain reports are normal.ECG report was abnormal but doctor said its a machine error, there are p waves in the report which the machine isnt able to recognise and hence is generating wrong report

Mar 15th, 2014 10:20pm

this is how i damaged my brain-

1. I gained too much fat (130kgs) that i needed to sleep after every meal and after that meal i again felt hungry.I had no exercise for 9 or more years before i lost weight.

then one day i decided to loose weight and then in 3 months i lost 52 kgs ,the last month without having food.(ketones found in blood)

Even after weight loss, the sleep issue didnt got resolved and i had one more issue ,i couldnt focus at all while sitting.

So i need to stand and speak aloud to read something and i gained too much interest in reading that i never took a single second pause and keep on reading.Then i took a pause.This is when i felt something isnt good.I am losing listening power, bvefore weight loss i used to write at the speed at which someone speaks but now i cant

another issue that i am facing after weight loss is in the morning.BEfore wt loss, i could wake up any time in the night or anytime i want and i never lack energy but now i just have hardly any energy to think.I need to do exercise to start my day.

Mar 15th, 2014 10:06pm

This answered a lot of questions I had and still have about TBI's. It explains a lot to me, about why I'm so tired all the time.

Mar 15th, 2014 6:22pm

It is a feeling like you brain is in quicksand.

Mar 15th, 2014 4:44pm

Hi Nicole (Nov 11 2013)

I know what you are going through. Please call/email.

bjry@hotmail.com

252-757-2627

Jean

Feb 14th, 2014 9:42am

Hi I acquired a traumatic brain injury when I was 11 years of age, am 28 now, and suffer quite badly from fatigue. It is only in more recent years that I can read a full chapter of a book without wanting to sleep. Anyway I'm back in college now doing a masters and college days are very long. Usually after Lunch I can't stop yawning until little break, 2 hours later and so am not taking in afternoon lectures. As far as memory goes I have trouble encoding information so being alert is very important. Can you please give me any suggestions as to how to combat this. Thanks Nicole :)

Nov 18th, 2013 12:52pm

Going into my 3rd week after brain tumor removal. Feel 100% better than when it was in there. But get very very tired. Trying to do the right thing and listen to my body. If it says I need rest or a nap then thats what I do. Never been one to be idle during day, but I have discovered that if I rest im much nicer.

Sep 26th, 2013 5:00am

For me, coffee - several FDA approved caffeine compounds - alertness aids temporarily improve my alertness level a little as well as temporarily reduce fatigue/provide some small, real energy - both mental and physical. Charles Thomas Wild - Inattentive ADHD/Organic Brain Syndrome as a result of a non-normal, three day delivery (identical twin) in 1946. ADHD at one time in the USA was officially called Minimal Brain Damage (MBD). Thank you.

Mar 27th, 2013 10:26am

These comments are good to hear in that I see that I am not alone in being exhausted. I sustained a sacral spinal injury and one yr out sustained first of two TBIs where I loss consciousness, developed epilepsy, memory loss, chronic fatigue, etc. Although I hold a MSN I cannot work for a variety of reasons. My speech came back after about 5 months and I also relearned how to perform simple tasks. I still had energy after the spinal cord injury but the TBIs really took it from me, especially the second one. My left arm movement returned. My anti-seizure meds had to be adjusted after the second TBI because of the fatigue. I just hate that I am so tired.... I used to be the most energic person with endless energy. If I don't rest and overexert, I wind up seizing and losing bladder and bowel function. I hope that more research is done as TBIs are so common now with our veterans. I started taking Savella for fibromygia and it has helped the fatigue tremendously. I recommend it! Does anyone take any herbs or vitiamins which help? Thank you and Good Luck!!

Nov 19th, 2012 8:43am

Startle reaction: yes, I experience it too. I thought I was the only one in the world because it happened once in a doctor's office and he yelled at me. I was sitting during a rough exam and he reached across my face, in front of my eyes, to touch the other part of my head. Inadvertently, I jumped and my arm swung out and I hit him. I told him I was sorry, that I jump when things surprise me visually, but he was angered and threatened me with cancelling the rest of the appointment. In retrospect, I should have cancelled it. But he was the only game in town and I was too dizzy and physically stressed to take the affirmative steps that I would have taken if I had not been injured and had not been there in the first place. Still hopping to the drugstore on a broken leg for pain pills. (By the way, this happens in response to aural stimulii as well. There is a special sense of unreality when the people paid to treat us have so little understanding of our condition.

Apr 4th, 2011 9:57am

I am a 60 yr old survivor and midlevel provider of 3 Severe TBIs from one incident, now 2 yrs. My story or comment is intended for help to others and TBI Awareness. Prior to my TBIs I interviewed potential military mTBI, and seen or managed very few mod or severe TBIs. These were done bt generalist AND REFERED TO SPECIALTY. I interviewed and followed minor cases and refered to determine further rehab management. All cases complained of fatigue in ome form or another most had family, work or family involvement, esteem, depressed or anxiety/frstration components. If applicable would be refered to BH mainly for safety. I didnot and really have not understand the full story of a TBI and idiosincrasies until mine. I donot have headaches or bad memory lapses or confusion. However I HAVE EXTREME FATIGUE TO POINT OF EXHASTION, SPEECH GARBLE OR SLURINESS and word droping, but I BECOME Tangent, wordy and try to talk to get my point across. Sometimes I feel like the energizer rabbit, but my collegues and friends laugh always with me as they don't see this as abnormal, as I seemed to be like this before my injury. The difference now is that they try to be polite and wait till my point is made which I usually forgot a long time prior, before they would leave. I wake up tired, get tired if ride in auto more than 20-30 min, at diinner time, but at 12 midnight like now Wide awake, can not turn thoughts off at night, insomnia during bedtime. During night can't turn off, day unable to be fully awake. Ask my phsiatrist who told me fatigue is common, usually if made aware seem to accept and becomes waiting game. I HAVE ANTE AND POST AMNESIA OF MY EVENT THEREFORE NO PTSD, but experience vivid dreams. I experience polyuria due to my worse diabetes from oral to insuliN dependent which also causes fatigue, drowsiness with hyperglycemia. Rarely hypoglycemia and no coma episodes also normal thyroid. nOW i INTERTAIN MY DREAMS TIRER ME AS THEY ARE PANORAMIC, LARGE SCALE BUT NON TERROR. Than I read my med may interact on the fatigue and diabetes which is Cymbalta. Seen Psychiatrist who felt cognitive stable and most physical didn't need to see him unless want to change med so will start Prosac soon after 1 week taper and sleep hygiene. Was originally d/c with Oxygen but NOT MONITORED AND HAVE NOT USED SINCE D/C'D 2 yrs ago. May restart. Was using aricept caused me increas urinating got up too much at night, also anti spasmotics and pain meds increased drowsiness so d/c'd and didn't notice change with provigil but it raised B/p. I am in for long haul will wait and see. This articl is helpful and is reference for use now and fture. I sustained a Glasscoe Coma 3 on presentation, remained in coma 2 weeks, sustained a intra cranial subarachnoid bleed, frontal and temporal shearing, thus 3 severe TBIs that were confirmed by spect scan 3-4 months later. Subarachnoid bleed resolved in accute phase. Released after cervical fusion C5C6 24 days post trauma to rehab and sent home 34 days later. Initially return to work trial, however fatigue was very interfering thus awaiting MMI and retirement. Hope this helps someone. Just sharing this is helpful for me.

Apr 2nd, 2011 3:51am

My 17 year old daughter is 7 years post TBI. Stills becomes extremely fatigued, both physically and mentally. she needs to be in bed no later than 9 pm or she is exhausted the next day. We have her taking Yi yoga and she sees a personal trainer to try to build her muscle/body strength. But she has developed these extreme 'startle reactions" to simple noises!! We have tried meds like Stratera with no evail. Any suggestions? could this be related to the fatigue; since you mentioned anxiety. It's so bad that we have to warn her before we sneeze! Any suggestions would be greatly appreciated.

Apr 1st, 2011 9:26pm

I sustained mtbi in 1994 and 1998 and still feel like a failure because fatigue makes me less able to take care of myself. People can often see the debilitating fatigue come over me before I feel it. It comes with blurry vision, slurred speech, slow processing, clumsiness. Glad to see fatigue addressed here. But I am confused by the doctor's comments, "One thing that surprises me time and time again is that no one these days takes the initiative to interview potential doctors before making a selection. You can set up an appointment with a doctor you are considering to get a sense of his bedside manner, knowledge, and philosophy. When it comes to TBI, the patient/physician relationship may continue for many years, so choosing well is very important." In my case, the tbi prevented me from doing the things that I knew to be reasonable. I can't even set up one doctor appointment much less set up some (dealing with medical office structure, insurance requirements, telephone answering methods, scheduling, arranging transportation, dealing with MD's (even when appt is for discussion only) who place a person with tbi in a disabling physical environment, etc. All the things that are tbi to me are the things that prevent me from doing as the doctor is surprised more people don't do. It's like expecting me to hop to the drugstore on a broken leg to get a pain pill. I am stunned at the doctor's surprise. I wish I lived in the world where I could do those things-or had someone to do them for me. I'm just too damn tired.

Apr 1st, 2011 2:36pm

o HAD A RPUTURED MIDDLE CEREBRAL ARERY ANEURYSM IN LATE oCTOBER 2009, EQURING CRQINOTOMY TO DIP THE WNEURYWM, WITH CRQINOPLASTY IN LATE jANUARY, SUFFERED 3 MINOR STROKES ON mri AND MOTOR FUNCGION HAS COMPLETELY RETURNED THANKS TO 4 MONTHS O F HARD THRAPY. i STILL AM COMPETELTIED OT. IS THIS USUAL? FURTHER COMPLICAIONS INCLUDED BLOOD CLO OT THE LEG SHOEWEING TO THE BRAIN CAUSING HE "STROKES". I JUST WAN MY USUAL ENERGEY BACK. DIET IS HELATHY, ND TAKING A DAILY MUTI-VITAMIN ON TOP OF POEIN SHAKES.

May 17th, 2010 3:30pm


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