Turn Text Only Off
Page Utilities
Fatigue After Brain Injury: BrainLine Talks With Dr. Nathan Zasler
Victoria Tilney McDonough, BrainLine
Page 1 of 2
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?
BrainLine
Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CBIST is an internationally respected physician specialist in brain injury care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, Tree of Life, a living assistance and transitional neurorehabilitation program for persons with brain injury in Glen Allen, Virginia.
The contents of Brainline (the “Web Site”), such as text, graphics, images, information obtained from the Web Site’s licensors and/or consultants, and other material contained on the Web Site (collectively, the “Content”) are for informational purposes only. The Content is not intended to be a substitute for medical, legal, or other professional advice, diagnosis, or treatment.
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 [7]
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!!
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.
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.
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.
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.
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.
See All TBI Topics
BrainLine Footer
Getting Started |
Site Features |
Follow Us |
About |
Facebook
Twitter
LinkedIn
YouTube
RSS Feeds
BrainLine.org is a WETA website funded by the Defense and Veterans Brain Injury Center through a contract with the Henry M. Jackson Foundation. Government funding support is not an endorsement of WETA or any of its products, including this website.
© 2013 WETA All Rights Reserved
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