
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?
- Do you suffer from significant chronic pain?
The more information an individual or their family can provide, the more information a doctor has to make a precise diagnosis.
BrainLine: Can you explain why making sure you get a specific or accurate diagnosis is so important?
Dr. Zasler: With any medical issue, an incorrect diagnosis can set a person back in his recovery. It is important to make sure that you are seeing a clinician who is knowledgeable about traumatic brain injury. You can ask for references from other clinicians, from TBI organizations like your state’s Brain Injury Association, and from other patients. And you want a doctor with whom you feel secure, someone who is truly listening to you and asking questions.
Don’t be afraid to take your time in selecting a doctor. 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.
BrainLine: What can make fatigue worse?
Dr. Zasler: If you have neurogenic fatigue — that is, fatigue related to the damage in the brain’s nerve cells — here are some things that can make the fatigue worse:
- not using pacing strategies appropriately, like dividing work into “chunks,” and not getting overly fatigued by working to long at a given task
- not getting regular, restorative sleep
- not taking the necessary naps or getting the rest you need throughout the day
- not getting proper exercise or nutrition
- taking medications that have sedative properties
- having too much stress in your daily life
These suggestions are basic common-sense guidelines that clinicians should apply to help people with fatigue after brain injury. After all, the more a person learns about how and when his fatigue manifests itself, the more he can schedule his day around his levels of energy and create strategies to keep symptoms at bay.
BrainLine: Are there related problems that often occur with fatigue after TBI?
Dr. Zasler: The main ones are depression, anxiety, and stress. These often go hand-in-hand with post-TBI fatigue; one can exacerbate the other.
BrainLine: What advice or strategies do you offer your patients who are struggling with fatigue after a brain injury?
Dr. Zasler: Once I’m pretty sure that the fatigue is related to the TBI, I emphasize basic strategies like:
- getting good regular, restorative sleep
- making sure to get rest when you need it, not after you have become overly tired, stressed, depressed, or in pain
- breaking activities into several steps through scheduling activities, “chunking” (that is grouping certain activities together) and pacing exercising
- eating nutritious foods
- asking for help when needed
BrainLine: What about medications for fatigue?
Dr. Zasler: Medications can sometimes be quite effective. There are different medications that range from more mild, pro-arousal agents like Provigil or Nuvigil to other non-stimulant agents like atomoxetine (Strattera). In the most resistant cases, traditional psychostimulants like methylphenidate or dextroamphetamine can also be considered. In general, drugs are not what should be tried first. They are something to consider for people who don’t seem to be improving with their TBI-related fatigue or when their fatigue is very functionally disabling. The potential for keeping people on long-term drug treatment is certainly present, although to my knowledge this has not been studied in persons with TBI and fatigue. We need more research in this area to determine which drugs might be effective, and for whom.
For a list of current research on fatigue, click here.
BrainLine
Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CBIST
Dr. Zasler 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.
He is board certified in physical medicine and rehabilitation (PM&R) and fellowship trained in brain injury. Dr. Zasler is a clinical professor of PM&R at Virginia Commonwealth University in Richmond, Virginia, as well as a clinical associate professor of PM&R at the University of Virginia in Charlottesville, Virginia. He is a fellow of the American Academy of Disability Evaluating Physicians and a diplomate of the American Academy of Pain Management. His main areas of clinical and research interest include neuromedical issues in acquired brain injury (particularly mild TBI, neuropsychopharmacology, and low level neurologic states), differential diagnosis in acquired brain injury community-based care issues, and chronic pain rehabilitation, including headache.
Dr. Zasler is a practicing clinician who is involved with community-based neurorehabilitation and neuromedical assessment and management of persons with brain injury, neurodisabililty, and chronic pain. www.tree-of-life.com.
Comments (83)
Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.
Anonymous replied on Permalink
I'm going to try HBOT treatments either in OK or LA soon. Check out HBOT.com for more information. I've had five brain injuries in just over nine years time. I've had the more extreme fatigue since a fall on the ice in Nov 2013. The second of three TBIs in a two year period. The other two were car accidents where my car was rear ended each time causing whiplash injuries.
Anonymous replied on Permalink
I am a vet post tbi 15 yrs ago. I am still having cognitive issues as well as chronic fatigue . Hearing loss/ tinnitus.
Anonymous replied on Permalink
I am six most post tbi. I would like to offer some information that I believe will be helpful to myself and others. Yoga Nidra is a type of healing meditation yoga that puts you in a deep healing sleep. Its like getting 4 hours of sleep in 30 minutes. Please do the research and look this up Yoga Nidra. I plan to go for a weekend and learn the techniques. Ill do anything at this point to get my life back. Good Luck
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Mic replied on Permalink
Hello. I know this is an older post but I am reading it just now and not sure if you will see this reply. I am ten months post concussion after two head injuries about ten hours apart. Previous severe brain trauma 13 years earlier with a severed vertebral basilar artery. You are the only other person I have heard experiencing increased symptoms after exercise. It is weirdly comforting to know others experience similar things. I hope you are doing much better now and will continue to improve. Best, Mic
Clayton replied on Permalink
Me too guys. I am 6 years down the line and exercise has never been the same for me.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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!
Anonymous replied on Permalink
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
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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?
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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
Anonymous replied on Permalink
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
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
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.
Anonymous replied on Permalink
It is a feeling like you brain is in quicksand.
Anonymous replied on Permalink
Hi Nicole (Nov 11 2013)
I know what you are going through. Please call/email.
bjry@hotmail.com
252-757-2627
Jean
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