Fatigue: A Common Complaint of Individuals with TBI

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Fatigue A Common Complaint of Individuals with
TBI
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Wayne A. Gordon, Ph.D. Jack Nash
Professor Department of Rehabilitation
Medicine Mount Sinai School of Medicine Mount
Sinai Medical Center New York, NY E-mail
wayne.gordon_at_mssm.edu Website www.tbicentral.org
This presentation is supported by Grant No.
H133A02501, National Institute on Disability and
Rehabilitation Research.
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• More than 70 of those studied by Olver et al,
  1996 complained of fatigue up to 5 years

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• LaChapelle et al, 1998 reported that many
  individuals with TBI report that fatigue is their
  most disabling symptom

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Why are individuals with TBI fatigued?

• It has been suggested that more mental effort is
  needed to get the job done (VonZomeron, 1984)

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Why are individuals with TBI fatigued?

• Zino et al, 2006 and Riese et al, 1999 have
  reported that the blood pressure of individuals
  with TBI increased while they were performing
  cognitive tasks

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• Given the importance of this issue in the last
  funding cycle (2002-2007) 3 TBI model
  systems independently examined Post-TBI Fatigue
  (PTBIF)
• Santa Clara Valley Medical Center
• Craig Hospital
• Mount Sinai Medical Center

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• The findings of these research projects were
  published in the January 2008 issue of JHTR

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Fatigue over time

• SCVMC examined a group of individuals at 1 and 2
  years post-injury and found that levels of
  fatigue ranged between 23 and 61 depending on
  the measure used
• These values were stable between years 1 and 2

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Fatigue over time

• They also reported some decrease in fatigue in
  the first year post-injury that increased again
  between 18 and 24 months post-injury

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The Mount Sinai group examined two issues

• The relationship between fatigue and cognitive
  performance
• The relationship between fatigue and participation

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Fatigue and cognition

• The relationship between fatigue and cognitive
  performance examined by creating a cognitive
  challenge and comparing the response of
  individuals with TBI (n 202) and non-disabled
  individuals (n 73)

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Fatigue and cognition

• Evaluation lasted on average 4.5 hours and
  consisted of two administrations of 6 subtests
  taken from the CANTAB (double baseline)
• Followed by a third administration about two
  hours later
• In between the second and third administration
  the person was given paper and pencil tasks

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Fatigue and cognition

• Changes in performance on the CANTAB was viewed
  as a measure of objective fatigue
• Situational fatigue was based by a 7 point rating
  of fatigue on a Likert scale
• Day-to-day fatigue was measured by scores on
  the GAF

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Fatigue and cognition

• In order to reduce the number of variables CANTAB
  was factor analyzed and three factors emerged
• Speed
• Accuracy
• Executive function

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Fatigue and cognition

• Individuals with TBI did poorer than ND on the
  CANTAB and were also more fatigued

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Fatigue and cognition

• On the speed factor scores the ND became faster
  indicating that they were benefiting from
  practice
• Those in the TBI group remained stable across
  administration indicating no benefits from
  practice

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Fatigue and cognition

• In terms of accuracy, individuals with TBI made
  more errors over time
• Those in the ND group remained constant
• No change on executive function scale in either
  group

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Fatigue and cognition

• Speed was associated with situational fatigue at
  all points in time in the TBI group but not in
  the controls
• Day-to-day fatigue (GAF score) was related to
  speed at T1 and T3 in the TBI group but not the
  controls
• In the control group those who were more fatigued
  experienced a greater decline in their speed

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Fatigue and cognition

• These findings suggest that different patterns of
  cognitive performance are associated with fatigue
  in individuals with TBI and controls
• Response speed decrease as the cognitive demands
  increase

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Fatigue and participation

• 75 of TBI (n 223) had significant fatigue as
  opposed to 40 of controls (n 85)

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Fatigue and participation

• The relationship between fatigue (GFI), pain,
  sleep and depression was examined by eliminating
  items from the non-fatigue scales that overlap
  with the GFI, i.e., fatigue
• TBI had higher levels of depression, pain, poorer
  sleep quality and health related quality of life

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Fatigue and participation

• In predicting fatigue it was found that sleep
  quality, pain and depression accounted for 58 of
  the variance in the controls and 23

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Fatigue and participation

• GFI scores were not correlated with measure of
  participation
• Fatigue did not appear to limit what folks were
  doing

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Fatigue and treatment

• The group at Craig examined the utility of
  modafinil as a treatment for fatigue defined as
  daytime sleepiness
• There was no clear benefit of the drug over
  placebo!

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Future plans

• Collaborative study on post-TBI insomnia
  involving four other TBI model systems
• Carolinas Rehabilitation
• JFK Johnson Rehabilitation Institute
• Kessler Medical Rehabilitation and Research
  Center
• Santa Clara Valley Medical Center

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Future Plans

• Study will examine insomnia in individuals at 1
  and 2 years post injury and 2 and 5 years
  post-injury

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Future Plans

• Mount Sinai is also studying the utility of
  exercise as a treatment for post-TBIF

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