Randomized Controlled Trial of Light Therapy for Fatigue Following Traumatic Brain Injury

Background. Fatigue is a common, persistent complaint following traumatic brain injury (TBI). Effective treatment is not well established. Objective. The current study aimed to investigate the efficacy of 4 weeks of light therapy for fatigue in patients with TBI. Methods. We undertook a randomized, placebo-controlled study of 4-week, 45 min/morning, home-based treatment with short wavelength (blue) light therapy (λmax = 465 nm, 84.8 µW/cm2, 39.5 lux, 1.74 × 1014 photons/cm2/s) compared with yellow light therapy (λmax = 574 nm, 18.5 µW/cm2, 68 lux, 1.21 × 1012 photons/cm2/s) containing less photons in the short wavelength range and a no treatment control group (n = 10 per group) in patients with TBI who self-reported fatigue and/or sleep disturbance. Assessments of fatigue and secondary outcomes (self-reported daytime sleepiness, depression, sleep quality, and sustained attention) were conducted over 10 weeks at baseline (week −2), midway through and at the end of light therapy (weeks 2 and 4), and 4 weeks following cessation of light therapy (week 8). Results. After controlling age, gender, and baseline depression, treatment with high-intensity blue light therapy resulted in reduced fatigue and daytime sleepiness during the treatment phase, with evidence of a trend toward baseline levels 4 weeks after treatment cessation. These changes were not observed with lower-intensity yellow light therapy or no treatment control conditions. There was also no significant treatment effect observed for self-reported depression or psychomotor vigilance performance. Conclusions. Blue light therapy appears to be effective in alleviating fatigue and daytime sleepiness following TBI and may offer a noninvasive, safe, and nonpharmacological alternative to current treatments.

Unstimulated cortisol secretory activity in everyday life and its relationship with fatigue and chronic fatigue syndrome: a systematic review and subset meta-analysis

The hypothalamic-pituitary-adrenal (HPA) axis is a psychoneuroendocrine regulator of the stress response and immune system, and dysfunctions have been associated with outcomes in several physical health conditions. Its end product, cortisol, is relevant to fatigue due to its role in energy metabolism. The systematic review examined the relationship between different markers of unstimulated salivary cortisol activity in everyday life in chronic fatigue syndrome (CFS) and fatigue assessed in other clinical and general populations. Search terms for the review related to salivary cortisol assessments, everyday life contexts, and fatigue. All eligible studies (n=19) were reviewed narratively in terms of associations between fatigue and assessed cortisol markers, including the cortisol awakening response (CAR), circadian profile (CP) output, and diurnal cortisol slope (DCS). Subset meta-analyses were conducted of case-control CFS studies examining group differences in three cortisol outcomes: CAR output; CAR increase; and CP output. Meta-analyses revealed an attenuation of the CAR increase within CFS compared to controls (d=-.34) but no statistically significant differences between groups for other markers. In the narrative review, total cortisol output (CAR or CP) was rarely associated with fatigue in any population; CAR increase and DCS were most relevant. Outcomes reflecting within-day change in cortisol levels (CAR increase; DCS) may be the most relevant to fatigue experience, and future research in this area should report at least one such marker. Results should be considered with caution due to heterogeneity in one meta-analysis and the small number of studies.

Sustained attention following traumatic brain injury: use of the Psychomotor Vigilance Task

OBJECTIVE

Deficits in sustained attention are common following traumatic brain injury (TBI), as a result of primary (i.e., neuropathology) and/or secondary factors (i.e., fatigue, sleep disturbance, depressed mood). The extent to which secondary factors play a role in attention deficits is relatively unexamined. Moreover, the Psychomotor Vigilance Task (PVT) is seldom used in TBI assessment despite its sensitivity to secondary factors observed following injury. The primary aim of the current study was to examine the usefulness of the auditory PVT in identifying attentional difficulties in patients with TBI compared with noninjured controls, and also to explore the impact of fatigue, sleep quality, and daytime sleepiness on sustained attention performances.

METHOD

Participants (n = 20 per group) completed the auditory PVT and self-report measures of fatigue, sleep quality, daytime sleepiness, and depression.

RESULTS

Compared to controls, patients with TBI had widespread PVT deficits including slower response times, increased response variability and attention lapses, and delayed responding in the slowest 10% of responses. Distribution analyses suggested this was likely due to generalized cognitive slowing. Self-reported secondary factors had varying impacts on aspects of PVT performance, with self-reported fatigue exhibiting a more global impact on attention performance.

CONCLUSIONS

The auditory PVT is a sensitive measure of sustained attention deficits in patients with TBI, with aspects of performance influenced by fatigue, sleep disturbance, and depression.

Examining Emotional Sequelae of Sport Concussion

Depression, fatigue, irritability, confusion, and general mood disturbance are frequently reported after cerebral concussion in sport. Recent trends in research point to the importance of examining postconcussive emotional disturbances more thoroughly, empirically, and clinically. An overview of the complexity of human emotion and its study is provided herein, followed by a review of emotional correlates identified in the existing sparse literature. The significance and clinical implications of identifying emotional correlates of concussion in sport and athletics are discussed.

Fatigue and tiredness in people with spinal cord injury

OBJECTIVE

Fatigue is a common symptom in people with neurological injury such as spinal cord injury (SCI), though its nature and occurrence in people with SCI are not well understood. The objective of this research was to investigate fatigue and its relationship to factors such as mood states and self efficacy in adult people with SCI compared to able-bodied controls.

METHODS

Participants included 41 adults with SCI living in the community and 41 able-bodied controls matched for age and sex ratios and education. All participants first completed a comprehensive psychological assessment and were then asked to take part in a 2-3 hour session composed of a regimen of cognitive tasks that required constant concentration and attention. Participants were assessed after completing this task.

RESULTS

The SCI group was found to have significantly elevated levels of fatigue, as well as elevated depressive mood, anxiety and poor self-efficacy. The SCI group was also found to suffer excessive levels of tiredness as a consequence of the 2-3 hour task. Factors such as depressive mood and poor self-efficacy were shown to increase the risk of excessive tiredness.

CONCLUSION

People with a neurological injury such as SCI have a high risk of having fatigue and are susceptible to experiencing excessive tiredness when performing extended tasks, and the presence of elevated depressive mood or poor expectations towards self management will increase this susceptibility. Implications for managing fatigue and improving social access in SCI populations are discussed.

Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury

OBJECTIVE

To determine relationships among chronic stress, fatigue-related quality of life (QOL-F), and related covariates after mild to moderate traumatic brain injury (TBI).

DESIGN

Observational and cross-sectional.

PARTICIPANTS

A total of 84 community-dwelling individuals with mild to moderate TBI recruited from multiple out patient rehabilitation clinics assessed on average 15 months after injury.

METHOD

Self-report surveys and chart abstraction.

MEASURES

Neurofunctional Behavioral Inventory, Perceived Stress Scale-14, Impact of Events Scale, McGill Pain Short-form Scale, and modified version of the Fatigue Impact Scale.

RESULTS

QOL-F was associated with somatic symptoms, perceived situational stress, but not with event-related stress (posttraumatic stress disorder symptoms) related to index TBI, preinjury demographic, or postinjury characteristics. Somatic symptoms and chronic situational stress accounted for 42% of the variance in QOL-F.

CONCLUSIONS

QOL-F in community-dwelling individuals with mild to moderate TBI is associated with chronic situational stress and somatic symptoms. Symptom management strategies may need to include general stress management to reduce fatigue burden and improve quality of life.

Cancer-related fatigue: physical assessment is not enough

Cancer-related fatigue has been referred to as 'inevitable, unimportant and untreatable' (Stone et al, 2000), with patient experiences easily overlooked or even dismissed by health professionals. This article examines literature regarding the prevalence of cancer-related fatigue, its manifestation and assessment. It also aims to encourage fellow health professionals to reflect on their own practice when assessing and managing fatigue, and identifies the need to address the psychosocial dimensions of the experience, as well as the physical.

Measuring perceived difficulty in post-acute brain injury rehabilitation: The Sister Kenny Symptom Management Scale

PRIMARY OBJECTIVE

Patients' perceptions of difficulty managing symptoms contribute to disability after brain injury. This study introduces the Sister Kenny Symptom Management Scale (KSMS) and reports on its factor structure, reliability, validity and clinical value.

METHOD

Archived data from (overlapping) samples of patients with brain injuries of mixed aetiologies, seen at an outpatient clinic over 16 years were used in development and validation studies of the KSMS. Comparison measures included the Profile of Mood States (POMS), neuropsychological test scores and employment.

RESULTS

Factor analysis of 34 items (n = 328) identified five sub-scales with satisfactory internal consistency and test-re-test stability representing difficulty with executive functions, language, recent memory, aggressive behaviour and physical symptoms. A pattern of correlations (n = 336) with Profile of Mood States (POMS) sub-scales of similar and different content supported the concurrent validity of KSMS sub-scales. Only the Memory sub-scale correlated with its test index. The Language score and test index approached significance. The Executive sub-scale did not. Hierarchical regression analysis (n = 102) that included ratings of mood and symptom management showed that employment after discharge was only predicted by post-treatment ratings of difficulty with cognitive functions.

CONCLUSION

Self-assessments of difficulty managing symptoms can be reliably assessed and may contribute to understanding patients' disability, treatment response and future prospects.

Mental fatigue and impaired information processing after mild and moderate traumatic brain injury

PRIMARY OBJECTIVE

Mental fatigue is a common symptom after brain injury. Its mechanisms are not fully understood and it has been difficult to find an objective way of measuring it. The aim was to compare cognitive tests with a new self-assessment questionnaire about mental fatigue.

METHODS AND PROCEDURES

Individuals reporting mental fatigue for 6 months or more after mild traumatic brain injury (MTBI) or traumatic brain injury (TBI) and controls were assessed for subjective fatigue, information processing speed, working memory and attention. Depression and anxiety were also assessed in the individuals with brain injury.

RESULTS

Individuals with MTBI or TBI reported significantly more problems with mental fatigue and related symptoms than controls. A significantly decreased information processing speed (digit symbol-coding, reading speed, trail making test) was found in those on sick leave due to MTBI or TBI, compared to controls. Divided attention was affected to a lesser extent and no effect was detected on working memory.

CONCLUSION

Mental fatigue after MTBI can last for several years. It can be profoundly disabling and affect working capacity as well as social activities. Subjective mental fatigue following brain injury is suggested to mainly correlate with objectively measured information processing speed.

Volunteer work and psychological health following traumatic brain injury

OBJECTIVES

To compare the long-term psychological functioning of 3 groups of survivors of traumatic brain injury (TBI): (1) those who report being regularly active either by working or studying, (2) those who are not competitively employed but are active volunteers, and (3) those who report neither working, studying, nor volunteering. PARTICIPANTS AND PROCEDURE: Two hundred eight participants aged 16 years and older with minor to severe TBI were classified as (1) Working/Studying (N = 78), (2) Volunteering (N = 54), or (3) Nonactive (N = 76).

MAIN OUTCOME MEASURES

Measures of psychological distress (anxiety, depression, cognitive disturbance, irritability/anger), fatigue, sleep disturbance, and perception of pain.

RESULTS

Survivors of TBI who report being active through work, studies, or volunteering demonstrate a significantly higher level of psychological adjustment than persons who report no activity. Even among participants who are unable to return to work and are declared on long-term disability leave, those who report engaging in volunteer activities present significantly better psychological functioning than participants who are nonactive.

CONCLUSION

Volunteering is associated with enhanced psychological well-being and should be encouraged following TBI.

Fatigue in Parkinson disease, stroke, and traumatic brain injury

Fatigue is a serious, QoL-limiting symptom of many neurologic conditions. Physicians should be thorough and consistent in their assessment for this problem and not let motor symptoms monopolize an office visit. Although the use of pharmacology to treat this problem has predominantly only anecdotal evidence of efficacy, several nonpharmacologic interventions may prove helpful. The directions of future research should aim to create clear treatment guidelines using the pharmacologic agents available.

Baseline predictors of fatigue 1 year after mild head injury

OBJECTIVE

To compare reports of fatigue 12 months after minor trauma by participants with mild head injury (MHI) with those with other injury, and identify injury and baseline predictors of fatigue.

DESIGN

An inception cohort study of participants with MHI and other nonhead injuries recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months.

SETTING

Level II community hospital ED.

PARTICIPANTS

Participants (n=58) with MHI and loss of consciousness (LOC) of 30 minutes or less and/or posttraumatic amnesia (PTA) less than 24 hours, 173 with MHI but no PTA/LOC, and 128 with other mild nonhead injuries.

INCLUSION CRITERIA

age 18 years or older, within 24 hours of injury, Glasgow Coma Scale score of 13 or higher, and discharge from the ED.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Medical Outcomes Study 36-Item Short-Form Health Survey Vitality subscale.

RESULTS

Significant predictors of fatigue severity at 12 months were baseline fatigue, having seen a counselor for a mental health issue, medical disability, marital status, and in some stage of litigation. Injury type was not a significant predictor.

CONCLUSIONS

Fatigue severity 12 months after injury is associated with baseline characteristics and not MHI. Clinicians should be cautious about attributing persisting fatigue to MHI without comprehensive consideration of other possible etiologic factors.

Psychological and biological correlates of fatigue after mild-to-moderate traumatic brain injury

Relationships between chronic perceived stress, cortisol response (area under the curve) and posttraumatic brain injury fatigue were examined with persons from outpatient settings. Seventy-five injured persons with traumatic brain injury and their relatives/significant others participated in this cross-sectional study. Using interviews and self-reported data from the Neurofunctional Behavioral Inventory, the Perceived Stress Scale, the Profile of Mood States-Fatigue subscale, the McGill Pain Scale, as well as self-collection of salivary cortisol over a 12-hour period (N = 50), we found that perceived chronic stress explained 40% of the variance in fatigue until depressive symptoms and pain were in the model. Hypocortisolemia was evident. Somatic symptom frequency and perceived chronic stress represented 50% of the variability in post-TBI fatigue. Fatigue and stress management interventions, as suggested in the Centers for Disease Control Acute Concussion guidelines, may be beneficial in reducing this common symptom.

Psychosocial and emotional outcomes 10 years following traumatic brain injury

OBJECTIVES

To investigate the association of psychosocial outcome 10 years following traumatic brain injury (TBI) with demographic variables, injury severity, current cognitive functioning, emotional state, aggression, alcohol use, and fatigue.

SETTING

Community-based follow-up.

PARTICIPANTS

Fifty-three participants with mild to very severe TBI sustained 10 years previously and significant others.

MEASURES

Sydney Psychosocial Reintegration Scale, Extended Glasgow Outcome Scale, Hospital Anxiety and Depression Scale, NFI Aggression scale, Fatigue Severity Scale, Alcohol Use Disorders Identification Test, neuropsychological tests of attention/processing speed, memory, and executive function.

RESULTS

Psychosocial functioning was lowest in the occupational activity domain and highest in the living skills domains. Variables including education, posttraumatic amnesia duration, numerous cognitive measures, concurrent fatigue, aggression, anxiety, and depression were all significantly associated with psychosocial outcome, although the strength of correlations varied between ratings of participants with TBI and relatives. Posttraumatic amnesia duration was most strongly associated with psychosocial outcome measured by relatives; anxiety, aggression, and depression were the strongest predictors when ratings were assigned by participants with TBI. Self-reported fatigue, depression, and alcohol use were the strongest predictors of aggression.

CONCLUSIONS

It is important to address problems with anxiety, depression, fatigue, and alcohol use as a possible means of improving long-term psychosocial outcome following TBI.

Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design

OBJECTIVE

To test the efficacy of a cognitive-behavioral therapy (CBT) for insomnia in persons having sustained traumatic brain injury (TBI).

DESIGN

Single-case design with multiple baselines across participants.

SETTING

Outpatient rehabilitation center.

PARTICIPANTS

Eleven subjects having sustained mild to severe TBI who developed insomnia after the injury.

INTERVENTION

Eight-week CBT for insomnia including stimulus control, sleep restriction, cognitive restructuring, sleep hygiene education, and fatigue management.

MAIN OUTCOME MEASURES

Total wake time, sleep efficiency, and diagnostic criteria.

RESULTS

Visual analyses, corroborated by intervention time series analyses and t tests, revealed clinically and statistically significant reductions in total wake time and sleep efficiency for 8 (73%) of 11 participants. An average reduction of 53.9% in total wake time was observed across participants from pre- to post-treatment. Progress was in general well maintained at the 1-month and 3-month follow-ups. The average sleep efficiency augmented significantly from pretreatment (77.2%) to post-treatment (87.9%), and also by the 3-month follow-up (90.9%). Improvements in sleep were accompanied by a reduction in symptoms of general and physical fatigue.

CONCLUSIONS

The results of this study show that psychologic interventions for insomnia are a promising therapeutic avenue for TBI survivors.