Unique contribution of fatigue to disability in community-dwelling adults with traumatic brain injury

Complementary and Integrative Medicine in Treating Headaches, Cognitive Dysfunction, Mental Fatigue, Insomnia, and Mood Disorders Following Traumatic Brain Injury: A Comprehensive Review

Traumatic brain injury (TBI) is a complex condition associated with a range of persistent symptoms including headaches, cognitive dysfunction, mental fatigue, insomnia, and mood disorders. Conventional treatments for TBI-related symptoms can be insufficient, leading to interest in complementary and integrative medicine (CIM) approaches. This comprehensive article examines the existing literature on CIM modalities, including mind-body interventions, acupuncture/acupressure, herbal remedies, nutritional supplements, biofeedback, yoga, and tai chi in the context of managing secondary complications following TBI. The article highlights potential benefits and limitations of CIM modalities, while acknowledging the need for further research to better establish efficacy and safety in this specific population.

Emotional, Behavioral, and Cognitive Symptom Associations With Community Participation in Chronic Traumatic Brain Injury

OBJECTIVES

To determine the association between self-reported emotional and cognitive symptoms and participation outcomes in chronic traumatic brain injury (TBI) and to explore the relative contribution of self-reported versus performance-based cognition to participation outcomes.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ( n = 135) with a lifetime history of mild to severe TBI.

DESIGN

Secondary analysis of a cross-sectional study on neurobehavioral symptoms in chronic TBI.

MAIN MEASURES

Behavioral Assessment Screening Tool (BAST) (Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, Substance Abuse subscales) measured self-reported neurobehavioral symptoms; Participation Assessment with Recombined Tools (Productivity, Social Relations, and Out and About) measured self-reported participation outcomes; and Brief Test of Adult Cognition by Telephone (BTACT) measured performance-based cognition (Episodic Memory and Executive Function summary scores) in a subsample ( n = 40).

RESULTS

The BAST Executive Dysfunction was significantly associated with less frequent participation and had the strongest effect on participation in all participation domains. No other BAST subscales were associated with participation, after adjusting for all subscale scores and age, with the exception of BAST Impulsivity, which was associated with more frequent Social Relationships. Exploratory analysis in the sample including the BTACT revealed that, after accounting for subjective Executive Dysfunction using the BAST, performance-based Executive Function was associated with Productivity and Working Memory was associated with Social Relations, but neither was associated with being Out and About; the BAST Executive Dysfunction remained significant in all models even after including BTACT scores.

CONCLUSIONS

Self-reported Executive Dysfunction contributed to participation outcomes after mild to severe TBI in community-dwelling adults, whereas self-reported emotional and fatigue symptoms did not. Performance-based cognition measures may capture different variability in participation after injury.

A cross-sectional comparison of patient characteristics across healthcare settings using the minimal dataset for adults with acquired brain injury (MDS-ABI)

Acquired Brain Injury (ABI) can have lifelong consequences and accordingly, persons with ABI often receive various types of healthcare. Facilities have their own preferences towards measurement instruments used to evaluate patients, impeding data comparison across healthcare settings. In this cross-sectional study, we used the previously developed minimal dataset for persons with ABI (MDS-ABI) to uniformly document and compare characteristics and outcomes of ABI patients in three healthcare settings: (1) residential care (n = 21), (2) non-residential care (n = 80), and (3) no ABI-related care (n = 22). Overall, patients of residential care settings had the lowest functional outcome compared with patients in the remaining groups. Nonetheless, all groups showed substantial disabilities within numerous life domains, indicating that the consequences of ABI are widespread among patients within and outside of healthcare facilities. These results demonstrate the need for a broad measurement of the potential consequences of ABI. The MDS-ABI covers twelve life domains most frequently affected by ABI and therefore helps to better recognize the consequences of ABI. In research contexts, implementation of the MDS-ABI allows for direct comparison of research findings. Future directions should be aimed at further implementation of the MDS-ABI to guide clinical decision-making and assist in identifying treatment goals specific to each healthcare setting.

Stability and Change in Biopsychosocial Factors Associated With Fatigue 6 and 12 Months After Traumatic Brain Injury: An Exploratory Multilevel Study

OBJECTIVE

To explore factors associated with stability and change in fatigue from 6 to 12 months following traumatic brain injury (TBI).

SETTING

Combined in- and outpatient acute care and postacute rehabilitation settings.

PARTICIPANTS

A total of 103 patients with confirmed intracranial injury were assessed 6 and/or 12 months following TBI.

DESIGN

A prospective observational study with repeated measures at 2 time points, analyzed with a hybrid mixed-effects model.

MAIN MEASURES

Primary outcomes were the fatigue factor derived from items from several fatigue patient-reported outcome measures (PROMs; Fatigue Severity Scale, Chalder Fatigue Scale, Giessen Subjective Complaints List-fatigue subscale, and Rivermead Post-Concussion Symptoms Questionnaire-fatigue item) Secondary outcomes were PROMs relating to pain, somatic and psychological distress, insomnia, sleepiness, personality traits, optimism, resilience, behavioral activation and inhibition, and loneliness, as well as neuropsychological measures. Demographic variables and injury severity characteristics were included as covariates.

RESULTS

In multilevel regression, female sex, years of education, and 3 factors related to injury severity, somatic vulnerability, and psychosocial robustness were all significantly associated with variation in fatigue between subjects, and explained 61% of the variance in fatigue that was due to stable between-subject differences. Fatigue levels declined significantly over time. Changes in pain severity, somatic symptom burden, psychological distress, and behavioral inhibition were positively associated with changes in fatigue, explaining 22% of the variance in fatigue within subjects.

CONCLUSIONS

The study demonstrated that several previously implicated factors show robust effects in distinguishing individuals with TBI on levels of fatigue, but only a few show additional within-subject associations across time. Pain severity, somatic symptom burden, psychological distress, and behavioral inhibition correlated with fatigue across time, implicating these factors as crucial targets for rehabilitation of patients with TBI who suffer from persistent fatigue.

Defining a Treatment Model for Self-Management of Fatigue in Rehabilitation of Acquired Brain Injury Using the Rehabilitation Treatment Specification System

Systematic treatment descriptions to standardize and evaluate management of fatigue after acquired brain injury (ABI) are lacking. The purpose of this multi-phase qualitative study was to formulate a treatment model for promoting self-management of fatigue in rehabilitation of ABI based on practice-based understandings and routines. The study was conducted in a community-based rehabilitation center in Denmark. The model was defined using the Rehabilitation Treatment Specification System. Phase 1 comprised co-production workshops with five service providers (occupational therapists, physiotherapists, and a neuropsychologist) to elicit preliminary treatment theories. In Phase 2, four case studies were conducted on management of fatigue in vocational rehabilitation. Interviews (n = 8) and treatment log entries (n = 76) were analyzed thematically to specify treatment targets and active ingredients. The treatment model comprised five main components: (i) Knowledge and understanding of fatigue, (ii) Interoceptive attention of fatigue, (iii) Acceptance of fatigue, (iv) Activity management, and (v) Self-management of fatigue. For each component, lists of targets and active ingredients are outlined. In conclusion, management of fatigue includes multiple treatment components addressing skills, habits, and mental representations such as knowledge and attitudes. The model articulates treatment theories, which may guide clinical reasoning and facilitate future theory-driven evaluation research.

The Behavioral Assessment Screening Tool for Mobile Health (BASTmHealth): Development and Compliance in 2 Weeks of Daily Reporting in Chronic Traumatic Brain Injury

OBJECTIVES

To develop and evaluate the feasibility of a short form of the Behavioral Assessment Screening Tool (BASTmHealth) for high frequency in situ self-reported assessment of neurobehavioral symptoms using mobile health technology for community-dwelling adults with traumatic brain injury (TBI).

DESIGN

Prospective, repeated-measures study of mHealth assessment of self-reported neurobehavioral symptoms in adults with and without a lifetime history of TBI over a 2-week period.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults with (n=52) and without (n=12) a lifetime TBI history consented to the study (N=64).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

BASTmHealth subscales (2-items each): negative affect, fatigue, executive function, substance abuse, impulsivity; feasibility measured via compliance (assessments assigned/assessments completed) and participant-reported usability.

RESULTS

We developed the 10-item BASTmHealth as a screener for high frequency in situ self-reported assessment of neurobehavioral symptoms leveraging mHealth. Compliance for 2 weeks of BASTmHealth supports its feasibility. Fifty-six of 64 participants (87.5%) who completed baseline assessments completed the 2 weeks of daily assessments; all 8 participants who did not complete ecological momentary assessment had a history of TBI. Overall compliance was 81.4% (496 completed of 609 assigned assessments) among all 52 participants with TBI and 96.7% (494 completed of 511 assigned assessments) among the 44 who completed any daily measures, compared with 91.8% (135 completed of 147 assigned assessments) among those with no TBI history. Participants thought the daily surveys were easy to understand and complete and the number of prompts were reasonable.

CONCLUSIONS

Conducting daily high-frequency in situ self-reported assessment of neurobehavioral symptoms using the BASTmHealth is feasible among individuals with and without a lifetime history of TBI. Developing and evaluating self-reported assessments for community-based assessment is a critical step toward expanding remote clinical monitoring systems to improve post-TBI outcomes.

An Internet-Based Self-Management Intervention to Reduce Fatigue Among People With Traumatic Brain Injury: A Pilot Randomized Controlled Trial

IMPORTANCE

Fatigue is a chronic and distressing sequela of traumatic brain injury (TBI). Little evidence exists for the efficacy of interventions that address post-TBI fatigue.

OBJECTIVE

To evaluate the preliminary efficacy of a self-management intervention (Maximizing Energy; MAX) for reducing the impact (primary outcome) and severity of fatigue on daily life, improving fatigue experience, and increasing participation compared with a health education (HE) intervention.

DESIGN

Pilot randomized controlled trial (RCT).

SETTING

Community.

PARTICIPANTS

Forty-one participants randomly assigned to the MAX (n = 20) or HE (n = 21) intervention.

INTERVENTIONS

The MAX intervention included problem-solving therapy with energy conservation education to teach participants fatigue management. The HE intervention included diet, exercise, and energy conservation education. Both interventions (30 min/day, 2 days/wk for 8 wk) were delivered online by occupational therapists.

OUTCOME AND MEASURES

The primary outcome was the modified Fatigue Impact Scale (mFIS). Outcome measures were collected at baseline, postintervention, and 4- and 8-wk postintervention.

RESULTS

At 8 wk postintervention, participants in the MAX group reported significantly lower levels of fatigue impact (mFIS) than those in the HE group, F(1, 107) = 29.54, p = .01; Cohen's d = 0.87; 95% confidence interval [0.18, 1.55].

CONCLUSIONS AND RELEVANCE

These findings provide preliminary evidence that the MAX intervention may decrease the impact of fatigue on daily life among people with post-TBI fatigue. What This Article Adds: An internet-based, self-management intervention combining occupational therapy- delivered energy conservation education with cognitive-behavioral therapy seems to reduce fatigue impact and severity among people with post-TBI fatigue. Future appropriately powered RCTs could positively contribute to the evidence available to occupational therapy practitioners for this chronic, debilitating, and often overlooked symptom.

Reducing fatigue following acquired brain injury: A feasibility study of high intensity interval training for young adults

The aim was to evaluate feasibility of high-intensity interval training (HIIT) in fatigued adults (20-40 years old) with acquired brain injury (ABI). A prospective pre-post single-arm intervention trial was conducted, including 6-8 months follow-up assessment and interview. Intervention was 18 sessions of intermittent exercise on a cycle ergometer over six weeks. Six out of ten participants without motor impairments completed the intervention (all females, mean age = 30.2 years, months post-injury = 22). On average, participants attended 88% of sessions and achieved high intensity (93% of max heart rate). VO_2max improved by 0.53 l/min (SD = 0.29), and participants continued exercising post-intervention. All participants were satisfied with HIIT, were more inclined to exercise, and reported positive effects of exercising for self-management of fatigue. Three sessions a week were demanding to some participants. Findings support feasibility of HIIT as a promising intervention for young adults with post-ABI fatigue.

Validation of the Traditional Chinese Version of the Pittsburgh Fatigability Scale for Older Adults

OBJECTIVES

The Pittsburgh Fatigability Scale (PFS) is a self-administered 10-item tool to measure physical and mental fatigability in older adults. The aim of the current study was to validate the psychometric properties of the traditional Chinese version of PFS (TC-PFS).

METHODS

We recruited 114 community-dwellingolder adults, where 35 were diagnosed with late-life depression (LLD), 26 with mild cognitive impairment (MCI), and 53 were cognitively normal (CN) from a larger community study of older adults. Statistical analyses were done separately for TC-PFS Physical and Mental subscales. Factor analysis was used for reliability, Cronbach's alpha for internal consistency, Pearson's correlation for construct validity, and group comparison for discriminative validity.

RESULTS

Factor analysis revealed a two-factor structure for both the TC-PFS Physical and Mental subscales with high reliability (α = 0.89 and 0.89, respectively). Patients with LLD had the highest PFS scores, with 80.0% and 82.9% classified as having greater physical and mental fatigability. For concurrent validity, we found moderate associations with the vitality and physical functioning subscales of the 36-Item Short Form Health Survey. For convergent validity, TC-PFS showed moderate association with emotional-related psychometrics, particularly for the Physical subscale in those with LLD. In contrast, TC-PFS Mental subscale showed correlations with cognitive function, particularly in the MCI group.

CONCLUSIONS

Our results indicate that the TC-PFS is a valid instrument to measure perceived physical and mental fatigability in older Taiwanese adults.Clinical implications: Perceived fatigability reflects the underlying physical, mental or cognitive function in older adults with or without depression.

Impact of Somatic Vulnerability, Psychosocial Robustness and Injury-Related Factors on Fatigue following Traumatic Brain Injury-A Cross-Sectional Study

Fatigue is a common symptom after traumatic brain injuries (TBI) and a crucial target of rehabilitation. The subjective and multifactorial nature of fatigue necessitates a biopsychosocial approach in understanding the mechanisms involved in its development. The aim of this study is to provide a comprehensive exploration of factors relevant to identification and rehabilitation of fatigue following TBI. Ninety-six patients with TBI and confirmed intracranial injuries were assessed on average 200 days post-injury with regard to injury-related factors, several patient-reported outcome measures (PROMS) of fatigue, neuropsychological measures, and PROMS of implicated biopsychosocial mechanisms. Factor analytic approaches yielded three underlying factors, termed Psychosocial Robustness, Somatic Vulnerability and Injury Severity. All three dimensions were significantly associated with fatigue in multiple regression analyses and explained 44.2% of variance in fatigue. Post hoc analyses examined univariate contributions of the associations between the factors and fatigue to illuminate the relative contributions of each biopsychosocial variable. Implications for clinical practice and future research are discussed.

Development of a Home-Based Light Therapy for Fatigue Following Traumatic Brain Injury: Two Case Studies

Background and Objectives: Fatigue and sleep disturbance negatively impact quality of life following brain injury and there are no established treatments. Building on research showing efficacy of blue light therapy delivered via a lightbox in reducing fatigue and daytime sleepiness after traumatic brain injury (TBI), this paper describes the development and implementation of a novel in-home light therapy to alleviate fatigue and sleep disturbance in two case studies. Methods: During the 8-week lighting intervention, participants' home lighting was adjusted to provide high intensity, blue-enriched (high melanopic) light all day as a stimulant and dimmer, blue-depleted (low melanopic) light for 3 h before sleep as a soporific. The sham 8-week control condition resembled participants' usual (baseline) lighting conditions (3,000-4,000 K all day). Lighting conditions were crossed-over. Outcomes were measures of fatigue, subjective daytime sleepiness, sleep quality, insomnia symptoms, psychomotor vigilance and mood. Case study participants were a 35-year old male (5 years post-TBI), and a 46-year-old female (22 years post-TBI). Results: The relative proportion of melanopic lux was greater in Treatment lighting than Control during daytime, and lower during evenings. Participants found treatment to be feasible to implement, and was well-tolerated with no serious side effects noted. Self-reported compliance was >70%. Both cases demonstrated reduced fatigue, sleep disturbance and insomnia symptoms during the treatment lighting intervention. Case 2 additionally showed reductions in daytime sleepiness and depressive symptoms. As expected, symptoms trended toward baseline levels during the control condition. Discussion: Treatment was positively received and compliance rates were high, with no problematic side-effects. Participants expressed interest in continuing the ambient light therapy in their daily lives. Conclusions: These cases studies demonstrate the acceptability and feasibility of implementing a personalized in-home dynamic light treatment for TBI patients, with evidence for efficacy in reducing fatigue and sleep disturbance. Clinical Trial Registration:www.anzctr.org.au, identifier: ACTRN12617000866303.

Mental Fatigue after Mild Traumatic Brain Injury in Relation to Cognitive Tests and Brain Imaging Methods

Most people recover within months after a mild traumatic brain injury (TBI) or concussion, but some will suffer from long-term fatigue with a reduced quality of life and the inability to maintain their employment status or education. For many people, mental fatigue is one of the most distressing and long-lasting symptoms following an mTBI. No efficient treatment options can be offered. The best method for measuring fatigue today is with fatigue self-assessment scales, there being no objective clinical tests available for mental fatigue. The aim here is to provide a narrative review and identify fatigue in relation to cognitive tests and brain imaging methods. Suggestions for future research are presented.

Community Integration After Traumatic Brain Injury and Related Factors: A Study in the Nepalese Context

Introduction

Community integration is an essential component for rehabilitation among traumatic brain injury (TBI) survivors, which yields positive outcomes in terms of social activities, community participation, and productive work. A factor that usually facilitates community integration among TBI survivors is social support, whereas physical environment and fatigue are most often found as barriers.

Objectives

This study aimed to (1) describe the level of community integration, fatigue, physical environment, and social support of persons after TBI, and (2) examine the relationship between community integration and these three factors.

Methods

This is a descriptive correlational study. One hundred and twenty TBI survivors living in the communities of Province Number Three, Nepal were enrolled using the stratified sampling technique. The data were collected using the Community Integration Questionnaire, Modified Fatigue Impact Scale, Craig Hospital Inventory of Environmental Factors, and the Multidimensional Scale of Perceived Social Support. Descriptive statistics and Pearson's correlation were used to analyze the data.

Results

Community integration, fatigue, and physical environment showed a moderate level, while social support revealed a high level. Fatigue was significantly correlated with overall community integration, whereas physical environment was found to correlate with two subscales of community integration, home integration and productive activities.

Conclusion

To enhance the level of community integration among TBI survivors, health care providers, in particular rehabilitation nurses and community nurses, should plan and implement strategies such as follow-up appointments or continued rehabilitation at home.

Greater Severity and Functional Impact of Post-traumatic Headache in Veterans With Comorbid Neck Pain Following Traumatic Brain Injury

BACKGROUND

Post-traumatic headache (PTH) is a commonly experienced symptom after mild traumatic brain injury (mTBI). Blast injury- or blunt injury-related mechanisms for mTBI in veterans can also affect musculoskeletal structures in the neck, resulting in comorbid neck pain (NP). However, it is unknown whether the presence of comorbid NP may be associated with a different pattern of headache symptoms, physical functioning, or emotional functioning compared to those without comorbid NP. The purpose of this study is to examine the role of comorbid NP in veterans with mTBI and PTH.

DESIGN AND METHODS

This was a cross-sectional investigation of an existing dataset that included 33 veterans who met inclusion criteria for PTH after mTBI. Standardized measures of headache severity and frequency, insomnia, fatigue, mood disorders, and physical and emotional role function were compared between groups with and without comorbid NP.

RESULTS

The majority of participants with PTH reported comorbid NP (n = 22/33, 67%). Those with comorbid NP experienced more headache symptoms that were severe or incapacitating, as compared to mild or moderate for those without NP (φ = 0.343, P = .049); however, no differences in headache frequency (φ = 0.231, P = .231) or duration (φ = 0.129, P = .712) were observed. Participants with comorbid NP also reported greater insomnia (d = 1.16, P = .003) and fatigue (d = 0.868, P = .040) as well as lower physical functioning (d = 0.802, P = .036) and greater bodily pain (d = 0.762, P = .012). There were no differences in anxiety, depression, mental health, emotional role limitations, vitality, or social functioning between those with and without comorbid NP (d ≤ 0.656, P ≥ .079).

CONCLUSIONS

A majority of veterans with mTBI and PTH in our sample reported comorbid NP that was associated with greater headache symptom severity and physical limitations, but not with mood or emotional limitations. Preliminary findings from this small convenience sample indicate that routine assessment of comorbid NP and associated physical limitations should be considered in veterans with mTBI and PTH.

Brain structural connectomes indicate shared neural circuitry involved in subjective experience of cognitive and physical fatigue in older adults

Cumulative evidence suggests the existence of common processes underlying subjective experience of cognitive and physical fatigue. However, mechanistic understanding of the brain structural connections underlying the experience of fatigue in general, without the influence of clinical conditions, is limited. The purpose of the study was to examine the relationship between structural connectivity and perceived state fatigue in older adults. We enrolled cognitively and physically healthy older individuals (n = 52) and categorized them into three groups (low cognitive/low physical fatigue; low cognitive/high physical fatigue; high cognitive/low physical fatigue; no subjects had high cognitive/high physical fatigue) based on perceived fatigue from cognitive and physical fatigue manipulation tasks. Using sophisticated diffusion tensor imaging processing techniques, we extracted connectome matrices for six different characteristics of whole-brain structural connections for each subject. Tensor network principal component analysis was used to examine group differences in these connectome matrices, and extract principal brain networks for each group. Connected surface area of principal brain networks differentiated the two high fatigue groups from the low cognitive/physical fatigue group (high vs. low physical fatigue, p = 0.046; high vs. low cognitive fatigue, p = 0.036). Greater connected surface area within striatal-frontal-parietal networks was correlated with lower cognitive and physical fatigue, and was predictive of perceived physical and cognitive fatigue measures not used for group categorization (Pittsburgh fatigability physical subscale, R2 = 0.70, p < 0.0001; difference in self-report fatigue before and after gambling tasks, R2 = 0.54, p < 0.0001). There are potentially structural connectomes resilient to both cognitive and physical fatigue in older adults.

Cognitive Fatigability Interventions in Neurological Conditions: A Systematic Review

INTRODUCTION

Although fatigue is a well-studied concept in neurological disease, cognitive fatigability (CF) is less understood. While most studies measure fatigue using subjective self-report, fewer have measured CF objectively. Given the negative impact of CF on quality-of-life, there is a need for targeted interventions. The objective of this review was to determine which procedural, behavioural and pharmacological treatments for objectively measured CF are available to people living with neurological conditions.

METHODS

In accordance with the PRISMA guidelines, systematic searches for randomized control trials (RCTs), case-controlled studies and case reports/series were conducted across the Ovid Medline, PsycInfo, EMBASE and Cochrane Library databases. English-language articles published between 1980 and February 2019 were considered for eligibility. Included were those that objectively measured CF in individuals with neurological disease/disorder/dysfunction between the ages of 18 and 65 years. Studies were reviewed using a modified Cochrane Data Extraction Template. Risk of bias was assessed using the Cochrane Risk of Bias tool. The review process was facilitated using Covidence software (www.covidence.org). Two authors reviewed articles independently, with a third resolving conflicts regarding article inclusion.

RESULTS

The search identified 450 records. After duplicates were removed and remaining titles/abstracts were screened for eligibility, 28 full-text articles were assessed, and two studies were included in the qualitative synthesis. Studies were a priori divided into those with pharmacological, procedural or behavioural interventions. Two studies met eligibility criteria; both of these included participants with multiple sclerosis. One study utilized a procedural intervention (i.e. transcranial direct current stimulation), while the other utilized a pharmacological intervention (i.e. fampridine-SR). Studies were evaluated for risk of bias, and evidence from both eligible studies was discussed.

CONCLUSION

Despite the positive results of the procedural intervention, the paucity of eligible studies and the nascent nature of the field suggests that more studies are required before firm conclusions can be drawn regarding the amenability of CF to treatment.

TRIAL REGISTRATION

The review was registered with PROSPERO (CRD42019118706).

Variability in daily self-reported emotional symptoms and fatigue measured over eight weeks in community dwelling individuals with traumatic brain injury

OBJECTIVE

To investigate within-person variability in daily self-reported emotional and fatigue symptoms and factors associated with high within-person variability among individuals with chronic traumatic brain injury (TBI).

DESIGN

This was a prospective descriptive pilot study of n = 18 adults with chronic TBI (2-27 years post-injury) who owned and could independently use an Apple or Android device.

METHODS

Participants completed daily assessments for 8 weeks via smartphone. Outcome measures included the Positive and Negative Affect Schedule, Patient Health Questionnaire-2, Generalized Anxiety Disorder-2, and a 7-point fatigue rating. We examined within-person variability over time using individual Multilevel Linear Models. We categorized within-person variability as High or Low based on individual standard deviations in relationship to sample standard deviation.

RESULTS

Significant temporal within-person variability occurred for all measures. High variability was associated with more symptom reporting versus Low variability, and variability was associated with sex (High variability: 88% women; Low variability 90% men).

CONCLUSIONS

Symptom measurement at a single time point among adults with chronic TBI may not capture day-to-day symptom fluctuation and may misidentify individuals in need of intervention. Assessing symptom profiles over time to capture temporal and individual variability may provide a more ecologically valid measure for managing long-term symptoms after TBI.

Effects of Depression and Antidepressant Use on Cognitive Deficits and Functional Cognition Following Severe Traumatic Brain Injury

OBJECTIVE

To use a Rehabilomics framework to evaluate relations hips between post-traumatic brain injury (TBI) depression (PTD) and potential associated factors, including antidepressant use, on cognitive recovery following severe TBI.

PARTICIPANTS

Severe TBI survivors (n = 154), recruited from a level 1 trauma center.

DESIGN

Prospective cohort study with assessments at 6 and 12 months postinjury.

MAIN MEASURES

Patient Health Questionnaire-9 (PTD symptoms); cognitive composite score from a neuropsychological assessment battery (cognitive impairment); and Functional Independence Measure-Cognition (FIM-Cog, self-reported functional cognition).

RESULTS

Individuals with and without PTD did not differ with respect to cognitive impairment. However, antidepressant use, regardless of PTD status, was associated with cognitive impairment. Individuals with PTD reported lower FIM-Cog scores at both time points compared with those without PTD. In a post hoc longitudinal analysis, individuals with late-onset PTD had worse cognitive impairment.

CONCLUSION

These results suggest that antidepressant use impairs cognition among individuals without PTD. Also, PTD did not directly affect cognitive impairment but may affect functional cognitive limitations through self-evaluation and apathy/motivation factors.

Feasibility of a Cognitive Behavioral Intervention to Manage Fatigue in Individuals With Traumatic Brain Injury: A Pilot Study

OBJECTIVE

To evaluate the feasibility of conducting a randomized clinical trial of an Internet-based manualized intervention to teach individuals with traumatic brain injury to manage their fatigue.

SETTING

Community dwelling.

PARTICIPANTS

Forty-one participants randomized to Maximizing Energy (MAX) intervention group (n = 20) and Health Education group (n = 21).

INTERVENTION

The experimental group (MAX intervention) received an 8-week program that combined education and Problem-Solving Therapy to teach individuals to manage fatigue-related problems. The attention control group received health education.

MEASURES

Primary outcome measures pertained to the feasibility of conducting the trial. Secondary outcomes were fatigue impact and fatigue severity assessed at baseline and postintervention.

RESULTS

Of the 65 participants referred, 41 were enrolled (63% recruitment rate), of which 3 withdrew (92% retention rate). Participants in the experimental and control groups completed their homework 75% and 85% of the time, respectively, and were equally engaged in the sessions. Participants in the experimental group were able to learn and implement the MAX intervention steps. Effect sizes for all measures ranged from small (-0.17) to medium (-0.58) in favor of the intervention group.

CONCLUSION

Findings from the study suggest that the MAX intervention is feasible to administer to individuals with post-traumatic brain injury fatigue.

Understanding the interplay between mild traumatic brain injury and cognitive fatigue: models and treatments

Nearly 2 million traumatic brain injuries occur annually, most of which are mild (mTBI). One debilitating sequela of mTBI is cognitive fatigue: fatigue following cognitive work. Cognitive fatigue has proven difficult to quantify and study, but this is changing, allowing models to be proposed and tested. Here, we review evidence for four models of cognitive fatigue, and relate them to specific treatments following mTBI. The evidence supports two models: cognitive fatigue results from the increased work/effort required for the brain to process information after trauma-induced damage; and cognitive fatigue results from sleep disturbances. While there are no evidence-based treatments for fatigue after mTBI, some pharmacological and nonpharmacological treatments show promise for treating this debilitating problem. Future work may target the role of genetics, neuroinflammation and the microbiome and their role in complex cognitive responses such as fatigue.

TBI Rehabilomics Research: an Exemplar of a Biomarker-Based Approach to Precision Care for Populations with Disability

PURPOSE OF REVIEW

The purpose of this review is to summarize how "-omics" technologies can inform rehabilitation-relevant outcomes for a range of populations with neurologically related disability by including outcome metrics linked to the World Health Organization's International Classification of Functioning, Disability, and Health (WHO-ICF) domains of impairments in body function, activity limitations, and participation restrictions.

RECENT FINDINGS

To date, nearly every area of medicine uses biomarkers in some capacity to aid in understanding how personal biology informs clinical care. "-Omics"-based approaches use high throughput genomics, proteomics, and transcriptomics assay platforms to tailor and personalize treatments for subgroups of similar individuals based on these results. The recent Precision Medicine Initiative (PMI), sponsored by the National Institutes of Health (NIH), has propelled biomarker-based and genomics research to the forefront of many translational research and care programs addressing a variety of medical populations. Yet, the literature is sparse on precision medicine approaches for those with neurologically related and other disability. We demonstrate how the Rehabilomics Research model represents a translational framework for programs of precision rehabilitation research and care focused on linking personal biology to the biopsychosocial constructs that represent the WHO-ICF model and multidimensional outcome. We provide multiple exemplars from our own research program involving individuals with moderate-to-severe traumatic brain injury (TBI) to demonstrate how genomics and other biomarkers can be identified and assessed for their capacity to assist with personalized (precision) neurorehabilitation care and management.

Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of adapted cognitive behavioral therapy (CBT) for sleep disturbance and fatigue in individuals with traumatic brain injury (TBI).

DESIGN

Parallel 2-group randomized controlled trial.

SETTING

Outpatient therapy.

PARTICIPANTS

Adults (N=24) with history of TBI and clinically significant sleep and/or fatigue complaints were randomly allocated to an 8-session adapted CBT intervention or a treatment as usual (TAU) condition.

INTERVENTIONS

Cognitive behavior therapy.

MAIN OUTCOME MEASURES

The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) posttreatment and at 2-month follow-up. Secondary measures included the Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI), Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale.

RESULTS

At follow-up, CBT recipients reported better sleep quality than those receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI], 2.56-7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI difference, 1.54; 95% CI, 0.66-2.42). Secondary improvements were significant for depression. Large within-group effect sizes were evident across measures (Hedges g=1.14-1.93), with maintenance of gains 2 months after therapy cessation.

CONCLUSIONS

Adapted CBT produced greater and sustained improvements in sleep, daily fatigue levels, and depression compared with TAU. These pilot findings suggest that CBT is a promising treatment for sleep disturbance and fatigue after TBI.

A randomised control trial of walking to ameliorate brain injury fatigue: a NIDRR TBI model system centre-based study

Fatigue is one of the most commonly reported sequelae after traumatic brain injury (TBI). This study evaluated the impact of a graduated physical activity programme on fatigue after TBI. Using a prospective randomised single-blind crossover design, 123 individuals with TBI, over the age of 18, were enrolled. Interventions included a home-based walking programme utilising a pedometer to track daily number of steps at increasing increments accompanied by tapered coaching calls over a 12-week period. Nutritional counselling with the same schedule of coaching calls served as the control condition. Main outcome measures included: the Global Fatigue Index (GFI), the Barrow Neurological Institute (BNI) Fatigue Scale Overall Severity Index Score, and the Multidimensional Fatigue Inventory (MFI). Step counts improved over time regardless of group assignment. The walking intervention led to a decrease in GFI, BNI Total, and MFI General scores. Participants reported less fatigue at the end of the active part of the intervention (24 weeks) and after a wash out period (36 weeks) as measured by the BNI Overall. The study suggests that walking can be used as an efficient and cost-effective tool to improve fatigue in persons who have sustained a TBI.

Clinical Utility of Mindfulness Training in the Treatment of Fatigue After Stroke, Traumatic Brain Injury and Multiple Sclerosis: A Systematic Literature Review and Meta-analysis

BACKGROUND

Fatigue is a common symptom following neurological illnesses and injuries, and is rated as one of the most debilitating sequela in conditions such as stroke, traumatic brain injury (TBI), and multiple sclerosis (MS). Yet effective treatments are lacking, suggesting a pressing need for a better understanding of its etiology and mechanisms that may alleviate the symptoms. Recently mindfulness-based interventions have demonstrated promising results for fatigue symptom relief.

OBJECTIVE

Investigate the efficacy of mindfulness-based interventions for fatigue across neurological conditions and acquired brain injuries.

MATERIALS AND METHODS

Systematic literature searches were conducted in PubMed, Medline, Web of Science, and PsycINFO. We included randomized controlled trials applying mindfulness-based interventions in patients with neurological conditions or acquired brain injuries. Four studies (N = 257) were retained for meta-analysis. The studies included patients diagnosed with MS, TBI, and stroke.

RESULTS

The estimated effect size for the total sample was -0.37 (95% CI: -0.58, -0.17).

CONCLUSION

The results indicate that mindfulness-based interventions may relieve fatigue in neurological conditions such as stroke, TBI, and MS. However, the effect size is moderate, and further research is needed in order to determine the effect and improve our understanding of how mindfulness-based interventions affect fatigue symptom perception in patients with neurological conditions.

Brain lesion correlates of fatigue in individuals with traumatic brain injury

The purpose of this study was to investigate the neurological correlates of both subjective fatigue as well as objective fatigability in individuals with traumatic brain injury (TBI). The study has a cross-sectional design. Participants (N = 53) with TBI (77% male, mean age at injury 38 years, mean time since injury 1.8 years) underwent a structural magnetic resonance imaging (MRI) scan and completed the Fatigue Severity Scale (FSS), while a subsample (N = 36) was also tested with a vigilance task. While subjective fatigue (FSS) was not related to measures of brain lesions, multilevel analyses showed that a change in the participants' decision time was significantly predicted by grey matter (GM) lesions in the right frontal lobe. The time-dependent development of the participants' error rate was predicted by total brain white matter (WM) lesion volumes, as well as right temporal GM and WM lesion volumes. These findings could be explained by decreased functional connectivity of attentional networks, which results in accelerated exhaustion during cognitive task performance. The disparate nature of objectively measurable fatigability on the one hand and the subjective experience of fatigue on the other needs further investigation.

Preliminary Associations Between Brain-Derived Neurotrophic Factor, Memory Impairment, Functional Cognition, and Depressive Symptoms Following Severe TBI

Background Traumatic brain injury (TBI) often leads to mood and cognitive complications, affecting functional recovery. Understanding neurobiological alterations common in post-TBI depression (PTD) and cognition may identify novel biomarkers for TBI complications. Brain-derived neurotrophic factor (BDNF) is a likely target based on evidence of reduced BDNF signaling in experimental TBI and depression models and its role in learning and memory. Objective To evaluate BDNF as a biomarker for PTD, cognitive impairment, and functional cognition in a prospective cohort with severe TBI. Methods Participants with TBI (n = 113) were evaluated for PTD (Patient Health Questionnaire-9 [PHQ-9]), cognitive impairment (cognitive composite score), and functional cognition (Functional Independence Measure-Cognition, FIM-Cog). BDNF levels were measured in cerebrospinal fluid and serum at 0 to 6 days postinjury and in serum at 6 and 12 months postinjury.

RESULTS

Serum BDNF was reduced after TBI versus controls at all time points. Acute serum BDNF positively correlated with memory composites (6 months: r = 0.43, P = .019, n = 30; 12 months: r = 0.53, P = .005, n = 26) and FIM-Memory scores (6 months: r = 0.35, P = .019, n = 45; 12 months: r = 0.38, P = .018, n = 38). Acute serum BDNF negatively correlated with 12-month PHQ-9 scores (r = -0.38; P = .044; n = 29). At 12 months, chronic serum BDNF tended to be lower in participants with PTD (P = .07) and correlated with PHQ-9 scores (r = -0.41; P = .019; n = 32). Conclusions Acute BDNF associations with memory recovery may implicate hippocampal damage/degeneration. Comparatively, BDNF associations with PTD status were not as strong as associations with PTD severity. Further investigation may delineate longitudinal BDNF patterns, and BDNF responsive treatments, reflecting mood and cognitive recovery following TBI.

Affective state and community integration after traumatic brain injury

Previous studies investigating the relationship between affective state and community integration have focused primarily on the influence of depression and anxiety. In addition, they have focused on frequency of participation in various activities, failing to address an individual's subjective satisfaction with participation. The purpose of this study was to examine how affective state contributes to frequency of participation and satisfaction with participation after traumatic brain injury among participants with and without a current major depressive episode. Sixty-four community-dwelling participants with a history of complicated mild-to-severe traumatic brain injury participated in this cross-sectional cohort study. High positive affect contributed significantly to frequency of participation (β = 0.401, P = 0.001), and both high positive affect and low negative affect significantly contributed to better satisfaction with participation (F2,61 = 13.63, P < 0.001). Further investigation to assess the direction of these relationships may better inform effective targets for intervention. These findings highlight the importance of assessing affective state after traumatic brain injury and incorporating a subjective measure of participation when considering community integration outcomes.

Sleep and fatigue following traumatic brain injury

This article reviews literature relating to sleep disturbance and fatigue after traumatic brain injury. It discusses the nature and prevalence of sleep disturbances associated with traumatic brain injury and the measures used to assess them. Potential causes are discussed, including damage to sleep-wake regulating centers, disruption of circadian timing of sleep, and secondary causes, such as pain, depression, and anxiety. The nature and assessment of fatigue are discussed, followed by a review of evidence regarding causes. Evidence is reviewed of the consequences of sleep disturbance and fatigue. Potential treatments of nonpharmacologic and pharmacologic natures are reviewed.

Screening for sleep dysfunction after traumatic brain injury

Numerous studies on the high prevalence of sleep disorders in individuals with traumatic brain injury (TBI) have been conducted in the past few decades. These disorders can accentuate other consequences of TBI, negatively impacting mood, exacerbating pain, heightening irritability, and diminishing cognitive abilities and the potential for recovery. Nevertheless, sleep is not routinely assessed in this population. In our review, we examined the selective screening criteria and the scientific evidence regarding screening for post-TBI sleep disorders to identify gaps in our knowledge that are in need of resolution. We retrieved papers written in the English-language literature before June 2012 pertinent to the discussion on sleep after TBI found through a PubMed search. Within our research, we found that sleep dysfunction is highly burdensome after TBI, treatment interventions for some sleep disorders result in favorable outcomes, sensitive and specific tests to detect sleep disorders are available, and the cost-effectiveness and sustainability of screening have been determined from other populations. The evidence we reviewed supports screening for post-TBI sleep dysfunction. This approach could improve the outcomes and reduce the risks for post-TBI adverse health and nonhealth effects (e.g., secondary injuries). A joint sleep and brain injury collaboration focusing on outcomes is needed to improve our knowledge.

Fatigue in adults with traumatic brain injury: predictors and consequences. A systematic review of longitudinal study protocols

BACKGROUND

Despite strong indications that fatigue is the most common and debilitating symptom after traumatic brain injury, little is known about its frequency, natural history, or relation to other factors. The current protocol outlines a strategy for a systematic review that will identify, assess, and critically appraise studies that assessed predictors for fatigue and the consequences of fatigue on at least two separate time points following traumatic brain injury.

METHODS/DESIGN

MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO will be systematically searched for relevant peer-reviewed studies. Reference lists of eligible papers will also be searched. All English language studies with a longitudinal design that focus on fatigue in adults with primary-impact traumatic brain injury will be included. Studies on fatigue following brain injury due to secondary pathological processes (intracranial complications, edema, ischemia/infarction, and systemic intracranial conditions) will be excluded. Excluded studies, along with the reasons for exclusion will be reported. Two independent reviewers will conduct all levels of screening, data abstraction, and quality appraisal. Randomized control trial data will be treated as a cohort. The quality will be assessed using the criteria defined by Hayden and colleagues. The review will be conducted and reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

CONCLUSIONS

The review will summarize the current knowledge in the field with the aim of increasing understanding and guiding future research on the associations between fatigue and clinically important factors, as well as the consequences of fatigue in traumatic brain injury. PROSPERO registry number: CRD42013004262.