Factors contributing to chronic fatigue after traumatic brain injury

Dynamic Prevalence of and Factors Associated With Fatigue Following Traumatic Brain Injury: A Systematic Review and Meta-analysis of Observational Studies

OBJECTIVE

To implement a systematic review and meta-analysis to comprehensively synthesize the prevalence of and factors associated with fatigue following traumatic brain injury (TBI).

METHODS

We systematically searched the PubMed, EMBASE, Cochrane Library, Cumulated Index to Nursing and Allied Health Literature, PsycINFO, and ProQuest Dissertations and Theses A&I databases in all fields from their inception to March 31, 2021. We included observational studies investigating fatigue at specific time points following TBI or factors associated with post-TBI fatigue. All data were analyzed using a random-effects model.

RESULTS

This meta-analysis included 29 studies that involved 12 662 patients with TBI and estimated the prevalence of post-TBI fatigue (mean age = 41.09 years); the meta-analysis also included 23 studies that involved 6681 patients (mean age = 39.95 years) and investigated factors associated with post-TBI fatigue. In patients with mild-to-severe TBI, the fatigue prevalence rates at 2 weeks or less, 1 to 3 months, 6 months, 1 year, and 2 years or more after TBI were 52.2%, 34.6%, 36.0%, 36.1%, and 48.8%, respectively. Depression ( r = 0.48), anxiety ( r = 0.49), sleep disturbance ( r = 0.57), and pain ( r = 0.46) were significantly associated with post-TBI fatigue. No publication bias was identified among the studies, except for those assessing fatigue prevalence at 6 months after TBI.

CONCLUSION

The pooled prevalence rates of post-TBI fatigue exhibited a U-shaped pattern, with the lowest prevalence rates occurring at 1 to 3 months after TBI. Depression, anxiety, sleep disturbance, and pain were associated with post-TBI fatigue. Younger patients and male patients were more likely to experience post-TBI fatigue. Our findings can assist healthcare providers with identifying appropriate and effective interventions targeting post-TBI fatigue at specific periods.

Prevalence of fatigue and cognitive impairment after traumatic brain injury

BACKGROUND

Following traumatic brain injury (TBI) some patients develop lingering comorbid symptoms of fatigue and cognitive impairment. The mild cognitive impairment self-reported by patients is often not detected with neurocognitive tests making it difficult to determine how common and severe these symptoms are in individuals with a history of TBI. This study was conducted to determine the relative prevalence of fatigue and cognitive impairment in individuals with a history of TBI.

METHODS

The Fatigue and Altered Cognition Scale (FACs) digital questionnaire was used to assess self-reported fatigue and cognitive impairment. Adults aged 18-70 were digitally recruited for the online anonymous study. Eligible participants provided online consent, demographic data, information about lifetime TBI history, and completed the 20 item FACs questionnaire.

RESULTS

A total of 519 qualifying participants completed the online digital study which included 204 participants with a history of TBI of varied cause and severity and 315 with no history of TBI. FACs Total Score was significantly higher in the TBI group (57.7 ± 22.2) compared to non-TBI (39.5 ± 23.9; p<0.0001) indicating more fatigue and cognitive impairment. When stratified by TBI severity, FACs score was significantly higher for all severity including mild (53.9 ± 21.9, p<0.0001), moderate (54.8 ± 24.4, p<0.0001), and severe (59.7 ± 20.9, p<0.0001) TBI. Correlation analysis indicated that more severe TBI was associated with greater symptom severity (p<0.0001, r = 0.3165). Ancillary analysis also suggested that FACs scores may be elevated in participants with prior COVID-19 infection but no history of TBI.

CONCLUSIONS

Adults with a history of even mild TBI report significantly greater fatigue and cognitive impairment than those with no history of TBI, and symptoms are more profound with greater TBI severity.

Exploring the link between vitamin D deficiency and obstructive sleep apnea: A comprehensive review

Despite the high prevalence and significant health burden of obstructive sleep apnea (OSA), its underlying pathophysiology remains incompletely understood. This comprehensive review explores the emerging connection between vitamin D deficiency and OSA, discusses potential mechanisms underlying this association, and explores the therapeutic implications of these findings. Recent research has consistently highlighted the high incidence of vitamin D deficiency among patients with OSA, which often occurs independently of geographical location. This suggests that factors beyond lack of sunlight exposure may be involved. This review also discusses how reduced vitamin D may be associated with more severe manifestations of OSA. In addition, it explores the potentiality of using vitamin D supplements as a therapeutic strategy for OSA, noting that some studies have found improvements in sleep quality and a reduction in OSA severity. Potential mechanisms are proposed, including the role of vitamin D deficiency in promoting inflammation, oxidative stress, hypoxia, impairing immune function, muscle function, and gene polymorphism of vitamin D receptors, all of which could contribute to the pathogenesis of obstructive sleep apnea. The paper underscores the need for future research to validate these observations, to determine optimal vitamin D supplementation dosage and duration, to explore potential side effects and risks, and to investigate potential interactions with other treatments.

Self-reported Fatigue was Associated with Increased White-matter Alterations in Long-term Traumatic Brain Injury and Posttraumatic Stress Disorder Patients

Fatigue is a long-lasting problem in traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), with limited research that investigated the fatigue-related white-matter changes within TBI and/or PTSD cohorts. This exploratory cross-sectional study used diffusion tensor imaging (DTI) and neuropsychological data collected from 153 male Vietnam War veterans, as part of the Alzheimer's Disease Neuroimaging Initiative - Department of Defense, and were divided clinically into control veterans, PTSD, TBI, and with both TBI and PTSD (TBI + PTSD). The existence of fatigue was defined by the question "Do you often feel tired, fatigued, or sleepy during the daytime?". DTI data were compared between fatigue and non-fatigue subgroups in each clinical group using tract-based spatial statistics voxel-based differences. Fatigue was reported in controls (29.55%), slightly higher in TBI (52.17%, PBenf = 0.06), and significantly higher in both TBI + PTSD (66.67%, PBenf = 0.001) and PTSD groups (79.25%, PBenf < 0.001). Compared to non-fatigued subgroups, no white-matter differences were observed in the fatigued subgroups of control or TBI, while the fatigued PTSD subgroup only showed increased diffusivity measures (i.e., radial and axial), and the fatigued TBI + PTSD subgroup showed decreased fractional anisotropy and increased diffusivity measures (PFWE ≤ 0.05). The results act as preliminary findings suggesting fatigue to be significantly reported in TBI + PTSD and PTSD decades post-trauma with a possible link to white-matter microstructural differences in both PTSD and TBI + PTSD. Future studies with larger cohorts and detailed fatigue assessments would be required to identify the white-matter changes associated with fatigue in these cohorts.

Effect of Vitamin D Supplementation on the Prognosis of Post-stroke Fatigue: A Retrospective Cohort Study

Objective: We aimed to evaluate the effect of vitamin D supplementation in post-stroke fatigue (PSF) patients with vitamin D deficiency on fatigue symptoms and outcomes. Methods: Patients with primary acute ischemic stroke (AIS) were recruited consecutively from July 2016 to June 2018. Post-stroke fatigue patients were screened out with the Fatigue Severity Scale (FSS) questionnaire, serum concentrations of 25-hydroxyvitamin D [25-(OH)-D] were assessed with enzyme-linked immunosorbent assay (ELISA), and neurological function was evaluated with FSS and modified Rankin Scale (mRS) scoring criteria. Post-stroke fatigue patients with vitamin D deficiency were divided into two groups: a study group in which patients received vitamin D supplementation (cholecalciferol, 600 IU/day) along with usual care, and a control group in which patients received usual care alone. At the end of 1 and 3 months after treatment, all PSE patients accepted re-measurement of serum vitamin D and re-evaluation of fatigue and neurological function. Results: A total of 532 AIS patients were consecutively recruited to participate in this study. Patients without PSF, non-vitamin D deficiency, pre-stroke fatigue, or vitamin D supplementation were excluded from the study. In addition, patients who were lost to follow-up were also excluded. Finally, 139 out of 532 (26.1%) patients with PSF and vitamin D deficiency received vitamin D supplementation treatment. Fatigue Severity Scale score was significantly lower in the study group than in the control group at 1 month (t = -4.731, p < 0.01) and 3 months (t = -7.937, p < 0.01) after treatment. One month after treatment, mRS score in the study group was lower than that in the control group without statistical difference (t = -0.660, p > 0.05), whereas mRS was significantly higher in the study group than in the control group at 3 months after treatment (t = -4.715, p < 0.01). Conclusions: Our results indicated that vitamin D supplementation could improve fatigue symptoms and neurological outcomes in PSF patients with vitamin D deficiency. Subject to replication in other settings, a randomized controlled trial (RCT) might be undertaken to validate the potential beneficial impact of vitamin D supplementation in post-stroke patients found to be vitamin D deficient.

Effects of Alpha-2 Adrenergic Agonist Mafedine on Brain Electrical Activity in Rats after Traumatic Brain Injury

The search for and development of new neuroprotective (or cerebroprotective) drugs, as well as suitable methods for their preclinical efficacy evaluation, are priorities for current biomedical research. Alpha-2 adrenergic agonists, such as mafedine and dexmedetomidine, are a highly appealing group of drugs capable of reducing neurological deficits which result from brain trauma and vascular events in both experimental animals and human patients. Thus, our aim was to assess the effects of mafedine and dexmedetomidine on the brain’s electrical activity in a controlled cortical-impact model of traumatic brain injury (TBI) in rats. The functional status of the animals was assessed by electrocorticography (ECoG), using ECoG electrodes which were chronically implanted in different cortical regions. The administration of intraperitoneal mafedine sodium at 2.5 mg∙kg⁻¹ at 1 h after TBI induction, and daily for the following 6 days, restored interhemispheric connectivity in remote brain regions and intrahemispheric connections within the unaffected hemisphere at post-TBI day 7. Animals that had received mafedine sodium also demonstrated an improvement in cortical responses to photic and somatosensory stimulation. Dexmedetomidine at 25 μg∙kg⁻¹ did not affect the brain’s electrical activity in brain-injured rats. Our results confirm the previously described neuroprotective effects of mafedine sodium and suggest that ECoG registration and analysis are a viable method evaluating drug efficacy in experimental animal models of TBI.

Dietary Supplementation for Para-Athletes: A Systematic Review

The use of dietary supplements is high among athletes and non-athletes alike, as well as able-bodied individuals and those with impairments. However, evidence is lacking in the use of dietary supplements for sport performance in a para-athlete population (e.g., those training for the Paralympics or similar competition). Our objective was to examine the literature regarding evidence for various sport supplements in a para-athlete population. A comprehensive literature search was conducted using PubMed, SPORTDiscus, MedLine, and Rehabilitation and Sports Medicine Source. Fifteen studies met our inclusion criteria and were included in our review. Seven varieties of supplements were investigated in the studies reviewed, including caffeine, creatine, buffering agents, fish oil, leucine, and vitamin D. The evidence for each of these supplements remains inconclusive, with varying results between studies. Limitations of research in this area include the heterogeneity of the subjects within the population regarding functionality and impairment. Very few studies included individuals with impairments other than spinal cord injury. Overall, more research is needed to strengthen the evidence for or against supplement use in para-athletes. Future research is also recommended on performance in para-athlete populations with classifiable impairments other than spinal cord injuries.

Nutritional and metabolic supplementation for the injured brain: an update

PURPOSE OF REVIEW

Energy dysfunction is increasingly recognized as a key factor in the pathogenesis of acute brain injury (ABI). This one characterized by a high metabolic rate and nitrogen loss is often associated with an undernutrition support. We review the metabolism evolution and nutritional status in brain injured patient and summarize evidence on nutritional support in this condition.

RECENT FINDINGS

The role of nutrition support for improving prognosis in brain injured patient has been underlined recently. A fast nutrition institution whatever the route is essential to prevent an imbalance in caloric support. Moreover, hypermetabolic state must be prevented with a sufficient nitrogen support. Glycemic control is particularly relevant in this group of patient, with the discovery of new fuel that could potentially improve cerebral metabolism and replace glucose. Few data support also the use of immunonutrition input in this group of patients.

SUMMARY

Nutritional support is a key parameter in brain injured patient and must be initiated quickly to counteract hypermetabolic state by caring to improve caloric and nitrogen input. Recent clinical data support the use of immunonutrition, glutamine and zinc in this particular setting.

Physical activity, fatigue and sleep quality at least 6 months after mild traumatic brain injury in adolescents and young adults: A comparison with orthopedic injury controls

OBJECTIVES

To compare physical activity (PA), fatigue and sleep quality in adolescents and young adults (AYAs) after mild TBI (mTBI) to persons of similar age after orthopedic injury (OI) on the longer term.

SETTING

Follow-up at least 6 months after visiting the emergency department of one of 2 general hospitals.

PARTICIPANTS

Forty-nine patients aged 12-25 years (mean 18.4 years), diagnosed with mTBI and 54 patients aged 12-25 years (mean 15.8 years) with OI.

DESIGN

Cross-sectional electronic survey study.

MAIN OUTCOME MEASURES

The Activity Questionnaire for Adults and Adolescents with results dichotomized for meeting/not meeting Dutch Health Enhancing PA recommendations (D-HEPA), the Checklist Individual Strength (range 20-140, low-high) measuring fatigue, and the Pittsburgh Sleep Quality Index (range 0-21, high-low) measuring sleep quality were administered.

RESULTS

Patients with mTBI less frequently met D-HEPA recommendations than patients with OI (49% vs. 70%; OR 2.87, 95%CI 1.07, 7.72) and reported more concentration-related fatigue problems (mean 19.1 (SD 8.0), mean 13.9 (SD 7.8), respectively; β 3.98, 95%CI 0.39, 7.56), after adjusting for potential confounders, sex, BMI, age and time since injury. No differences were found in sleep quality.

CONCLUSIONS

Identifying symptoms and limitations in activities is important after mTBI so that rehabiliation treatment can be initiated. Whether physical activity or fatigue is the best target for treatment remains to be established.

Pituitary dysfunction and association with fatigue in stroke and other acute brain injury

BACKGROUND

Poststroke fatigue (PSF) is a highly prevalent and debilitating condition. However, the etiology remains incompletely understood. Literature suggests the co-prevalence of pituitary dysfunction (PD) with stroke, and the question raises whether this could be a contributing factor to the development of PSF. This study reviews the prevalence of PD after stroke and other acquired brain injuries and its association with fatigue.

SUMMARY

We performed a bibliographic literature search of MEDLINE and EMBASE databases for English language studies on PD in adult patients with stroke, traumatic brain injury (TBI) or aneurysmatic subarachnoid hemorrhage (aSAH). Forty-two articles were selected for review. Up to 82% of patients were found to have any degree of PD after stroke. Growth hormone deficiency was most commonly found. In aSAH and TBI, prevalences up to 49.3% were reported. However, data differed widely between studies, mostly due to methodological differences including the diagnostic methods used to define PD and the focus on the acute or chronic phase. Data on PD and outcome after stroke, aSAH and TBI are conflicting. No studies were found investigating the association between PD and PSF. Data on the association between PD and fatigue after aSAH and TBI were scarce and conflicting, and fatigue is rarely been investigated as a primary end point.

KEY MESSAGES

Data according to the prevalence of PD after stroke and other acquired brain injury suggest a high prevalence of PD after these conditions. However, the clinical relevance and especially the association with fatigue need to be established.

Improvement of fatigue after vitamin D supplementation in kidney transplant recipients

Low serum levels of vitamin D have been associated with fatigue in both healthy and clinical populations. Our aim was to evaluate the effect of vitamin D supplementation on fatigue in kidney transplant recipients (KTRs). In total, 137 patients after kidney transplant and 119 age- and sex-matched healthy volunteers were recruited. Serum levels of 25-hydroxyvitamin D (25(OH)D) were measured by competitive protein-binding assay. Fatigue was assessed using the subscale fatigue of the Checklist Individual Strength (CIS). Of all KTRs, 60 patients without initial vitamin D3 supplementation were started on vitamin D3 supplementation (cholecalciferol) 800 IU/d, with a follow-up examination after 3.0 to 9.0 months (mean, 6 months). Fatigue was found in 40.1% of KTRs. Serum 25(OH)D levels were inversely and independently associated with CIS scores in KTRs (P = .002). In the 60 patients who received vitamin D3 supplementation, 25(OH)D was overall increased at follow-up with 18.5% (P = .004) and CIS scores improved with 10.0% (P = .007). As vitamin D has beneficial effects on fatigue scores in KTRs, we suggest monitoring this parameter in KTRs and supplementation with vitamin D3 when vitamin D levels are low.

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.

Functional Changes after Recombinant Human Growth Hormone Replacement in Patients with Chronic Traumatic Brain Injury and Abnormal Growth Hormone Secretion

We explored the effects of recombinant human growth hormone (rhGH) replacement on physical and cognitive functioning in subjects with a moderate-to-severe traumatic brain injury (TBI) with abnormal growth hormone (GH) secretion. Fifteen individuals who sustained a TBI at least 12 months prior to study enrollment were identified as having abnormal GH secretion by glucagon stimulation testing (maximum GH response less than 8 ng/mL). Peak cardiorespiratory capacity, body composition, and muscle force testing were assessed at baseline and one year after rhGH replacement. Additionally, standardized neuropsychological tests that assess memory, processing speed, and cognitive flexibility, as well as self-report inventories related to depression and fatigue, were administered at baseline and 1 year after rhGH replacement. Comparison tests were performed with proper post hoc analyses. All analyses were carried out at α < 0.05. Peak O₂ consumption, peak oxygen pulse (estimate of cardiac stroke volume), and peak ventilation all significantly increased (p < 0.05). Maximal isometric and isokinetic force production were not altered. Skeletal muscle fatigue did not change but the perceptual rating of fatigue was reduced by ∼25% (p = 0.06). Cognitive performance did not change significantly over time, whereas self-reported symptoms related to depression and fatigue significantly improved. The observed changes suggest that rhGH replacement has a positive impact on cardiorespiratory fitness and a positive impact on perceptual fatigue in survivors of TBI with altered GH secretion.

Predictors of cognitive and physical fatigue in post-acute mild-moderate traumatic brain injury

Post-traumatic fatigue (PTF) is a common, disabling, and often chronic symptom following traumatic brain injury (TBI). Yet, the impact of chronic cognitive and physical fatigue and their associations with psychiatric, sleep, cognitive, and psychosocial sequelae in mild-moderate TBI remain poorly understood. Sixty Veterans with a history of mild-moderate TBI and 40 Veteran controls (VC) were administered the Modified Fatigue Impact Scale, a validated measure of TBI-related cognitive and physical fatigue as well as measures of neuropsychiatric, psychosocial, sleep, and objective cognitive functioning. Compared to VC, TBI Veterans endorsed significantly greater levels of cognitive and physical fatigue. In TBI, psychiatric symptoms, sleep disturbance, and post-traumatic amnesia (PTA) were associated with both cognitive and physical fatigue, while loss of consciousness (LOC) and poor attention/processing speed were related to elevations in cognitive fatigue only. In regression analyses, anxiety, sleep disturbance, and LOC significantly predicted cognitive fatigue, while only post-traumatic stress symptoms and PTA contributed to physical fatigue. Cognitive and physical fatigue are problematic symptoms following mild-moderate TBI that are differentially associated with specific injury and psychiatric sequelae. Findings provide potential symptom targets for interventions aimed at ameliorating fatigue, and further underscore the importance of assessing and treating fatigue as a multi-dimensional symptom following TBI.

Perceived Social Support and Its Impact on Mental Fatigue in Patients with Mild Traumatic Brain Injury

BACKGROUND

Although mental fatigue was well-recognized as one of the long-term consequences following mild traumatic brain injury (MTBI) that required ongoing support, evidences for the optimal management remained inadequate.

AIMS

To investigate the temporal profile of mental fatigue during the first year after MTBI and examine the impact of perceived social support on the recovery from post-MTBI fatigue.

STUDY DESIGN

Observational case-control study.

METHODS

This study was conducted among post-MTBI patients admitted to the emergency department in a tertiary-care hospital in Sichuan, China. During four waves of assessments at 1 week, 3, 6 and 12 months, mental fatigue was assessed through Mental Fatigue Scale (MFS) whereas social support was assessed by the Multidimensional Scale of Perceived Social Support (MSPSS).

RESULTS

There were 65.1%, 37.1%, 34.8% and 32.5% individuals being identified as those with mental fatigue at 1 week, 3, 6 and 12 months, respectively. The scores of MFS didn't change substantially since 3 months post-injury. Compared to non-fatigued MTBI patients, those with long-lasting post- MTBI fatigue reported extremely lower level of perceived social support. Moreover, improved social support at 1 week was negatively associated with the occurrence of long-lasting fatigue.

CONCLUSION

Sufficient social support could significantly decrease the occurrence of long-lasting mental fatigue among MTBI cases. It seemed of great importance to modify the emphasis of rehabilitation to include assessment and improvement of perceived social support at earlier stages after injury.

Systematic review of interventions for fatigue after traumatic brain injury: a NIDRR traumatic brain injury model systems study

OBJECTIVE

To conduct a systematic review of the evidence on interventions for posttraumatic brain injury fatigue (PTBIF).

METHODS

Systematic searches of multiple databases for peer-reviewed studies published in English on interventions targeting PTBIF as a primary or secondary outcome through January 22, 2014. Reference sections were also reviewed to identify additional articles. Articles were rated using the 2011 American Academy of Neurology Classification of Evidence Scheme for therapeutic studies.

RESULTS

The searches yielded 1526 articles. Nineteen articles met all inclusion criteria: 4 class I, 1 class II/III, 10 class III, and 4 class IV. Only 5 articles examined fatigue as a primary outcome. Interventions were pharmacological and psychological or involved physical activity, bright blue light, electroencephalographic biofeedback, or electrical stimulation. Only 2 interventions (modafinil and cognitive behavioral therapy with fatigue management) were evaluated in more than 1 study.

CONCLUSIONS

Despite areas of promise, there is insufficient evidence to recommend or contraindicate any treatments of PTBIF. Modafinil is not likely to be effective for PTBIF. Piracetam may reduce it, as may bright blue light. Cognitive behavioral therapy deserves additional study. High-quality research incorporating appropriate definition and measurement of fatigue is required to explore the potential benefits of promising interventions, evaluate fatigue treatments shown to be effective in other populations, and develop new interventions for PTBIF.

Fatigue and Vitamin D Status in Iranian Female Nurses

Introduction:

Given that nurses are among professions with frequent problems of fatigue, and given the nature of their profession that provides little exposure to sunlight and the subsequent deficiency of vitamin D, the present study examined the relation between fatigue and circulating vitamin D levels in female nurses working in Shahid Beheshti Hospital, Kashan, Iran in 2013.

Material and Methods:

This cross-sectional study was conducted in 200 female nurses working in Shahid Beheshti Hospital. To measure fatigue, fatigue questionnaire containing 9 questions eliciting the subject’s feeling in scales of 1 to 7, getting a possible score of 9 to 63, and Visual Analogue Scale in which nurses specified their fatigue in a band of zero to 10 were used. The 25-hydroxyvitamin D, which is the most important vitamin D metabolite, also was determined. The data was analyzed by SPSS-16. The Pearson’s correlation of coefficients, t-test, and multiple regression analysis were used in this study.

Results:

The mean fatigue score of nurses was 38.76±12.66 in questionnaire and 5.73±2.12 in Visual Analog Scale. The 89 per cent of nurses suffered from vitamin D deficiency, 9.5 percent of them had normal level and 1.5 per cent had toxicity level of vitamin D. There was a significant relationship between vitamin D level and fatigue scores (P<0.0001), and visual fatigue scores (P<0.0001). According to multivariate regression analysis, vitamin D level accounted for 13 per cent of the fatigue based on data on questionnaire and 18.6 per cent of fatigue according to Visual Analog Scale.

Conclusion:

High prevalence of fatigue among nurses could be attributed to vitamin D deficiency.

The influence of vitamin D on postpartum relapse and quality of life in pregnant multiple sclerosis patients

BACKGROUND AND PURPOSE

In relapsing-remitting MS patients, lower serum vitamin D concentrations are associated with higher relapse risk. In a number of conditions, low vitamin D has been associated with fatigue. Pregnant women are at particular risk for vitamin D insufficiency. Our objective was to investigate whether vitamin D status is associated with postpartum relapse and quality of life during pregnancy.

METHODS

Forty-three pregnant relapsing-remitting MS patients and 21 pregnant controls were seen at regular times before, during and after pregnancy. At every clinical assessment visit, samples for 25-hydroxyvitamin D (25(OH)D) measurements and quality of life questionnaires were taken.

RESULTS

Lower 25(OH)D concentrations were not associated with postpartum relapse risk. Pregnancy 25(OH)D levels of patients and controls were not significantly different. In controls, but not patients, higher 25(OH)D concentrations were correlated with better general health, social functioning and mental health, but not with vitality.

CONCLUSION

Low vitamin D levels are not associated with postpartum relapse. In pregnant MS patients, vitamin D levels are similar to levels in healthy women and are not associated with quality of life. Therefore, with regard to quality of life and postpartum relapse, no arguments were found for advising pregnant MS patients to take more vitamin D supplements than healthy women.

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.

Neuropsychological and physiological correlates of fatigue following traumatic brain injury

BACKGROUND

Fatigue is a common and debilitating phenomenon experienced by individuals with traumatic brain injury (TBI) that can negatively influence rate and extent of functional recovery by reducing participation in brain injury rehabilitation services and increasing maladaptive lifestyle practices. The underlying mechanisms of TBI-related fatigue are not entirely understood and focused research on symptom reduction or prevention is limited.

REVIEW

The current review of the literature suggests that the aetiology of TBI-related fatigue can be viewed as a multifactorial and complex model impacting physiological systems (i.e. endocrine, skeletal muscle and cardiorespiratory) that can be directly or indirectly influenced by neuropsychological correlates including cognitive and psychological impairment. Distinguishing central from peripheral fatigue is helpful in this regard. Potential therapeutic strategies and pharmacological agents to help alleviate fatigue in this patient population are discussed.