Fatigue

• Fatigue is the Biggest Common Denominator
• Consequence of "Over-Attending"
• Often Most Disabling Symptom
• Hardest to Accommodate in Workplace

Many sources talk about fatigue as an issue in brain injury. Gronwall and Wrightson in Mild Head Injury say it has a greater direct impact on a patient's life than any other factor. The universally recognized treatise by Muriel Lezak, Neuropsychological Assessment, ©1995 Oxford University Press, at page 183 contains the following outstanding explanation of fatigue:

As a result of the slowed processing resulting from many microscopic sites of damage diffusely distributed throughout cerebral white matter and the upper brain stem, activities that were automatic now may only be accomplished with deliberate effort.

The activities that are normally automatic but become effortful after the injury, particularly during the first weeks or months, include many that are performed frequently throughout a normal activity day, such as concentrating, warding off distractions, reading for meaning, doing mental calculations, monitoring ongoing performances, planning the days activities, attending to two conversations at once or conversing with background noise, etc. ... It is little wonder that by late afternoon, if not by noon, many of these patients are exhausted. Making matters worse, as they get fatigued their efficiency plummets to even lower levels so that activities that were difficult when they were most rested and competent become extremely labored and even more error prone; e.g., they become more distractible, make more mistakes when speaking, become more clumsy, etc.

Wrightson and Gronwall in Mild Head Injury, ©1999, Oxford concur.

In most cases, fatigue is brought on most quickly by cognitive effort, desk work, reading, or any activity that needs attention. Physical effort does have some effect, particularly in early stages when it may bring on somatic symptoms, but later it is better tolerated.

Characteristically, providing their sleep has not been disturbed, the patients starts the day with some feeling of energy. Then, fairly suddenly, often they say like a curtain falling down, they find they are struggling to keep going; and can't make sense of what they're doing. If they recognize this warning and rest for an hour or two they may recover and be able to start again for another period. If they neglect the warning and go on working until they can cope no longer they bring on a state of severe fatigue which will stop them doing anything productive for the rest of the day; often it will persist and prevent useful work the next day, or even longer.

Comments by the family or pressure at work can make the situation worse. It is difficult for others to understand the limitations imposed by the fatigue and they can encourage or embarrass the patient into continuing in spite of it. When a patient who has been improving starts to regress, this sort of situation will often be uncovered.

It is not necessary to have a loss of consciousness to suffer permanent brain injury.

Source: Definition of Mild Traumatic Brain Injury Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. J Head Trauma Rehabil 1993:8(3):86-87

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