Neuro Occupational Therapy and Fatigue 

The complexities of fatigue following traumatic brain injury 

 

  Following brain injury fatigue can occupy time, preoccupy the mind and restrict physical abilities. It can be all-consuming leaving no space for activities or roles that were previously valued and enjoyed.  

Jo Throp

Neuro Occupational Therapy and Fatigue at Krysalis Consultancy

Fatigue is the most commonly reported symptom in the wake of brain injury. Symptoms of fatigue can impact negatively on an individual’s functional ability including their psychological, emotional and physical wellbeing. It can occupy time, preoccupy the mind and restrict physical abilities. It can be all-consuming leaving no space for activities or roles that were previously valued and enjoyed. 

A wide variety of variables impacts on the unique subjective experience of fatigue for each individual. Fatigue is multifaceted in nature and is influenced by bio-social factors. It can therefore be difficult to understand and monitor. 

Understanding fatigue and implementing strategies to help manage fluctuating fatigue within the context of activities should be the foundation of any occupational therapy rehabilitation programme, given the significant impact of fatigue on an individual’s ability engage in day to day activities, roles and occupations following brain injury.  

Complexities of fatigue following traumatic brain injury (TBI)

Fatigue can be hard to define and articulate for many brain injury survivors. ‘People with ABI commonly report three types of fatigue; physical, mental and emotional, with the latter being difficult to understand and define to others.’ (1)

I get so tired. In busy places I have to rest, or sleep, otherwise I can’t function. 

Krysalis client and ABI survivor 

The complex nature of mental fatigue and ‘brain flooding’ can set in when the brain becomes over-loaded either by physical, cognitive or emotional demands. The consequences of fatigue are unique to each individual and can include a wide variety of functional symptoms including:

  • Physical symptoms such as muscle weakness, problems with co-ordination or recurring headaches.
  • Cognitive symptoms such as reduced concentration or ‘brain fog’.
  • Sensory disturbance such as visual problems.
  • Difficulties engaging in daily activities or interacting socially with others.
  • Reduced tolerance to busy and noisy environments.

Neuro OT, fatigue and brain injury

Fatigue can present a complex challenge for rehabilitation professionals. It is therefore essential that occupational therapists working with clients who have a brain injury take time to identify the factors that influence fatigue, either in a positive or negative way, before an appropriate fatigue management programme can be designed. 

Fatigue education is the foundation of empowerment 

The occupational therapist must take time to help an individual understand the impact of their brain injury, the mechanism of the injury, how these impact on the fatigue they now experience and the functional consequences. 

Education is central to helping an individual develop their insight and awareness. This forms the foundation of supporting behaviour change and is a platform for introducing practical coping strategies. Care needs to be taken to reflect, together with the individual, on a number of key factors that will influence the formulation of a rehabilitation programme and the approach used.

Self-care is about giving the world the best of you instead of what is left of you

Katie Reed

The impact of belief systems on fatigue management 

Long established behaviour patterns and belief systems around perceptions of fatigue need to be understood. This includes an understanding of the very personal internal viewpoints of an individual’s unique reaction and response to fatigue, such as: “I like to ignore it and push on - I won’t be beaten!” These insights are central to devising a successful and client-centred occupational therapy programme. 

 

  Long established behaviour patterns and belief systems around perceptions of fatigue need to be understood. This includes an understanding of the very personal internal viewpoints of an individual’s unique reaction and response to fatigue    

Jo Throp

 

For example, a highly driven and ‘busy’ individual may not adapt well to the functional restrictions that fatigue presents. Long-established coping strategies such as ‘I like to be busy’, may be exacerbating fatigue. Equally, however, well-meaning advice such as: “You have to slow down and have rest periods” may create conflict between internal belief systems, jeopardising the success of rehabilitation and the therapeutic relationship. An individualised approach to fatigue management must be adopted, considering the individuals roles, routines, goals and aspirations. 

The impact of the environment on fatigue management 

Care needs to be taken to assess the impact of the environment on the individual’s fatigue levels. 

The OT assessment should include a review of:

  • the impact of other people who maybe living or working within the shared enviroment
  • the differentiation between the actual or percieved impact of physical, sensory, cognitive and emotional load
  • the 'weighting' or impact of the different factors that imoact on fatigue

Care must be taken to differentiate between fatigue and sleepiness which, whilst they may co-exist, are considered to be separate entities. Disrupted sleep patterns, however, will exacerbate both. Medical review of sleep abnormalities should be considered where required. 

Fatigue, the individual and daily activities

It is also important to consider other factors including:

  • the impact of fatigue on emotional wellbeing and vice versa.
  • the energy levels required by different activities and interactions in everyday life, and how the impact of these external demands has changed post-injury.
  • establishing a baseline of function, including the patterns of fatigue, energy levels and ‘boom and bust’ patterns.
  • the relationship between fatigue and other symptoms such as pain and mood disorders.
  • activities that ‘drain energy’ and those that ‘top up’ energy reserves.
  • grading activities including ‘activity weighting’ within the context of time of day and duration of activity, output required, and familiarity of the activity among other things. 
  • empowering individuals with knowledge so that fatigue becomes something that can be managed rather than a symptom that restricts potential. 

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