WHAT IS POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
Post-traumatic brain injury fatigue (PTBIF) is one of the most distressing, pervasive, and challenging symptoms after a concussion or brain injury. It is a common, non-specific symptom related to various neurological conditions (like stroke, multiple sclerosis, etc.); for the purpose of this article, the focus will be on fatigue after concussion or mild traumatic brain injury.
PTBIF is often described as a general sense of reduced energy. It involves both physical and mental fatigue. And it becomes pathological when present for longer than 3 months after the injury. Unlike ‘normal’ fatigue, which is time-limited and alleviated by rest, the intense feeling of fatigue after brain injury may be present most of the time and can have a significant impact on quality of life. For more detail about fatigue in general, please read the “Fatigue: What is it?” article.
HOW COMMON IS POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
Fatigue is one of the most reported symptoms after brain injury; it ranks second only after headache. For most patients, significant fatigue appears 2 days up to 3 months after a concussion and persists afterwards. About two thirds (68%) of patients report fatigue 1 week after the injury. At the one-month mark, it ranges between 27-69% of patients. It remains roughly stable at the 3-month mark with a 22-61% prevalence. At 6 months it decreases to 19-45%. While some research mentions that fatigue is back to pre-injury levels 1 year after the concussion, other data shows that significant fatigue persists in 45% of patients. A small cross-sectional study conducted in Ontario showed that 50% of patients with mild TBI had ongoing fatigue at 10 years post injury.
WHAT ARE THE SYMPTOMS OF POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
On top of general fatigue symptoms (see article ‘Chronic fatigue’), patients struggling with PTBIF often reports symptoms of:
- drop in cognitive and/or physical performances,
- irritability,
- avoidance of social activities or leisure,
- exacerbation of pain (e.g., headache), and/or
- increased inactivity or time spent in bed.
For most, mental fatigue associated with brain injury is present nearly every day or the week. It is characterized by (1) being easily fatigued (e.g., compared to people without a brain injury) and (2) a disproportionate long recovery time (compared to the effort) to restore cognitive energy, taking sometimes days to recover. Patients struggling with PTBIF usually report their mental fatigue to be less severe in the morning, and to steadily increase as the day passes reaching its zenith in the evening, after dinner time.
Physical fatigue in concussion patients is often not relieved by a good night sleep due to underlying concussion related conditions (e.g., autonomic dysfunction.).
WHAT CAUSES POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
Researchers have elaborated different hypotheses to explain PTBIF: (1) dysfunction of the basal ganglia, (2) frontocerebellar dysfunction, (3) neuroendocrine dysfunction (which leads to hormonal imbalance like hypopituitarism), (4) genetic component, (5) diffuse axonal injury, and/or (6) impaired motor cortex excitability. Many other conditions common after a brain injury can cause or add to the fatigue toll, like mood issues, autonomic dysfunction, sleep disturbances, vestibular or visual disorders, chronic pain (e.g., headache), etc. Lifestyle changes (e.g., inactivity, deconditioning) common post-concussion contribute to fatigue as well. All other causes of fatigue (see article ‘Chronic fatigue’) should also be ruled out.
WHO IS AT RISK OF STRUGGLING WITH POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
Women are more at risk of struggling with PTIBF. Those who experience severe fatigue within a week of their injury or have headache/nausea within the first two weeks are also at increased risk. Poor medical health, litigation, mental health issues, marital status (widower, divorce or separated), chronic pain, unemployment, substance abuse, cognitive issues and prior brain injury are other factors than can increase the risk of persistent fatigue after a concussion.
WHAT IS THE IMPACT OF POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
PTBIF can become an important obstacle on the road to recovery as it often worsens other problems like pain, cognitive problems, or balance problems. Chronic fatigue negatively impacts work performance, family life and social relationships. It can have detrimental effects on patients’ overall well-being. For example, patients often give up activities they enjoy (either social, leisure or occupational activities) because of the fatigue. In turn this decreases their quality of life and causes more social isolation.
WHAT OPTIONS ARE AVAILABLE TO TREAT POST-TRAUMATIC BRAIN INJURY FATIGUE (PTBIF)?
There is no specific treatment for fatigue after a concussion. Research on PTBIF is sparse, even more so on treatment options. The first step is always to optimize other medical conditions (e.g., sleep optimization, headache management, autonomic dysfunction physical retraining, neuroendocrine dysfunction correction…). Returning to work (or school, volunteer work) is associated with significant improvement of fatigue in the long term. Undertaking proper energy management (cognitive and behavioural modifications) helps TBI patients better manage their energy levels and improves their quality of life. Research has shown that the optimal timing for chronic fatigue intervention is at the 3-month mark.
Sometimes psychostimulants (e.g., Ritalin or methylphenidate) are used in patients with mild TBI for short periods of time or episodic situations to increase attention and alertness rather than treating fatigue. Common side effects from psychostimulants include headache, restlessness, insomnia, and dry mouth.
For more detail about other therapeutic options for fatigue in general, read the article “Fatigue: What is it?“.
Last update: January 2024