Monday, March 17, 2014

Fatigue after Brain Surgery

This excellent article is from BrainLine. The subject is about Fatigue after a
traumatic brain injury, but since invasive brain surgery is considered a traumatic brain injury, I felt very appropriate to share with you all. I copied and paste what I felt was related to surgery, from what I have experienced. 

BrainLine sat down with Dr. Nathan Zasler to talk about the issues of fatigue after a traumatic brain injury. Dr. Zasler is an internationally respected neurorehabilitation physician who specializes in brain injury.

BrainLine: Describe fatigue. What exactly is traumatic brain injury-related fatigue?

Dr. Zasler: Think about a car. It needs gas to run. If your tank is low, your car will start sputtering and then stop once you have reached the end of your reserve. It’s the same way with fatigue after TBI. Fatigue is caused by a decrease in physiological reserve, which includes a person’s physical and mental reserves. When your brain is “tapped out,” you feel tired. Basically, when a person’s brain is overtaxed, fatigue will set in.
Although one formal definition of fatigue that has been proposed states that it is the failure to initiate or sustain attention or physical activity that requires self-motivation, there continues to be debate about how best to define "fatigue." In part, it’s difficult to define the term because fatigue is subjective — that is, it is solely based on patient report — and it is really more a symptom than a diagnosis. Just like it is difficult to tell if someone is in pain, it is also challenging to know if someone suffers from fatigue unless they tell you so. But generally, people with TBI have described fatigue as a sense of mental or physical tiredness, exhaustion, lack of energy, and/or low vitality. Unfortunately, we don’t have any definitive screening tools for fatigue, so there is no universal way to measure it.
Cognitive and physical fatigue can occur separately or together, but most people seem to have more problems with the mental side of fatigue after a brain injury. They say they are not as quick as they used to be, mental tasks that were once easy are much more difficult, and they tire far more easily even doing something that used to be simple like reading, studying, or working.
Although there are limited long-term studies, some research indicates that fatigue is usually short-lived after most mild TBIs. And in my experience as a physiatrist, fatigue in patients with mild TBI usually lasts no longer than three to six months. However, for some people with mild TBI, their fatigue is more persistent.

BrainLine: How common is fatigue after a brain injury?

Dr. Zasler: In the general population, fatigue is a common complaint with some studies citing an incidence of 10 percent. But for people with traumatic brain injury, it is one of the most common problems post-injury. Fatigue affects not only people with moderate to severe TBI, but also those with mild TBI. And we still need more research to better understand this issue.

BrainLine: What does fatigue look like after TBI?

Dr. Zasler: The spectrum of fatigue is as broad as the spectrum of traumatic brain injury, itself. Everyone’s brain injury is different and everyone’s symptoms will be different. There are also many variables when it comes to post-TBI fatigue — from levels of severity to pervasiveness. Some people may be very fatigued all the time and others may only be fatigued after mental or physical exertion.
Most people who have fatigue resulting from brain injury only experience the problem at certain times and not all the time. They have more energy in the morning and tend to be more tired later in the day. People’s levels of fatigue also depend on how much they are pushing themselves physically or cognitively, and whether they are making time to rest periodically during the day and pace themselves.
Depression, anxiety, or stress can also contribute to the degree of a person’s fatigue or, alternatively, may even be the cause of the fatigue. Not everyone with a TBI will experience fatigue due to their brain injury. So, each person’s levels of fatigue, if present, may change over time during their recovery, in terms of both cause and level of severity.

BrainLine: Why do these problems occur?

Dr. Zasler: Unfortunately, we don’t really know. There have not been a lot of conclusive studies conducted on fatigue after brain injury. Much of what we are discussing is experiential. Some have theorized that damage to the basal ganglia — which are structures deep in the brain — are the critical areas involved in the generation of fatigue. Others have noted that other areas of the brain may be involved as well.

BrainLine: Can you explain why making sure you get a specific or accurate diagnosis is so important?

Dr. Zasler: With any medical issue, an incorrect diagnosis can set a person back in his recovery. It is important to make sure that you are seeing a clinician who is knowledgeable about traumatic brain injury. You can ask for references from other clinicians, from TBI organizations like your state’s Brain Injury Association, and from other patients. And you want a doctor with whom you feel secure, someone who is truly listening to you and asking questions.
Don’t be afraid to take your time in selecting a doctor. One thing that surprises me time and time again is that no one these days takes the initiative to interview potential doctors before making a selection. You can set up an appointment with a doctor you are considering to get a sense of his bedside manner, knowledge, and philosophy. When it comes to TBI, the patient/physician relationship may continue for many years, so choosing well is very important.

BrainLine: What can make fatigue worse?

Dr. Zasler: If you have neurogenic fatigue — that is, fatigue related to the damage in the brain’s nerve cells — here are some things that can make the fatigue worse:

  • not using pacing strategies appropriately, like dividing work into “chunks,” and not getting overly fatigued by working to long at a given task
  • not getting regular, restorative sleep
  • not taking the necessary naps or getting the rest you need throughout the day
  • not getting proper exercise or nutrition
  • taking medications that have sedative properties
  • having too much stress in your daily life
These suggestions are basic common-sense guidelines that clinicians should apply to help people with fatigue after brain injury. After all, the more a person learns about how and when his fatigue manifests itself, the more he can schedule his day around his levels of energy and create strategies to keep symptoms at bay.

BrainLine: Are there related problems that often occur with fatigue after TBI?

Dr. Zasler: The main ones are depression, anxiety, and stress. These often go hand-in-hand with post-TBI fatigue; one can exacerbate the other.

BrainLine: What advice or strategies do you offer your patients who are struggling with fatigue after a brain injury?

Dr. Zasler: Once I’m pretty sure that the fatigue is related to the TBI, I emphasize basic strategies like:

  • getting good regular, restorative sleep
  • making sure to get rest when you need it, not after you have become overly tired, stressed, depressed, or in pain
  • breaking activities into several steps through scheduling activities, “chunking” (that is grouping certain activities together) and pacing exercising
  • eating nutritious foods
  • asking for help when needed

Nathan D. Zasler, MD Nathan D. Zasler, MD, Nathan Zasler, MD is CEO and medical director for Concussion Care Centre of Virginia, Ltd. as well as CEO and medical director for Tree of Life Services, Inc.  He is board certified in physical medicine and rehabilitation and fellowship trained in brain injury.

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