NON-PHARMACOLOGICAL MANAGEMENT STRATEGIES
Fatigue post ABI can be managed using pharmacological or non-pharmacological techniques. Non-pharmacological strategies include educating both patients and their family members about the occurrence of fatigue post TBI and how to manage expectations. Diet and lifestyle may also play a role in combating fatigue; thus it is believed that eating a “balanced diet” and learning to balance exercise with rest may help to reduce fatigue (Elovic et al. 2005; Rao et al. 2006).
Those who are suffering from fatigue may benefit by performing important activities when they feel they are at their best (Lezak 1978). Conserving energy and pacing are two ways an individual is encouraged to overcome or deal with his or her levels of fatigue following brain injury (Fellus & Elovic 2007). Many patients find that simple tasks require more concentration and effort than they did previously and, as a result, they tire more easily (Lezak 1978). As part of their rehabilitation, individuals may be taught or re-taught how to prioritize their commitments and are encouraged to recognize their abilities and limitations (Fellus & Elovic 2007). For some this may come easily, but for others it may require more education or other interventional programs (Fellus & Elovic 2007). Although pacing is a concept that has been accepted with health care professionals and encouraged within the ABI/TBI population, its benefits have not yet been studied with this group.
The effects of pacing strategies for those who have sustained an ABI are not known.
Cognitive Behavioural Therapy
Cognitive behavioural therapy (CBT) has been found to be effective at improving fatigue in disorders such as multiple sclerosis, chronic fatigue syndrome, and rheumatoid arthritis (Cantor et al. 2014). However limited research exists on the effect of fatigue and sleep disturbances after brain injury (Ouellet & Morin 2004). Sleep disorders, such as insomnia, can affect a person’s quality of life, family and social commitments, as well as their ability to return to work (Ouellet & Morin 2004). CBT for the treatment of insomnia among a brain injury population was studied in a single study.
Ouellet and Morin (2007) found that CBT was effective in dealing with insomnia. Patients received eight to ten weeks of CBT, totaling eight sessions. For some, improvements in sleep were noted within the first 2 weeks of treatment; for others, improvement was more progressive. Pre to post treatment, significant improvements were found for total wake time (p<0.001), sleep efficacy (p=0.01), fatigue (p<0.012), and insomnia (p<0.01) but not for total sleep time (Ouellet & Morin 2007). No additional significant gains were made once the treatment had concluded, although gains were maintained at 3-month follow-up. This study suggests that a relatively short duration of CBT can lead to positive sleep improvements. Evidently, psychological interventions for insomnia may have therapeutic benefits for individuals post TBI.
There is Level 4 evidence, based on one study, to suggest that cognitive behavioural therapy may assist in treating insomnia and help in the management of fatigue post TBI.
Cognitive behavioural therapy has been shown to be effective in treating insomnia related to TBI. Additional research in this area is warranted.
The use of acupuncture has been shown to be of benefit in treating insomnia within healthy individuals and other patient populations; however, the research is limited within a brain injury population.
Zollman et al. (2012) explored the use of acupuncture, compared to education, in addressing issues of insomnia within a TBI population. A between group comparison showed no significant difference in the Insomnia Severity Index (ISI) scores at three time points (e.g., baseline, post treatment and at one month post treatment). The groups also did not differ significantly in terms of sleep time pre and post treatment. When examining the within-group ISI scores, the treatment group showed a statistically significant decrease in the perception of insomnia severity between pre and post treatment. No such differences were seen in the control group. Those in the treatment group also showed significant improvement on overall cognitive functioning and divided attention. This treatment modality should be studied further within a brain injury population
There is Level 2 evidence to suggest acupuncture is effective in improving perception of sleep and sleep quality in those who sustain a TBI.
Acupuncture therapy has been shown to improve perception of sleep and sleep quality; however due to the small sample further research is needed.
Light therapy has not been well studied in the ABI population; however, it has been said to be a potential treatment modality to address fatigue and daytime sleepiness. In healthy individuals and other patient populations, light exposure has led to improvements in sleepiness, mood and vigilance performance, as well as resulted in an arousing effect on various biological mechanisms (Ponsford et al. 2012).
Sinclair et al. (2014) conducted a RCT examining the effectiveness of light therapy, both blue and yellow, compared to a control group. The blue light therapy was shown to significantly decrease fatigue (p<0.001) and daytime sleepiness (p<0.01) compared to the control group. The yellow light therapy did not show such improvements compared to the control group. The improvements measured during the treatment phase did not persist at follow-up (week 8).
There is level 1b evidence, from a single study, that blue light therapy is effective in reducing fatigue and daytime sleepiness during treatment.
Blue light therapy was found to reduce fatigue and daytime sleepiness; however the improvements did not persist beyond the treatment period.