MENTAL FATIGUE BRAIN INJURY

Transkript

1 MENTAL FATIGUE MENTAL AFTER FATIGUE TRAUMATIC AFTER AN ACQUIRED BRAIN BRAIN INJURY INJURY Lars Rönnbäck Birgitta Johansson Sahlgrenska Academy, University of Gothenburg

2 Mental fatigue - is a special kind of fatigue.

3 Mental Fatigue Limited energy reserves for accomplishing ordinary everyday activities. For many people - a long-lasting problem. Substantial impact on the ability to resume work, studies, and social activities.

4 Definition of fatigue, (Aaronson et al., 1999) The awareness of a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization, and /or restoration of resources needed to perform activity.

5 Frequency of fatigue Frequency of prolonged fatigue after traumatic brain injuries varies from 16 up to 73 %.

6 There is no correlation between: Persistent fatigue and severity of the primary injury Age of the person at injury Time since injury

7 Concentration problems SAHLGRENSKA AKADEMIN Typical symptoms Diurnal variation Mental fatigue Long recovery time Rapid drain of mental energy

8 Associated symptoms SAHLGRENSKA AKADEMIN Lack of initiative Sleep problems Mood swings Headache following overexertion Irritability Sensitivity to light and noise Mental fatigue Slowness of thinking Sensitivity to stress Memory problems

9 Mental fatigue is often present in the following situations: Situations in which there is an invasion of the senses with an overload of impressions, and noisy and hectic environments Reading Conversations

10 Friends Some of my friends weren t very understanding. They thought I was making excuses or that I didn t want to see them. But it was only because I felt too tired."

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12 High Mental energy After a brain injury SAHLGRENSKA AKADEMIN Good recovery after a brain injury. Partially recovered After a while, the individual becomes totally exhausted if it has not been possible to adapt the work load to manageable levels. Low A slight recovery but the person is not able to return to work or studies. Time (months to years)

13 If the fatigue is not acknowledged in time: A total and almost paralyzing fatigue can occur. Longer periods of rest may be needed, often over several days. A worsening of symptoms over time.

14 Depression Separate depression and mental fatigue.

15 Factors interacting after a brain injury Silver et al., 2009

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18 Hypothetical development of mental fatigue Neuroinflammation Acquired brain injury Riskfactors? Pre-pro inflammatory CNS environment Previous brain injury Other diseases Genetic Apolipoprotein ApoE e4 Recovered, no mental fatigue Neuroinflammation low grade? Impaired brain efficiency. Mental fatigue

19 Normal function

20 Impaired glucose supply

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22 Adlibris Bokus

23 Mental Fatigue Scale, MFS SAHLGRENSKA AKADEMIN Navn: Dato: Vi er interesserede i din nuværende tilstand, dvs. hvordan du har haft det den sidste måned. Når du skal sammenligne hvordan det var tidligere, skal du sammenligne det med hvordan det var før du blev syg / blev skadet. I tabellen for hvert spørgsmål findes 4 påstande som beskriver ingen (0), let (1), middelsvært (2) og udtalt besvær (3). Vi ønsker, at du markerer det tal som bedst beskriver dit problemer. Hvis du synes, at du ligger mellem to påstande, markerer du tallet imellem de to påstande. 1 Træthed Har du følt dig træt den seneste måned? Det betyder ikke noget, om det er fysisk (muskulær træthed) eller træt i hovedet. Hvis der for nylig er sket noget uvant (fx en ulykke eller kortvarig sygdom) skal du forsøge at se bort fra det. 0 Jeg har slet ikke følt mig træt (aldrig unormalt træt, ikke behov for at hvile mere end sædvanligt) Jeg har været træt flere gange om dagen, men jeg bliver mere frisk af at hvile Jeg har følt mig træt det meste af dagen og hvile har ingen eller kun lidt effekt Jeg føler mig altid træt og hvile har ingen effekt. 2 Manglende initiativ Har du svært ved at komme i gang med aktiviteter? Føler du dig initiativløs og er det svært at komme i gang med noget, uanset om det er en ny opgave eller det drejer sig om ting, som du gør hver dag. 0 Jeg har ingen vanskeligheder med at komme i gang med aktiviteter Jeg har sværere end tidligere ved at komme i gang med aktiviteter. Jeg udskyder det gerne Det kræver en stor anstrengelse for mig at komme i gang med aktiviteter. Dette gælder også dagligdags aktiviteter, som at stå ud af sengen, vaske mig osv Jeg kan ikke få de enkle hverdagsaktiviteter gjort (spise, tage tøj på). Jeg må have hjælp til alt. 3 Mental træthed Bliver du hurtigt træt i hovedet, når hjernen skal arbejde? Bliver du mentalt træt af aktiviteter, som at læse, se TV eller deltage i samtale med flere personer. Er du nødt til at holde pauser eller skifte aktivitet? 0 Jeg kan blive ved som før. Min udholdenhed ved hjernearbejde er ikke blevet mindre Jeg bliver hurtigere træt, men kan udføre hjernearbejde som tidligere Jeg bliver hurtigt træt og bliver nødt til at holde pause eller gøre noget andet oftere end jeg plejer Jeg bliver så let træt, at jeg ikke kan gøre noget som helst eller må afbryde alle aktiviteter efter kort tid (ca. 5 minutter).

24 Diagnostic criteria for mental fatigue Cut-off 10,5 points and above MFS Johansson, B., & Rönnbäck, L. (2014). Evaluation of the Mental Fatigue Scale and its relation to Cognitive and Emotional Functioning after Traumatic Brain Injury or Stroke. International Journal of Physical Medicine and Rehabilitation, 2, 182. doi: /

25 25 MFS

26 Mental fatigue (MFS) SAHLGRENSKA AKADEMIN 40 Correlation MFS - age Mental fatigue persons r=0.15, ns n= Healthy controls r=0.02, ns n= age

27 MFS Arbetar 100% (151) Arbetar 75% (15) Arbetar 50% (12) Arbetar 25% (5) 100% sjuksriven/sjuers. (17) SAHLGRENSKA AKADEMIN MFS and employment status, 4 months 5 years aftertbi No correlation between MFS and age, severity of injury, time since injury. MFS - higher for those who had sustained a previous TBI. S. Palm, L. Rönnbäck and B. Johansson. LONG-TERM MENTAL FATIGUE AFTER TRAUMATIC BRAIN INJURY AND IMPACT ON EMPLOYMENT STATUS, PhDJ Rehabil Med 2017; 49:

28 Assessment of mental fatigue Subjectively: Mental Fatigue Scale, MFS Objectively: Cognitive tests?

29 Cognitive tests Most sensitive cognitive functions (on group level): Processing speed Attention Working memory

30 Cognitive function individual level Can perform within normal range but can become extremey fatigued later.

31 Mentally tiring activities after brain injury are related to reduced resources. Patients with brain injury describe mental activity as more energydemanding than healthy persons. - severe TBI, increase in reaction time during a dual-task condition and a higher subjective mental effort. (Azouvi et al., 2004). TBI subjects - slower on a complex attention test, made more errors and reported a higher level of subjective fatigue. (Ziino & Ponsfold, 2006). Practice increased the response speed over time for controls, while this was not the case for subjects with mental fatigue after TBI. (Ashman et al., 2008). A high load on working memory (conscious) was more tiring for TBI subjects than an automatic activity. (Park, et al., 1999)

32 cods/2 min SAHLGRENSKA AKADEMIN *** Processing speed 0 Controls mtbi TBI Stroke

33 words/second 3,5 3 2,5 2 1,5 1 0,5 0 Reading speed SAHLGRENSKA AKADEMIN Controls MTBI MTBI TBI

34 Treatment? SAHLGRENSKA AKADEMIN

35 Strategies Information - understand Take regular breaks -Encourage rest before becoming over-tired Plan the days activities or the activities for the week in a diary or journal taking one task at a time with short working periods, and prioritize the tasks. Decrease inner and outer impressions

36 Treatment studies Central stimulating drugs Mindfulness

37 Now follow-up after 6 years Johansson, B., Wentzel, A-P., Andréll, P., Rönnbäck, L. and Mannheimer, C. (2016) Long-term treatment with methylphenidate for fatigue after traumatic brain injury. Accepted for publication in Acta Neurologica Scandinavica Johansson, B., Wentzel, A-P., Andréll, P., Rönnbäck, L and Mannheimer, C. (2015) Methylphenidate reduces mental fatigue and improves processing speed in persons suffered a traumatic brain injury. Brain Injury, 29(6): Johansson, B., Wentzel, A-P., Andréll, P., Odenstedt, J., Mannheimer, C., Rönnbäck, L. (2014). Evaluation of dosage, safety and effects of methylphenidate on posttraumatic brain injury symptoms with focus on mental fatigue and pain. Brain Injury 28(3):

38 25 Mental Fatigue *** Baseline Normal 6 m 22 m

39 Processing speed Baseline Normal 6 m 22 m

40 MFS 25 OSU6162 dopamin- och serotonine stabilizer SAHLGRENSKA AKADEMIN Placebo OSU6162 Johansson, B., Carlsson, A., Carlsson, M. L., Karlsson, M., Nilsson, M. K. L., Nordquist-Brandt, E., & Rönnbäck, L. (2012). Placebo-controlled cross-over study of the monoaminergic stabiliser ( )-OSU6162 in mental fatigue following stroke or traumatic brain injury. Acta Neuropsychiatrica,, 24(5),

41 MINDFULNESS It s not about a particular method or technique, it s a way of being.

42 Definition of mindfulness: Paying attention in a particular way; on purpose, in the present moment, and non-judge-mentally. /John Kabat-Zinn

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45 Why mindfulness? Stop and rest Compassion Richard Matthieu: Happiness: A Guide to Developing Life's Most Important Skill

46 Acceptans change and growth

47 MBSR Mindfulness Based Stress Reduction The MBSR program was created 38 years ago by The Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School

48 MBSR The course consists of eight weekly sessions and one day silent retreat all included live on Internet Guided in mindfulness meditations, gentle mindful yoga Group dialogue Daily home assignments, formal and informal. For help during the week prerecorded meditations

49 Johansson, B., Bjuhr, H., & Rönnbäck, L. Mindfullness based stress reduction impairs long-term mental fatigue after stroke or traumatic brain injury. Brain Injury. 2012;26(13-14): Johansson, B, Bjuhr, H, Karlsson, M, Karlsson, J-O, Rönnbäck, L. Mindfulness-Based Stress Reduction (MBSR) Delivered Live on the Internet to Individuals Suffering from Mental Fatigue After an Acquired Brain Injury. Mindfulness. 2015;6: Johansson, B., Bjuhr, H., & Rönnbäck, L. (2015). Evaluation of an Advanced Mindfulness Program Following a Mindfulness- Based Stress Reduction Program for Participant Suffering from Mental Fatigue After Acquired Brain Injury. Mindfulness, 6(2),

50 MFS 25 Mental fatigue 20 ** ** ** MBSR gr 1 pretest MBSR gr 1 posttest Control pretest Control posttest MBRS gr 2 pretest MBSR gr 2 posttest

51 Helena Bjuhr,

52 Mental Fatigue

53 AB T2 Changes from pretest to posttest AB Test MBSR live on Internet SAHLGRENSKA AKADEMIN * * MBSR face-toface * ms 504 ms 756 ms Distance between T1 and T2

54 Results MBSR appears promising for the treatment of persons suffering from mental fatigue after stroke Reduced ratings on mental fatigue scale (MFS) Reduced rating on depression and anxiety (CPRS/MADRS) Improved attention and processing speed

55 Mindfulness for people suffering from mental fatigue? Brain rest balance in rest and activity Insight New ways to handle life Acceptance Better attention Less anxiety and stress Compassion

56 Mental Fatigue - summary Etiology is poorly understood. Further research is necessary to develop objective and subjective measures. Development of efficient treatments for fatigue is important today we can alleviate fatigue.

57 Tanks!