Topic: Brain Injury-Related Fatigue

Question:

I am taking college classes and in spite of my continued struggle with fatigue, it's going well so far. In the first course (of seven) I have a 90% average and I expect to write my first two exams and finish this part in about 3 weeks time.

Do you have tips on dealing with fatigue? I know that sleeping 8 hours will help, but taking in a lot of information at once really knocks me back. Do you have any suggestions? The next six courses move to a different type of studying. We only meet for 2 four hour sessions a week and are assigned computer-based modules to do in the mean time. I can download the modules here at home as well as pace out my studies a bit better. Maybe that will help.

Thanks,
Shauna

Dear Shauna,

First of all, congratulations on taking college-level courses! If you got a 90% on your first exam, this means you must be doing something right!

Learning new material is a particular challenge for anyone with a brain injury! And yes, it is very exhausting. You're right, be sure you get enough sleep at night, but there are some other things you might want to try too.

First, be aware that there really is such a thing as "cognitive fatigue" and it ends up translating into physical tiredness, just as physical work does. The difference is that there are some specific strategies that work for "cognitive fatigue" that may or may not help with other kinds of fatigue or tiredness.

Even though you didn't mention stamina, we should probably talk about "increasing cognitive stamina" too, since reducing fatigue and increasing stamina are related, especially when we want to be successful in new, more demanding environments.

The challenge of new environments
When a person with brain injury starts to branch out, and is in a new, challenging environment (like work or school), the brain is being challenged constantly, virtually non-stop! In addition to all the extra work the brain is doing just to process normal activities of life, it is now being given the added burden of learning new information (or handling new tasks, such as ringing phones, or demanding bosses). This is a lot!

When I first went back to work, I could not believe how much extra work was involved with "working"-- not just to do the work itself, but to do all the work involved in learning new things with my damaged processor! What I had taken for granted before, and what had been "automatic" before, could not be taken for granted any longer. Nor was it automatic. Work was much more WORK! Going back to school is the same thing!

Cognitive Breaks
A strategy I have found useful is something I call taking lots of little "cognitive breaks." A cognitive break is like any regular "break" except I make sure it's in as quiet and as darkened a place as possible, and it doesn't last very long.

A break room (in an office, for example) might have too much light or too many people to be effective. The bathroom sometimes works. Or even a spare room that no one is using that is completely quiet and where the lights can be turned off can be good too (don't tell anyone, but I have actually used closets for these breaks).

The idea is to take a complete break from all visual, auditory and mental stimulation for approximately one or two minutes, every hour -- whether you think you need it or not. This kind of break need not be long, just "total." Now, if you can't find such a place in your physical environment, you can take more aggressive steps to create the right environment. It's as simple as acquiring ear protectors (the kind jack hammer operators wear, mine cost about $15.00) and ear plugs (the kind hunters use). I wear them in combination -- first the ear plugs go in, and then the ear protectors go over the top. Then, if I need to block out the light, I can always simply close my eyes.

This little ritual may sound a bit odd, but all I can tell you is it works! It has worked for me, and it work for others I know who have brain injury and are struggling with "cognitive fatigue." In my case, by taking cognitive breaks regularly, after about a year and a half, I was able to extend my "cognitive stamina" for working from only several hours per week, to full four hours per day, five days a week.

When I started working my first six hour shift (about 18 months post), I wasn't sure the "break thing" would help because I felt I had pushed myself to the max (but I really wanted to keep the job so I tried it). I found I was able to extend my stamina to a full eight hours within about three months. I noticed the benefits fairly rapidly -- as soon as I started taking the breaks religiously (every hour, on the hour, whether I felt tired or not). Instead of fading at 2:00 PM and collapsing in a heap at 4:00 PM when I got home, I was able to be relatively alert after lunch and did not collapse in a pile after I got home.

Compensation and "cognitive fatigue"
Another factor was mastery of certain compensatory strategies. I found that the more proficient I became with compensation strategies, the less I had to struggle with memory, and the less tired I became (I knew I could look something up so didn't struggle with or stress out over trying to remember things). This works best when the strategies have become automatic, which mine were after about two years.

It's amazing how much energy those of us with brain injury expend worrying about what we might have forgotten, or struggling to "find" something in our heads, when both of these anxieties can be reduced by having mastery of certain compensatory techniques.

Specific strategies for school
I'm actually taking some classes myself now (second time since my injury), and I have found that the combination of audio taping the classes and taking notes with my laptop at the same time, is a combination that works well for me. I can reinforce what I'm hearing by typing notes (and they are organize-able later, since they are in electronic form, not hand written), and I have the audio tapes as a back up if I need them. This reduces much of the "stress and struggle" I would feel if I didn't have these two strategies at my disposal. We know that both stress and struggle make us tired, so anything we can do to reduce these things will either reduce fatigue, increase stamina, or both!

Crash and burn -- cumulative effects of work and stressors
Other people I know who have brain injury report that when stressors accumulate, they are more prone to fatigue and often end up in what is called a "crash and burn" situation. It is important to listen carefully to one's body to avoid this, but this is easier said than done! Sometimes we are listening to our "old" body, not realizing that the new one is delivering different messages!

Learning how to avoid "crash and burn" and also how to regroup from it is important. Many of us "old timers" who have been at this task of getting back into the swing of things for a while now, know that "crash and burn" is something many/most of us go through as we continue to challenge ourselves.

I suppose some of us learn from our mistakes, but I don't seem to be able to! One minute I'll seem fine and the next minute I'm in total shutdown, in a "crash and burn" mode, and have to honor the fact that my body and brain is just not capable of doing any more. I work with a lot of accomplished, competent, successful persons with brain injury now, and we all seem to experience this phenomenon, as we grow and take on new challenges. Knowing that tomorrow will be better helps. Knowing how to regroup and start over helps. Most important, if you do "crash and burn" do not take it to mean that the "game is over." It means you simply may have to play it differently!

Brain-injury related "fatigue" is different
As I'm sure you know, many persons with brain injury have more fatigue than they did before their injury. This is very, very common. Some of this fatigue appears to be organic (meaning, it's rooted in the new brain configuration and no amount of rest will help; we just need to rest whenever our body says, "REST"). For some of us, problems with fatigue are manageable over time, for others, it never seems to abate. I still struggle with fatigue. I simply cannot work the same kinds of hours I used to. But, I can work longer and with more clarity, if I rely on my strategies and take cognitive breaks! This double-barrel approach seems to work for many of my students too! However, we need to keep in mind that brain-injury induce fatigue seems to be, in its character, different and more powerful that the kind of tiredness we used to feel, before our injuries.

Fatigue, seizures and other problems
I have been told that some people who are prone to seizure activity are more likely to experience a seizure when they are overly tired -- so pushing it to the "crash and burn" stage is not wise. Also, the incidence of automobile accidents goes way up too.

You did know, I hope, that in general, persons with brain injury are more likely than the average population to have a second or third brain injury -- in part because reaction time, judgment, all kinds of things are affected. Add fatigue to this formula, and well. . . you know where I am going with this.

Balance
In a nutshell, I guess I am saying that a balance needs to be struck between strategies for overcoming or outsmarting fatigue, and having a healthy respect for its power following brain injury. I never experienced such a profound "Tiredness" (with a capital "T") as I did after my brain injury. You know, the kind of total exhaustion where willpower or a desire to stay awake or even upright, has absolutely NO EFFECT! And it still nails me once in a while.

We do need to listen to our bodies, and if it means taking a reduced course load, sleeping longer at night, taking a mid-day nap, that is what we need to do! If it means reducing hours at work, well, that may be necessary too. On the other hand, some combination of enough rest, enough breaks, enough environmental controls (and all the other things we should do, like eating a balanced diet, getting enough exercise, etc., etc.), may increase physical and cognitive stamina to the point where you/we can do what we need and want to do in our lives.

Hope this helps!

Kathy M.

University of Missouri - Columbia
School of Health Professions
Great Plains RCEP