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Post stroke fatigue where is the evidence to guide practice, loud ringing in ears and dizziness - Test Out

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Stroke Report 2015: Canadians are not getting the care they need fast enough in the critical first hoursGaps in the healthcare system and Canadians’ inability to recognize stroke put them at risk of death or disability. The Greater Manchester Stroke Assessment Tool (GM-SAT) is an evidence-based assessment tool that has been designed specifically for the six month post-stroke review. GM-SAT encompasses a wide range of potential post-stroke care needs, from medication management and secondary prevention, through to mood and fatigue.
Defining and therefore operationalising fatigue is challenging as there are many confounding factors associated with it. Confounding factors contributing towards fatigue following brain injury incorporate pathophysiological, physical, mood and cognitive elements, including slowed speed of processing and difficulty sustaining attention,10 executive dysfunction,11 reward and effort perception,9 anxiety and depression,12,13 sleep disturbance12 and pain.14,15 Clinically these interacting elements may be considered as ‘vulnerability factors’ for fatigue as they are common consequences of an acquired brain injury and so addressing these factors may lead to a reduction in fatigue experienced and enhance levels of social participation.
There are numerous self-report fatigue scales available, though few valid and reliable measures have been developed for people with ABI. Figure 1: Clinical model for understanding responses to fatigue following acquired brain injury. In terms of clinical management, given that fatigue is considered a multidimensional construct, attention should be paid to the variety of factors which may contribute to both performance fatigability (objective signs) and perception of fatigue (subjective symptoms). There is an acknowledged discrepancy between objective signs (performance fatigability) and subjective experience (perception) of fatigue in the literature, which has led to a proposal for a unified taxonomy to guide assessment and intervention.25 Several models of fatigue have been proposed in the literature.
The clinical model proposed provides guidance on domains of functioning to assess and support fatigue management.
Assessment and management of fatigue remains complex and challenging for both clinicians and researchers.
It is now widely accepted as a multidimensional, biopsychosocial construct, authors describing both primary and secondary, or physiological (central and peripheral) fatigue and psychological fatigue impacting resultant behaviour, felt experience and its presentation within societal and cultural contexts.2 Central fatigue is considered to result from impairment to structures within the central nervous system and is characterised by depletion of hormones and neurotransmitters. Pathological fatigue, which may indicate need for clinical intervention, does not necessarily dissipate with rest and is of greater intensity and duration compared to ‘normal fatigue’ experienced following exertion, with a corresponding impact on ability to undertake functional activities.
Such scales include the Barrow Neurological Institute Fatigue Scale18 for acute stages post-injury, the Mental Fatigue Scale19 which has been developed for the ABI population, the Neurological Fatigue Index – Stroke20 which has been developed for Stroke.
This involves identifying and addressing both personal and injury-related factors (primary causes and secondary consequences) that make an individual vulnerable to fatigue following ABI. However, to date, none of these have been found to be clinically useful for understanding fatigue following acquired brain injury, to capture all aspects of this challenging construct and an individual’s potential responses to it. A review of personal factors, including coping styles and co-morbid illness, is recommended, with evaluation of injury-related vulnerability factors that could be contributing to fatigue based on pathology and assessment of associated physical, cognitive and psychological factors.
A clinically useful model to aid a shared understanding and response to fatigue and thereby reduce an individual’s vulnerability to fatigue is proposed.

Fatigue & Sleep Disturbance Following Traumatic Brain Injury – Their Nature, Causes, and Potential Treatments.
Unique Contribution of Fatigue to Disability in Community-Dwelling Adults with Traumatic Brain Injury. Fatigue and pain: Relationships with physical performance and patient beliefs after stroke. A self-assessment questionnaire for mental fatigue and related symptoms after neurological disorders and injuries. Measuring the functional impact of fatigue: initial validation of the fatigue impact scale.
The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Assessing construct validity of the self-rating version of the European Brain Injury Questionnaire (EBIQ) using Rasch analysis. An evaluation of a fatigue management intervention for people with acquired brain injury: an exploratory study. Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury.
Peripheral fatigue is considered as a diminished ability to contract muscles, involving the peripheral motor and sensory systems.2,7 Brain structures and networks thought to be involved include the hypothalamic-pituitary axis, ascending reticular activating system, frontal cortex and basal ganglia.
People experiencing pathological fatigue following ABI frequently refer to their brain as “shutting off”, with an intolerance to sensory stimuli and struggle to think and communicate effectively. Therefore from a clinical rehabilitation perspective, measures are selected based upon the clinical question to be addressed or the domain which is expected to be changed as a result of intervention. Awareness of indicators of fatigue for that individual, mediating factors affecting behaviour (e.g. The following model has therefore been developed by our clinical team, inspired by the fatigue model proposed for multiple sclerosis [cited in 26], current evidence and clinical experience, and it has been found useful when working with people with fatigue following ABI.
Use of analogies in fatigue management, such as recharging a phone battery, can be helpful. Mindfulness-Based Stress Reduction has also been demonstrated as effective when delivered as an eight week group programme.29 Sinclair and colleagues30 have identified short wave (blue) light therapy as a potentially useful intervention. For example, neural circuits involved in the regulation of attention and executive function may contribute to development of tiredness and aversion to effort leading to fatigue,8 whilst other authors9 note involvement of the ventro-medial pre-frontal cortex following penetrating traumatic brain injury. In our experience, when people begin to feel less fatigued, they naturally attempt to engage in more activity and so their overall level of fatigue may not reduce significantly, as measured on a fatigue scale.

One important aspect of clinical intervention for people with ABI is to notice signs and symptoms of fatigue before they perceive their brain as ‘shutting down’ or fully ‘draining their battery’. Cognitive and environmental strategies and mood management all contribute towards reducing effort involved in completing activities and associated errors, which may then contribute towards reducing rumination and self criticism. Further research is required to operationalise and validate fatigue assessment tools and to identify specific interventions that may reduce an individual’s vulnerability to fatigue following ABI. They consider fatigue after brain injury as an “umbrella term” describing “different symptom clusters with potentially heterogeneous aetiologies and consequences” 6 [p.
However, it is possible to capture changes in their felt experience, such as a reduction in level of worry about their fatigue, an increase in their sense of control or self efficacy, an increase in their perceived quality of life or an increase in their awareness and understanding of fatigue. Fatigue management aims to increase a person’s ability to participate in their desired activities more effectively, improve their quality of life and improve their sense of control over their fatigue. Self-monitoring of fatigue levels can be challenging following ABI secondary to dysexecutive syndrome, or as a consequence of reduced interoception. Adequate hydration, nutrition and physical exercise, implementing good sleep hygiene and having an understanding of preferences and challenges in sensory processing will also aid fatigue management depending on vulnerability factors identified.
Given the multiple factors and interventions that may be involved, a specialist neurological multidisciplinary rehabilitation team are likely best placed to support people with fatigue following ABI. This change can be captured through using a recognised scale of these constructs or for example using an individualised likert scale before and after intervention.
Identifying personal signs and symptoms of fatigue, through discussion, observation and asking others for signs of fatigue they notice will enable creation of a personalised ‘fatigue scale’ to indicate signs and symptoms of fatigue at an early enough stage to take action. Use of behavioural experiments to test out the impact of coping strategies and beliefs about the self has been useful in fatigue management intervention within our neuropsychological rehabilitation setting. Patients report that fatigue significantly impacts upon their ability to participate in rehabilitation and daily living activities and influences their mood, relationships and quality of life. It is recommended to identify helpful coping responses to both reduce effort involved and to re-energise oneself, both ‘in the moment’ and ‘in anticipation’ of certain triggers when planning to support an individual to pace themselves. Eilertsen, Ormstad and Kirkevold17 identified the need for acknowledgement of this distressing symptom from others as a key factor influencing coping as it presented as a ‘hidden dysfunction’ which could be misinterpreted by others. Through creation of a personalised fatigue formulation and management plan, based on the proposed clinical model, a shared understanding and validation of the fatigue experience can be facilitated.

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Comments to “Post stroke fatigue where is the evidence to guide practice”

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