A nearly universal complaint that people have with head injury is fatigue. Although fatigue decreases over time, it is a very persistent problem. Many patients recover from nearly all of their other deficits, only to have fatigue prevent them from returning to work full time (they go back, but at a part-time level). A lot of people are used to working 50, sometimes even 60, hours a week. In addition to a 9 to 5 job, they come home and work in the home, or they have a second job. Fatigue from a head injury drastically alters their lifestyle.
Mental versus Physical Fatigue
There are two types of fatigue: physical fatigue and mental fatigue. "Physical" refers to doing some sort of physical labor such as mowing the lawn or working in a flower garden. Just after a head injury, physical fatigue may be troublesome. For example, if you're relearning to walk, the amount of effort it requires to relearn to coordinate the muscles and build up strength is going to be substantial. For most people, physical fatigue tends to go away after 6 months. What surprises people with a head injury is the mental fatigue. For example, you could spend all day in your yard pulling out weeds and not feel tired from it, but an hour of balancing the checkbook will leave you exhausted. This is mental fatigue, and tends to go on for long periods of time. Let's use another analogy. Think of owning a car that you can only fill with half a tank of gas. You can now only go half as far as you used to. When you run out of gas, the engine stops. With mental fatigue, it's as if the brain runs out of chemicals and just shuts down.
Why does this occur? Let's look at the brain as a big phone line system. We make a daily call from Chicago to New York City and its a direct line. If the line breaks, you lose the connection. The phone company is prepared, however; they realize that phone lines break, so they've programmed their computers to reroute phone calls. As a result, a phone call from Chicago to New York may have to go to St. Louis, Pittsburgh, and then to New York. It's no longer a direct call--we've added 3 more connections. More time and energy is needed to send the same information. This analogy seems to make sense. People with a head injury tell me that it takes much more effort to get the same answer.
Does fatigue get better over time? For most, it does. Does it go away completely? For most, it does not. At first, people may work for 3 hours and then they're beat. Eventually, they work for 4 hours, then 5 hours, then 6. I have many people who finally work 8 hours a day, but are extremely tired in the evenings and need the weekend to recover. If you become physically ill with a cold, or have surgery, this fatigue disorder briefly comes back with a vengeance.
What Can I Do?
Most people tend to get fatigued in the afternoon, generally around 2:00 or 3:00. One suggestion--if you're going to do something that is stressful or hard, do it in the morning. Your mind will be a lot clearer in the morning and less prone to making mistakes. Realize that fatigue will affect your memory. If you learn information when you are fresh, it is more likely to stay with you. If you stay up late studying for a big exam, you will have more problems trying to recall this information the next day.
Exercise improves your ability to think. This seems pretty obvious, but for individuals with head injury, it becomes crucial. If your doctor has cleared you to do exercise, you should make a conscious effort to do it. Why? Even though the brain weighs less than 5% of the entire body, it uses 30% of the oxygen in the body, and probably the same amount of glucose (which is the energy that runs your body). If we use a car analogy, a clogged air filter and gunked up carburetor will not allow full power. With exercise, you get more oxygen into your blood system. Also, for people who have chronic pain syndromes, some types of exercise are very beneficial. For example, swimming is a very good exercise for people who have neck or back pain. Always talk with your doctor about what exercise works best for you.
Diet is another important consideration. When I say "diet", I don't necessarily mean to lose weight. It's important to eat 3 good meals a day. In our rushed society, we'll eat a doughnut, have some coffee, and run off to work. That's not a very good diet. The sugar that you get from a doughnut or the caffeine from coffee gives you a brief burst of energy, but that energy doesnt last. We've all heard of a "sugar buzz." Children are very prone to this. The same thing occurs in adults. The problem with sugar is that you "roller coaster"--you get that burst of energy but you come crashing down. The trick is to have a constant supply of energy to the brain.
You need to gradually increase your stamina. Going from not working to working 40 hours a week is very stressful. For the head-injured individual, this is nearly impossible. You must give the brain time to build a tolerance to fatigue. A common approach to this problem is by having people gradually return to work. You might start off with part-time, beginning with 1 to 3 hours on returning to work. Gradually, add hours only as you can tolerate it. What's the problem with this? Most employers only want you 100%. They want you there 40 hours or they don't want you there at all. Many employers are beginning to realize that this is a discriminatory policy. A head injury program will work with the employer. Businesses are beginning to see that good employees are hard to come by. If you can't return to work, however, volunteering is a good means of building job skills. This will also help to decrease fatigue and will improve self-esteem.
By Dr. Glen Johnson, Clinical Neuropsychologist
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