Posts Tagged fatigue

[BLOG POST] One day at a time. Cognition and Caregiving after a TBI

By Bill Herrin

Thinking comes so naturally that most people take it for granted, but after a traumatic brain injury – many times, thinking can be more of a deliberate action. It takes focus and effort to put a series of thoughts together after TBI, to speak clearly, or to even move. Simply put, the brain (like the body) takes time to heal. Since no two brain injuries are identical, there is no clear path to better cognition. There are, however, certain broad directives that can get you moving in the right direction in most situations. The hardest part of this is to accept your “new normal”. Acceptance, once you come to terms with it, gives you the desire to work toward the goal of better cognition, coordination, memory, anger management, judgement, attention, and other challenges. Once you accept your situation isn’t going to change overnight, you can start the process of healing, along with testing your limitations. Although finding your limitations is difficult, knowing what they are is a huge step towards improvement in areas that need changing. When a person lacks enough cognition to be self-aware or to strive towards improvement, that’s a test for the caregiver’s guidance and patience. Sometimes just being there for your friend, spouse, or loved one is all you can do.

As a caregiver, high expectations from a TBI survivor shouldn’t be overly discouraged, as they can bring progress through their desire to improve. They may not reach the goal they wanted to, but they’ll make strides towards it! That is positivity in its purest form. Nobody wants to be working through such a huge change in their life without encouragement – cheer them onward and upward! Even if they fail, they are trying, and that shows initiative. Their desire to improve should never be underappreciated.

When cognition is in the early stages of improvement, the changes may be noticed more by the family or caregiver than they are by the survivor. Sometimes incremental change is just too subtle for survivors to realize, but pointing out the changes to them is incredibly positive reinforcement. The following tips on cognition are excerpted from Lash & Associates’ tip card titled “Cognition – Compensatory strategies after brain injury”

Cognitive fatigue is one of the most common consequences of brain injury. The survivor’s brain is simply working harder to think and learn. Cognitive rest is just as important – maybe even more important – as physical rest after the brain has been injured. Cognitive fatigue can have a ripple effect. You may have a shorter temper, find it harder to concentrate, make more errors, misplace things or forget appointments. You may feel like you can’t think straight no matter how hard you try. Many survivors describe cognitive fatigue as “hitting the wall”.

Do you…

• Feel tired after mental exertion?

• Have a harder time thinking after working on longer or more complex tasks?

• Need more sleep than usual?

• Find it hard to get through the day without napping?

Tips on compensatory strategies…

• Take breaks.

• Schedule rest periods.

• Stay organized.

• Use a daily planner.

• Use time management strategies.

• Eat nutritious meals on a regular schedule.

• Go to bed at a consistent time.

– Create a weekly exercise routine.

• Request a medical evaluation.

• Discuss medications that may help with a physician specializing in brain injury rehabilitation.

There are a plenty of great suggestions for compensatory strategies for survivors and their caregivers in the tip card referenced above. Here’s a link to it here!

When it comes to cognitive functional rehabilitation – seek professional advice first (of course), but when the TBI survivor is at home with a caregiver, clinician, friend or family member, there are some great approaches to working on communication, social interaction, organization, reading, attention, problem solving, and rebuilding other deficits through consistent application by any or all of the people involved in the care of the TBI survivor.

Referencing the book titled “Cognition Functional Rehabilitation Activities Manual” (Developed by Barbara Messenger, MEd, ABDA and Niki Ziarnek, MS, CCC-SLP/L), I’m sharing an excerpt that provides a glimpse into the workbook’s approach to helping a person with cognitive challenges. Many of the exercises use interaction and documentation to assess where the TBI survivor is at (cognitively speaking) on an ongoing basis. Remember, this is a workbook, and there are plenty of exercises that build activities and responses ongoing. Here is the example of how the manual challenges a TBI survivor with structured and specific activities:

Task: Provide awareness training.

Procedure:

  1. Prompt participant to work on awareness training.
  2. Ask why participant is here receiving rehabilitation.
  3. Ask what skills/activities are harder since the brain injury.
  4. Ask what participant does to compensate for these difficulties and which therapies address them.Ask what participant’s strengths are (what is participant good at?).
  1. Ask the participant how the brain injury and difficulties affect daily activities.
  2. Provide answers and examples when needed.
  3. Provide positive reinforcement for strengths, being receptive to information regarding brain injury, for participating in the task, and for being motivated to participate in rehabilitation.

Staff Reminder: (clinician, caregivers, family, etc.)

Provide a complete description of this activity in the Functional Rehabilitation Documentation Form.

Last words…

By asking specific questions, and recording the corresponding answers, this workbook is a great tool for tracking progress – and the exercises can be done more than once, to check and see how/if the answers have changed. So, what’s the takeaway from this excerpt? It illustrates that structure and consistency of care and treatment by family/caregivers and professionals can overlap and create a solid overview of cognitive deficits, and improvements.

In closing, the main goal of this post is to address the expectations of TBI survivors and their caregivers, to encourage them to strive for progress and to offer resources for compensatory strategies, and cognitive rehabilitation. If all parties work in tandem with the common goal of helping a TBI survivor make it to the next level, they’re all closer to the goal…and the whole team wins. That’s the goal!

 

via cognition-caregiving-tbi

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[WEB SITE] How to keep your brain healthy and avoid cognitive fatigue

The Globe and Mail and Morneau Shepell have created the Employee Recommended Workplace Award to honour companies that put the health and well-being of their employees first. Read about the 2018 winners of the award at tgam.ca/workplaceaward.

Registration is now open for the 2019 Employee Recommended Workplace Awards at www.employeerecommended.com.

Morneau Shepell is hosting a free webinar on Thurs. Sept. 13 from 1 p.m. ET to 2 p.m. ET to discuss seven ways to improve mental health in your workplace. If you would like to participate, click here to register.

Think back to your school days, especially postsecondary school, and how your brain felt after cramming all night for a tough exam. Remember that? When you felt like your brain had been pushed to the limit and was no longer functioning properly? That is called cognitive fatigue.

Cognitive fatigue can be defined as a decrease is one’s cognitive abilities due to prolonged mental demands, brought on by excessive wear and tear on the brain. It’s not simply being sleep-deprived, although sleep is important and necessary for healthy brain functioning.

Sometimes the challenges we take on, such as work-related commitments and education goals, can be stressful, challenging and require a high level of cognitive demand over an extended period of time.

Daniel Goleman reports that cognitive exhaustion can occur due to extended periods of focus, and the brain, like any muscle, can be pushed to the point of exhaustion. When this happens, the brain’s capacity to perform to its full potential can be dramatically decreased.

Understanding cognitive fatigue can help us know the actions we can take to reduce the risk and increase our capacity to manage high-demand mental task when necessary. When we’re not aware that cognitive fatigue is happening, we can be at increased risk for being distracted, anxious and irritable.

This micro skill provides some ideas to mitigate risk for cognitive fatigue. The focus is on people who engage in some form of activity (such as work or school) that requires a high level of concentration over an extended period.

Awareness

People who have suffered a head injury or some form of mental illness can be at increased risk for experiencing cognitive fatigue. Research shows that cognitive fatigue can significantly impair physical performance that could put a person at increased risk for making mistakes.

Common signs of cognitive fatigue include a decrease in motivation, creativity and ability to analyze and think clearly. Someone who’s experiencing any of these symptoms may not be able to process what’s happening, so they need to learn the concept of cognitive fatigue and what actions to take if they’ve reached that point.

Accountability

Sometimes we may order more food at a restaurant than we can eat. The same can happen when we want to achieve something. We focus on the end goal and may not consider the ongoing effort or commitment we’ve made to achieve it.

To reduce the risk for cognitive fatigue, you need to not only be aware of your capacity and the potential for cognitive fatigue, you need to set realistic expectations. For example, you wouldn’t commit to running a marathon unless you trained and worked up to it. The mind needs the same consideration. If you want to do something in your career or education that will be a challenge, it’s helpful to make a commitment to train your brain and rest it like any other muscle. You want to develop it to be as strong as possible.

Action

Here are some actions you can take to reduce your risk for cognitive fatigue.

Prepare for challenges – Accept that for your brain to work to its full potential it needs to be trained and prepared. If you’re taking a course that requires lots of studying over a period of a year or two, develop a capacity-building plan that may involve increasing your daily reading or taking a study strategy program to maximize your study habits.

Create a schedule and stick to it – Schedule periods in your day when you’ll focus, and rest periods above and beyond getting your required sleep. The purpose is to provide times in your day when your mind can rest and enjoy other activities.

Develop a daily resiliency plan – Too much caffeine or alcohol can hurt your brain’s ability to perform while exercise and strong coping skills – the strategies that enable us to solve problems under stress – can help your brain stay strong when its being stressed. A resiliency plan is a minimum commitment to provide the mind and body the most opportunity to have the energy it needs to push through daily challenges as well as to reduce risk for cognitive fatigue. A daily plan may include:

  • Getting seven to nine hours’ sleep
  • Drinking no more than two cups of coffee – and no other sources of caffeine
  • Taking a 10-minute break every 90 minutes
  • Eating three healthy meals, with healthy snacks between them
  • Exercising 30 minutes each day
  • Drinking at least 2.5 litres of water
  • Meditating for 15 minutes first thing in the morning to kick off the day
  • Journaling at the end of the day to process the day’s challenges and acknowledge things to be grateful for
  • Spending a minimum of 30 minutes with your partner to catch up on life

Bill Howatt is the chief research and development officer of work force productivity with Morneau Shepell in Toronto.

You can find all the stories in this series at tgam.ca/workplaceaward

via How to keep your brain healthy and avoid cognitive fatigue – The Globe and Mail

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[Systematic Review] Complementary and alternative interventions for fatigue management after traumatic brain injury: a systematic review – Full Text

We systematically reviewed randomized controlled trials (RCTs) of complementary and alternative interventions for fatigue after traumatic brain injury (TBI).

We searched multiple online sources including ClinicalTrials.gov, the Cochrane Library database, MEDLINE, CINAHL, Embase, the Web of Science, AMED, PsychINFO, Toxline, ProQuest Digital Dissertations, PEDro, PsycBite, and the World Health Organization (WHO) trial registry, in addition to hand searching of grey literature. The methodological quality of each included study was assessed using the Jadad scale, and the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. A descriptive review was performed.

Ten RCTs of interventions for post-TBI fatigue (PTBIF) that included 10 types of complementary and alternative interventions were assessed in our study. There were four types of physical interventions including aquatic physical activity, fitness-center-based exercise, Tai Chi, and aerobic training. The three types of cognitive and behavioral interventions (CBIs) were cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and computerized working-memory training. The Flexyx Neurotherapy System (FNS) and cranial electrotherapy were the two types of biofeedback therapy, and finally, one type of light therapy was included. Although the four types of intervention included aquatic physical activity, MBSR, computerized working-memory training and blue-light therapy showed unequivocally effective results, the quality of evidence was low/very low according to the GRADE system.

The present systematic review of existing RCTs suggests that aquatic physical activity, MBSR, computerized working-memory training, and blue-light therapy may be beneficial treatments for PTBIF. Due to the many flaws and limitations in these studies, further controlled trials using these interventions for PTBIF are necessary

Fatigue is a common phenomenon following traumatic brain injury (TBI), with a reported prevalence ranging from 21% to 80% [Ouellet and Morin, 2006Bushnik et al. 2007Dijkers and Bushnik, 2008Cantor et al. 2012Ponsford et al. 2012], regardless of TBI severity [Ouellet and Morin, 2006Ponsford et al. 2012]. Post-TBI fatigue (PTBIF) refers to fatigue that occurs secondary to TBI, which is generally viewed as a manifestation of ‘central fatigue’. Associated PTBIF symptoms include mental or physical exhaustion and inability to perform voluntary activities, and can be accompanied by cognitive dysfunction, sensory overstimulation, pain, and sleepiness [Cantor et al. 2013]. PTBIF appears to be persistent, affects most TBI patients daily, negatively impacts quality of life, and decreases life satisfaction [Olver et al. 1996Cantor et al.20082012Bay and De-Leon, 2010]. Given the ubiquitous presence of PTBIF, treatment or management of fatigue is important to improve the patient’s quality of life after TBI. However, the effectiveness of currently available treatments is limited.

Although pharmacological interventions such as piracetam, creatine, monoaminergic stabilizer OSU6162, and methylphenidate can alleviate fatigue, adverse effects limit their usage and further research is needed to clarify their effects [Hakkarainen and Hakamies, 1978Sakellaris et al.2008Johansson et al. 2012b2014]. Therefore, many researchers have attempted to identify complementary and alternative interventions to relieve PTBIF [Bateman et al. 2001Hodgson et al. 2005Gemmell and Leathem, 2006Hassett et al. 2009Johansson et al. 2012aBjörkdahl et al. 2013Sinclair et al. 2014]. In this study, we aimed to systematically review randomized controlled trials (RCTs) that evaluated treatment of PTBIF using complementary and alternative medicine (CAM) to provide practical recommendations for this syndrome. […]

 

Continue —>  Complementary and alternative interventions for fatigue management after traumatic brain injury: a systematic review – Gang-Zhu Xu, Yan-Feng Li, Mao-De Wang, Dong-Yuan Cao, 2017

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[BLOG POST] 5 Things Every TBI Survivor Wants You to Understand

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March is National Brain Injury Awareness Month, and as promised, I am writing a series of blogs to help educate others and bring awareness to traumatic brain injuries (TBI).

1. Our brains no longer work the same. 
We have cognitive deficiencies that don’t make sense, even to us. Some of us struggle to find the right word, while others can’t remember what they ate for breakfast. People who don’t understand, including some close to us, get annoyed with us and think we’re being “flaky” or not paying attention. Which couldn’t be further from the truth, we have to try even harder to pay attention to things because we know we have deficiencies.

Martha Gibbs from Richmond, VA, suffered a TBI in May of 2013 after the car she was a passenger in hit a tree at 50 mph. She sums up her “new brain” with these words:

Almost 2 years post-accident, I still suffer short-term memory loss and language/speech problems. I have learned to write everything down immediately or else it is more than likely that information is gone and cannot be retrieved. My brain sometimes does not allow my mouth to speak the words that I am trying to get out.

2. We suffer a great deal of fatigue.
We may seem “lazy” to those who don’t understand, but the reality is that our brains need a LOT more sleep than normal, healthy brains. We also have crazy sleep patterns, sometimes sleeping only three hours each night (those hours between 1 and 5 a.m. are very lonely when you’re wide awake) and at other times sleeping up to 14 hours each night (these nights are usually after exerting a lot of physical or mental energy).

Every single thing we do, whether physical or mental, takes a toll on our brain. The more we use it, the more it needs to rest. If we go out to a crowded restaurant with a lot of noise and stimulation, we may simply get overloaded and need to go home and rest. Even reading or watching tv causes our brains to fatigue.

Toni P from Alexandria, VA, has sustained multiple TBI’s from three auto accidents, her most recent one being in 2014. She sums up fatigue perfectly:

I love doing things others do, however my body does not appreciate the strain and causes me to ‘pay the price,’ which is something that others don’t see.  I like to describe that my cognitive/physical energy is like a change jar. Everything I do costs a little something out of the jar.  If I keep taking money out of the jar, without depositing anything back into the jar, eventually I run out of energy. I just don’t know when this will happen.  Sometimes it’s from an activity that seemed very simple, but was more work then I intended. For me, like others with TBIs, I’m not always aware of it until after I’ve done too much.

3. We live with fear and anxiety. 
Many of us live in a constant state of fear of hurting ourselves again. For myself personally, I have a fear of falling on the ice, and of hitting my head in general. I know I suffered a really hard blow to my head, and I am not sure exactly how much it can endure if I were to injure it again. I am deeply afraid that if it were to take another blow, I may not recover (ie, death) or I may find myself completely disabled. I am fortunate to have a great understanding of the Law of Attraction and am trying my hardest to change my fears into postive thoughts with the help of a therapist.

Others have a daily struggle of even trying to get out of bed in the morning. They are terrified of what might happen next to them. These are legitimate fears that many TBI survivors live with. For many, it manifests into anxiety. Some have such profound anxiety that they can hardly leave their home.

Jason Donarski-Wichlacz from Duluth, MN, received a TBI in December of 2014 after being kicked in the head by a patient in a behavioral health facility. He speaks of his struggles with anxiety:

I never had anxiety before, but now I have panic attacks everyday. Sometimes about my future and will I get better, will my wife leave me, am I still a good father. Other times it is because matching socks is overwhelming or someone ate the last peanut butter cup.

I startle and jump at almost everything. I can send my wife a text when she is in the room. I just sent the text, I know her phone is going to chime… Still I jump every time it chimes.

Grocery stores are terrifying. All the colors, the stimulation, and words everywhere. I get overwhelmed and can’t remember where anything is or what I came for.

4. We deal with chronic pain.
Many of us sustained multiple injuries in our accidents. Once the broken bones are healed, and the bruises and scars have faded, we still deal with a lot of chronic pain. For myself, I suffered a considerable amount of neck and chest damage. This pain is sometimes so bad that I am not able to get comfortable in bed to fall asleep. Others have constant migraines from hitting their head. For most of us, a change in weather wreaks all sort of havoc on our bodies.

Lynnika Butler, of Eureka, CA, fell on to concrete while having a seizure in 2011, fracturing her skull and resulting in a TBI. She speaks about her chronic migraine headaches (which are all too common for TBI survivors)

I never had migraines until I sustained a head injury. Now I have one, or sometimes a cluster of two or three, every few weeks. They also crop up when I am stressed or sleep deprived. Sometimes medication works like magic, but other times I have to wait out the pain. When the migraine is over, I am usually exhausted and spacey for a day or two.

5. We often feel isolated and alone.
Because of all the issues I stated above, we sometimes have a hard time leaving the house. Recently I attended a get together of friends at a restaurant. There were TVs all over the room, all on different channels. The lights were dim and there was a lot of buzz from all of the talking. I had a very hard time concentrating on what anyone at our table was saying, and the constantly changing lights on the TVs were just too much for me to bear. It was sensory stimulation overload. I lasted about two hours before I had to go home and collapse into bed. My friends don’t see that part. They don’t understand what it’s like. This is what causes many of us to feel so isolated and alone. The “invisible” aspect of what we deal with on a daily basis is a lonely struggle.

Kirsten Selberg from San Francisco, CA, fell while ice skating just over a year ago and sustained a TBI. She speaks to the feelings of depression and isolation so perfectly:

Even though my TBI was a ‘mild’ one, I found myself dealing with a depression that was two-fold. I was not only depressed because of my new mental and physical limitations, but also because many of my symptoms forced me to spend long periods of time self-isolating from the things — like social interactions — that would trigger problems for me. With TBI it is very easy to get mentally and emotionally turned inward, which is a very lonely place to be.

Also, check out my other blogs on the Huffington Post:
“Life With a Traumatic Brain Injury”
“Life With a TBI: March is National Brain Injury Awareness Month”

I invite you to join my TBI Tribe on Facebook if you are a survivor, or loved one of a survivor.

via 5 Things Every TBI Survivor Wants You to Understand | HuffPost

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[Abstract] Cognitive behavior therapy to treat sleep disturbance and fatigue after traumatic brain injury – CNS

OBJECTIVE: To evaluate the efficacy of adapted cognitive behavioral therapy (CBT)
for sleep disturbance and fatigue in individuals with traumatic brain injury
(TBI).
DESIGN: Parallel 2-group randomized controlled trial.
SETTING: Outpatient therapy.
PARTICIPANTS: Adults (N=24) with history of TBI and clinically significant sleep
and/or fatigue complaints were randomly allocated to an 8-session adapted CBT
intervention or a treatment as usual (TAU) condition.
INTERVENTIONS: Cognitive behavior therapy.
MAIN OUTCOME MEASURES: The primary outcome was the Pittsburgh Sleep Quality Index
(PSQI) posttreatment and at 2-month follow-up. Secondary measures included the
Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI),
Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale.
RESULTS: At follow-up, CBT recipients reported better sleep quality than those
receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI],
2.56-7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI
difference, 1.54; 95% CI, 0.66-2.42). Secondary improvements were significant for
depression. Large within-group effect sizes were evident across measures (Hedges
g=1.14-1.93), with maintenance of gains 2 months after therapy cessation.
CONCLUSIONS: Adapted CBT produced greater and sustained improvements in sleep,
daily fatigue levels, and depression compared with TAU. These pilot findings
suggest that CBT is a promising treatment for sleep disturbance and fatigue after
TBI.

via Traumatic Brain Injury Resource Guide – Research Reports – Cognitive behavior therapy to treat sleep disturbance and fatigue after traumatic brain injury

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[WEB SITE] 17 Ways To Help Stroke Survivors Recover Faster – Saebo

If you or a loved one has suffered from a stroke, there are many difficulties that can develop as a result. Primarily, these effects are physical, emotional, and cognitive.

Below, we provide tips on how to overcome these common post-stroke conditions. Keep in mind that dealing with the aftermath of a stroke can be frustrating, but with patience and consistent effort, considerable progress can be made.

 

 

Tip 1. Recognize Symptoms of Stroke

One of the most important ways to successfully recover from stroke, is by taking preventative measures such as knowing and recognizing the symptoms of a stroke because immediate treatment can be life saving and greatly affects the chances for a full recovery. Unfortunately the chances of a second stroke occurring increases in stroke survivors. According to The National Stroke Association, about 25% of stroke survivors will experience a second stroke. Within the first 5 years after the first stroke, risk of a second stroke is about 40% higher. Fortunately it is estimated that of all secondary strokes, about 80% of them are preventable with lifestyle changes and medical intervention. Read more about recognizing the symptoms of stroke in men and in women to better prepare you to act FAST.

 

Tip 2. Walking Again and Foot Drop

Foot drop is the difficulty or inability to lift the front part of the foot because of fatigue or damage affecting the muscles and nerves that aid in its movement. To combat this, using a brace or Ankle-foot Orthoses (AFO) has proven to be a major aid in rehabilitation. These devices prevent the front of the foot from dipping down and disrupting walking movements.

Leg exercises described in this supplementary post after experiencing a stroke are crucial for recovery. While each patient should have a custom exercise routine, personalized for you, there are several exercises that should be included in most every stroke survivor’s regimen. These low-impact strength and stretching leg exercises for stroke recovery are a good complement to use in conjunction with the Saebo MyoTrac Infiniti biofeedback system.

Richard Sealy, director of The Rehab Practice, a private neuro-therapy rehabilitation program in the United Kingdom, regularly works with individuals, families, and caregivers to establish custom exercise routines to aid in recovery from long-term neurological problems, like the damage caused by stroke. While he acknowledges that each patient should have a custom exercise routine specific and personal to their struggles, he recommends a series of exercises for anyone working to strengthen their legs and improve range of motion during stroke recovery.

Rehabilitation of the legs and feet can occur at a faster rate with a combination of the aforementioned exercises and orthopedic aids such as the SaeboStep.The SaeboStep is a unique foot drop brace worn on the outside of the shoe that assists with lifting the toes when walking. It is made to eliminate cumbersome, unreliable splints and braces placed within the shoe.

 

Tip 3. Dealing with Curled Toes

Often referred to as “curled toes” or “claw toe,” this symptom is caused by a miscommunication between the brain and muscles within the foot. This misfiring of signals causes an issue with controlling muscular movements, leading to over-contracting of the toes and spasticity, a condition where there is a miscommunication between the brain and the muscles in the toes, causing them to over contract.

The best way to regain strength and movement while dealing with this condition is to create a routine with a variety of exercises—toe taps, floor grips, finger squeezes, and toe-extensor strengthening. With effort and repetition, these workouts can make a huge difference in recovery.

 

Tip 4. Lack of Arm Function

One of the most common deficiencies following a stroke is the impairment of the arm and hand. This typically results in decreased strength, coordination, and range of motion. Those affected are often unable to support their own arms in order to perform rehabilitation exercises. When this occurs it is crucial that you include additional arm support during rehabilitation to avoid the arms becoming weaker due to learned non-use.

Learned non-use occurs when a stroke survivor prefers to use their strong arm because it is easier to move. This tendency makes it even more difficult for a stroke survivor to recover, because challenging the weakened arm with these exercises plays a crucial role in regaining arm function. Often physical therapists and occupational therapists use a technique known as Constraint-Induced Movement Therapy (or CIMT) to challenge a weakened shoulder and make further exercises and drills possible. Mobile arm supports such as the SaeboMAS and SaeboMAS mini help support the weight of the arm, allowing the user to do a much wider range of exercises. For more information about the SaeboMAS and how it can aid in stroke recovery click here.

As with rehabilitating any part of the body with reduced function after a stroke, it is important to consistently repeat the exercises and stretches to strengthen the brain-muscle connections. It is also important to stay positive and try to have fun with your rehab. Here are 35 fun rehab activities for stroke patients to help keep you motivated.

 

Tip 5. Hand Paralysis

Paralysis is the inability of a muscle to move voluntarily. The National Stroke Association sites as many as 9 out of 10 stroke survivors have some degree of paralysis following a stroke. Rehabilitation and therapy can help to regain voluntary movement, even several years after the stroke takes place.

The primary symptoms of hand paralysis are spasticity (stiff muscles), weakness, and lack of coordination. Fortunately, there are several methods of treatment in addition to therapy to help manage and recover from spasticity. Additional treatments include medications to relax muscles, botox injections (relaxes muscles temporarily), stretching exercises, anti-spasticity orthotics, and functional orthoses. Surgery is another option in the most severe cases.

The least invasive and most permanent treatment for hand paralysis is therapy to rehabilitate the connection between your brain and muscles using neuroplasticity. To make these exercises even more effective and to increase your rate of recovery, it is important to repeat your hand exercises often. By performing exercises repeatedly, you are strengthening that brain-muscle connection.

 

Tip 6. Difficulty Speaking and Communicating

Another common side effect of stroke is aphasia, which is the inability to speak or understand speech. This is one of the most frustrating side effects for survivors to deal with. It’s estimated that 25 to 40 percent of people who suffer from a stroke develop aphasia, though this condition is not limited to stroke survivors. Aphasia occurs when there is damage to the brain, specifically the left side that deals with language. There are two primary forms of aphasia: receptive aphasia and expressive aphasia. Receptive aphasia is when the individual has trouble understanding what is being said to them. Expressive aphasia is when the individual is having difficulty expressing what they want to say.

When communicating with someone with receptive aphasia, try not to use long complex sentences. When communicating with someone with expressive aphasia, it is important to be patient and remember that the person’s intelligence has not been affected by the stroke, just their ability to speak.

For those with aphasia, the most important thing you can do to improve your communication is to take a deep breath and try to relax. If you can remain relaxed and focus on what you are trying to say you will have much greater success. It is easy to get flustered or feel self conscious, but you shouldn’t. Create tools that you can use to make communication easier such as a book of words, pictures, phrases, or symbols that can help you get your message across. If you are going out and know you will not be around friends or family, it may also be helpful to carry a card or piece of paper that indicates that you have aphasia and explains what it is, just in case you find yourself needing to explain your condition.

Once these tools are set in place, seeking the help of a speech-language pathologist (SLP) can greatly increase one’s ability to regain normal speech behavior. SLPs can assist in rehabilitating all types of physical speech behavior and offer support and proper guidance for you or a loved one. Read more about aphasia and recovery here.

 

Tip 7: Coping with PTSD After Stroke

Following a stroke, it is fairly common for a survivor to experience PTSD, or Post-Traumatic Stress Disorder. This condition is usually associated with combat veterans and sexual-assault survivors; however, according to a study published in the journal PLoS One, almost a quarter of stroke survivors experience some form of PTSD.

Common symptoms of PTSD include the victim experiencing the traumatic event over and over in their head or in the form of nightmares. This replaying of the event is typically accompanied by the individual’s unyielding anxiety and feelings of self doubt or misplaced guilt over their condition. Some experience a state of hyperarousal or feelings of being overly alert.

The two main treatments for PTSD include medications such as antidepressants, anti-anxiety medications or psychotherapy. If you are experiencing PTSD, it is important that you communicate how you feel with your doctor, family, and friends, as a strong support system can help you find the relief from psychological pain that you deserve.

 

Tip 8: Understanding Fatigue

Feeling tired is a normal part of life for everyone, but for stroke survivor, fatigue is a very common symptom that can be frustrating to deal with. About 40 to 70 percent of stroke survivors experience fatigue, which can make recovering feel even more difficult. Post-stroke fatigue is draining both physically and emotionally/mentally, and rest may not be the only solution.

It is important to discuss the fatigue with a doctor so they can rule out potential medical causes or determine if fatigue might stem from current medications. By speaking with the proper medical professionals and taking time to squeeze in a nap or rest as often as possible—and by maintaining a positive mindset—you can help yourself or a loved one combat the constant drowsiness of fatigue and work on returning to pre-stroke energy levels. The key thing to realize is that some level of post-stroke fatigue is normal and that survivors need to be proactive about treating and working around it.

 

Tip 9: Counteract Learned Non-Use

If the limbs weakened after stroke are not consistently exercised over time, muscles have the potential to atrophy—waste away due to cell degeneration. This often occurs when the person tries to compensate for their weak limb by using their stronger limb more often. Daily attempts to move the affected limbs are necessary to maintain and improve functionality.One method is the use of Constraint-Induced Movement Therapy (CIMT). CIMT is a form of therapy that prevents the unaffected limbs from moving while trying to exercise the affected ones.

 

Tip 10: Reduce Inflammation and Stress

Inflammation in the body can cause other issues to arise, which is why it’s important to stay stress free whenever possible. When stress does begin to take hold, a hormone called cortisol floods the body, causing pH levels to become imbalanced with acidity. High acidity levels—after an extended period of time—can kill good bacteria in the body while giving rise to bad bacteria, ultimately weakening the immune system.

With that in mind, a natural probiotic like yogurt is a great way to boost good bacteria in the body. Supplemental drinks can also improve the immune system significantly. In addition to pH balance, adopting stress management exercises such as yoga, deep breathing, tai chi, qi gong, and meditation, can limit one’s cortisol levels, promoting overall health.

 

Tip 11: Coping with Emotional Effects

Experiencing a stroke is not only a major hardship to overcome physically; it can also take a huge toll on a survivor’s emotions in many ways.

If the area of your brain that controls personality or emotion is affected, you may be susceptible to changes in your emotional response or everyday behavior. Strokes may also cause emotional distress due to the suddenness of their occurrence. As with any traumatic life experience, it may take time for you or your loved one to accept and adapt to the emotional trauma of having experienced a stroke.

Some common emotional changes strokes may cause are PseudoBulbar Affect, depression, and anxiety. Thankfully, there are several methods for treating the emotional changes associated with a stroke, with the first step being to discuss how you or your loved one is feeling with a doctor. Treatment may consist of one, or a combination, of the following: one-on-one counseling, group counseling, medication, diet, and exercise. The most effective treatment is different for everyone, so it is important to discuss and explore which combination works best for your or your loved one.

 

PseudoBulbar Affect

Sometimes referred to as “reflex crying,” “emotional lability,” or “labile mood,” PseudoBulbar Affect (PBA) is a symptom of damage to the area of the brain that controls expression of emotions, and it is one of the most frequently reported post-stroke behaviors. Characteristics of the disorder include rapid changes in mood, such as suddenly bursting into tears and stopping just as suddenly or even beginning to laugh at inappropriate times.

 

Depression

Survivors have a one in four chance of developing serious depression as a side effect of stroke. If you are feeling sad, hopeless, or helpless after having suffered a stroke, you may be experiencing this. Other symptoms of depression may include irritability or changes to your eating and sleeping habits. Talk to your doctor if you are experiencing any of these symptoms, as it may be necessary to treat with prescription antidepressants or therapy to avoid it becoming a road block to your recovery.

Along with medication and therapy, a lot of research shows that a few simple lifestyle changes help relieve the symptoms of depression. If you or a loved one is having a difficult time coping with the emotional repercussions of a stroke, here are tips on how to implement positivity and resilience:

  • Attend a support group. Talking about your struggles with people in the same situation makes you feel less lonely and can offer helpful insight or different approaches to dealing with difficulties.
  • Eat healthy food. A good diet is important for your general health and your recovery from stroke and can also improve your mental health.
  • Remain socially active. Although you may not be able to do as much as you used to, it’s crucial to stay in touch with family and friends and take part in social activities.
  • Be as independent as possible. Humans need to feel independent and competent. Stroke recovery may require the help of caregivers, but if there are things that you can safely do by yourself, insist on it.
  • Exercise regularly. Physical activity, especially a low-impact one like walking, is proven to boost mental health and will also contribute to your recovery.

 

 

Tip 12: Set Recovery Goals with Your Therapist

Setting specific and meaningful goals can help keep one focused and motivated once they are achieved, and these goals can range from simple tasks to long-term accomplishments. By establishing a list consisting of difficulties and goals, overcoming obstacles can be put within reach.

When setting these goals, working with a therapist, doctor, or close friend can be a good way to find encouragement, as well as assistance in creating a list that places goals into an appropriate timeframe. Overall, a therapist will be familiar with your case, understanding the issues and complications, and will be able to offer sound advice in all aspects of recovery.

 

Tip 13: Stay Motivated

Since apathy is common during stroke recovery, staying motivated can be a challenge. Combining one’s interests with a solid rehabilitation regimen can effectively eradicate feelings of lethargy and depression. The best thing to do is to focus on a reason for recovery and to associate it with your plan of action. This can be done by implementing sentimental items into daily routines, thus giving you personal and motivational support at all times. For example, if one of your routines is to write a list of things to do for the day, try writing it on the back of a special photo. That way, as you’re checking things off, you’ll have a little reminder to keep you motivated.

 

Tip 14: Watch Out For The Recovery Plateau Stage

The recovery plateau stage refers to the point at which a stroke survivor begins to see a slow down or stop in the progression in their recovery. Some of the most significant improvements often occur in the subacute phase, which is usually the first three to six months after the stroke  (though there is anecdotal evidence of people making significant stroke recovery progress outside of that zone.)

Seeing improvement in the early days of a survivor’s recovery can make it a lot easier for them to stay motivated and continue working hard in therapy. Research shows that further recovery is still very possible after the plateau stage though, which is why it is so important to have a strong support system to encourage you to continue with therapy and working on recovery.

 

Tip 15: Working After Stroke

Since the brain is a major organ affected when it comes to strokes, chances are that some of its functions may have trouble performing like they did before. After a stroke, learning new things, or even just recalling information can be a challenge, and working through thoughts may suddenly be difficult.

After rehabilitation, many stroke survivors do find themselves able to return to work, but preparing for this transition can come with a lot of questions. Are you physically going to be able to perform your job? Will your disability benefits lapse? What do you need to communicate with your employer? These can be tough questions, but they do have answers. Some may not ever be able to go back to the same work, but for others, just a little assistance is needed.

When you are ready to return to work, it is important to know your rights and what your employer is, and is not, legally required to provide to employees with disabilities. Keep in mind that if you are unable to perform the essential functions of your job even with reasonable accommodation, your employer is not obligated to offer you a different position or create a new role for you. They might be willing to anyway, but it is not a requirement.

 

Tip 16: Understand and Combat Memory Loss

Not only is it common for stroke survivors to experience, but memory loss can affect a wide range of people through multiple factors. Age, physical trauma, and emotional stress have the potential to cause memory decline, but rebuilding memory’s strength is highly possible and can be fun.

Specifically, incorporating technology into daily rehabilitation exercises is a great way to show quick improvements. There are numerous apps for smartphones and tablets that use different techniques to significantly improve memory, and they have the ability to set reminders, schedule appointments, and oversee other illnesses.

 

Tip 17: Be Aware of Vascular Dementia

A common problem among stroke survivors, this symptom disrupts cognitive functions, which can make it challenging for one to sort out information.

Due to the damage of blood vessels from a stroke, blood pressure, cholesterol, and blood sugar must be maintained at healthy levels to ensure good blood flow throughout the body. If you are diabetic, it is crucial that you are paying careful attention to your blood sugar and insulin levels. Studies have shown that by managing these three components, vascular dementia can be decreased or prevented.

Helping Stroke Survivors Help Themselves

The process of stroke recovery is long and full of ups, downs, twists, and turns. It takes hard work and dedication to regain mental and physical function after a stroke. The information and tips above will help you to identify and overcome the many challenges that come with recovery.

To read our answers to the most common stroke recovery questions, click here. And remember, at the end of the day, there are dozens of approaches you can take to improve the speed of stroke recovery.


All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

via 17 Ways To Help Stroke Survivors Recover Faster | Saebo

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[Poster] Sleep Experiences Following Traumatic Brain Injury: A Qualitative Descriptive Study

First page of article

To describe the sleep experiences of adults living with moderate or severe traumatic brain injury (TBI).

via Sleep Experiences Following Traumatic Brain Injury: A Qualitative Descriptive Study – Archives of Physical Medicine and Rehabilitation

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[SLIDE SHOW] The Invisible Effects of Stroke – PDF File

The Invisible Effects of Stroke

By Nicole Walmsley

Overview

The objective is to:
1. identify four common invisible effects of a stroke
2. demonstrate how nursing staff can identify these on an
acute stroke unit

Download the PDF File

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[ARTICLE] Fatigue and Cognitive Fatigability in Mild Traumatic Brain Injury are Correlated with Altered Neural Activity during Vigilance Test Performance – Full Text

Introduction: Fatigue is the most frequently reported persistent symptom following a mild traumatic brain injury (mTBI), but the explanations for the persisting fatigue symptoms in mTBI remain controversial. In this study, we investigated the change of cerebral blood flow during the performance of a psychomotor vigilance task (PVT) by using pseudo-continuous arterial spin labeling (PCASL) MRI technique to better understand the relationship between fatigability and brain activity in mTBI.

Material and methods: Ten patients (mean age: 37.5 ± 11.2 years) with persistent complaints of fatigue after mTBI and 10 healthy controls (mean age 36.9 ± 11.0 years) were studied. Both groups completed a 20-min long PVT inside a clinical MRI scanner during simultaneous measurements of reaction time and regional cerebral blood flow (rCBF) with PCASL technique. Cognitive fatigability and neural activity during PVT were analyzed by dividing the performance and rCBF data into quintiles in addition to the assessment of self-rated fatigue before and after the PVT.

Results: The patients showed significant fatigability during the PVT while the controls had a stable performance. The variability in performance was also significantly higher among the patients, indicating monitoring difficulty. A three-way ANOVA, modeling of the rCBF data demonstrated that there was a significant interaction effect between the subject group and performance time during PVT in a mainly frontal/thalamic network, indicating that the pattern of rCBF change for the mTBI patients differed significantly from that of healthy controls. In the mTBI patients, fatigability at the end of the PVT was related to increased rCBF in the right middle frontal gyrus, while self-rated fatigue was related to increased rCBF in left medial frontal and anterior cingulate gyri and decreases of rCBF in a frontal/thalamic network during this period.

Discussion: This study demonstrates that PCASL is a useful technique to investigate neural correlates of fatigability and fatigue in mTBI patients. Patients suffering from fatigue after mTBI used different brain networks compared to healthy controls during a vigilance task and in mTBI, there was a distinction between rCBF changes related to fatigability vs. perceived fatigue. Whether networks for fatigability and self-rated fatigue are different, needs to be investigated in future studies.

Introduction

Fatigue is a frequently reported symptom after mild traumatic brain injury (mTBI) (13) and a major reason why patients fail to return to work (4). The subjective experience of fatigue may be concomitant with physiological fatigue or with deteriorating performance, but may also be a sole complaint (56). Research on the relationship between underlying neural correlates to fatigue in mTBI, and possible performance decrements is complicated by the fact that fatigue is still not a well-defined concept. It is multidimensional in its nature, involving both physiological and psychological components (79) and, therefore, a single explanatory mechanism is unlikely (310).

Kluger and coworkers (11) suggested distinguishing the self-rated fatigue measures from objective measures of fatigue by labeling the later as fatigability. Such distinction might encourage among others more focused correlational studies; such as fatigue in relation to the neural activity. Measuring performance during sustained cognitive process provides a method to evaluate fatigue/fatigability objectively (1214). For example, sustained attention during vigilance performance is a demanding cognitive task and performance induced fatigability has been demonstrated as increased error rate and reaction time (15). Our group has also found fatigability in mTBI on a higher order attention demanding task (16).

More recently, we studied the behavioral correlates of changes in resting-state functional connectivity before and after performing a 20-min psychomotor vigilance task (PVT) for mTBI patients with persistent post-concussion fatigue (17). Taking advantage of a quantitative data-driven analysis approach developed by us, we were able to demonstrate that there was a significant linear correlation between the self-rated fatigue and functional connectivity in the thalamus and middle frontal cortex. Furthermore, we found that the 20 min PVT was sufficiently sensitive to invoke significant mental fatigue and specific functional connectivity changes in mTBI patients. These findings indicate that resting-state functional MRI (fMRI) measurements before and after a 20 min PVT may serve as a useful method for objective assessment of fatigue level in the neural attention system. However, these measurements neither provide any information about the dynamic change of the neural activities in the involved functional networks during the performance of PVT nor can they answer whether other neural systems mediate the observed functional connectivity change in the attention network.

Arterial spin labeling (ASL) MRI technique has recently been used to examine the cerebral blood flow (CBF) in patients with amnestic mild cognitive impairment and cognitively normal healthy controls both at rest and during the active performance of a memory task (18). As compared to rest, CBF measurement during the task performance showed increased group difference between patients and healthy controls indicating that CBF measures during a cognitive task may increase the discriminatory ability and the sensitivity to detect subtle functional changes in neurological diseases. In another ASL MRI study, Lim et al. (19) investigated the neural correlates of cognitive fatigue effects in a group of healthy volunteers during a 20-min PVT (19). They observed progressively slower reaction times and significantly increased mental fatigue ratings after the task and reported that such persistent cognitive fatigue effect was significantly correlated with regional cerebral blood flow (rCBF) decline in the right fronto-parietal attention network in addition to the basal ganglia and sensorimotor cortices. They also found that the rCBF at rest in the thalamus and right middle frontal gyrus before the PVT task was predictive of subjects’ subsequent performance decline. Based on these findings, they claimed that the rCBF at rest in the attention network might be a useful indicator of performance potential and a marker of the level of fatigue in neural attention system. However, it remains to be clarified how the relationship between the neural activity in mTBI patients and their fatigability is dynamically influenced by the performance of a difficult cognitive task.

Pseudo-Continuous Arterial Spin Labeling (PCASL) can provide quantitative rCBF measurements with whole-brain coverage and high signal-to-noise ratio. Furthermore, it is non-invasive and repetitive experiments can be carried out. It has been shown that fMRI experiments based on PCASL perfusion measurements may have higher sensitivity than experimental designs based on blood oxygenation level-dependent (BOLD) fMRI, particularly when studying slow neural activity changes within a subject (2022) and useful as a biomarker of brain function (18). To shed light on the questions discussed above, in this study we used PCASL MRI technique to measure the rCBF changes during a 20 min PVT in a group of mTBI patients with chronic fatigue and matched healthy control subjects. The aims of the present study are the following: (1) evaluate the PVT induced fatigability over time by dividing the performance data (error rate and reaction time) into quintiles to verify if the change of fatigability for mTBI patients follows the same pattern as that for healthy controls; (2) estimate the dynamic change of neural activity during PVT in terms of rCBF measurements in each quintile to reveal brain activities significantly associated with the change of fatigability. (3) Voxel-wise assessment of the rCBF values pre- and post-PVT to detect brain activity associated with changes in self-rated fatigue level. […]

Continue —> Frontiers | Fatigue and Cognitive Fatigability in Mild Traumatic Brain Injury are Correlated with Altered Neural Activity during Vigilance Test Performance | Neurology

Figure 4. Summary of the F-score results from the three-way ANOVA modeling of the regional cerebral blood flow data acquired during a 20-min psychomotor vigilance task (PVT) performance to illustrate the brain regions of statistically significant differences (family-wise error rate, p ≤ 0.05) in neural activity associated with the two fixed factors (the PVT performance time and subject group) and their interaction. (A) The effect of PVT performance time; (B) the interaction effect between the PVT performance time and subject groups. The color bar indicates the F-score of the three-way ANOVA results.

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[BLOG POST] Tired After a Stroke? Understanding Post-Stroke Fatigue | Saebo

Feeling tired is a normal part of life. Whether you didn’t get a good night of sleep or wore yourself out with a busy day or an exerting activity, your body can only handle so much before you start to feel the physical effects of being tired. In cases like these, all you need to do is rest in order to feel re-charged and rejuvenated. But for individuals who have suffered from a stroke, it’s not that easy.

Fatigue after a stroke is common, and it’s different from simply feeling tired. Post-stroke fatigue can make somebody feel like they completely lack energy or strength, with a persistent feeling of being tired or weary. Unlike typical tiredness, a nap or sleeping longer at night won’t solve things. If you are experiencing post-stroke fatigue, it is important to consult with your doctor so you can take the proper steps to start feeling better and more energized.

 

What is Post-Stroke Fatigue?

Post-stroke fatigue can occur after a mild or severe stroke, and roughly 40 to 70 percent of stroke patients experience this “invisible symptom.” It’s a particularly frustrating side effect of a stroke because it can make you feel completely exhausted and off your game, which in turn makes recovering from the stroke seem even more difficult.

Those who experience post-stroke fatigue can feel like they are not in control of their recovery, as it’s hard for them to muster the energy to participate in their rehab activities or normal day-to-day functions. Many individuals with post-stroke fatigue initially confuse it with “being tired,” but post-stroke fatigue is not the same thing as just being tired. It can come out of nowhere, without warning, and rest isn’t always the solution.

Post-stroke fatigue is draining both physically and emotionally/mentally, and the severity of the stroke does not seem to correlate to the severity of the fatigue. Even a mild stroke can result in extreme post-stroke fatigue, and even if you suffered a stroke some time ago and feel as if you’ve made a full recovery, post-stroke fatigue can still impact you.

 

What Causes Post-Stroke Fatigue?

 

Experts aren’t entirely sure what causes post-stroke fatigue because there has been limited research on the subject.Medical conditions like diabetes and heart disease can play a role, as can any pre-existing fatigue issues an individual had before suffering from a stroke. In addition to fatigue, sleep apnea is another issue reported by stroke survivors, so it’s possible there is some sort of link between the two, though nothing has been proven.

Survivors often feel stressed or depressed about the stroke afterwards, from worrying about the recovery process to being concerned with their symptoms. Stress and the mental demands that come with it can lead to fatigue. There are a lot of unknowns about the cause of post-stress fatigue, but one thing is certain: a stroke takes a big toll on a person’s body, and many stroke survivors feel severe fatigue as a result.

 

How Do You Tell if You Have Post-Stroke Fatigue?

Remember that there’s a difference between feeling tired and having post-stroke fatigue. The latter will give you afeeling of complete exhaustion; you will lack all energy and feel extremely weary. You will probably feel like you have to rest every day, or even multiple times a day. This can make it difficult to accomplish things, whether it’s something as simple as spending time with family, running errands, or even attending your post-stroke therapy sessions.

Until you feel the type of exhaustion that comes with post-stroke fatigue it’s difficult to explain, so don’t feel frustrated if your friends and family don’t understand why you’re struggling. If you think you have post-stroke fatigue, don’t hesitate to consult with your doctor.

 

Tips to Increase Your Energy

The first step in combating post-stroke fatigue is to discuss it with your doctor. Let them know what you’ve been feeling. Your doctor will probably start the process by making sure you’ve had an up-to-date physical. With that information, your doctor can rule out other potential causes for your fatigue or determine if your fatigue might stem from your medication.

It goes without saying, but try to take naps if time allows. Naps won’t cure you of your fatigue long term, but resting when you feel run down can help you feel more refreshed, even if only for a short while.

Do your best to relax. Don’t let your post-stroke fatigue, or any other side effects of your stroke, get you down. Stay positive! Being stressed or tense will only sap you of more energy. A positive attitude goes a long way in feeling upbeat and energetic. Try to get back into the swing of things by returning to your pre-stroke routines. Simple things like staying active and involved with friends and family can yield big benefits.

Yes, it will seem overwhelming at times. Suffering from a stroke, dealing with the aftermath, and having no energy on top of it can be tough, but celebrate your successes. Take baby steps, and be proud of the progress you’ve made. Focus on what you’ve accomplished during your recovery so far, rather than dread what’s left to be done.

 

Tired of Being Tired

Post-stroke fatigue is a daunting condition, and many people who are recovering from a stroke might not even realize they have it, instead thinking they are simply tired. If you’ve had a stroke and find yourself feeling sapped of your energy on a consistent basis, talk to your doctor. There’s a chance you have post-stroke fatigue. You’re not alone; 40 to 70 percent of stroke survivors experience this kind of exhaustion.

By speaking with the proper medical professionals, making it a point to rest as often as possible, and having a positive mindset, you can combat the constant drowsiness and work on returning to your pre-stroke energy levels.

Source: Tired After a Stroke? Understanding Post-Stroke Fatigue | Saebo

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