Posts Tagged fatigue

[WEB SITE] TBI and PTSD: Navigating the Perfect Storm – BrainLine

Marilyn Lash, MSW, Brain Injury Journey magazine
TBI and PTSD: Navigating the Perfect Storm

So often people talk about the effects of traumatic brain injury or the consequences of post-traumatic stress disorder as separate conditions — which they are. But for the person who is living with the dual diagnosis of TBI and PTSD, it can be hard to separate them.

Just as meteorologists predict “the perfect storm” when unusual and unprecedented conditions move in to create catastrophic atmospheric events, so can the combination of PTSD and TBI be overpowering and destructive for all in its path. The person with TBI and PTSD is living in a state unlike anything previously experienced. For the family, home is no longer the safe haven but an unfamiliar front with unpredictable and sometimes frightening currents and events.

While awareness of PTSD has greatly increased with recently returning service members and veterans, it is not new and nor limited to combat. Anyone — children, adolescents, adults, elderly — who is exposed to a life-threatening trauma can develop PTSD. Car crashes, shootings, floods, fires, assaults, or kidnapping can happen to anyone anywhere. But the rate of PTSD after brain injury is much higher in veterans than civilians due to their multiple and prolonged exposure to combat. According to O’Connor and Drebing, it is estimated that up to 35% of returning veterans with mild brain injury also have PTSD.

What’s unique about PTSD?

Symptoms of PTSD include:

  • Unwanted and repeated memories of the life-threatening event
  • Flashbacks where the event is relived and person temporarily loses touch with reality
  • Avoidance of people, places, sights, or sounds that are reminders
  • Feelings of detachment from people, even family, and emotional numbness
  • Shame about what happened and was done
  • Survivor guilt with loss of friends or comrades
  • Hypervigilance or constant alertness for threats.

Individuals with PTSD are at increased risk for depression, physical injuries, substance abuse, and sleep problems, which in turn can affect thoughts and actions. These risk factors also occur with brain injury.

PTSD is a mental disorder, but the associated stress can cause physical damage. TBI is a neurological disorder caused by trauma to the brain. It can cause a wide range of impairments and changes in physical abilities, thinking and learning, vision, hearing, smell, taste, social skills, behaviors, and communication. The brain is so complex, the possible effects of a traumatic injury are extensive and different for each person.

When PTSD and TBI coexist, it’s often difficult to sort out what’s going on. Changes in cognition such as memory and concentration, depression, anxiety, insomnia, and fatigue are common with both diagnoses. One basically feeds and reinforces the other, so it’s a complicated mix — it’s the perfect storm. It may help to consider and compare changes commonly seen with TBI and PTSD.

Memory

TBI: A period of amnesia for what went on just before (retrograde amnesia) or after (anterograde amnesia) the injury occurred is common. The length of time (minutes, hours, days, or weeks) of amnesia is an indicator of the severity of the brain injury. For example, the person may have no memory of what happened just before or after the car crash or IED explosion.

PTSD: In contrast, the person with PTSD is plagued and often haunted by unwanted and continuing intrusive thoughts and memories of what happened. The memories keep coming at any time of day or night in such excruciating detail that the person relives the trauma over and over again.

Sleep

TBI: Sleep disorders are very common after brain injury. Whether it is trouble falling asleep, staying asleep, or waking early, normal sleep patterns are disrupted, making it hard to get the restorative rest of sleep so badly needed.

PTSD: The mental state of hypervigilance interferes with slowing the body and mind down for sleep. Nightmares are so common with PTSD that many individuals dread going to bed and spend long nights watching TV or lying on the couch to avoid the night’s terrors. Waking up with night sweats so drenching that sheets and clothing are soaked. Flashbacks so powerful that bed partners have been struck or strangled while sleep battles waged.

Isolation

TBI: Many survivors of TBI recall the early support and visits of friends, relatives, and coworkers who gradually visited or called less often over time. Loss of friends and coworkers leads to social isolation, one of the most common long-term consequences of TBI.

PTSD: The isolation with PTSD is different as it is self-imposed. For many it is simply too hard to interact with people. The feeling of exposure outside the safe confines of the house is simply too great. The person may avoid leaving the house as a way of containing stimuli and limiting exposure to possible triggers of memories. As a result, the individual’s world becomes smaller and smaller.

Emotions

TBI: When the areas of the brain that control emotions are damaged, the survivor of a TBI may have what is called “emotional lability.” This means that emotions are unpredictable and swing from one extreme to the other. The person may unexpectedly burst into tears or laughter for no apparent reason. This can give the mistaken impression that the person is mentally ill or unstable.

PTSD: Emotional numbness and deadened feelings are a major symptom of PTSD. It’s hard for the person to feel emotions or to find any joy in life. This emotional shutdown creates distance and conflicts with spouses, partners and children. It is a major cause of loss of intimacy with spouses.

Fatigue

TBI: Cognitive fatigue is a hallmark of brain injury. Thinking and learning are simply harder. This cognitive fatigue feels “like hitting the wall,” and everything becomes more challenging. Building rest periods or naps into a daily routine helps prevent cognitive fatigue and restore alertness.

PTSD: The cascading effects of PTSD symptoms make it so difficult to get a decent night’s sleep that fatigue often becomes a constant companion spilling over into many areas. The fatigue is physical, cognitive, and emotional. Feeling wrung out, tempers shorten, frustration mounts, concentration lessens, and behaviors escalate.

Depression

TBI: Depression is the most common psychiatric diagnosis after brain injury; the rate is close to 50%. Depression can affect every aspect of life. While people with more severe brain injuries have higher rates of depression, those with mild brain injuries have higher rates of depression than persons without brain injuries.

PTSD: Depression is the second most common diagnosis after PTSD in OEF and OIF veterans. It is very treatable with mental health therapy and/or medication, but veterans in particular often avoid or delay treatment due to the stigma of mental health care.

Anxiety

TBI: Rather than appearing anxious, the person acts as if nothing matters. Passive behavior can look like laziness or “doing nothing all day,” but in fact it is an initiation problem, not an attitude. Brain injury can affect the ability to initiate or start an activity; the person needs cues, prompts, and structure to get started.

PTSD: Anxiety can rise to such levels that the person cannot contain it and becomes overwhelmed by feelings of panic and stress. It may be prompted by a specific event, such as being left alone, or it can occur for no apparent reason, but the enveloping wave of anxiety makes it difficult to think, reason or act clearly.

Talking about the Trauma

TBI: The person may retell an experience repetitively in excruciating detail to anyone who will listen. Such repetition may be symptomatic of a cognitive communication disorder, but it may also be due to a memory impairment. Events and stories are repeated endlessly to the frustration and exasperation of caregivers, friends, and families who have heard it all before.

PTSD: Avoidance and reluctance to talk about the trauma of what was seen and done is a classic symptom of PTSD, especially among combat veterans.

Anger

TBI: Damage to the frontal lobes of the brain can cause more volatile behavior. The person may be more irritable and anger more easily, especially when overloaded or frustrated. Arguments can escalate quickly, and attempts to reason or calm the person are often not effective.

PTSD: Domestic violence is a pattern of controlling abusive behavior. PTSD does not cause domestic violence, but it can increase physical aggression against partners. Weapons or guns in the home increase the risks for family members. Any spouse or partner who feels fearful or threatened should have an emergency safety plan for protection.

Substance Abuse

TBI: The effects of alcohol are magnified after a brain injury. Drinking alcohol increases the risks of seizures, slows reactions, affects cognition, alters judgment, interacts with medications, and increases the risk for another brain injury. The only safe amount of alcohol after a brain injury is none.

PTSD: Using alcohol and drugs to self-medicate is dangerous. Military veterans drink more heavily and binge drink more often than civilian peers. Alcohol and drugs are being used often by veterans to cope with and dull symptoms of PTSD and depression, but in fact create further problems with memory, thinking, and behavior.

Suicide

TBI: Suicide is unusual in civilians with TBI.

PTSD: Rates of suicide have risen among veterans of OEF and OIF. Contributing factors include difficult and dangerous nature of operations; long deployments and multiple redeployments; combat exposure; and diagnoses of traumatic brain injury, chronic pain, post-traumatic stress disorder, and depression; poor continuity of mental health care; and strain on marital and family relationships. Veterans use guns to commit suicide more frequently than civilians.

Summary

There is no easy “either/or” when it comes to describing the impact of TBI and PTSD. While each diagnosis has distinguishing characteristics, there is an enormous overlap and interplay among the symptoms. Navigating this “perfect storm” is challenging for the survivors, the family, the caregivers, and the treatment team. By pursuing the quest for effective treatment by experienced clinicians, gathering accurate information, and enlisting the support of peers and family, it is possible to chart a course through the troubled waters to a safe haven.

References:

O’Connor, M. & Drebing, C. (2011). Veterans and Brain Injury. In Living Life Fully after Brain Injury: A workbook for survivors, families and caregivers, Eds. Fraser, Johnson & Bell. Youngsville, NC: Lash & Associates Publishing/Training, Inc.

Ehde, D. & Fann, J. (2011). Managing Depression, Anxiety, and Emotional Challenges. In Living Life Fully after Brain Injury: A workbook for survivors, families and caregivers, Eds. Fraser, Johnson & Bell. Youngsville, NC: Lash & Associates Publishing/Training, Inc.

Posted on BrainLine March 7, 2013. Reviewed July 26, 2018.

 

via TBI and PTSD: Navigating the Perfect Storm | BrainLine

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[Abstract] Poststroke Fatigue Is Related to Motor and Cognitive Performance

Abstract

Background and Purpose: Poststroke fatigue (PSF) is a common debilitating and persistent symptom after stroke. The relationship between PSF and motor and cognitive function remains inconclusive partly due to lack of control for effects of depression and use of insensitive measures. We examined the relationship between PSF and motor and cognitive performance using a comprehensive set of behavioral measures and excluding individuals with depression.

Methods: Fifty-three individuals poststroke (16 female) were included (median age: 63 years, median months poststroke: 20 months). Poststroke fatigue was quantified using the Fatigue Severity Scale (FSS) and cognitive performance was measured with the Montreal Cognitive Assessment, simple and choice reaction time (SRT and CRT) tasks. Lower extremity motor performance included Fugl-Meyer Motor Assessment, 5 times sit-to-stand test (5 × STS), Berg Balance Scale, Functional Ambulation Category, and gait speed. Upper extremity motor performance was indexed with Fugl-Meyer, grip strength, and Box and Block test. Spearman correlation and stepwise linear regression analyses were performed to examine relationships.

Results: Two motor performance measures, Berg Balance Scale and Functional Ambulation Category, were significantly correlated with FSS (ρ = −0.31 and −0.27, respectively) while all cognitive measures were significantly correlated with FSS (ρ = −0.28 for Montreal Cognitive Assessment, 0.29 for SRT, and 0.29 for CRT). Regression analysis showed that Berg Balance Scale was the only significant determinant for FSS (R2 = 0.11).

Discussion and Conclusions: Functional gait, balance, and cognitive performance are associated with PSF. Fatigue should be considered when planning and delivering interventions for individuals with stroke. Future studies are needed to explore the potential efficacy of balance and cognitive training in PSF management.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A287).

 

via Poststroke Fatigue Is Related to Motor and Cognitive Perform… : Journal of Neurologic Physical Therapy

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[BLOG POST] 10 Things My Doctor Didn’t Tell Me About Traumatic Brain Injury Recovery

10 Things My Doctor Didn’t Tell Me About Traumatic Brain Injury Recovery 

After my traumatic brain injury (TBI), a trauma doctor, a neurologist, and a brain surgeon watched over me while I was in the ICU and trauma wing of the hospital. I am extremely grateful for their help during that fragile and scary experience. However, when I left the hospital, they largely left me in the dark regarding traumatic brain injury recovery.

With help from others (mostly my mom) I was able to connect with resources to help me face the challenges I was having. Lo and behold my challenges were very common for TBI survivors. I had no idea that other people were facing the same thing.

I wish my doctors would have prepped me better for what life is like after a TBI. If you are new to the journey of at TBI survivor (or still trying to figure things out), here are 10 things I wish the doctors would have told me about traumatic brain injury recovery before I left the hospital.

1. No Two TBI’s Are the Same

Even when people have similar challenges as a result of their injury, the speed of a recovery, how much a person recovers (50%, 70%, or 90%), which medication can help resolve symptoms (if it works at all), and many other factors vary widely from person to person. You can’t see a person who recovered 100% and say “that will be me”. You also can’t see someone who faces significant challenges after a long period of time and think that you will not make any improvement.

2. There Are Groups with Resources to Help TBI Survivors and Caregivers

Lots of them. In the US, the Brain Injury Association of America is a great resource with branches in many states. The branch in California put me in touch with a doctor that really helped me. Another good resource are hospitals. They often host support groups for TBI survivors and their families. If not, they will be aware of the groups that do meet in your area.

Please take advantage of these groups! Everything changes so much for everyone involved, especially the relationships between them. The support groups give you a place to vent your frustrations and get support from other people walking the TBI road.

For some help with exploring the new relationships, I’ve written two articles, one for survivors, and one for family & friends that highlight some of the big changes and give ideas for addressing them.

3. There Are Some Very Common Deficits after a TBI

Since a TBI affects your brain, it can ripple into every part of your life. Some of it also depends on the part of the brain that is affected. Nevertheless, here are some common ways that at TBI shows up:

  • Memory problems, especially short term memory
  • Bad temper/mood swings
  • Balance
  • Visual processing
  • Motor control
  • Depression
  • Anxiety

If you are experiencing any (or several of) these effects after your TBI, know that it’s completely normal for TBI survivors. If you have any doubt about that, go to a TBI support group. You WILL find survivors there who will offer you encouragement because they dealt (or are dealing) with the same thing.

4. There is No Time Threshold for Recovery

The medical opinion used to say that said your recovery will happen within two years. It also said that whatever abilities haven’t returned by then will never come back. Some doctors who don’t specialize in traumatic brain injury recovery, continue perpetuating that myth. Over the last several years, doctors have found that our brains are capable of learning indefinitely after a brain injury.

I can tell you from my own experience that this seems to be true. My accident was nearly 6 years ago. Although my recovery was the fastest in the first two years, I still feel and observe occasional improvements in different things. Another example is of a woman I met recently at TBI support who is starting to learn to walk again. Her injury happened 13 years ago and has been confined to a wheelchair since then. It’s a long road. Don’t give up. Keep working at it.

5. Spend Some Time Investigating Alternative Approaches to Dealing with Your Symptoms

Medication did provide the biggest breakthrough to controlling my temper after my injury. However, I wanted to explore additional options to cope with it. I found exercising to be very helpful. Mindfulness meditation also provided some help. I still use both of these strategies on a regular basis. I haven’t used it myself, but some people in support groups mention that aromatherapy helps them. Explore the different options and listen to your mind and body to see what works best for you.

6. BEWARE of Overstimulation

Yes, I put beware in all caps. This is a big deal. I can’t believe that no one mentioned this to me when I left the hospital after my injury. Many TBI challenges are made worse once your brain is maxed out. An injured brain’s tolerance for stimulation is much lower than a brain that is not injured. Remember any outside input is stimulation.

For me, by biggest challenges were on my phone. Too much social media, YouTube, and too many games. I also watched to much TV. The stimulation from those activities accelerated me reaching my threshold. Once I maxed out, I became more irritable, had a harder time focusing on important tasks, and had a harder time remembering stuff. Give your brain the down time it needs to recover. Over time you will likely be able to tolerate more outside stimuli. But at the beginning, take it easy.

7. Balance Pushing Yourself and Allowing Down Time

I firmly believe that getting back to work quickly helped me recover as much as I did. However, in retrospect, I might have done it differently. For the first 6 months I didn’t know I needed to beware of overstimulation, so I would work like I was operating at 100%. But by 1pm everyday, I was maxed out, irritable, and extremely angry. Some down time during the work day, or taking on fewer projects would have helped me avoid that anger. Listen to your brain, your body, and those closest to you. Push yourself as much as you can, but back-off when necessary.

8. Physical Fatigue

Rebuilding a brain must take a lot of energy, because it can leave you very tired. During the first few weeks after my injury, I slept for 12-16 hours a day. I needed 10 hours of sleep per night until about 3 months after my injury. It’s normal, and it’s giving your brain the time it needs to heal itself.

9. You Will Be Living with an Invisible Injury

It’s quite likely that you have some physical injuries associated with whatever caused your TBI. Most of them will heal 6-12 weeks after your accident. Once the casts, splints, and braces are removed, people will stop asking what happened and assume that you are doing well. It’s hard to blame them, because there aren’t any visual cues telling them something is wrong. Any of us might do the same thing.

Of course, we know that we have an injury and we are healing. Since our injury is invisible to others, there will be times when we seem “off”. Maybe it’s a word that we can’t seem to find, or we are unusually forgetful or irritable. People will make a judgment, because they don’t have the whole picture. It’s tough to be on the receiving end of those judgments.

10. Accepting the new normal

After a TBI, we can’t hit an undo button. This is who we are now. I spent a lot of time worrying at the beginning of my TBI journey because I didn’t want to accept this. Once I accepted what was, it made it easier to look at what was in my control and start working with that. My post-TBI life became a re-start opportunity. Reframing the situation didn’t make my problems go away, but it did make it easier to face them.

Bonus: Give Yourself Time to Grieve

I nearly forgot to include this. The transition from the “pre-TBI you” to the “new-TBI you” is very real, and it’s a lot like mourning your own death. Sounds odd, I admit. However there is a real loss that happens after a TBI. Some of what we might experience includes the loss of cognitive function, the loss of your old personality, of your memories, the loss of physical abilities, the loss of relationships, the loss of employment, to name a few.

Note to the wives, mothers, girlfriends, etc of men who have experienced a TBI. Grieving does not equal crying. Crying can be part of the grieving process, but it doesn’t have to be. There are lots of ways to grieve. If your man grieves one way, and you grieve another, that’s perfectly normal. What’s important is that you support each other in the process, so you can prepare for the journey that is to come.

Note to men: Guys, we’re not always great about feelings. We’re tough, want to be independent, and have a hard time admitting when something is wrong with us. But this grieving process is important. It helps you process the changes that have happened, face what is, and prepare for the new journey into the future. And I am not telling you to cry. Crying might be part of your grieving (it was for me), but it doesn’t have to be. Find what works for you. If you’ve had a TBI, take the time to grieve what’s happened. It will do worlds of good to help you through the recovery process.

The grieving process also applies to those around us: spouses, children, parents, friends, and employers. You can check out this great article from Brainline about about the grieving process after at TBI.

Traumatic brain injury recovery is HARD, and it takes more grit that I thought I had. If someone had shared this information with me at the beginning, it would have really helped me regroup sooner, work smarter, and be more patient with myself.

Is there anything else you would have included on this list? Leave it in the comments below.

If you found this guide useful you can sign up here to get get ideas and support to help with your recovery from TBI. Starting tomorrow, you will receive my 4 part email series where I cover several techniques to help you (or your loved one) with the TBI recovery journey.

 

via Traumatic Brain Injury Recovery | 10 Things My Doctor Didn’t Tell Me

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[Quotation] I Feel Like I’m Already Tired Tomorrow

Relationships Quotes Top 337 Relationship Quotes And Sayings 120

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[WEB SITE] Hidden signs of depression: How to spot them and what to do

Recognizing the hidden signs of depression

 

Some people with depression may try to hide the signs from others, or they may not even realize that they have depression. Although the typical symptoms of depression, such as sadness or hopelessness, can be easy to recognize, there are symptoms that may be less obvious.

In this article, we discuss some of the possible hidden signs of depression. However, it is important to note that some of these signs can also indicate other medical issues.

We also cover what healthcare professionals believe to be common causes of depression, what a person should do if they think they or someone else has depression, and some sources of help for people with depression.

 

Appetite and weight changes

A man eating at his desk. A hidden sign of depression can include appetite and weight changes.

Hidden signs of depression can include appetite and weight changes.

These changes in food intake can cause a person to start gaining or losing weight.

Dramatic weight changes can also exacerbate depression, as they can affect a person’s self-esteem.

There may also be physiological factors at play. For example, there is a link between carrying excess fat and increased inflammation in the body. This, in turn, may play a role in the development or increased severity of depressive symptoms.

 

Changes in sleep habits

There is a strong link between mood and sleep. A lack of sleep can contribute to depression, and depression can make it more difficult to sleep.

According to the National Sleep Foundation, people with insomnia are 10 times more likely to have depression than those without the condition.

Sleeping too much can also be a sign that a person may have depression.

 

Alcohol or drug use

Some people with mood disorders may use alcohol or drugs to cope with their feelings of sadness, loneliness, or hopelessness.

The Anxiety and Depression Association of America (ADAA) report that in the United States, around 1 in 5 people with anxiety or a mood disorder such as depression also have an alcohol or substance use disorder.

Conversely, the same number of those with an alcohol or substance use disorder also have a mood disorder

Fatigue

Feeling excessively tired is a very common symptom of depression. Some research suggests that over 90% of people with depression experience fatigue.

Although everyone feels tired from time to time, people who have severe or persistent tiredness — especially if it accompanies other symptoms — may have hidden depression.

 

Forced happiness

Sometimes, people refer to hidden depression as “smiling depression.” This is because people who hide their symptoms may put on a happy face when in the company of others.

However, it can be difficult to keep up this forced happiness, so the mask may slip and a person may show signs of sadness, hopelessness, or loneliness.

 

Less optimistic than others

woman looking around in an office.

Studies suggest that people with depression may have more pessimistic tendencies.

People with depression may also be more pessimistic. Studies suggest that those with major depressive disorder often have a more negative view of the future.

Being more realistic or pessimistic than others may be one sign of depression, especially if the person has other possible symptoms of depression.

 

Loss of concentration

When a person trails off during conversations or loses their train of thought, it can indicate issues with memory and concentration, which is a common symptom of depression.

2014 study suggests that these difficulties with concentration and focus can worsen the social impact of depression by making work life and personal relationships more challenging.

 

Disinterest in hobbies

The National Institute of Mental Health list a “loss of interest or pleasure in hobbies and activities” as one of the telltale symptoms of depression.

Disinterest in activities that a person used to enjoy can be one of the first signs that other people notice when their loved one has depression.

 

Physical pains and health disorders

Depression is a mental health condition, but it can also have physical consequences. In addition to weight changes and fatigue, other physical symptoms of hidden depression to look out for include:

  • backache
  • chronic pain conditions
  • digestive problems
  • headache

Research also indicates that those with major depression are more likely than those without the condition to experience:

 

Being angry or irritable

Many people do not associate anger and irritability with depression, but these mood changes are not unusual among those with the condition.

Instead of appearing sad, some people with hidden depression may display irritability and overt or suppressed anger.

 

Low sex drive

According to Dr. Jennifer Payne, director of the Women’s Mood Disorders Center at Johns Hopkins Medicine in Baltimore, MD, some health professionals consider changes in sex drive a key indicator for diagnosing episodes of major depression.

There are several reasons that a person’s libido might decrease when they have depression, including:

  • loss of interest in pleasurable activities such as sex
  • fatigue and low energy levels
  • low self-esteem

 

Common causes of depression

Scientists do not yet know the exact cause of depression. However, many experts think that several factors play a role in its onset, including:

  • Genetics: Depression can run in families. Having a close relative with the condition can raise a person’s risk for developing it themselves.
  • Biological and chemical differences: Physical changes or chemical imbalances in the brain may contribute to the development of depression.
  • Hormones: Hormonal changes or imbalances in the body may cause or trigger depression. For example, many women experience postpartum depression after giving birth.
  • Trauma or stress: Periods of high stress, traumatic events, or major life changes can trigger an episode of depression in some people.
  • Personality traits: Having low self-esteem or being pessimistic, for example, may increase the risk of depression.
  • Other illnesses: Having another mental or physical health condition or taking certain medications can increase the risk of depression.

 

What to do if you think you have hidden depression

ladies socialising over food.

Spending time with others can help treat depression.

Other steps to treat depression might include:

  • reducing stress, such as through meditation, deep breathing exercises, or yoga
  • improving self-esteem through positive self-affirmations
  • socializing with others (though this can be challenging with depression)
  • engaging in activities that the person used to enjoy or attempting to identify new activities that they may be interested in
  • exercising regularly
  • eating a balanced diet
  • asking family or friends for support
  • joining a support group

 

What to do if a loved one has hidden depression

If a loved one appears to have signs of hidden depression, try to talk to them about their symptoms and offer nonjudgmental support and advice.

This can include:

  • encouraging them to seek treatment
  • offering to accompany them to appointments
  • planning enjoyable activities together
  • exercising together
  • encouraging them to socialize with others

People looking after someone with depression also need to practice good self-care in order to preserve their own mental well-being.

 

Getting help for depression

People with symptoms of depression should consider seeking help from a loved one or a healthcare professional, such as a doctor or psychotherapist.

Other sources of help for people with mental health conditions and mood disorders include the ADAA’s website and Mental Health America’s list of support groups.

Suicide prevention

  • If you know someone at immediate risk of self-harm, suicide, or hurting another person:
  • Call 911 or the local emergency number.
  • Stay with the person until professional help arrives.
  • Remove any weapons, medications, or other potentially harmful objects.
  • Listen to the person without judgment.
  • If you or someone you know is having thoughts of suicide, a prevention hotline can help. The National Suicide Prevention Lifeline is available 24 hours a day at 1-800-273-8255.

 

Summary

Not everyone with depression will display the typical symptoms of sadness and despair.

Sometimes, the only signs a person may show are physical, such as fatigue, insomnia, or weight changes.

Other signs of hidden depression can include using alcohol or drugs, acting irritable or angry, and losing interest in pleasurable activities such as sex and hobbies.

People concerned that a loved one has hidden depression should try talking to them about their symptoms and offering nonjudgmental support and advice.

Individuals who suspect that they have depression should consider discussing it with a friend or mental health professional.

There are also a number of organizations that provide support to those dealing with depression.

 

via Hidden signs of depression: How to spot them and what to do

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[BLOG POST] One Is The Loneliest Number – after TBI Traumatic Brain Injury Survivor

By Bill Herrin

TBI can make you feel isolated

One of the most unsettling things I see in the TBI community is when survivors feel isolated and lonely. There have been heart-wrenching posts and comments on our blog site about families that shun (or brush off) their own family members that have experienced a traumatic brain injury. Worse yet, I’ve heard people say that they are totally on their own because they just don’t have emotional support from family (or friends). There is no way that I can offer a solution that will work for everybody – for that matter, even for one survivor…but I’m gonna try to give some pointers that can alleviate some of the frustration and hurt that’s caused by loneliness and the things that can make it feel even worse.

It’s hard work

The very first thing I’ve recognized as the rallying cry of survivors is “you don’t know it unless you’ve experienced it” – and that surely is true. Letting people know how your brain injury feels is like describing the color and texture of an abstract painting to a blind person. They have no point of reference to even work with.  To many, the conditions, effects, and feelings experienced by a TBI survivor are inexplicable in words…although some are able to do it. I will be referencing a book offered by Lash & Associates Publishing to help find ways to combat the depression and anxiety that survivors experience, to find ways to cope, and to encourage caregivers as well.

In the book titled “Lost & Found” – a brain injury survivor herself, offers these succinct nuggets of wisdom:  “Healing and rehabilitating from a brain injury takes a long time. It continues long after formal rehabilitation has ended. It is the hardest work I have ever done. It requires endless courage, determination, motivation, and
support. It usually involves rebuilding multiple areas of not just your life but also your being – all at once. How could there be an easy solution for all of that!

Brain injury doesn’t have to be a destination. It is a journey. Let it be only part of who you are to become. “Don’t accept timetables for recovery.”

— Jill Bolte Taylor, Ph.D., Neuroanatomist

The Key is Incremental Strategy

Follow your heart...and find progress.

Strategies are key in making “baby steps” toward better cognition, a better mood, a better outlook, and a better life. Much progress can be made with encouragement from friends or family…but what about those that don’t have that kind of social “safety net”? Be encouraged. Your will to improve is the key to doing the right things and working to get the right results. As always, there will be naysayers that will immediately point out that “you’ve been this way for a long time” or “you’re wasting your time.” Well, with that kind of encouragement, you’ll be better off doing your best – one step forward at a time. Don’t even consider the steps backward…life hands those to everyone anyway!

Incremental strategies are the ticket to incremental change. Biting off more than you can chew is not a good plan! Start off small, find strategies that work for YOU, and repetition is a good thing. If you’re repeating a step, and you know that you are…that’s a great thing! If you recall how your brain used to process information, but you realize that it has changed…good for you! That is a baseline for working on your cognition. Remember, working in tandem with your doctors, therapists, caregivers, etc. is also very important. You’re not going to make measurable progress without someone that can see your “mile markers” and take note of them. Caregivers can also help with that.

Here’s an excerpt from Lost & Found that is a prime example of working toward healing: “Know that in time, as you heal, it won’t always be this hard. You won’t have to plan and strategize each and every little step you take. So remember you are healing, imagine yourself with a cast on your head and be kind to yourself. Treat yourself like you would any loved one with a serious health issue.

Remember to reward yourself for every successful task and effort, no matter how small. Pat yourself on the back and take a break doing something that will make you smile. We have to be our own cheerleaders now, like the supportive people in our lives were when we were growing up.”

Wow…that’s powerful, but also takes grit and determination. Believing in yourself is always easier when you have cheerleaders – but for those who don’t, that excerpt makes a lot of sense.

Believe.

Emotional healing can come through a combination of things – here are a few (a more detailed version is available in the book, Lost & Found), but here’s a brief Believe in yourselfoverview… Keep a grateful journal or victory log; Discover your “inner poet” by writing phrases that are meaningful to you; Journaling about your day can help you build confidence and see progress; Keep your perspective by noting improvements on a calendar; Challenge and learn from negative thoughts; Take time to smile; Forgive yourself – can’t do what you used to do? You’re only human! Remember that you’re still the same unique and valuable person that you always were; Try to have positive people around you…that supports your life moving in a positive direction; Work with art. Creative outlets are rewarding and fun. These are things that encourage and grow you as a person – with or without others’ approval.

Many times, people in your life are grieving the loss of the “old you” and trying to establish how to interact with the “new you” – just like you are. That can also make an awkward transition for family and friends. Seeking spiritual counsel can be a huge boost as well – if you attend a church, synagogue, etc., or want to…that could be a great way to grow your positivity in life and make some new acquaintances too.

Here’s another excerpt from Lost & Found:  “Keep in mind that your family members and friends may be grieving too. They have lost the person you used to be and the roles you used to play in their lives. They don’t know how much of your former self will return, or when.”

And a quote from the same book: “Honoring your feelings is what helps you move beyond the pain.”

— Janelle Breese-Biagioni

This last excerpt from the book really sums up what so many TBI survivors need to hear…

“Remember you are healing, even if you can’t see a wound! Think of your brain in a cast, as it would be if you broke any other part of your body. If you broke your leg, you wouldn’t expect yourself to run a marathon right away, even if you were previously a marathon runner. First, you would be in a cast and you would rest a lot. Then you would start walking with crutches on even surfaces. The next step might be walking with a cane. You get the idea; it would take a lot of healing before you could run again, never mind run a marathon! Most of us try to run marathons with our brains all the time!

Work to make good things happen.

You won’t be able to do everything you used to, at least not right away. Everything will be harder and take a lot longer to do than it used to. You can compensate by cutting back, simplifying and being kind and patient with yourself. Avoid the tendency to push yourself too hard. Rehabilitation is a delicate balance between challenging yourself enough to promote healing and not so much that you have discouraging setbacks.

So picture yourself with a cast on your head and remember to rest, celebrate the smallest gains and balance out all the hard work with something that makes you smile, every day. You are engaged in one of the toughest challenges of your life, if not the hardest but it will get easier in time.”

Root for the Home Team…YOU!

In closing, the hardest takeaway from all this is that “going it alone” is hard but doing it without positive people surrounding you may be even harder. Cheerleaders are great, but they have to be rooting for the home team…and you’re the captain of the home team! Make the best choices that you possibly can and be encouraged – knowing that if all else doesn’t go as planned, you can rely on yourself to try and make things better. And you can also claim all of the credit. As always, be sure to let your doctor(s) know your intentions, and hopefully, they’ll be excited for your long-term efforts to improve. TBI is tiring, overloading, depressing at times, and can cause irrational behavior. With all that said, there’s always room to plan for incremental change.

Here’s a great and inspirational quote from Beverly Bryant:

“Being a brain injury survivor = Being a stranger in a familiar place.”

Amen to that!

 

If you’d like to know more about the Lash & Associates book titled “Lost & Found”…just click this link!

via One Is The Loneliest Number – after TBI Traumatic Brain Injury Survivor

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[Abstract + References] Electromyographic indices of muscle fatigue of a severely paralyzed chronic stroke patient undergoing upper limb motor rehabilitation

Abstract

Modern approaches to motor rehabilitation of severe upper limb paralysis in chronic stroke decode movements from electromyography for controlling rehabilitation orthoses. Muscle fatigue is a phenomenon that influences these neurophysiological signals and may diminish the decoding quality. Characterization of these potential signal changes during movement patterns of rehabilitation training could therefore help improve the decoding accuracy. In the present work we investigated how electromyographic indices of muscle fatigue in the Deltoid Anterior muscle evolve during typical forward reaching movements of a rehabilitation training in healthy subjects and a stroke patient. We found that muscle fatigue in healthy subjects changed the neurophysiological signal. In the patient, however, no consistent change was observed over several sessions.
1. V. L. Feigin , B. Norrving , M. G. George , J. L. Foltz , A. Roth Gregory , and G. A. Mensah , “Prevention of stroke: a strategic global imperative,” Nat. Rev. Neurol., vol. 107, pp. 501–512, 2016.

2. A. Ramos-Murguialday et al , “Brain-machine interface in chronic stroke rehabilitation: a controlled study,” Ann. Neurol., vol. 74, no. 1, pp. 100–108, 2013.

3. A. Sarasola-Sanz et al , “A hybrid brain-machine interface based on EEG and EMG activity for the motor rehabilitation of stroke patients,” IEEE Int Conf Rehabil Robot, vol. 2017, pp. 895–900, Jul. 2017.

4. R. M. Enoka and J. Duchateau , “Muscle fatigue: what, why and how it influences muscle function,” J Physiol, vol. 586, no. 1, pp. 11–23, Jan. 2008.

5. M. González-Izal , A. Malanda , E. Gorostiaga , and M. Izquierdo , “Electromyographic models to assess muscle fatigue,” J. Electromyogr. Kinesiol., vol. 22, no. 4, pp. 501–512, Aug. 2012.

6. A. Sarasola Sanz et al , “EMG-based multi-joint kinematics decoding for robot-aided rehabilitation therapies,” in 2015 IEEE International Conference on Rehabilitation Robotics (ICORR), 2015.

7. P. V. Komi and P. Tesch , “EMG frequency spectrum, muscle structure, and fatigue during dynamic contractions in man,” Eur. J Appl Physiol, vol. 42, no. 1, pp. 41–50, Sep. 1979.

8. D. R. Rogers and D. T. MacIsaac , “A comparison of EMG-based muscle fatigue assessments during dynamic contractions,” J. Electromyogr. Kinesiol., vol. 23, no. 5, pp. 1004–1011, Oct. 2013.

9. B. Bigland-Ritchie , E. F. Donovan , and C. S. Roussos , “Conduction velocity and EMG power spectrum changes in fatigue of sustained maximal efforts,” J Appl Physiol Respir Env. Exerc Physiol, vol. 51, no. 5, pp. 1300–1305, Nov. 1981.

10. G. V. Dimitrov , T. I. Arabadzhiev , K. N. Mileva , J. L. Bowtell , N. Crichton , and N. A. Dimitrova , “Muscle Fatigue during Dynamic Contractions Assessed by New Spectral Indices,” Med. Sci. Sports Exerc., 2006.

11. N. A. Riley and M. Bilodeau , “Changes in upper limb joint torque patterns and EMG signals with fatigue following a stroke,” Disabil Rehabil, vol. 24, no. 18, pp. 961–969, Dec. 2002.

12. M. J. Campbell , A. J. McComas , and F. Petito , “Physiological changes in ageing muscles,” J. Neurol. Neurosurg. Psychiatry, vol. 36, no. 2, pp. 174–182, 1973.

 

via Electromyographic indices of muscle fatigue of a severely paralyzed chronic stroke patient undergoing upper limb motor rehabilitation – IEEE Conference Publication

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[BLOG POST] 9 promising advances in the management of traumatic brain injury – The Neurology Lounge

 

Traumatic brain injury (TBI) is simply disheartening. It is particularly devastating because it usually affects young people in their prime, with the consequent personal, social, and economic consequences. This blog has previously touched a little on TBI with the post titled Will Smith and chronic traumatic encephalopathy? This was a light-hearted take on concussion in sports, but traumatic brain injury is nothing but a serious burden. So what are the big brains in white coats doing to take down this colossus? Quite a lot it seems. Here, for a taster, are 9 promising advances in the management of traumatic brain injury.

Better understanding of pathology

An amyloid PET imaging study by Gregory Scott and colleagues, published in the journal Neurology, reported a rather surprising link between the pathology seen in long-term survivors of traumatic brain injury, with the pathology seen in Alzheimers disease (AD). In both conditions, there is an increased burden of β-amyloid () in the brain, produced by damage to the nerve axons. The paper, titled Amyloid pathology and axonal injury after brain trauma, however notes that the pattern of  deposition in TBI can be distinguished from the one seen in AD. The big question this finding raises is, does TBI eventually result in AD? The answer remains unclear, and this is discussed in the accompanying editorial titled Amyloid plaques in TBI.

Blood tests to detect concussion

The ideal biomarker for any disorder is one which is easy to detect, such as a simple blood test. A headline that screams Blood test may offer new way to detect concussions is therefore bound to attract attention. The benefits of such a test would be legion, especially if the test can reduce the requirement for CT scans which carry the risks of radiation exposure. This is where glial fibrillary acidic protein (GFAP) may be promising. The research is published in the journal, Academic Research Medicine, with a rather convoluted title, Performance of Glial Fibrillary Acidic Protein in Detecting Traumatic Intracranial Lesions on Computed Tomography in Children and Youth With Mild Head Trauma. The premise of the paper is the fact that GFAP is released into the blood stream from the glial cells of the brain soon after brain injury. What the authors therefore did was to take blood samples within 6 hours of TBI in children. And they demonstrated that GFAP levels are significantly higher following head injury, compared to injuries elsewhere in the body. This sounds exciting, but we have to wait and see where it takes us.

Advanced imaging

Brain Scars Detected in Concussions is the attention-grabbing headline for this one, published in MIT Technology Review. Follow the trail and it leads to the actual scientific paper in the journal Radiology, with a fairly straight-forward title, Findings from Structural MR Imaging in Military Traumatic Brain Injury The authors studied >800 subjects in what is the largest trial of traumatic brain injury in the military. Using high resolution 3T brain magnetic resonance imaging (MRI), they demonstrated that even what is reported as mild brain injury leaves its marks on the brain, usually in the form of white matter hyperintense lesions and pituitary abnormalities. It simply goes to show that nothing is mild when it comes to the brain, the most complex entity in the universe.

Implanted monitoring sensors

Current technologies which monitor patients with traumatic brain injury are, to say the least, cumbersome and very invasive. Imagine if all the tubes and wires could be replaced with microsensors, smaller than grains of rice, implanted in the brain. These would enable close monitoring of critical indices such as temperature and intracranial pressure. And imagine that these tiny sensors just dissolve away when they have done their job, leaving no damage. Now imagine that all this is reality. I came across this one from a CBS News piece titled Tiny implanted sensors monitor brain injuries, then dissolve away. Don’t scoff yet, it is grounded in a scientific paper published in the prestigious journal, Nature, under the title Bioresorbable silicon electronic sensors for the brain. But don’t get too exited yet, this is currently only being trialled in mice.

Drugs to reduce brain inflammation

What if the inflammation that is set off following traumatic brain injury could be stopped in its tracks? Then a lot of the damage from brain injury could be avoided. Is there a drug that could do this? Well, it seems there is, and it is the humble blood pressure drug Telmisartan. This one came to my attention in Medical News Today, in a piece titled Hypertension drug reduces inflammation from traumatic brain injury. Telmisartan seemingly blocks the production of a pro-inflammatory protein in the liver. By doing this, Telmisartan may effectively mitigate brain damage, but only if it is administered very early after traumatic brain injury. The original paper is published in the prestigious journal, Brain, and it is titled Neurorestoration after traumatic brain injury through angiotensin II receptor blockage. Again, don’t get too warm and fuzzy about this yet; so far, only mice have seen the benefits.

Treatment of fatigue

Fatigue is a major long-term consequence of traumatic brain injury, impairing the quality of life of affected subjects in a very frustrating way. It therefore goes without saying, (even if it actually has to be said), that any intervention that alleviates the lethargy of TBI will be energising news. And an intervention seems to be looming in the horizon! Researchers writing in the journal, Acta Neurologica Scandinavica, have reported that Methylphenidate significantly improved fatigue in the 20 subjects they studied. Published under the title Long-term treatment with methylphenidate for fatigue after traumatic brain injury, the study is rather small, not enough to make us start dancing the jig yet. The authors have rightly called for larger randomized trials to corroborate their findings, and we are all waiting with bated breaths.

Treatment of behavioural abnormalities

Many survivors of traumatic brain injury are left with behavioural disturbances which are baffling to the victim, and challenging to their families. Unfortunately, many of the drugs used to treat these behaviours are not effective. This is where some brilliant minds come in, with the idea of stimulating blood stem cell production to enhance behavioural recovery. I am not clear what inspired this idea, but the idea has inspired the paper titled Granulocyte colony-stimulating factor promotes behavioral recovery in a mouse model of traumatic brain injury. The authors report that the administration of G‐CSF for 3 days after mild TBI improved the performance of mice in a water maze…within 2 weeks. As the water maze is a test of learning and memory, and not of behaviour, I can only imagine the authors thought-surely only well-behaved mice will bother to take the test. It is however fascinating that G‐CSF treatment actually seems to fix brain damage in TBI, and it does so by stimulating astrocytosis and microgliosis, increasing the expression of neurotrophic factors, and generating new neurons in the hippocampus“. The promise, if translated to humans, should therefore go way beyond water mazes, but we have to wait and see.

Drugs to accelerate recovery

The idea behind using Etanercept to promote recovery from brain injury sound logical. A paper published in the journal, Clinical Drug Investigation, explains that brain injury sets off a chronic lingering inflammation which is driven by tumour necrosis factor (TNF). A TNF inhibitor will therefore be aptly placed to stop the inflammation. What better TNF inhibitor than Eternacept to try out, and what better way to deliver it than directly into the nervous system. And this is what the authors of the paper, titled Immediate neurological recovery following perispinal etanercept years after brain injury, did. And based on their findings, they made some very powerful claims: “a single dose of perispinal etanercept produced an immediate, profound, and sustained improvementin expressive aphasia, speech apraxia, and left hemiparesis in a patient with chronic, intractable, debilitating neurological dysfunction present for more than 3 years after acute brain injury”. A single patient, mind you. Not that I am sceptical by nature, but a larger study confirming this will be very reassuring.

Neuroprotection

And finally, that elusive holy grail of neurological therapeutics, neuroprotection. Well, does it exist? A review of the subject published in the journal, International Journal of Molecular Sciences, paints a rather gloomy picture of the current state of play. Titled Neuroprotective Strategies After Traumatic Brain Injury, it said “despite strong experimental data, more than 30 clinical trials of neuroprotection in TBI patients have failed“. But all is not lost. The authors promise that “recent changes in experimental approach and advances in clinical trial methodologyhave raised the potential for successful clinical translation”. Another review article, this time in the journal Critical Care, doesn’t offer any more cheery news about the current state of affairs when it says that the “use of these potential interventions in human randomized controlled studies has generally given disappointing results”. But the review, titled Neuroprotection in acute brain injury: an up-to-date review, goes through promising new strategies for neuroprotection following brain injury: these include hyperbaric oxygensex hormones, volatile anaesthetic agents, and mesenchymal stromal cells. The authors conclude on a positive note: “despite all the disappointments, there are many new therapeutic possibilities still to be explored and tested”.

What an optimistic way to end! We are not quite there yet, but these are encouraging steps.

via 9 promising advances in the management of traumatic brain injury | The Neurology Lounge

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[ARTICLE] Muscle fatigue assessment during robot-mediated movements – Full Text

Abstract

Background

Several neuromuscular disorders present muscle fatigue as a typical symptom. Therefore, a reliable method of fatigue assessment may be crucial for understanding how specific disease features evolve over time and for developing effective rehabilitation strategies. Unfortunately, despite its importance, a standardized, reliable and objective method for fatigue measurement is lacking in clinical practice and this work investigates a practical solution.

Methods

40 healthy young adults performed a haptic reaching task, while holding a robotic manipulandum. Subjects were required to perform wrist flexion and extension movements in a resistive visco-elastic force field, as many times as possible, until the measured muscles (mainly flexor and extensor carpi radialis) exhibited signs of fatigue. In order to analyze the behavior and the characteristics of the two muscles, subjects were divided into two groups: in the first group, the resistive force was applied by the robot only during flexion movements, whereas, in the second group, the force was applied only during extension movements. Surface electromyographic signals (sEMG) of both flexor and extensor carpi radialis were acquired. A novel indicator to define the Onset of Fatigue (OF) was proposed and evaluated from the Mean Frequency of the sEMG signal. Furthermore, as measure of the subjects’ effort throughout the task, the energy consumption was estimated.

Results

From the beginning to the end of the task, as expected, all the subjects showed a decrement in Mean Frequency of the muscle involved in movements resisting the force. For the OF indicator, subjects were consistent in terms of timing of fatigue; moreover, extensor and flexor muscles presented similar OF times. The metabolic analysis showed a very low level of energy consumption and, from the behavioral point of view, the test was well tolerated by the subjects.

Conclusion

The robot-aided assessment test proposed in this study, proved to be an easy to administer, fast and reliable method for objectively measuring muscular fatigue in a healthy population. This work developed a framework for an evaluation that can be deployed in a clinical practice with patients presenting neuromuscular disorders. Considering the low metabolic demand, the requested effort would likely be well tolerated by clinical populations.

Background

Muscle fatigue has been defined as “the failure to maintain a required or expected force” [1] and it is a complex phenomenon experienced in everyday life that has reached great interest in the areas of sports, medicine and ergonomics [2]. Muscle fatigue can affect task performance, posture-movement coordination [3], position sense [4] and it can be a highly debilitating symptom in several pathologies [5]. For many patients with neuromuscular impairments, taking into account muscle fatigue is of crucial importance in the design of correct rehabilitation protocols [6] and fatigue assessment can provide crucial information about skeletal muscle function. Specifically, several neuromuscular diseases (e.g. Duchenne, Becker Muscular Dystrophies, and spinal muscular atrophy) present muscle fatigue as a typical symptom [7], and fatigue itself accounts for a significant portion of the disease burden. A systematic approach to assess muscle fatigue might provide important cues on the disability itself, on its progression and on the efficacy of adopted therapies. In particular, therapeutic strategies are now under deep investigation and a lot of effort has been devoted to accelerate the development of drugs targeting these disorders [8]. Therefore, the need for an objective tool to measure muscle fatigue is impelling and of great relevance.

Currently, in clinical practice muscle fatigue is evaluated by means of qualitative rating scales like the 6-min walk test (6MWT) [9] or through subjective questionnaires administered to the patient (e.g. the Multidimensional Fatigue Inventory (MFI), the Fatigue Severity Scale (FSS), and the Visual Analog Scale (VAS)) [10]. During the 6MWT patients have to walk, as fast as possible, along a 25 meters linear course and repeat it as often as they can for 6 min: ‘fatigue’ is then defined as the difference between the distance covered in the sixth minute compared to the first. Obviously, such a measure is only applicable to ambulant patients and this is a strong limitation to clinical investigation because a patient may lose ambulatory ability during a clinical trial, resulting in lost ability to perform the primary clinical endpoint [11]. It should also be considered that neuromuscular patients, e.g. subjects with Duchenne Muscular Dystrophy, generally lose ambulation before 15 years of age [12], excluding a large part of the population from the measurement of fatigue through the 6MWT. Since neuromuscular patients often experience a progressive weakness also in the upper limb, reporting of muscle fatigue in this region is common. A fatigue assessment for upper limb muscles could be used to monitor patients across different stages of the disease. As for the questionnaires, the MFI is a 20 items scale designed to evaluate five dimensions of fatigue (general fatigue, physical fatigue, reduced motivation, reduced activity, and mental fatigue) [13]. Similarly, the FSS questionnaire contains nine statements that rate the severity of fatigue symptoms and the patient has to agree or disagree with them [14]. The VAS is even more general: the patient has to indicate on a 10 cm line ranging from “no fatigue” to “severe fatigue” the point that best describes his/her level of fatigue [15]. Despite the ease to administer, such subjective assessments of fatigue may not correlate with the actual severity or characteristics of fatigue, and may provide just qualitative information with low resolution, reliability and objectivity. Considering various levels of efficacy among the methods currently used in clinical practice, research should focus on the development of an assessment tool for muscle fatigue, that is easy and fast to administer, even to patients with a high level of impairment. Such a tool, should provide clear results, be easy to read and understand by a clinician, be reliable and objectively correlated with the physiology of the phenomenon.

In general, muscle fatigue can manifest from either central and/or peripheral mechanisms. Under controlled conditions, surface electromyography (sEMG) is a non-invasive and widely used technique to evaluate muscle fatigue [16]. Certain characteristics of the sEMG signal can be indicators of muscle fatigue. For example during sub-maximal tasks, muscle fatigue will present with decreases in muscle fiber conduction velocity and frequency and increases in amplitude of the sEMG signal [16]. The trend and rate of change will depend on the intensity of the task: generally, sEMG amplitude has been observed to increase during sub-maximal efforts and decrease during maximal efforts; further it has been reported that there is a significantly greater decline in the frequency content of the signal during maximal efforts compared to sub-maximal [17]. Accordingly, spectral (i.e. mean frequency) and amplitude parameters (i.e. Root Mean Square (RMS)) of the signals, can be used to measure muscle fatigue as extensively discussed in many widely acknowledged studies [161819], however, context of contraction type and intensity must be specified for proper interpretation. A significant problem with the majority of existing protocols is that they rely on quantifying maximal voluntary force loss, maximum voluntary muscle contraction (MVC) [182021] or high fatiguing dynamic tasks [1922] that cannot be reliably performed in clinical practice, especially in the case of pediatric subjects. Actually, previous works pointed out that not only the capacity to maintain MVC can be limited by a lack of cooperation [2324], but also, that sustaining a maximal force in isometric conditions longer than 30 s reduces subject’s motivation leading to unreliable results [25]. Besides, neuromuscular patients might have a high level of impairment and low residual muscular function thus making even more difficult, as well as dangerous for their muscles, sustaining high levels of effort or the execution of a true MVC. In order to overcome this issue, maximal muscle contractions can be elicited by magnetic [10] or electrical stimulation [26]. Although such procedures allow to bypass the problem mentioned above, these involve involuntary muscle activation and not physiological recruitment of motor units [24]; moreover, they can be uncomfortable for patients and can require advanced training, which makes them difficult to be included in clinical fatigue assessment protocols. As for the above mentioned problem with children motivation, work by Naughton et al. [27] showed that the test-retest coefficient of variation of fatigue index during a Wing-Gate test, significantly decreased when using a computerized feedback game linked to pedal cadence, suggesting that game-based procedures may ensure more consistent results in children assessment.

In recent years, the assessment of sensorimotor function has been deepened thanks to the introduction of innovative protocols administered through robotic devices [28293031]. These methods have the ambition to add meaningful information to the existing clinical scales and can be exploited as a basis for the implementation of a muscle fatigue assessment protocol. In order to fill the gap between the need of a quantitative clinical measurement protocol of muscle fatigue and the lack of an objective method which does not demand a high level of muscle activity, we propose a new method based on a robotic test, which is fast and easy to administer. Further, we decided to address the analysis of muscle fatigue on the upper limb as to provide a test suitable to assess patients from the beginning to the late stages of the disease, regardless of walking ability. Moreover, we focused on an isolated wrist flexion/extension tasks to assess wrist muscle fatigue. This ensured repeatability of the tests and prevented the adoption of compensatory movements or poor postures that may occur in multi-segmental tasks, involving the shoulder-elbow complex. In the present work, we tested the method on healthy subjects with the specific goal to evaluate when during the test the first meaningful symptoms of fatigue appaered and not how much subjects are fatigued at the end of the test. The most relevant and novel features of the proposed test include the ability to perform the test regardless of the subjects’ capability and strength, the objectivity and repeatability of the data it provides, and the simplicity and minimal time required to administer.[…]

 

Continue —->  Muscle fatigue assessment during robot-mediated movements | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1

Fig. 1 Experimental setup. Participant sitting on a chair with the forearm secured to the WRISTBOT while performing the wrist rotation reaching task. The visual targets of the reaching task are shown on a dedicated screen

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[ARTICLE] Effort and Fatigue-Related Functional Connectivity in Mild Traumatic Brain Injury – Full Text

Mental fatigue in healthy individuals is typically observed under conditions of high cognitive demand, particularly when effort is required to perform a task for a long period of time—thus the concepts of fatigue and effort are closely related. In brain injured individuals, mental fatigue can be a persistent and debilitating symptom. Presence of fatigue after brain injury is prognostic for return to work/school and engagement in activities of daily life. As such, it should be a high priority for treatment in this population, but because there is little understanding of its behavioral and neural underpinnings, the target for such treatment is unknown. Here, the neural underpinnings of fatigue and effort are investigated in active duty military service members with mild traumatic brain injury (mTBI) and demographically-matched orthopedic controls. Participants performed a Constant Effort task for which they were to hold a pre-defined effort level constant for long durations during fMRI scanning. The task allowed for investigation of the neural systems underlying fatigue and their relationship with sense of effort. While brain activation associated with effort and fatigue did not differentiate the mTBI and controls, functional connectivity amongst active brain regions did. The mTBI group demonstrated immediate hyper-connectivity that increased with effort level but diminished quickly when there was a need to maintain effort. Controls, in contrast, demonstrated a similar pattern of hyper-connectivity, but only when maintaining effort over time. Connectivity, particularly between the left anterior insula, rostral anterior cingulate cortex, and right-sided inferior frontal regions, correlated with effort-level and state fatigue in mTBI participants. These connections also correlated with effort level in the Control group, but only the connection between the left insula and superior medial frontal gyrus correlated with fatigue, suggesting a differing pattern of connectivity. These findings align, in part, with the dopamine imbalance, and neural efficiency hypotheses that pose key roles for medial frontal connections with insular or striatal regions in motivating or optimizing performance. Sense of effort and fatigue are closely related. As people fatigue, sense of effort increases systematically. The data propose a complex link between sense of effort, fatigue, and mTBI that is centered in what may be an inefficient neural system due to brain trauma that warrants further investigation.

Introduction

A signature injury of service members deployed during the conflicts in Iraq and Afghanistan is traumatic brain injury (TBI). Of the approximately 360,000 service members who suffer from TBI, 70% are classified as mild injuries (mTBI; DVBIC Quarterly Reports). At least 19% of the service members with mTBI have persistent symptoms that contribute to difficulty engaging in social and work activities. The consequences of persistent fatigue in mTBI pose a real challenge to rehabilitation (1). High levels of mental fatigue commonly persist and relate to failure to return to work and loss of productivity (23). In fact, presence of fatigue is the strongest predictive factor of poor outcomes following TBI (1). Despite the prevalence of fatigue in TBI, our understanding of its behavioral and neural underpinnings is lacking.

Mental fatigue is a complex process that is operationally defined by time on task and increased mental effort. When performance suffers (reaction time, accuracy, etc.) over time, presumably from fatigue, there tends to be fairly diffusely increased brain activity (4). Simultaneously, there may also be decreased motivation under high effort (5). According to Kahneman’s “resource capacity theory,” the amount of effort needed to perform a task is related to the complexity of the task and an individual’s limited general capacity to perform mental work [i.e., resource capacity, (67)]. When a task is difficult, the demand for resources is high, and performance suffers when resources near depletion. When a person recognizes that performance is suffering, tasks are perceived as more difficult, and require greater effort, which Kahneman equates with the experience of mental fatigue.

Brain imaging in mTBI indicates an increase in brain activity with increased time on task regardless of the type or demand requirements of the task (8). In contrast, healthy individuals have decreased activation over time without a serious decrement in performance, and without reporting significant fatigue. This brain response in TBI may suggest a perception of higher levels of effort when the task is long, or that individuals with TBI inefficiently regulate cognitive control and exert more mental effort to maintain a high-level of performance, resulting in fatigue.

While there is a plethora of literature reporting that task demand causes degradation of performance in mTBI, few have investigated whether task demand results in fatigue more so than in healthy controls, or how this fatigue manifests in behavior or in neural function. The few available studies have small sample sizes [e.g., (9)] limiting their generalizability. The brain networks implicated in effort and fatigue include frontostriatal circuitry, or the ventromedial prefrontal cortex more specifically. Damage to these brain regions is thought to diminish resource capacity and impair allocation of resources, resulting in an increased perception of expended effort (1012). Additionally, fatigue related to lack of motivation to engage and maintain performance on a task, or to predict and manage change in performance based on feedback about performance, is associated with the integrity of the ventromedial prefrontal cortical. That is, individuals with larger lesions of this brain region report more fatigue and apathy (1314). The frontostriatal network is involved in coding the incentive value for an expected outcome (15), and is mediated by dopaminergic frontostriatal networks (131619). Breakdowns in ventromedial prefrontal cortex-related network connectivity may disrupt the ability to appropriately detect, monitor, and self-correct errors or to adequately motivate behavior (2021). For example, the anterior cingulate cortex is associated with monitoring and detecting errors, the pre-supplementary motor area with engaging in task, and the connectivity amongst these two regions is related to fatigue (22).

One gap in the existing literature on fatigue is that paradigms infer “probable” fatigue [exception is Wylie et al. (22)], rather than directly measuring it. In the present study, we investigate brain activity and network connectivity in mTBI participants while they perform a task explicitly designed to study the relationship between task-related effort and fatigue. We assess fatigue with a questionnaire about fatigue over the week prior to scanning (trait) as well as with task manipulation during brain imaging [state, Constant Effort Task [CE]]. For Constant Effort, subjects are asked to squeeze a bulb to a prescribed effort level and hold it constant for a discrete period of time. The task is considered a general index of central fatigue as it is not specific to motor system engagement (2324). Varying effort levels result in predictable changes in the ability to maintain pressure on the bulb such that the time it takes to fatigue is slower at low effort levels than at higher effort levels. Performance on the CE task during functional fMRI allowed for identification of the neural systems underlying effort and fatigue as well as the differences in these systems in mTBI relative to control. We hypothesize that fatigue in mTBI arises when there is an altered perception of the amount of effort needed to perform the task, either because there is a failure to:

a) update the amount of effort given to the task based on internal feedback about performance, which is assessed by contrasting performance across effort levels,

b) sustain a given effort level, which is assessed via time on task, or

c) both.

Because estimating and maintaining effort are likely a result of a complex network of interacting brain regions, we examined not only brain activation during task performance, but also functional connectivity (FC) amongst the regions active during the task. We predict that mTBI participants will demonstrate increased pre-frontal and anterior cingulate cortex activation, as well as increased connectivity of these regions to ventral-striatal regions relative to Control participants.[…]

 

Continue —> Frontiers | Effort and Fatigue-Related Functional Connectivity in Mild Traumatic Brain Injury | Neurology

Figure 1. Effort and Fatigue in the Constant Effort task demonstrated differing regional effects with effort associated with caudal, medial prefrontal cortex (red) while fatigue was associated with rostral prefrontal cortex as well as postcentral and posterior cingulate cortex (blue). Controls demonstrated significantly higher activity than mTBI in a small area of the right medial prefrontal cortex (green) while mTBI had more activity in the posterior occipital cortex, but there were no other significant group effects. When these regions were used in computing functional connectivity, it was only the connectivity amongst the regions of the effort effect (red) that demonstrated group differences in connection strength. For example, the connection between the left insula (A) and the right inferior frontal gyrus (B, pars orbitalis) was significantly stronger in the TBI group for time on task at 75% effort.

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