Fatigue in workers with traumatic brain injury

Researcher: Tatyana Mollayeva, MD, PhD Candidate

Research Supervisor: Prof. Angela Colantonio Research Committee: Prof. Colin M Shapiro, Prof. David J

Cassidy

There is no conflict of interest to disclose

Disclosure

Three-component model –sleep, fatigue and performance Sleep after traumatic brain injury (TBI)

Fatigue after TBI: chicken or egg? Or both? How sleep and fatigue modulate performance after TBI – gap in

knowledge Study: Disorders of sleep and wakefulness in Ontario workers with

head injury: preliminary results Conclusions

Presentation outline

Fatigue in workers with TBI: a three-component model

Mollayeva et al, 2014

TBI vs. general population: Insomnia: 30%1, >3 times the rate in gen. pop.2 Sleep-related breathing disorder: 25%-35%3 vs. 6%4 Hypersomnia: 30%5 vs. 0.05%6 Circadian rhythm sleep disorder: 36%4 vs. 6.6%7 Periodic legs movement syndrome: 17%8 vs. 4%-11%9-1

Sleep disorders in the TBI population

1 F i c h t e n b e r g N L , Z a f o n t e R D , P u t n a m S , M a n n N R , M i l l a r d A E . I n s o m n i a i n a p o s t - a c u t e b r a i n i n j u r y s a m p l e . B r a i n I n j 2 0 0 2 ; 1 6 ( 3 ) : 1 9 7 - 2 0 6 . 2 O u e l l e t M , M o r i n C M . S u b j e c t i v e a n d o b j e c t i v e m e a s u r e s o f i n s o m n i a i n t h e c o n t e x t o f t r a u m a t i c b r a i n i n j u r y : a p r e l i m i n a r y s t u d y . S l e e p M e d 2 0 0 6 ; 7 ( 6 ) : 4 8 6 - 9 7 . 3 W i l d e M C , C a s t r i o t t a R J , L a i J M , A t a n a s o v S , M a s e l B E , K u n a S T . C o g n i t i v e i m p a i r m e n t i n p a t i e n t s w i t h t r a u m a t i c b r a i n i n j u r y a n d o b s t r u c t i v e s l e e p a p n e a . A r c h P h y s M e d R e h a b i l 2 0 0 7 ; 8 8 ( 1 0 ) : 1 2 8 4 - 8 . 4 C a s t r i o t t a R J , W i l d e M C , L a i J M e t a l . P r e v a l e n c e a n d c o n s e q u e n c e s o f s l e e p d i s o r d e r s i n t r a u m a t i c b r a i n i n j u r y . J C l i n S l e e p M e d 2 0 0 7 ; 3 ( 4 ) : 3 4 9 - 5 6 . 5 M a s e l B E , S c h e i b e l R S , K i m b a r k T , K u n a S T . E x c e s s i v e d a y t i m e s l e e p i n e s s i n a d u l t s w i t h b r a i n i n j u r i e s . A r c h P h y s M e d R e h a b i l 2 0 0 1 ; 8 2 ( 1 1 ) : 1 3 2 6 - 3 2 . 6 L o n g s t r e t h W T J r , K o e p s e l l T D , T o n T G , H e n d r i c k s o n A F , v a n B e l l e G . T h e e p i d e m i o l o g y o f n a r c o l e p s y . S l e e p 2 0 0 7 ; 3 0 : 1 3 - 2 6 . 7 A y a l o n L , B o r o d k i n K , D i s h o n L , K a n e t y H , D a g a n Y . C i r c a d i a n r h y t h m s l e e p d i s o r d e r s f o l l o w i n g m i l d t r a u m a t i c b r a i n i n j u r y . N e u r o l 2 0 0 7 ; 6 8 ( 1 4 ) : 1 1 3 6 - 4 0 . 8 W e i t z m a n E D , C z e i s l e r C A , Z i m m e r m a n J C , M o o r e - E d e M C . B i o l o g i c a l r h y t h m s i n m a n : r e l a t i o n s h i p o f s l e e p - w a k e , c o r t i s o l , g r o w t h h o r m o n e , a n d t e m p e r a t u r e d u r i n g t e m p o r a l i s o l a t i o n . A d v B i o c h e m P s y c h o p h a r m a c o l 1 9 8 1 ; 2 8 : 4 7 5 - 9 9 . 9 H o r n y a k M , F e i g e B , V o d e r h o l z e r U . P e r i o d i c l e g m o v e m e n t s i n s l e e p a n d p e r i o d i c l i m b m o v e m e n t d i s o r d e r : p r e v a l e n c e , c l i n i c a l s i g n i f i c a n c e a n d t r e a t m e n t . S l e e p M e d R e v 2 0 0 6 ; 1 0 ( 3 ) : 1 6 9 - 7 7 . 1 0 S c o f i e l d H , R o t h T , D r a k e C . P e r i o d l i m b m o v e m e n t s d u r i n g s l e e p : p o p u l a t i o n p r e v a l e n c e , c l i n i c a l c o r r e l a t e s , a n d r a c i a l d i f f e r e n c e s . S l e e p 2 0 0 8 ; 3 1 ( 9 ) : 1 2 2 1 - 7 .

Fatigue: primary complaint in the TBI population1 Difficult to elucidate – many plausible biological causes of the

symptom acting independently or together2 Fatigue is burdensome and associated with poor outcomes3-5 Negatively impacts social, physical and cognitive functioning;6

participation in daily activities;7 results in increased work-related and other disabilities8

Fatigue in the TBI population

1Juengst S, Skidmore E, Arenth PM, Niyonkuru C, Raina KD. Unique contribution of fatigue to disability in community-dwelling adults with traumatic brain injury. Arch Phys Med Rehabil 2013; 94(1):74-9. 2Prins JB, van der Meer JW, Bleijenberg G. (2006) Chronic fatigue syndrome. The Lancet, 367: 346. 3Belmont A, Agar N, Hugerom C, Gallais B, Azouvi P. (2006) Fatigue and traumatic brain injury. Ann Readapt Med Phys 49(6):283-288. 4Ponsford J, Cameron P, Fitzgerald M, Grant M, Mickocka-Walus A. (2011) Long-term outcomes after uncomplicated mild traumatic brain injury: a comparison with trauma controls. J Neurotrauma, 28:937-946. 5Middleboe T, Andersen HS, Birket-Smith M, Friis ML. (1992) Minor head injury: impact on general health after 1 year, a prospective follow-up study. Acta Neurol Scand, 85(1):5-9. 6Ziino C, Ponsford J. (2006) Selective attention deficits and subjective fatigue following traumatic brain injury. Neuropsychology, 20(3):383-390. 7Cantor JB, Ashman T, Gordon W, Ginsberg A, Engmann C, et al. (2008) Fatigue after traumatic brain injury and its impact on participation and quality of life. J Head Trauma Rehabil, 23(1):41-51. 8McCrimmon S, Oddy M.(2006) Return to work following moderate-to-severe traumatic brain injury. Brain Inj, 20(10):1037-1046.

Recognized when activity results in diminished capacity to carry out a function1

Cited as factor in occupational disasters Chernobyl nuclear reactor, Exxon Valdez oil spill, Challenger space shuttle2,3

Growing evidence supporting association – sleepiness, fatigue and probability of involvement in accident4,5

As such, fatigue can be a proximate cause of TBI at the workplace (chicken)

Fatigue can also be a result of the TBI (egg)

Fatigue in the TBI population

1Sukovic A, Lack L, Wright H. What do the term “ sleepy”, “ tired” and “fatigued” mean? Sleep Biol Rhythms 2008; 6:A41. 2Dekker SWA. Ten questions about human error and system safety. Mahwah, NJ: Lawrence Erlbaum Associates; 2005. 3Pilcher JJ, Huffcutt AI, Effects of sleep deprivation on performance: a meta-analyses, Sleep 1996; 19:318-26. 4Krupp LB, Alvarez LA, LaRocca NG, Scheinberg LC. Fatigue in Multiple Sclerosis. Arch Neurol 1988; 45(4): 435-7. 5Lindberg E, Carter N, Gislason T, Janson C. Role of snoring and daytime sleepiness in occupational accidents. Am J Respir Crit Care Med 2001; 164(11): 2031-5.

National: 1.4 million persons living with TBI-related disability1

Affected persons usually young-mid age financial cost to society due to loss of productive activity1, unemployment2 Therefore, return to work (RTW)/productive activity is an

important endpoint of rehabilitation

TBI and disability

1Brain Injury Association of Canada. NHCC and BIAC Election messaging. Retrieved from: http://biac-aclc.ca/2011/03/29/nhcc-and-biac-election-messaging/ 2Lubusko AA, Moore AD, Stambrook M, Gill DD. Cognitive beliefs following severe traumatic brain injury: association with post-injury employment status. Brain Injury 1994; 8:65-70.

After TBI rate of RTW: 10-70%1

Highest in first six months after injury2

Factors affecting RTW: demographic, injury severity, rehabilitation, workplace accommodations, etc.3

Fatigue is a predictor of number of days from injury to RTW4

Sleep complaints two years post injury associated with lower rates of employment5

Returning to work after TBI

1Cifu DX, Keyser-Merkus L, Lopez E, Wehman P, Kreutzer JS, Englander J, High W. Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis. Archives of Phys Med and Rehabil.1997; 78:125-31. 2Radford K, Phillips J, Drummond A, Sach T, Walker M, Tyerman A, Haboubi N, Jones T. Return to work after traumatic brain injury: cohort comparison and economic evaluation. Brain Injury; 2013; 27:507-20. 3 Devitt R, Colantonio A, Ratcliff G, Chase S, Dawson D, Teare G. Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury. Disability and Rehabilitation 2006 ; 28:547-59. 4Wäljas M, Iverson GL, Lange RT, Liimatainen S, Hartikainen KM, Dastidar P, Soimakallio S, Ohman J. Return to Work Following Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2013 [epub ahead of print] %Cohen M, Oksenberg A, Snir D, Stern MJ, et al. Temporally related changes of sleep complaints in traumatic brain injured patients. J of Neurology, Neurosurg and Psychiatry.1992; 55:313-15.

Sleep problems are common after TBI, linked to employment rates post-TBI

Fatigue frequently cited post-TBI; symptom implicated in occupational errors

Both sleep and fatigue appear as components relevant to performance after TBI, specifically of occupational duties

The gap – study of sleep and fatigue and their relationship to work performance and disability after TBI

Sleep, fatigue and performance after TBI

Disorders of sleep and wakefulness in Ontario

workers with TBI

Objectives relevant to today’s topic: Prevalence: fatigue and sleep disorders in Ontario workers

with TBI Association between fatigue, sleep dysfunction, disability Review correlations between variables by sex

Methods: Cross-sectional, prospective recruitment TRI-UHN Neurology Services, WSIB Clinic

Objectives and methods

Sleep assessment: standardized scales, in accordance with ICSD-21

Psychological status: PHQ-92, HADS-A3 Pain: Pain Analogue Scale4 Other items: medications, other med disorders, shift work,

pre-morbid sleep condition, etc. Disability: Sheehan Disability Scale5

Measures used

1American Association of Sleep Medicine. The international classification of sleep disorders. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005 revised edition 2Zigmond AS, Snaith RP. The HADS: Hospital Anxiety and Depression Scale. Windsor: NFER Nelson;1983. 3Fann JR, Bombardier CH, Dikmen S, Esselman P, Warms CA, Pelzer E, et al. Validity of the patient health questionnaire-9 in assessing depression following traumatic brain injury. J Head Trauma Rehabil. 005;20: 501–11. 4Dobscha SK, Clark ME, Morasco BJ, Freeman M, Campbell R, Helfand M. Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain Med 2009;10: 1200–17. 5Sheehan, D. The anxiety disease. New York: Scribner; 1983.

Preliminary results

Median time since injury=531 days Mild TBI/concussion=95%

Preliminary results

Work status

Disability 66.7% Part-time 20.4% Full-time 11.1% Laid-off 1.9%

#work-related injuries in past 5 years

1 75.5% 2 17% ≥3 7.5%

Accident involvement due to sleepiness

Yes

5.6%

Shift-work

47.8% Rotating 80% Night 20%

Pre-morbid sleep disorders

SA 13.5%

Treated? Yes 83%; 67% not compliant

Most disabling symptoms

Order Symptom Percent 1 • Pain

• Insomnia/other sleep-related • Dizziness • Fatigue

22 14 9 7

2 • Fatigue • Pain • Insomnia/other sleep-related • Anxiety/depression

17 15 13 11

3 • Dizziness • Insomnia/other sleep-related • Fatigue • Poor memory

11 11 9 9

Sleep-related=38%

Fatigue=33%

Comorbid conditions

0 20 40 60 80

Depression

Arthritis

Sleep apnea

Heart disease

Diabetes

Seizure disorder

COPD

Fibromyalgia

%n

Frequencies: fatigue Measure: fatigue severity scale

0102030405060708090

Normal (<36) Excessive (>/=36)

%

Frequencies: insomnia Measure: insomnia severity scale

0

10

20

30

40

50

None/subthres(<15)

Moderate (15-21) Severe (22-28)

%

Insomnia, by sex

01020304050607080

Mod-sevinsomnia

0

10

20

30

40

50

60

70

Mod-sevinsomnia in shift-

workers

MaleFemale

Frequencies: daytime sleepiness Measure: Epworth sleepiness scale

48

48.5

49

49.5

50

50.5

51

Normal (0-9) Excessive (>/=10)

%

Frequencies: sleep apnea Measure: STOP-BANG

0

10

20

30

40

50

60

70

<3 3-5 >5

%

Frequencies: restless leg’s Measure: RLQ

020406080

100

NoYes

%n

Recurrent unpleasant sensation, tingling in legs while sitting, lying down

020406080

100

NtEve

%n

If present, worse in evening or night?

Three-component model based on correlations

Three-component model based on correlations

Three-component model based on correlations

Important to note

Fatigue was found to be strongly associated with insomnia and disability, with some variability between sexes

A strong negative association between fatigue and alertness may indicate workers’ inability to return to duties requiring sustained attention

Future research on the effects of circadian displacement due to shift work as a determinant of post-morbid fatigue, alertness and performance is warranted

Conclusions

Ontario workers with head injury Neurology services, WSIB clinic, Toronto Rehab-UHN Research sleep facility, Toronto Western Hospital-UHN Funding: MITACS Accelerate Canadian Institutes of Health Research Toronto Rehabilitation Institute, UHN

Acknowledgements

Thank you!