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!