#OTalk – Tuesday 19th October 2021 -Assessing fatigue: capturing what counts?

This #OTalk is hosted by Dr Leisle Ezekiel

Fatigue is a common and distressing consequence of many neurological conditions and has long been an area of focus in occupational therapy, particularly for therapists working with people with progressive neurological conditions. But it is increasingly evident that fatigue is a significant problem for people living with acquired brain injury and is a distinct and direct consequence of brain injury. Estimates of prevalence vary from 21-77% and there is evidence that fatigue may last for many years (Wylie and Flashman 2017; Acciarresi, Bogousslavsky and Paciaroni, 2014; Headway, 2019).

Fatigue is a complex and subjective experience which is difficult to define as it overlaps with concepts of tiredness and with the symptoms of depression, sleep dysfunction and muscle weakness (Doncker et al 2018, Mollayeva et al 2014). It is therefore best thought of as multi- dimensional phenomenon that consists of different types of fatigue with varying signs and symptoms. Cantor et al (2014) conceptualise fatigue as encompassing “psychological, motivational, situational, physical, and activity-related components” and define it as a: 

“subjective awareness of a negative balance between available energy and the mental and physical requirements of activities” (Cantor et al 2014)pp491.

So to understand an individual’s experiences of fatigue, we need to consider fatigue in the context of people’s daily lives (including occupations and environments), the behaviour associated with fatigue (i.e. coping strategies) and their beliefs around fatigue and activity. However, it can be difficult to disentangle fatigue experiences from other consequences of brain injury. For example: is a lapse in concentration a sign of fatigue or do people tire more easily because they have difficulty with attention (Wylie and Flashman 2017)

There have been several attempts to develop a taxonomy or case definition of fatigue after stroke (Kluger et al 2013, Lynch et al 2007). Others suggest a need to consider in-the-moment experiences of fatigue (state fatigue) separately from the chronic experience of fatigue (trait fatigue) as state fatigue is more likely to be associated with fatigue-related behaviours, for example, the decision to do something or whether to stop and rest (GR. Wylie and Flashman 2017) State fatigue is measured using a numeric rating scale or visual analogue scale (e.g. 0-10, with 0 being no fatigue and 10 worst fatigue). 

This complexity of fatigue creates challenges when we start to assess and measure fatigue and is a challenge in the development of fatigue outcome measures. There is a myriad of fatigue scales and measures used within research but many of them were not developed for the ABI population and tend to conflate the consequences of ABI with fatigue symptoms.  They are also completed retrospectively and ask for a summation of experience and are less reliable for those with cognitive challenges. When using a fatigue scale we need to pay close attention to what the scale measures, is fatigue uni or multi-dimensional, does the scale capture severity, intensity or impact or a combination of these? 

As occupational therapists, we focus on enabling people to manage their fatigue effectively, so that they can participate in the daily activities that are most meaningful and necessary. To do that, we need to understand the individual’s triggers, patterns of, and responses to fatigue so we can support them in developing and applying effective strategies.  But our assessment of fatigue is shaped by our conceptualisation of fatigue and depends on the tools we use to gather accurate and meaningful information about fatigue.  A survey of physiotherapists and occupational therapists highlighted significant differences in therapist’s beliefs about fatigue, with potential for these differences to result in clients/patients receiving conflicting advice (Thomas et al 2019)

The questions for today are: 

  1. How do we as OTs conceptualise fatigue for people with neurological conditions?
  2. What tools are useful in gathering data about people’s fatigue?
  3. What challenges do we experience in practice when gathering information about fatigue?
  4. How do we know assess whether our intervention has made a positive impact? 


Cantor JB, Ashman T, Bushnik T, Cai X, Farrell-Carnahan L, Gumber S, Hart T, Rosenthal J and Dijkers MP (2014) Systematic review of interventions for fatigue after traumatic brain injury: A nidrr traumatic brain injury model systems study. Journal of Head Trauma Rehabilitation. Lippincott Williams and Wilkins, 490–497.

Doncker W de, Dantzer R, Ormstad H and Kuppuswamy A (2018) Mechanisms of poststroke fatigue. Journal of Neurology, Neurosurgery & Psychiatry. BMJ Publishing Group Ltd 89(3): 287–293. Available at: https://jnnp.bmj.com/content/89/3/287 (accessed 06/08/21).

Kluger BM, Krupp LB and Enoka RM (2013) Fatigue and fatigability in neurologic illnesses: proposal for a unified taxonomy. Neurology. Neurology 80(4): 409–416. Available at: https://pubmed.ncbi.nlm.nih.gov/23339207/ (accessed 06/08/21).

Lynch J, Mead G, Greig C, Young A, Lewis S and Sharpe M (2007) Fatigue after stroke: the development and evaluation of a case definition. Journal of psychosomatic research 63(5): 539–44. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17980228 (accessed 19/06/14).

Mollayeva T, Kendzerska T, Mollayeva S, Shapiro CM, Colantonio A and Cassidy JD (2014) A systematic review of fatigue in patients with traumatic brain injury: The course, predictors and consequences. Neuroscience and Biobehavioral Reviews. Elsevier Ltd 47: 684–716. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25451201 (accessed 23/12/14).

Thomas K, Hjalmarsson C, Mullis R and Mant J (2019) Conceptualising post-stroke fatigue: a cross-sectional survey of UK-based physiotherapists and occupational therapists. BMJ Open. British Medical Journal Publishing Group 9(12): e033066. Available at: https://bmjopen.bmj.com/content/9/12/e033066 (accessed 06/08/21).

Wylie GR and Flashman LA (2017) Understanding the interplay between mild traumatic brain injury and cognitive fatigue: models and treatments. Concussion. Future Medicine Ltd 2(4): CNC50. Available at: http://www.futuremedicine.com (accessed 13/05/21).

Wylie GR and Flashman LA (2017) Understanding the interplay between mild traumatic brain injury and cognitive fatigue: models and treatments. Concussion (London, England). Concussion 2(4): CNC50. Available at: https://pubmed.ncbi.nlm.nih.gov/30202591/ (accessed 06/08/21).


Host:  Dr Leisle Ezekiel

Support on OTalk Account:  @helenotuk

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HCPC Standards for CPD.

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