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J Head Trauma Rehabil

Vol. 20, No. 5, pp. 416–425

c 2005 Lippincott Williams & Wilkins, Inc.

Subjective Reports of Fatigue

During Early Recovery From
Traumatic Brain Injury
Susan R. Borgaro, PhD; Jason Baker, PhD;
Jennifer V. Wethe, PhD; George P. Prigatano, PhD;
Christina Kwasnica, MD

Objective: To determine whether patients with traumatic brain injury (TBI) report higher levels
of fatigue than do normal controls and to identify demographic and cognitive correlates of self-
reported fatigue. Design: Prospective study. Setting: Inpatient neurorehabilitation unit in a medi-
cal center and neurological institute. Participants: Forty-seven neurorehabilitation inpatients with
TBI. Main Outcome Measures: Barrow Neurological Institute (BNI) Fatigue Scale and BNI Screen
for Higher Cerebral Functions. Results: Patients reported significantly greater levels of fatigue com-
pared to the levels reported by normal controls, although fatigue was found to be unrelated to
injury severity, number of days from injury to assessment, cognitive impairment, and gender. In-
spection of individual items revealed no significant differences between severe versus moderate
versus mild TBI groups. However, being able to last the day without taking a nap (ie, item 10) was
found to be the most sensitive item associated with fatigue in the TBI group. Conclusions: Re-
sults of this study suggest the need to integrate activities and interventions to increase endurance
in patients with TBI during early rehabilitation. Accommodating regular rest breaks and increasing
restful sleep should be a focus of inpatient neurorehabilitation units. Key words: brain injury,
fatigue, traumatic brain injury

F ATIGUE is a common symptom of many

neurological conditions.1 Although sub-
jective, it is often clinically observed in acute
and postacute phases of recovery2–14 and in
patients with unilateral focal and bilateral
lesions.15,16 Physical and cognitive difficul-
ties may be accentuated by fatigue,17 and fa-
tigue may be exacerbated by involvement in
physical and cognitive activities. It has been
reported in patients with neurologic condi-
tions, independent of mood disturbances.10
It has also been shown to have serious func-
tional and emotional consequences18,19 and
From the Division of Neurology, Barrow
Neurological Institute, St Joseph’s Hospital and
Medical Center, Phoenix, Ariz.
Corresponding author: Susan R. Borgaro, PhD, Barrow
Neurological Institute, St. Joseph’s Hospital and Medical
Center, 350 W Thomas Rd, Phoenix, AZ 85013 (e-mail:
sborgar@chw.edu).
416
may have implications for participation in
rehabilitation.20
While there is no universally accepted defi-
nition of fatigue, most agree that it is a multidi-
mensional construct, although variability ex-
ists as to its dimensions. For example, Grobar-
Murray and colleagues11 described fatigue as
consisting of 3 dimensions: (1) a perceived
sensation of weariness; (2) a diminished in-
terest or “task aversion”; and (3) observable
physical signs or somatic symptoms. Smets
and colleagues21 described physical and men-
tal components of fatigue as characterized by
the Multidimensional Fatigue Inventory mea-
sured in patients with cancer and chronic fa-
tigue syndrome. The Fatigue Impact Scale2 is
designed to measure fatigue as it relates to
cognitive, physical, and social functioning in
patients with multiple sclerosis.
In traumatic brain injury (TBI), fatigue has
been reported as a prominent symptom for
both mild and moderate/severe injuries.8,16 It
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Fatigue After Traumatic Brain Injury
has been documented as the third most preva-
lent symptom of postconcussive syndrome
following headaches and dizziness.22 Other
studies have shown similar results.23,24 van
Zomeren16 studied reports of 43 symptoms
in patients with TBI with a mean duration
of posttraumatic amnesia of 24.5 days. In the
sample studied, fatigue was endorsed as the
second most common complaint by 41% of
the patients, second only to memory prob-
lems, which were endorsed by 49% of the
patients.
Problems with fatigue have also been
shown to persist during the postacute stages
of recovery after TBI. In a study of patients
with mild to moderate TBI, 57% of patients
complained of fatigue at 1 month postinjury,
61% at 3 months postinjury, 45% at 6 months
postinjury, and 45% at 1 year postinjury.25 In
a follow-up study of patients with moderate
to severe TBI, 68% complained of fatigue at
2 years postinjury, while 73% complained of
fatigue at 5 years postinjury.26
There are few published questionnaires
that are specifically designed to quantify fa-
tigue, particularly during the acute stages of
recovery after brain injury. Typically, an as-
sessment of fatigue is obtained via a detailed
history,27 a structured interview,2 or question-
naires designed to measure broader condi-
tions (eg, Beck Depression Inventory). The
most recognized published questionnaires
were developed to assess fatigue in patients
with multiple sclerosis. The Fatigue Impact
Scale,2 for example, is a 40-item self-report
questionnaire that asks about the role of fa-
tigue as it relates to cognitive, physical, and so-
cial functioning in patients with multiple scle-
rosis. Responses are rated on a scale of 0 (no
problem) to 4 (extreme problem). The Fatigue
Severity Scale12 is a 9-item self-report ques-
tionnaire that asks patients to rate on a scale
from 1 (strongly disagree) to 7 (strongly agree)
the degree to which fatigue interferes with
their functioning. The Fatigue Severity Scale
has demonstrated sensitivity to the fatigue
problems of patients with multiple sclero-
sis. The Multidimensional Fatigue Inventory21
consists of 24 items that are rated on a 7-point
417
scale. Its psychometric properties yielded 5
dimensions when measured on patients with
cancer and chronic fatigue. The dimensions
were defined as the following: (1) general fa-
tigue; (2) physical fatigue; (3) reduced activ-
ity; (4) reduced motivation; and (5) mental
fatigue.
Although the scales developed to measure
fatigue have demonstrated good reliability in
the patient populations studied, most are dis-
ease specific and/or not conducive for assess-
ing fatigue in patients during early rehabilita-
tion. For example, the Fatigue Impact Scale
and the Multidimensional Fatigue Inventory
are lengthy and would likely exceed the level
of cognitive and mental endurance often dis-
played by patients during acute inpatient re-
habilitation. The Fatigue Severity Scale, albeit
shorter in length, and the Multidimensional
Fatigue Inventory consist of items that are not
necessarily relevant or specific enough to the
experiences of patients on an acute neurore-
habilitation setting.
The present study introduces a new mea-
sure of self-reported fatigue—the Barrow Neu-
rological Institute Fatigue Scale (BNI Fatigue
Scale).28 The BNI Fatigue Scale was specifi-
cally developed to provide a quick quantifi-
able self-report assessment of fatigue in pa-
tients during early rehabilitation from brain
injury. It is brief in length and easy to under-
stand, making it unique and conducive for ad-
ministration on an acute inpatient neuroreha-
bilitation unit. Whether the scale is sensitive
for detecting self-reports of fatigue in pa-
tients after TBI remains to be empirically de-
termined and is a focus of this exploratory
study.
The purpose of the present research is 2-
fold. First, this study will examine self-reports
of fatigue in patients with TBI during early
rehabilitation using the BNI Fatigue Scale. It
is expected that the patients with TBI will
report significantly higher levels of fatigue
compared to the levels reported by a sam-
ple of normal controls. A second focus of this
study is to determine whether there is an asso-
ciation between self-reported fatigue and po-
tential moderating variables. The number of
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418 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2005

days that pass from injury to neuropsycho-
logical assessment has been positively corre-
lated with severity of injury.29–31 Whether in-
jury severity, number of days postinjury, and
cognitive impairment are associated with self-
reported fatigue has not yet been studied
with the BNI Fatigue Scale. Also, fatigue has
been shown to differ for gender across several
studies11,32 and will therefore be examined in
the present study.
METHODS
Participants
Fatigue was studied in 47 patients with
TBIs, admitted to the inpatient neurorehabil-
itation unit of the BNI in Phoenix, Ariz. Pa-
tients had varying levels of injury severity as
classified by admission Glasgow Come Scale
(GCS) score.33 Average age was 35.93 (SD =
16.49), and average education was 12.43
(SD = 2.33) years. Table 1 shows the demo-
graphic and neurologic features of the patient
group.
Eighteen patients had sustained severe
head injuries (as evidenced by a GCS score
of 8 or less), 18 patients had sustained mod-
erate head injuries (GCS score between 9
and 12), and 11 patients had sustained mild
head injuries (GCS scores in the 13–15 range).
Of the 11 patients with mild injuries, 4
(36%) had injuries complicated by intracra-
nial lesions as visualized by computed tomog-
raphy and/or magnetic resonance imaging,
whereas 7 (64%) had uncomplicated injuries.
Of the total 40 patients with visualized in-
juries, 50% had bilateral lesions, 17.5% had left
hemisphere lesions, and 22.5% had right
hemisphere lesions. Another 10% had visu-
alized lesions in the brain stem, cerebel-
lum, or an unspecified location. The most
common visualized lesions were contusions
(45%), hemorrhages (39%), and hematomas
(16%).
The control group was a convenience sam-
ple of 30 volunteers recruited from the gen-
eral population. Participants were included
if they reported no history of psychiatric or
neurologic disease. Mean age was 36.20 years
(SD = 19.46), and mean education was 13.46
years (SD = 1.67). Sixty-two percent of
the normal control participants were male
(Table 1).

Table 1. Demographic and neurologic characteristics of patient and control groups

Patients with
traumatic brain Controls
injury (n = 45) (n = 30)
M SD M SD P
Age 35.93 16.49 36.20 19.46 .951
Education 12.43 2.33 13.46 1.67 .071
Gender
% Male 55.10 62.5 .238
Glasgow Coma Scale score 9.39 4.11
Postinjury days 24.37 17.01
Range of days 3–81
Lesion location, %
Right 22.5
Left 17.5
Bilateral 40.0
Other 10.0
Barrow Neurological Institute T Score 18.44 17.81
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Fatigue After Traumatic Brain Injury
Independent t tests were conducted to de-
termine whether the groups differed on age
and education. Chi-square analysis was con-
ducted to determine whether there were any
gender differences between the groups. The
analyses showed no statistical differences be-
tween the groups on age (t73 = 0.229, P =
.819), education (t73 = 1.90, P = .071), or gen-
der (X2 = −0.143, P = .238).
Measures
BNI Fatigue Scale
The BNI Fatigue Scale28 (Appendix) con-
sists of 10 items that are rated on a 7-point
scale. The scale ranges from 0 to 1 (rarely a
problem), 2 to 3 (occasional problem, but not
frequent), 4 to 5 (frequent problem), and 6
to 7 (a problem most of the time). Patients
are asked to characterize their level of fatigue
since their injury by choosing a number that
best describes their response. A total score is
obtained on items 1 through 10. A final item
(item 11) asks patients to circle their overall
level of fatigue since their injury on a scale
from 0 (no problem) to 10 (severe problem).
Patients with acute TBI typically complete the
questionnaire within 5 minutes. The scale was
found to have good test-retest reliability on a
heterogeneous sample (n = 30) of inpatient
neurologic patients (r = 0.96). Additional re-
liability and psychometric properties of this
scale have been documented elsewhere (see
Borgaro et al28 ).
BNI Screen for Higher Cerebral
Functions
The BNI Screen for Higher Cerebral Func-
tions (BNIS)34,35 was designed to provide a
brief but valid assessment of higher cerebral
functions from acute to chronic stages of
various brain disorders. Initial studies have
demonstrated its reliability and validity.36 The
BNIS takes approximately 10 to 25 minutes to
administer. It is composed of the following 7
subtests: (1) Speech and Language; (2) Orien-
tation; (3) Attention/Concentration; (4) Visu-
ospatial and Visual Problem Solving; (5) Learn-
ing and Memory; (6) Affect; and (7) Aware-
419
ness versus Performance. For a detailed
description of the individual items, see
Prigatano et al.34 A total raw score provides
an overall index of cognitive functioning. It
is obtained by summing all of the subtest
raw scores. Higher scores indicate a higher
level of functioning. The total raw score may
be converted to an age-corrected standard
(T) score using the norms of Prigatano and
colleagues.34 The total BNIS T score was used
as a dependent variable of overall cognitive
functioning.
Procedures
All patients who met the inclusion criteria
were evaluated within the first 90 days of their
injury. Participants were interviewed and ad-
ministered the BNI Fatigue Scale and the BNIS
by either a staff clinical neuropsychologist or
a postdoctoral resident in clinical neuropsy-
chology, as part of their neuropsychological
examination.
RESULTS
Performances on BNI Fatigue Scale
It was expected that the TBI group as a
whole would report higher levels of fatigue
than would the normal control group. Using
independent t tests and Bonferroni statistics,
with alpha set at P less than .004 for multi-
ple comparisons, it was found that the TBI
group reported higher levels of fatigue on the
BNI Fatigue Scale. Inspection of specific items
showed significantly higher reports of fatigue
in the TBI group on items 4 (How difficult is
it for me to complete a task without becom-
ing tired?), 5 (How difficult is it for me to stay
alert during activities?), 7 (How difficult is it
for me to stay out of my bed during the day?),
10 (How difficult is it for me to last the day
without taking a nap?), and 11 (overall index
of fatigue) (Table 2).
A stepwise multiple regression analysis
was performed to determine whether any of
the statistically significant items listed above
(ie, items 4, 5, 7, 10, and 11) would be most
associated with the TBI group. The single item
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420 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2005

Table 2. Group differences on Barrow Neurological Institute Fatigue Scale items

Patients with
traumatic brain Controls
injury (n = 47) (n = 30)
M SD M SD t P
Item 1 2.44 1.71 1.87 1.91 −1.26 .212
Item 2 2.13 1.98 1.17 1.13 −2.58 .012
Item 3 1.89 2.05 1.00 1.41 −2.12 .038
Item 4 2.18 1.97 0.83 0.76 −4.05 .000∗
Item 5 1.84 1.99 0.62 0.57 −3.82 .000∗
Item 6 1.60 1.90 1.54 1.93 −0.12 .904
Item 7 2.36 2.21 0.79 0.83 −4.20 .000∗
Item 8 2.04 2.08 1.95 1.42 −0.20 .840
Item 9 1.73 1.92 0.95 0.99 −2.20 .031
Item 10 2.53 2.23 0.66 0.76 −5.08 .000∗
Total score 20.71 16.49 11.41 6.99 −3.27 .002∗
Overall fatigue index 4.44 3.09 2.50 1.93 −3.20 .002∗

∗ Significant after appropriate adjustment of alpha level (α = .004).

most associated with TBI was item 10 (How
difficult is it for me to last the day without tak-
ing a nap?) (r2 = 0.183, F = 15.49, P = .000).
Correlates of fatigue in TBI
To better understand the role of self-
reported fatigue in the TBI group, poten-
tial moderating variables were examined for
their effects on fatigue. Pearson correlations
yielded no statistically significant findings for
cognitive performance on the BNIS (r =
−0.08, P = .628), days postinjury (r = −0.12,
P = .424), or injury severity as per the GCS
score at admission (r = −.05, P = .738). An
independent t test revealed no significant dif-
ference between gender and self-reported fa-
tigue (t73 = −1.01, P = .317).
injury to assessment (F2,45 = 4.18, P = .022).
There also was a dose-response relationship
between TBI groups and total cognitive im-
pairment score on the BNIS (F2,45 = 6.45,
P = .004), with patients with severe TBI hav-
ing the greatest cognitive impairment (M =
13.22, SD = 14.70), followed by the moder-
ate (M = 16.56, SD = 18.47) and mild groups
(M = 36.00, SD = 13.25), respectively. With
days postinjury and BNIS score covaried, and
alpha set at P less than .004 for multiple com-
parisons using Bonferroni statistics, analyses
of covariance revealed no significant differ-
ences between the TBI groups on any of the
BNI Fatigue Scale items.
DISCUSSION

Injury severity and fatigue This study examined self-reports of fatigue

Individual fatigue items were examined for
differences between TBI groups (mild vs mod-
erate vs severe) as classified by GCS score
(Table 3). The groups did not differ on age
(F2,45 = 2.65, P = .079), education (F2,45 =
.029, P = .971), or gender (X2 = 0.418, P =
.811). The TBI groups did differ on days from
in patients with TBI during early rehabilita-
tion. Self-reported fatigue was found to be a
problem during the early stages of recovery
from TBI, as measured by the BNI Fatigue
Scale. Patients with TBI reported significantly
greater fatigue than did normal controls, al-
though it was found to be unrelated to injury
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Fatigue After Traumatic Brain Injury 421

Table 3. Performance across traumatic brain injury groups on the Barrow Neurological Institute
Fatigue Scale total score∗

Severe (n = 18) Moderate (n = 18) Mild (n = 11) F P

Item 1 2.17 (1.62) 2.44 (1.85) 2.91 (1.51) 0.55 .653
Item 2 2.44 (2.17) 1.67 (1.41) 2.36 (2.29) 0.79 .506
Item 3 2.50 (1.98) 1.55 (2.12) 1.36 (1.74) 1.43 .249
Item 4 1.88 (2.05) 2.00 (1.85) 2.64 (2.01) 1.30 .288
Item 5 1.83 (1.98) 1.61 (1.94) 1.91 (2.21) 0.43 .730
Item 6 1.22 (1.44) 1.89 (2.05) 1.82 (2.22) 0.34 .796
Item 7 2.89 (2.72) 1.61 (1.68) 2.60 (1.58) 1.43 .247
Item 8 2.56 (2.45) 1.61 (1.58) 2.09 (1.87) 0.83 .482
Item 9 1.61 (2.00) 1.67 (1.78) 2.09 (1.92) 0.44 .728
Item 10 2.61 (2.61) 2.22 (2.02) 2.91 (1.75) 0.93 .433
Total (1–10) 21.72 (16.93) 18.28 (15.97) 22.45 (16.14) 0.55 .650
Overall index 4.44 (3.32) 4.17 (3.22) 5.09 (2.38) 0.46 .036

∗ Values are mean (SD).

severity, number of days postinjury, cogni-
tive impairment score on the BNIS, and gen-
der. No differences were found between TBI
groups on the BNI Fatigue Scale when classi-
fied by injury severity (ie, mild, moderate, and
severe).
Inspection of patient scores revealed great-
est difficulty on items related to staying alert
during rehabilitation activities, completing
tasks without becoming tired, and staying
awake and out of bed during the day. Being
able to last the day without taking a nap (item
10) was found to be the most sensitive item as-
sociated with TBI. The sensitivity of this item
may be due in part to sleep disturbances after
TBI. Sleep disturbances have been frequently
reported in patients after TBI37,38 and partic-
ularly during early rehabilitation because of a
variety of factors, including scheduled thera-
pies, recreational activities, visitors, medical/
nursing procedures, noise/activity level, etc.
Although sleep disturbances may be com-
mon during early recovery, fatigue may be re-
lated but independent of sleep for some pa-
tients. For example, Clinchot and colleagues39
found that 50% of the 45 patients studied by
them reported sleep disturbances, while 63%
reported fatigue. Of the 50% of patients with
sleep disturbances, 80% also reported fatigue,
suggesting that fatigue may be secondary to
sleep disturbances for some patients. Not all
patients with fatigue however reported sleep
disturbances, suggesting that fatigue may be a
separate domain. Thus, fatigue after brain in-
jury may be due in part to both sleep depriva-
tion and brain injury. Item 10 may be a sensi-
tive and useful quantifiable measure of fatigue
after TBI, regardless of sleep patterns.
Injury severity and cognitive impairment
on the BNIS were unrelated to fatigue as mea-
sured by the BNI Fatigue Scale. The lack of re-
lationship may be due to the acute nature of
patients studied. Patients may be too severely
injured, hence requiring inpatient rehabilita-
tion, to show differences in fatigue. It is pos-
sible that specific patterns of self-reported fa-
tigue might emerge as patients progress from
acute to postacute stages of recovery. Fur-
thermore, the severe TBI group in this study
was limited to those who were able to com-
plete a brief assessment. Thus, the most se-
vere patients (ie, those who could not com-
plete a brief assessment) were excluded from
this study.
Other studies have reported no relationship
between fatigue and cognitive impairment.
For example, recent research by Parmenter
and colleagues40 showed no differences
LWW/JHTR lwwj161-04 August 24, 2005 19:28 Char Count= 0
422 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2005
in cognitive performance in patients with
multiple sclerosis when tested during pe-
riods of high versus low fatigue. Similarly,
ratings of fatigue were unrelated to cogni-
tive performance in patients with chronic fa-
tigue syndrome.41 Other studies, however,
have shown an association between fatigue
and cognitive performance in patients with
myasthenia gravis42,43 and chronic fatigue
syndrome.32
The present study found no differences be-
tween fatigue and gender after TBI, which
may be characteristic of the acute and dif-
fuse nature of TBI. However, several studies
have documented differences between fa-
tigue and gender, with females often report-
ing more fatigue than do males. This pattern
has been reported in patients with myasthenia
gravis,11 sleep apnea,44 major depression,45
chronic fatigue syndrome,46 chronic hepati-
tis C,47 heart disease,48–50 cancer,51,52 and
rheumatoid arthritis.53 It is unknown why fe-
males have shown higher rates of fatigue com-
pared to those shown by males across the dif-
ferent conditions noted above.
This study consisted of several limitations
that should be considered when interpreting
the present results. Medication and related is-
sues (eg, dosage, type) were not controlled
for, which may have impacted self-reported fa-
tigue levels. Furthermore, this study did not
include a general medical control group to ex-
amine potential hospital-related variables im-
pacting fatigue (eg, medical conditions, com-
plications). Finally, future studies using the
BNI Fatigue Scale should examine the impact
of other variables on fatigue, including sleep
deprivation and injury location, as these are
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Fatigue After Traumatic Brain Injury 425

Appendix

Please rate the extent to which each of the items below has been a problem for you since
your injury. You should chose only ONE number from 0 to 7 on the scale below when making
your response.

0 1 2 3 4 5 6 7
Rarely a problem Occasional problem, A frequent problem A problem most
but not frequent of the time

1. How difficult is it for me to maintain my energy throughout the day?

2. How difficult is it for me to participate in activities because of fatigue?
3. How difficult is it for me to stay awake during the day?
4. How difficult is it for me to complete a task without becoming tired?
5. How difficult is it for me to stay alert during activities?
6. How difficult is it for me to build my energy level once I wake up in the morning?
7. How difficult is it for me to stay out of my bed during the day?
8. How difficult is it for me to stay alert when I am not involved in something?
9. How difficult is it for me to attend to something without becoming sleepy?
10. How difficult is it for me to last the day without taking a nap?
TOTAL RAW SCORE = T SCORE =

11. Please circle your OVERALL level of fatigue since your injury:

0 1 2 3 4 5 6 7 8 9 10
No problem Severe Problem