The Effects of Fatigue Following Catastrophic or Brain Injury and the Impact on Returning to Work: Part One

Fatigue is a complex barrier that individuals face when returning to employment following catastrophic injury. While it is frequently discussed in rehabilitation settings, its impact can often be underestimated by employers, families and even by the individuals experiencing it. Understanding how post-injury fatigue presents, how it differs from everyday tiredness and how it can be managed in vocational contexts is essential to supporting sustainable and successful return-to-work outcomes.

In the first of two parts, Kemi Sanusi, Vocational Case Manager at Bush & Co, shared the effects of fatigue on employment following catastrophic injury and brain injury.

How Post-Injury Fatigue Differs from Everyday Tiredness

Whilst everyday tiredness tends to follow predictable patterns and is usually relieved by rest, fatigue following injury is often unpredictable and not necessarily resolved through short periods of recuperation time.

In individuals with brain injury, levels of fatigue may be influenced by cognitive effort, motivation, emotional state and pain levels, as well as the severity of the brain injury itself. The body is often working harder than usual to support the recovery process, which contributes to persistent exhaustion. “Even brief cognitive activity can lead to overload, particularly where there are associated difficulties with attention, memory or problem-solving” explains Kemi.

Individuals with catastrophic injuries, such as complex orthopaedic injuries or polytrauma, will also experience fatigue, especially where multiple systems of the body are affected. In these cases, fatigue may be influenced by pain, reduced mobility, ongoing treatment or therapy and the overall demands of rehabilitation.

The Prevalence of Fatigue After Catastrophic Injury

In vocational rehabilitation practice, fatigue is one of the most frequently reported challenges affecting individuals throughout the recovery process and beyond following catastrophic injury. “It can arise regardless of the specific type of injury” says Kemi, “and often only becomes apparent when a person attempts to return to structured activity such as employment”. Individuals may have become accustomed to focusing on their rehabilitation, and the transition back into work can be both physically and cognitively demanding.

Importantly, both the presence and severity of fatigue are often only fully understood once someone begins attempting to return to employment. Fatigue may present in two main forms: physical and cognitive. Both can significantly affect a person’s ability to resume their previous role or adjust to alternative employment. In many cases, vocational rehabilitation planning begins early, including the consideration of alternative roles where returning to a pre-injury position may not be possible.

The Importance of Timing in Vocational Rehabilitation

Timing plays a critical role in successful vocational rehabilitation. Early involvement can help identify alternative career pathways where returning to a pre-injury role is unlikely to be achievable. However, involvement that is too early in the recovery process may limit the effectiveness of the intervention.

In some cases, rehabilitation planning focuses on using recovery periods productively to support retraining so that individuals are prepared for alternative employment once they reach ‘maximum recovery’. Maintaining engagement in meaningful activity during recovery is particularly important for individuals with catastrophic injuries. Extended periods away from work or structured activity can increase the impact of physical fatigue, whereas gradual early reintroduction to purposeful activity can support longer-term adjustment.

Supporting individuals through this process requires careful planning, clear communication, and collaboration between the individual, employer and multidisciplinary rehabilitation team.

Assessing Fatigue as a Barrier to Employment

Assessing whether fatigue is the primary barrier to returning to work depends on both the individual and the nature of their injury. In individuals with brain injury, fatigue is very frequently a central factor affecting work capacity, regardless of the stage of recovery. Although fatigue may improve over time with structured routines and consistent support strategies, it often remains a long-term consideration. Changes in routine or additional life demands can quickly increase fatigue levels again.

In individuals with catastrophic injuries, fatigue may be more closely linked with pain and physical recovery. In these cases, multidisciplinary input and functional capacity assessments can help identify the most significant barriers.

For some individuals, returning to paid employment may not be possible, both in the short-term or, in the most serious cases, ever. In these situations, meaningful voluntary work can provide structure and purpose while allowing fatigue levels to be monitored and managed more flexibly. Kemi understands the importance of considering voluntary roles all too well, as they “may also help individuals develop insight into their capabilities following injury, supporting the comprehension and acceptance that a career redirection or long-term voluntary work might be necessary”.

However, adjusting expectations around employment can be emotionally challenging, particularly for individuals who previously held primary income-earning roles within their families. Support from the wider multidisciplinary team can be essential in helping individuals emotionally and mentally adapt to these changes.

The Initial Impact and the Hidden Signs

Fatigue can affect both the initial return to employment and the ability to sustain a role over time. Cognitively, individuals may experience difficulties with attention, memory, awareness and problem-solving. Motivation may also be reduced, particularly where fatigue is persistent. Physically, individuals may find standing for long periods of time unsustainable, or they may find that they become sore, or existing pain worsens, throughout the day.

However, fatigue is not always immediately visible in the workplace. In individuals with brain injury, fatigue may present as increased reliance on written instructions, difficulty remembering tasks or the need for repeated explanations. Employers may also observe reduced flexibility when tasks fall outside of routine expectations. For those with catastrophic injuries, fatigue may be reflected in the need for more frequent breaks or reduced tolerance for sustained activity. Monitoring these patterns over time helps inform appropriate adjustments.

Fatigue is often not obvious, easily initially confused with extreme tiredness, and can worsen quietly over time; therefore, ongoing communication between the individual, employer and vocational case manager is necessary to build a clear picture of how someone is – or isn’t - coping.

Understanding how fatigue can affect an individual when considering a return to work is only the first step in effective vocational case management. In the second part of this exploration, Kemi outlines how this understanding can be translated into practice, highlighting common workplace adjustments, the impact that fear of failure can have on rehabilitation outcomes, and the importance of a robust support network that prioritises clear communication throughout the return-to-work journey.