Adaptation and Feasibility Testing of a Fatigue Intervention in Adults With TBI

Post-traumatic brain injury fatigue (PTBIF) is one of the most common and disabling long-term consequences of traumatic brain injury (TBI). Individuals with TBI frequently identify fatigue as their most challenging symptom, reporting that it substantially affects daily functioning, social participation, emotional well-being, and overall quality of life. PTBIF is often persistent, difficult to manage, and can remain problematic for years following injury. Fatigue after TBI is associated with cognitive difficulties such as reduced attention and slower information processing, as well as emotional concerns including depression, anxiety, and pain. Despite its prevalence and impact, effective fatigue management options for people with TBI remain limited.

Research in other chronic health conditions suggests that cognitive behavioral approaches are among the most effective interventions for managing fatigue because they teach practical self-management skills and help individuals identify and modify behaviors, thoughts, and routines that may contribute to fatigue. However, most existing fatigue management programs have been developed and tested in populations such as individuals with multiple sclerosis and cancer, with relatively few interventions specifically designed for people with TBI. In addition, many individuals with TBI face significant barriers to accessing behavioral health services, including transportation challenges, financial limitations, limited availability of specialized providers, and geographic distance from rehabilitation programs.

To address these challenges, this study focuses on FACETS-TBI (Fatigue: Applying Cognitive Behavioral and Energy Effectiveness Techniques to Lifestyle for Traumatic Brain Injury), an adaptation of the original FACETS program developed for individuals with multiple sclerosis. FACETS is an evidence-based fatigue management intervention that combines cognitive behavioral strategies with practical energy conservation and self-management techniques. The program was adapted specifically for adults with TBI through a systematic and stakeholder-informed adaptation process guided by the ADAPT framework. The adaptation incorporated input from researchers, clinicians, individuals living with TBI, and other key stakeholders to ensure that the content is relevant, acceptable, and responsive to the unique experiences of post-traumatic brain injury fatigue.

The purpose of this study is to evaluate the feasibility of delivering FACETS-TBI remotely to adults with TBI who experience significant fatigue and to generate preliminary data that will inform the development of a future large-scale randomized controlled trial. The study will assess participant engagement, retention, session attendance, understanding of intervention content, satisfaction with participation, and overall acceptability of the intervention. The study will also provide preliminary information regarding potential changes in fatigue-related outcomes, fatigue self-management confidence, and participation in everyday activities and community life.

FACETS-TBI is delivered remotely in a group format and is designed to support the development of practical fatigue management skills that participants can apply in their daily lives. The intervention addresses topics such as understanding fatigue, identifying contributing factors, balancing activity and rest, improving sleep and recovery practices, managing stress, recognizing unhelpful thinking patterns, developing effective coping strategies, and creating sustainable plans for long-term fatigue management. The program emphasizes participant involvement through facilitated discussions, structured activities, guided reflection, and between-session practice assignments. Participants are encouraged to apply newly learned strategies in real-world settings and reflect on their experiences throughout the program.

To support interpretation of the feasibility and preliminary outcome findings, the study includes an attention control program designed to account for the non-specific effects of group participation, facilitator attention, intervention dose, and social interaction. The attention control program is adapted from the Brain Health Group, an educational support intervention previously used with adults with TBI. Participants in the attention control program receive the same frequency and duration of group sessions as participants in FACETS-TBI and engage in structured discussions about general health and wellness topics relevant to life after TBI, such as memory, attention, emotional well-being, and healthy lifestyle behaviors. The attention control curriculum intentionally excludes fatigue management content and does not include the key cognitive behavioral and self-management strategies incorporated into FACETS-TBI. By providing a comparable group experience without the intervention's hypothesized active ingredients, the attention control program will help researchers distinguish the specific effects of FACETS-TBI from improvements that may result from receiving attention, support, education, or participation in a group-based program.

The study also seeks to better understand participants' experiences with the intervention. Participants who complete FACETS-TBI will provide feedback regarding the program's content, delivery, usefulness, and perceived impact. These perspectives will be used to identify strengths of the intervention, determine areas for improvement, and guide future refinements to the program before testing in a larger trial.

Data collected during the study will include participant-reported measures related to fatigue, fatigue impact on daily life, fatigue severity, confidence in managing fatigue, and participation in social and community activities. Additional information regarding participant engagement, intervention delivery, treatment fidelity, and satisfaction will be collected to evaluate the practicality of implementing FACETS-TBI in a remote rehabilitation setting. Qualitative interviews will provide further insight into participants' perceptions of the intervention and recommendations for future development.

By evaluating the feasibility, acceptability, and preliminary effects of FACETS-TBI, this study aims to advance the development of accessible, evidence-based interventions for individuals living with post-traumatic brain injury fatigue. Findings from this work will inform the design of a larger clinical trial and may ultimately contribute to expanding rehabilitation options for both civilian and military populations affected by TBI.