Navigating Cognitive Fatigue in Concussion Recovery: Strategies for Clinicians

Cognitive fatigue is one of the most disabling yet least visible symptoms experienced by patients during concussion recovery. It can disrupt attention, impair memory, reduce tolerance for sensory input, and significantly interfere with the ability to function in school, work, and daily life. For rehabilitation professionals, recognizing and addressing cognitive fatigue is central to restoring clients’ meaningful roles, routines, and overall identity.

In this article, we explore an evidence-informed approach to evaluating and treating cognitive fatigue in patients recovering from concussion. Drawing on clinical reasoning, practical tools, and a real-world case study, we highlight strategies to guide assessment, education, and functional reintegration.

Understanding cognitive fatigue in clinical practice

Post-concussion cognitive fatigue often presents as difficulty sustaining attention, decreased mental endurance, forgetfulness, and reduced tolerance for sensory or cognitive input. These symptoms can significantly disrupt a student’s return to the classroom, interfere with work performance, and limit engagement in daily routines.

The Concussion Clinical Practice Screen (CP Screen) is a structured symptom profiling tool that helps clinicians categorize concussion symptoms into key domains (such as cognitive/fatigue, vestibular, and anxiety/mood) while also identifying modifiers like sleep disruption or cervical involvement.^1,2

Let me share a case from my own experience to illustrate how this symptom profile can present in practice and how the CP Screen can support clinical decision-making.

Case example: High school student with cognitive fatigue

I worked with a 16-year-old high school student about a month post-injury at the time of our initial evaluation. She hadn’t yet returned to school full time and was experiencing persistent cognitive fatigue. She reported difficulty concentrating, frequent forgetfulness (often misplacing her phone or medication), and increasing headaches during cognitively demanding classes. Her energy consistently dropped off by early afternoon, and she was taking long naps that further disrupted her sleep cycle. Socially, she had withdrawn and was struggling to advocate for herself, feeling unsupported by teachers and misunderstood by peers.

Using the CP Screen, I identified her primary symptom profile as cognitive/fatigue, with insomnia as a significant modifier. This tool helped quantify her symptom burden and provided a structured foundation for guiding treatment planning and goal setting.

Evaluation tools to guide your practice

As an occupational therapist, I often lead the evaluation of how concussion symptoms are impacting a client’s ability to participate in everyday life. In the case example, this process began by helping her identify her priorities and performance concerns in her own words.

I used the Canadian Occupational Performance Measure (COPM) to guide this conversation, allowing her to articulate goals such as managing her medication schedule, improving her sleep, and sustaining participation in school. While we didn’t complete the numerical goal ratings during our first session due to time constraints, the COPM was invaluable in grounding our treatment plan in her lived experience.

To supplement this, I incorporated several targeted assessments to better understand the specific contributors to her cognitive fatigue:

• Insomnia Severity Index (ISI): This self-reported tool assesses the nature, severity, and impact of insomnia symptoms. It helps quantify how sleep disruption may be contributing to overall fatigue and recovery challenges.^3,4 In this case, the student scored 16 out of 28, indicating significant sleep-related impairment. This guided our focus on sleep hygiene and daytime activity regulation.

• Convergence Insufficiency Symptom Survey (CISS): This questionnaire screens for visual dysfunctions that can impair near-point tasks such as reading and screen use.⁵ Her elevated score indicated that visual strain was likely adding to her cognitive load, particularly in academic settings. These results informed accommodations like large-print materials and limited screen exposure.

• Clinical observation and symptom history: During our sessions, I paid close attention to behavioral cues and task responses: her pacing limitations, increased symptoms during screen use, and memory lapses in basic routines (e.g., forgetting her phone or homework). These insights provided a qualitative layer to the assessment process and helped me tailor both patient education and intervention strategies.

While neuropsychological testing can offer a more in-depth cognitive profile, I use it judiciously in cases like this. For patients already managing emotional distress and academic pressure, formal testing can feel invalidating or misaligned with their lived experience, particularly if they perceive the results as not reflecting their day-to-day struggles.⁶ Instead, I prioritize functional, context-sensitive tools that validate symptoms and directly inform intervention planning.

Supporting evaluation with a structured framework

Early concussion care often requires quick decisions: which symptom domains to prioritize, when to pause testing, and how to adapt your approach based on irritability. Having a structured framework to guide that process can make a real difference, especially when time is limited.

The Concussion Management Decision Tree PDF is one resource I’ve found helpful. It walks through key checkpoints for evaluating symptom profiles, recognizing red flags, and adjusting your exam sequence based on modifier severity and symptom irritability. It also complements tools like the CP Screen by offering a bigger-picture view of early clinical reasoning and triage. You can download a free copy below to keep on hand during your initial evaluations.

Intervention: Targeting what matters most in cognitive fatigue

Now that we’ve identified which tools can guide your assessment, the next step is delivering intervention that is both effective and sustainable. Cognitive fatigue requires a practical, patient-centered approach grounded in daily life and function. 

In alignment with current clinical guidelines for concussion recovery, this case followed a multimodal treatment model.

1. Symptom management

The first priority was education, helping the patient understand that not all symptoms indicate harm. We reframed mild, short-term symptom exacerbation (up to two points above baseline, resolving within an hour) as a normal and even helpful part of building cognitive tolerance. This shift in mindset supported her ability to manage symptoms rather than retreat from activity at the first sign of discomfort.

We also addressed the emotional and social aspects of concussion, where adolescents in particular may feel dismissed or misunderstood. Building her confidence in the recovery process was essential for engagement and progress.

To reduce overwhelm and improve self-regulation, we implemented the following strategies:

• Task prioritization using a modified Eisenhower Matrix, helping her sort daily tasks by urgency and importance.

• Gentle exercise while allowing for a mild and brief increase in symptoms.

• Calming techniques such as deep pressure input, paced breathing, and mindfulness-based activities.

• Brain health habits like staying hydrated, eating meals on a consistent schedule, and engaging in brief, restorative social interactions throughout the day.

These small but consistent interventions helped stabilize her energy, reduce cognitive load, and improve her overall functional capacity.

2. Impairment-based training

Next, we addressed the specific impairments contributing to her cognitive fatigue. Sleep hygiene became a central focus after her ISI results confirmed poor sleep satisfaction. Interventions included behavioral and environmental changes—removing schoolwork from her bed, replacing naps with movement-based breaks, and reinforcing a consistent wake-sleep routine.

We also supported visual function, based on findings from the Convergence Insufficiency Symptom Survey. Accommodations like large-print reading materials and reduced screen use helped lower her visual strain and allowed for more sustained academic participation.

All of these interventions followed the CO-OP (Cognitive Orientation to daily Occupational Performance) “goal-plan-do-check,” which gave her ownership of the strategies, encouraged self-monitoring, and built lasting confidence in her ability to problem-solve in real time.⁷

3. Graded return to activity

Rather than remove her from academic and social demands, we focused on restructuring her daily routine to promote sustainable participation. Together, we reviewed her school schedule, identified cognitive hot spots (like science and math classes), and planned brief breaks ahead of symptom escalation.

One of her biggest challenges, choir class, was modified to accommodate her light and sound sensitivities. We introduced short exits from the room and adjusted her seating placement to reduce sensory load while still keeping her engaged. These real-world modifications helped her maintain a sense of normalcy and avoid isolation, all while respecting her symptom limits.

Meaningful outcomes in cognitive fatigue management

By the third visit (approximately three months post-evaluation), the patient had made measurable and meaningful progress in her recovery from cognitive fatigue:

• CP Screen score: Decreased from 45 to 16, reflecting a significant drop in symptom burden.

• COPM goal ratings: Averaged 9.7/10, with most functional goals met or exceeded.

• Insomnia Severity Index score: Improved from 16 to 3, and sleep efficiency rose to 90 percent.

• Functional reintegration: She resumed full academic and extracurricular participation, including choir and school leadership activities.

• Sustained daily performance: Her energy levels were consistent throughout the day, and she no longer required midday naps or in-school accommodations.

This case illustrates how rehabilitative therapy extends beyond symptom tracking. It helps restore engagement, identity, and autonomy. Her return to valued roles like managing homework, advocating in school, and maintaining friendships marked not just recovery, but reconnection.

The outcome also highlights the value of interdisciplinary care. Ongoing collaboration with speech therapy enabled a cohesive, well-divided care plan, reducing redundancy and increasing efficiency.

Across just three sessions over two months, she regained functional independence and left with tools to self-manage future symptom flares. Her recovery affirms the critical role of rehabilitation in concussion recovery, especially in cases marked by persistent cognitive fatigue.

Supporting patients through cognitive fatigue recovery

Cognitive fatigue is an invisible but impactful consequence of concussion. Our role as rehabilitation professionals is to help clients navigate these challenges with clarity, compassion, and evidence-based strategies. By focusing on what clients can do, applying mild challenges, and supporting them in self-management, we reinforce both function and confidence.

To explore these strategies further and see how they apply across different cases, check out my Medbridge course, Concussion Clinical Application: Cognitive and Fatigue. The course offers a structured approach to evaluating and treating cognitive fatigue, with practical strategies for energy management, cognitive pacing, and return-to-school or -work planning.

If you're looking to deepen your expertise across other symptom domains, the full Concussion Clinical Application series offers additional focused content:

• Current Concepts: Evidence-based diagnostic criteria, return-to-activity protocols, and treatment strategies for sports, military, and civilian populations.

• Therapy Framework: A structured guide to symptom management, scope of practice, and patient-centered interventions.

• Anxiety and Mood: Practical tools for evaluating and treating emotional symptoms post-concussion.

• Sleep: CBT-I strategies for improving post-concussion sleep quality and daily energy.

• Ocular: Evaluation and treatment of visual dysfunction, including convergence, accommodation, and referrals.

• Migraine, Vestibular, and Cervical: Management strategies for complex symptom presentations involving headaches, dizziness, and neck pain.

References

1. Roelke, M. B., Jewell, V. D., & Radomski, M. V. (2022). Return-to-Activity: Exploration of Occupational Therapy in Outpatient Adult Concussion Rehabilitation. OTJR : occupation, participation and health, 42(4), 333–343. https://pubmed.ncbi.nlm.nih.gov/35848427/

2. Kontos, A. P., Elbin, R. J., Trbovich, A., Womble, M., Said, A., Sumrok, V. F., French, J., Kegel, N., Puskar, A., Sherry, N., Holland, C., & Collins, M. (2020). Concussion Clinical Profiles Screening (CP Screen) Tool: Preliminary Evidence to Inform a Multidisciplinary Approach. Neurosurgery, 87(2), 348–356. https://pubmed.ncbi.nlm.nih.gov/31950187/

3. Shahid, A., Wilkinson, K., Marcu, S., & Shapiro, C. M. (2011). Insomnia Severity Index (ISI). In A. Shahid, K. Wilkinson, S. Marcu, & C. Shapiro. (Eds.), STOP, THAT and one hundred other sleep scales. Springer. https://link.springer.com/chapter/10.1007/978-1-4419-9893-4_43

4. Bastien, C. H., Vallières, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep medicine, 2(4), 297–307. https://pubmed.ncbi.nlm.nih.gov/11438246/

5. Scheiman, M., Gallaway, M., Frantz, K. A., Peters, R. J., Hatch, S., Cuff, M., & Mitchell, G. L. (2003). Nearpoint of convergence: test procedure, target selection, and normative data. Optometry and vision science : official publication of the American Academy of Optometry, 80(3), 214–225. https://pubmed.ncbi.nlm.nih.gov/12637833/

6. Bigler, E. D., Allder, S., & Victoroff, J. (2024). What traditional neuropsychological assessment got wrong about mild traumatic brain injury. II: limitations in test development, research design, statistical and psychometric issues. Brain injury, 38(13), 1053–1074. https://pubmed.ncbi.nlm.nih.gov/39066740/

7. McEwen, S. E., Mandich, A., & Politajko, H. J. (2018). CO-OP Approach ™: A cognitive-based intervention for children and adults. In N. Katz & J Toglia (Eds.), Cognition, occupation, and participation across the lifespan, 315-334.