Archive for category Fatigue
[Systematic Review] Does Tai Chi relieve fatigue? A systematic review and meta-analysis of randomized controlled trials – Full Text
Fatigue is not only a familiar symptom in our daily lives, but also a common ailment that affects all of our bodily systems. Several randomized controlled trials (RCTs) have proven Tai Chi to be beneficial for patients suffering from fatigue, however conclusive evidence is still lacking. A systematic review and meta-analysis was performed on all RCTs reporting the effects of Tai Chi for fatigue.
In the end of April 2016, seven electronic databases were searched for RCTs involving Tai Chi for fatigue. The search terms mainly included Tai Chi, Tai-ji, Taiji, fatigue, tiredness, weary, weak, and the search was conducted without language restrictions. Methodological quality was assessed using the Cochrane Risk of Bias tool. RevMan 5.3 software was used for meta-analysis. Publication bias was estimated with a funnel plot and Egger’s test. We also assessed the quality of evidence with the GRADE system.
Ten trials (n = 689) were included, and there was a high risk of bias in the blinding. Two trials were determined to have had low methodological quality. Tai Chi was found to have improved fatigue more than conventional therapy (standardized mean difference (SMD): -0.45, 95% confidence interval (CI): -0.70, -0.20) overall, and have positive effects in cancer-related fatigue (SMD:-0.38, 95% CI: -0.65, -0.11). Tai Chi was also more effective on vitality (SMD: 0.63, 95% CI: 0.20, 1.07), sleep (SMD: -0.32, 95% CI: -0.61, -0.04) and depression (SMD: -0.58, 95% CI: -1.04, -0.11). However, no significant difference was found in multiple sclerosis-related fatigue (SMD: -0.77, 95% CI: -1.76, 0.22) and age-related fatigue (SMD: -0.77, 95% CI: -1.78, 0.24). No adverse events were reported among the included studies. The quality of evidence was moderate in the GRADE system.
The results suggest that Tai Chi could be an effective alternative and /or complementary approach to existing therapies for people with fatigue. However, the quality of the evidence was only moderate and may have the potential for bias. There is still absence of adverse events data to evaluate the safety of Tai Chi. Further multi-center RCTs with large sample sizes and high methodological quality, especially carefully blinded design, should be conducted in future research.
Although no one can exactly quantify or document fatigue , fatigue is a common symptom not only deeply related to most acute and chronic diseases, but also to everyday life. It is not only common, but problematic, for people with conditions such as cancer, multiple sclerosis, and rheumatoid arthritis . The National Comprehensive Cancer Network (NCCN) defined cancer related fatigue as ‘an persistent, unusual, subjective feeling of tiredness correlated with cancer or cancer treatment that obstruct to normal functioning’ . Definition of fatigue was also described as “a subjective feeling of lacking mental and/or physical energy, which was perceived by the caregiver or individuals interfering with usual and desired activities” . Because of its subjective nature, fatigue can only be gauged by self-reported or caregiver-reported questionnaires . Fatigue generally lasts longer than somnolence . Tiredness is a state of temporary decreasing in strength and energy, which may be experienced as a partial of fatigue . Some authors simply divided fatigue into acute and chronic fatigue . Acute fatigue occurs in healthy populations, with a rapid onset and short duration. After a period of rest and exercise, it is generally relieved. Chronic fatigue mainly affects clinically disordered individuals and is onset gradually, persists and develops over time. It usually can’t be alleviated by usual recovery techniques . As a symptom, fatigue is a common complaint among most people, and many ailments are accompanied by fatigue. However, it is often ignored, under-diagnosed, and seen as a natural result of physical deterioration .
A previous study had shown that 10.6% of women and 10.2% of men complained of fatigue for ≥ 1 month in the South London general practice attenders . The prevalence rate of chronic fatigue was 10.7% in general Chinese population . Among older adults with myocardial infarction, fatigue is frequently reported to be one of the most serious barriers to physical activity . Fatigue occurs in 50%-83% of patients with multiple sclerosis . Among breast cancer patients 58%-94% undergoing treatment and 56%-95% who are post-chemotherapy experience fatigue . Although the methods, standards, and results of these studies are not always consistent, it is undeniable that fatigue is a common symptom from which many patients suffer.
The mechanisms behind fatigue are unclear , however they may be related to a patient’s physical condition. There is no panacea for fatigue other than treating the symptoms . Evidence has shown that exercise including walking, running, jogging, swimming, resistance (strengthening) training, stretching, aerobic exercise can counter fatigue among sufferers of chronic fatigue syndrome , multiple sclerosis , fibromyalgia  and among cancer survivors [17,18]. So we supposes that Tai Chi, a traditional Chinese martial art, may be an effective treatment for patients suffering from fatigue.
Tai Chi has popular in China for several centuries. Many different types of Tai Chi exist, but most consist of movement, meditation and breathing, while concentrating on the mind and maintaining low intensity [19, 20], and further modulate various aspects of the body including the physical, the psychological, mood and spirit . In the theory of Chinese medicine (CM), Tai Chi can maintain the harmony between qi and the blood, keep yin and yang in balance and also enhance immunity [22, 23]. These properties are both important in relieving fatigue and maintaining energy. Qi, the energy which promotes the body’s movement, can circulate around the entire body freely if yin and yang are kept in balance .
Tai Chi may relieve fatigue via different mechanisms of action. Firstly, through slow movement and weight shifting, Tai Chi may relieve stress, make people more happy  and promote relaxation . Secondly, the proven efficacy of Tai Chi to enhance aerobic capacity and immune function  and to improve pain , depression and psychological well-being  may be beneficial to relieve fatigue.
An advantage of Tai Chi is that it is easy to learn, teach, and popularize, and more reports on evidence of its effects should lead to it becoming even more popular. As a low impact exercise, Tai Chi may be ideal for people with fatigue, lack of exercise or who do not have active lifestyles . Several studies have reported that Tai Chi plays a critical role in fighting fatigue [29–32]. However, there not been explicit studies to reach a conclusion on Tai Chi’s effects on fatigue. Others have shown no difference between Tai Chi groups and control groups [33,34]. In addition, most of the studies focus on only one ailment [32,35,36]. As far as we know, the majority of the literature on Tai Chi intervention for fatigue is empirical, and uses small sample sizes. Few of the existing studies have explored fatigue as the primary outcome. To date, there have been no systematic reviews nor meta-analyses to evaluate the effects of Tai Chi for fatigue, but single RCTs based on a specific population in a certain place. This systematic review evaluates the effects and safety of Tai Chi for fatigue, and provides an overall understanding of the current situation, as well as problems in this field.
[Abstract] Fatigue and its’ relationship to physical activity in adolescents and young adults with traumatic brain injury: a cross-sectional study
[ARTICLE] Complementary and alternative interventions for fatigue management after traumatic brain injury: a systematic review – Full Text
We systematically reviewed randomized controlled trials (RCTs) of complementary and alternative interventions for fatigue after traumatic brain injury (TBI).
We searched multiple online sources including ClinicalTrials.gov, the Cochrane Library database, MEDLINE, CINAHL, Embase, the Web of Science, AMED, PsychINFO, Toxline, ProQuest Digital Dissertations, PEDro, PsycBite, and the World Health Organization (WHO) trial registry, in addition to hand searching of grey literature. The methodological quality of each included study was assessed using the Jadad scale, and the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. A descriptive review was performed.
Ten RCTs of interventions for post-TBI fatigue (PTBIF) that included 10 types of complementary and alternative interventions were assessed in our study. There were four types of physical interventions including aquatic physical activity, fitness-center-based exercise, Tai Chi, and aerobic training. The three types of cognitive and behavioral interventions (CBIs) were cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and computerized working-memory training. The Flexyx Neurotherapy System (FNS) and cranial electrotherapy were the two types of biofeedback therapy, and finally, one type of light therapy was included. Although the four types of intervention included aquatic physical activity, MBSR, computerized working-memory training and blue-light therapy showed unequivocally effective results, the quality of evidence was low/very low according to the GRADE system.
The present systematic review of existing RCTs suggests that aquatic physical activity, MBSR, computerized working-memory training, and blue-light therapy may be beneficial treatments for PTBIF. Due to the many flaws and limitations in these studies, further controlled trials using these interventions for PTBIF are necessary.
Fatigue is a common phenomenon following traumatic brain injury (TBI), with a reported prevalence ranging from 21% to 80% [Ouellet and Morin, 2006; Bushnik et al. 2007; Dijkers and Bushnik, 2008; Cantor et al. 2012; Ponsford et al. 2012], regardless of TBI severity [Ouellet and Morin, 2006; Ponsford et al. 2012]. Post-TBI fatigue (PTBIF) refers to fatigue that occurs secondary to TBI, which is generally viewed as a manifestation of ‘central fatigue’. Associated PTBIF symptoms include mental or physical exhaustion and inability to perform voluntary activities, and can be accompanied by cognitive dysfunction, sensory overstimulation, pain, and sleepiness [Cantor et al. 2013]. PTBIF appears to be persistent, affects most TBI patients daily, negatively impacts quality of life, and decreases life satisfaction [Olver et al. 1996; Cantor et al.2008, 2012; Bay and De-Leon, 2010]. Given the ubiquitous presence of PTBIF, treatment or management of fatigue is important to improve the patient’s quality of life after TBI. However, the effectiveness of currently available treatments is limited.
Although pharmacological interventions such as piracetam, creatine, monoaminergic stabilizer OSU6162, and methylphenidate can alleviate fatigue, adverse effects limit their usage and further research is needed to clarify their effects [Hakkarainen and Hakamies, 1978; Sakellaris et al.2008; Johansson et al. 2012b, 2014]. Therefore, many researchers have attempted to identify complementary and alternative interventions to relieve PTBIF [Bateman et al. 2001; Hodgson et al. 2005; Gemmell and Leathem, 2006; Hassett et al. 2009; Johansson et al. 2012a; Björkdahl et al. 2013; Sinclair et al. 2014]. In this study, we aimed to systematically review randomized controlled trials (RCTs) that evaluated treatment of PTBIF using complementary and alternative medicine (CAM) to provide practical recommendations for this syndrome.
Continue —> Complementary and alternative interventions for fatigue management after traumatic brain injury: a systematic reviewTherapeutic Advances in Neurological Disorders – Gang-Zhu Xu, Yan-Feng Li, Mao-De Wang, Dong-Yuan Cao, 2017
Everyone has said “I’m tired” at one point or another. But those deceptively simple words can have so many meanings. Without knowing the extent of the exhaustion someone with chronic illness is feeling when they say they’re people may think your “tiredness” can be cured by a nap or early night, like theirs, not understanding the support you really need in that moment.
So we asked our Mighty community with chronic illness to reveal what they might actually mean when they say, “I’m tired.” It’s important for the people in your life to understand the challenges you’re dealing with and the empathy and kindness that can help you get through them.
Here’s what our community told us:
1. “Most people who are healthy don’t understand that ‘I’m tired’ is a very shortened phrase for us. When I actually admit to friends and family that I feel bad or am tired that means so much. That means I can no longer mask the symptoms I deal with on a daily basis and I need a little compassion to get through the next few hours or sometimes days.”
2. “When I say ‘I’m tired,’ I mean my body hurts to the point I can’t explain to a ‘normal’ person how bad it hurts. It means mentally, emotionally and physically I do not want to keep going. When I say ‘I’m tired’ I’m giving myself permission for a second to stop fighting my illness and to be vulnerable. When I say ‘I’m tired’ I’m trusting you enough to show you how I really feel before I get ready to get up and keep fighting again.”
3. “I don’t want to stop helping you, but I’m pretty sure I’m going to crumble if I do one more thing. So, just smile and nod as I go sit down and put my brace on.”
4. “Just sitting in a chair is exhausting. I just want to be able to melt into the floor because I don’t have the energy to hold myself up. I’m not sleepy, I’m exhausted!”
5. “When I say ‘I’m tired’ it means I don’t want to talk about it right now. It means I’m tired of the fight my body is constantly in against itself, I’m tired of being positive, I’m tired of pushing through the pain, I’m tired of never-ending procedures and continuous doctor appointments that tend to only discover new problems. I know everything will be OK and my faith will get me through this, but right now ‘I’m tired’ and don’t have the energy or the will to put that much effort in to finding the good in my situation.”
6. “‘I’m tired’ is code for: I’ve hit the exhaustion wall/power-off button; I don’t have the energy to explain the systemic overload my body and mind are experiencing; I need to be alone; I’m sorry I can’t do that for you right now, but I’m incapable of even doing that for myself.”
7. “Most of the time it actually means, ‘I know you mean well, but please give me some space. I’d like to be alone.’ Predominantly this is when I really am absolutely exhausted and have zero energy to consider those around me.”
8. “I’m mentally exhausted from having to keep it together on the surface at work, when what I really want to do is scream out loud with the pain. The majority of my day is spent ticking down the clock so I can go home and curl up and just be in pain out loud.”
9. “Half the time it means I don’t have any reason for feeling the way I do emotionally, mentally, or physically, but I feel I need to give one. The other half of the time it’s that I’m at my breaking point and there’s not enough rest or time away in the world to bring me out of it.”
10. “It’s usually my go-to response for pain, exhaustion, anxiety, everything. It’s easier than trying to explain something ‘normal’ people will never understand. Tiredness is something everyone can comprehend on some level.”
11. “I want, no need, to collapse right here. I’m in so much pain I want to cry, but it isn’t socially acceptable to do that. I can’t think straight enough to know my own name, let alone what I should be doing right now!”
12. “When I say I’m tired I mean I can’t keep smiling and acting as if nothing was happening. My whole day I try to show my best, I pretend to be the same person I was before the pain started. When I’m tired I cannot pretend anymore, I have to be who I am now.”
13. “I’m emotionally drained. But I don’t want to appear weak or go into details. Saying, ‘I’m just tired’ is simpler sometimes.”
14. “I say ‘I’m tired,’ but what I mean is I am fatigued beyond exhaustion, I can barely function, I feel like I haven’t slept in days, my body and mind ache for restful rest!”
15. “When I say I am tired, it means wherever I am could make a good place to lay down and hopefully sleep. The concrete floor over there? Yeah that looks like an amazing place.”
16. “I’m out of spoons. Of juice. Of battery. I physically cannot muster the energy needed to complete the task(s) being asked of me.”
17. “I’ll stare off into the brain fog and when someone notices, auto respond, ‘I’m just tired.’ It’s so much easier not to have to explain something you know they likely don’t understand. My being tired can’t be fixed. Take a nap, cured. If only it were that simple.”
[Helping Others Understand is an open-ended, intermittent series designed to support stroke survivors and family caregivers with helping friends and family better understand the nuances, complications and realistic expectations for common post-stroke conditions. If there is a specific post-stroke condition you’d like to see us address in future issues, we invite you to let us know: email@example.com.]
Stroke is unpredictable both in its arrival and in the consequences it leaves, but one common stroke deficit is fatigue. Some studies indicate that as many as 70 percent of survivors experience fatigue at some time following their stroke. Unlike exertional fatigue that we feel after working in the yard, post-stroke fatigue occurs from doing typical everyday tasks or sometimes from not doing anything. “It is a fatigue associated with the nervous system, which is quite difficult to understand,” said Jade Bender-Burnett, P.T., D.P.T., N.C.S., a neurological physical therapist in Falls Church, Virginia. “It’s very frustrating to the person who’s living with it because, unlike exertional fatigue, post-stroke fatigue doesn’t always resolve after you take a break, or get some rest.”
That has been Roman Nemec’s experience since surviving an ischemic stroke 11 years ago. It doesn’t seem to matter how much sleep he gets, “I walk around tired all the time, even after 9-10 hours of sleep,” he said from his home in Georgia.
This can be difficult for friends and family members to get their heads around because they have not likely experienced this kind of brain fatigue. Bender-Burnett has asked her clients who were marathoners prior to their stroke to compare the fatigue one feels following a marathon to post-stroke fatigue: “They said the fatigue you feel after damage to the brain is unlike any fatigue they’ve ever felt,” she said.
While there is no standardized scale for post-stroke fatigue, Bender-Burnett says that therapists distinguish between two types of fatigue. “Objective fatigue occurs when we can see physical, mental or cognitive changes,” she said. “With subjective fatigue we don’t see any changes, but the survivor will tell you that they’re feeling extremely weary and have no energy.”
For some this goes on for a few months after their stroke, for others, like Roman, it is persistent. Fatigue may be a side effect of medication. “Post-stroke fatigue is very individualized,” Bender-Burnett said. “One of the most frustrating parts of post-stroke fatigue is that it’s so unpredictable. Today, getting up, brushing your teeth and putting on your clothes may be fine, but tomorrow you may not be able to complete the morning routine without a rest break. That unpredictability is very frustrating for people and makes reintegration into daily life difficult.”
Post-stroke fatigue often changes over time. People report more and greater fatigue in the first six months. It’s episodic at first and seems to come out of nowhere: “They may be functioning well, and then all of a sudden they hit a wall,” she said. “It seems that as they get farther along in recovery, those hit-the-wall episodes decrease, and the lingering effect is ‘I just don’t have the energy to do all the things on my plate.’”
Life consequences span the spectrum from nuisance to career-ending. It can impact a survivor’s ability to function in unpredictable ways: As they tire, they may become clumsy or their speech may be affected. Their ability to understand, comprehend or recall may be compromised. Some people get irritable, while others experience increased emotional lability (crying or laughing with no apparent trigger). Bender-Burnett has worked with people who have made remarkable recoveries but were not able to return to work because of post-stroke fatigue.
Just as the consequences are individualized, so are the responses. If your energy is better in the morning, then take advantage of that. For mental fatigue, the most effective response is to sit quietly with low sensory stimulation, not necessarily take a nap. Some survivors may require regular and scheduled rest breaks or even a nap; that does not work for Roman: “I just live through it,” he said. “There are worse things than being tired. I feel good; I can get around; I can talk. Life is good compared to what it could be. Being tired all the time is not a big problem.”
Rhonda Hand, whose significant other, Tarvin, is a survivor, said: “In our household the fatigue issue is factored in before any event or activity and recuperation time after an event or activity. We just block off rest time like another activity; if we don’t, everything shuts down, including speech. Over the years, we have become much more proactive in scheduling appointments with anybody. There is nothing before 8 a.m. That’s when deep sleep is happening.”
Knowing your limits — and quitting before you hit them — is key to living with post-stroke fatigue. Survivors with fatigue have limited energy reserves, and if they get depleted, they take longer to replenish. “You don’t want push to the point just before you’re exhausted, you want to end on a high note, leaving some reserves,” Bender-Burnett said.
“We’re still learning about post-stroke fatigue from the healthcare perspective, and so I think it’s important that we all be willing to recognize it and have open communication about it,” Bender-Burnett said. “I urge family members and friends to come from a position of compassion and understanding rather than expectation that everything should be better, because, much like depression, others can’t always see it but, if you’re feeling it, it can be quite limiting.”
The Stroke Connection team knows that it can sometimes be hard for family and friends to understand how profoundly post-stroke fatigue may be impacting a survivor. We encourage you to share this article with the people in your life — and, for those pressed for time, we’ve created a quick-reference sheet that you can print or share via email or socia
Have you ever felt so tired that you wished you could hibernate? Or so out of energy that you wanted to plug into a wall outlet and recharge? Even if you haven’t, you’ve probably experienced the fatigue of a long day at work, a workout, or a poor night of sleep. This feeling is not only physical; emotional and mental fatigue can lead to irritability, difficulty concentrating, or in extreme cases, to locking ourselves in our room and watching reruns on television while our friends go out and enjoy themselves.
For people with chronic pain conditions, feelings of fatigue may be the norm rather than the exception. In fact, fatigue is one of the most common symptoms reported by patients with chronic pain, and increases as the intensity of the pain increases [1-2]. Chronic fatigue syndrome is highly comorbid with chronic pain conditions [3-4], and patients with fibromyalgia describe “fibro fog,” a set of symptoms characterized by difficulty with concentrating and performing other mental tasks .
Why does fatigue matter? It predicts low quality of life and poor functioning in a number of chronic pain populations [6-7], including cancer  and lower back pain . In our work, we found that fatigue predicts low satisfaction with life in patients with chronic orofacial pain (pain in the head and face), and partially explains why pain is associated with psychological distress [2,10]. Yet, despite the negative impact of fatigue on functioning, it is still largely treated as a single symptom. Our team wanted to take a more nuanced approach and test whether different subtypes of fatigue (general fatigue, mental fatigue, emotional fatigue, physical fatigue, and vigor), as well as total fatigue (as a single symptom), predicted pain-related interference with social and recreational activities. To do this, we examined medical and psychological data from over 2,000 patients seeking treatment for chronic orofacial pains at a university orofacial pain center. A full version of the report can be found here , but below I summarize the main results.
First, total fatigue (as a single symptom) significantly predicted pain interference, above and beyond pain intensity, depression, psychological distress, and poor sleep! This suggests fatigue is more than feeling tired or lacking energy and is likely influenced by a number of factors. In fact, there’s moderately strong evidence for a central governing mechanism that monitors an array of cognitive, emotional, and physiological inputs and produces feelings of fatigue to prevent catastrophic overexertion [12-13]. A pretty clever protective mechanism! How this central governor influences and is modulated by pain remains an exciting area for future research, and one with much clinical relevance.
A second interesting finding was that the fatigue subtypes did not overlap as much as might be expected (13 – 40% of shared variance). Most of the variance in any one type of fatigue was not accounted for by the other types, suggesting we can feel emotionally tired but physically energized, just as we can feel mentally tired but generally energized, for example. Think of a long airplane ride. After a few hours, you might feel eager to move but unable to concentrate. This nuanced condition of low physical fatigue but high mental fatigue is lost when we treat fatigue as a single symptom. Examples of being fatigued in one domain but not another abound, but pain research takes a less nuanced approach and treats all of fatigue as one and the same.
The reason this matters – and this is the third interesting finding- is that each of these fatigue subtypes predicts outcomes differently. In our study, physical fatigue and lack of vigor were the only two significant predictors of pain interference: general, emotional, and mental fatigue were not significantly associated. The more physically fatigued people felt, or the less energy they had, the more pain disrupted their social and recreational activities. This was the first study to look at how specific subtypes of fatigue predicted pain outcomes.
Clinically, these findings suggest that perhaps we should be looking at people’s fatigue profiles to target individualized treatment. If someone reports high mental fatigue, then simplifying medication regiments (and implementing physical aids that promote medication adherence such as alarm clocks and reminders) may be particularly important. If, on the other hand, someone else has particularly high physical fatigue, then a cognitive behavioral intervention aimed at reducing physical fatigue and improving exercise might be most helpful. And if a third person is particularly high on emotional fatigue, they might benefit most from learning emotion regulation strategies and interpersonal communication skills. Although these ideas sound good in theory, more work is needed on targeted interventions to fatigue subtypes to test if they would indeed promote successful outcomes in pain patients.
About Ian Boggero
Ian Boggero is a clinical psychology graduate student at the University of Kentucky, but is originally from Los Angeles and did his undergraduate studies at UCLA. His research interests involve the psychological and social factors that promote adaptive responses to pain. Clinically, he has worked with orofacial pain, chronic lower back pain, phantom limb pain, and fibromyalgia populations, among others. Aside from pain, Ian enjoys hiking, cooking, playing soccer and chess, but most of all, spending time with his wonderful wife (who also shares his clinical and research interest in management). For more information, please see https://psychology.as.uky.edu/users/iabo222
-  Hunt IM, Silman AJ, Benjamin S, McBeth J, Macfarlane GJ. The prevalence and associated features of chronic widespread pain in the community using the ‘Manchester’ definition of chronic widespread pain.Rheumatol 1999;38(3): 275-279. doi: 10.1093/rheumatology/38.3.275
-  Boggero IA, Rojas MV, Carlson CR, de Leeuw R. Satisfaction with life in orofacial pain disorders: Associations and theoretical implications. J Oral Facial Pain Headache 2016; 30(2): 99-106. doi: 10.11607/ofph.1526.
-  Clauw DJ, Chrousos GP. Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulat 1997; 4: 134-153. doi: 10.1159/000097332
-  Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000; 160: 221-227. doi: 10.1001/archinte.160.2.221
-  Williams DA, Clauw DJ, Glass JM. Perceived cognitive dysfunction in fibromyalgia syndrome.J Musculoskelet Pain 2011; 19(2): 66-75. doi: 10.3109/10582452.2011.558989
-  Sturgeon JA, Darnall BD, Kao MCJ, Mackey SC. Physical and psychological correlates of fatigue and physical function: a collaborative health outcomes information registry (CHOIR) study. J Pain 2015:16:291-298. doi: 10.1016/j.jpain.2014.12.004
-  de Leeuw R, Studts JL, Carlson CR. Fatigue and fatigue-related symptoms in an orofacial pain population. Oral Surg Oral Med O 2005; 99:168-174. doi: 10.1016/j.tripleo.2004.03.001
-  Servaes P, Verhagen C, Bleijenberg G. Fatigue in cancer patients during and after treatment: prevalence, correlates and interventions.Europe J Cancer 2002;38(1): 27-43. doi: 10.1016/S0959-8049(01)00332-X
-  Feuerstein M, Carter RL, Papciak AS. A prospective analysis of stress and fatigue in recurrent low back pain. Pain 1987; 3:333-344. doi: 10.1016/0304-3959(87)90162
-  Boggero IA, Kniffin TC, de Leeuw R, Carlson CR. Fatigue mediates the relationship between pain interference and distress in patients with persistent orofacial pain. J Oral Facial Pain Headache 2014; 28:38-45. doi: 10.11607/jop.1204
-  Boggero, I. A., Rojas Ramirez, M. V., & Carlson, C. R. (2017). All fatigue is not created equal: The association of fatigue and its subtypes on pain interference in orofacial pain. The Clinical Journal of Pain, 33(3), 231-237. doi: 10.1097/AJP.0000000000000391
-  Evans DR, Boggero IA, Segerstrom SC. Explaining self-regulatory fatigue and ‘ego depletion’: Lessons from physical fatigue. Personality Soc Psych Rev 2016; 20(4): 291-310. doi: 10.1177/1088868315597841
-  Noakes TD. The central governor model in 2012: Eight new papers deepen our understanding of the regulation of human exercise performance. British J Sports Med 2012; 46(1): 1-3. doi: 10.1136/bjsports-2011-090811
BACKGROUND: Post-stroke fatigue (PSF) is a common and distressing problem after stroke. The best ways to prevent or treat PSF are uncertain. Several different interventions can be argued to have a rational basis. OBJECTIVES: To determine whether, among people with stroke, any intervention reduces the proportion of people with fatigue, fatigue severity, or both; and to determine the effect of intervention on health-related quality of life, disability, dependency and death, and whether such intervention is cost effective.
[Abstract + References] The Nottingham Fatigue after Stroke (NotFAST) study: Factors associated with severity of fatigue in stroke patients without depression
To identify factors associated with post-stroke fatigue in a sample of stroke survivors without depression.
Cross-sectional cohort study.
Recruitment was from four stroke units in the UK.
Participants were assessed within four to six weeks of first stroke; those with high levels of depressive symptoms (score ⩾7 Brief Assessment Schedule Depression Cards) were excluded.
Participants were assessed after stroke on the Fatigue Severity Scale of the Fatigue Assessment Inventory, the Rivermead Mobility Index, Nottingham Extended Activities of Daily Living scale, Beck Anxiety Index, Sleep Hygiene Index, 6m walk test, and measures of cognitive ability.
Of the 371 participants recruited, 103 were excluded and 268 were assessed. Of the latter, the mean age was 67.7 years (SD 13.5) and 168 (63%) were men. The National Institutes of Health Stroke Scale mean score was 4.96 (SD 4.12). Post-stroke fatigue was reported by 115 (43%) of participants, with 71 (62%) reporting this to be a new symptom since their stroke. Multivariate analysis using the Fatigue Severity Scale as the outcome variable found pre-stroke fatigue, having a spouse/partner, lower Rivermead Mobility Index score, and higher scores on both the Brief Assessment Schedule Depression Cards and Beck Anxiety Index were independently associated with post-stroke fatigue, accounting for approximately 47% of the variance in Fatigue Severity Scale scores.
Pre-stroke fatigue, lower mood, and poorer mobility were associated with post-stroke fatigue.
|1.||McKevitt C, Fudge N, Redfern J, . Self-Reported Long-Term Needs After Stroke. Stroke. 2011;42:1398–1403. Google Scholar CrossRef, Medline|
|2.||Andersen G, Christensen D, Kirkevold M, Johnsen SP. Post-stroke fatigue and return to work: a 2-year follow-up. Acta Neurologica Scandinavia. 2012;125:248–253. Google Scholar CrossRef, Medline|
|3.||Morley W, Jackson K, Mead GE. Post-stroke fatigue: an important yet neglected symptom. Age and Ageing 2005;34:313. Google Scholar CrossRef, Medline|
|4.||van de Port IG, Kwakkel G, Schepers VP, Heinemans CT, Lindeman E. Is fatigue an independent factor associated with activities of daily living, instrumental activities of daily living and health related quality of life in chronic stroke? Cerebrovascular Diseases. 2007;23:40–45. Google Scholar CrossRef, Medline|
|5.||Lerdal A, Bakken LN, Kouwenhoven SE, . Poststroke fatigue – a review. Journal of Pain Symptom Management. 2009;38:928–949. Google Scholar CrossRef, Medline|
|6.||Duncan F, Wu S, Mead GE. Frequency and natural history of fatigue after stroke: a systematic review of longitudinal studies. Journal of Psychosomatic Research 2012;73:18–127. Google Scholar CrossRef, Medline|
|7.||De Groot MH, Phillips SJ, Eskes GA. Fatigue associated with stroke and other neurological conditions: implications for stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 2003;84:1714–1720. Google Scholar CrossRef, Medline|
|8.||Choi-Kwon S, Kim JS. Poststroke Fatigue: an emerging, critical issue in stroke medicine. International Journal of Stroke. 2011;6:328–336. Google Scholar Link|
|9.||Synder D, Body R, Parker M, Boddy MS. Sheffield Screening Test for Acquired Language Disorders (Manual). NFER Nelson, Windsor, 1993. Google Scholar|
|10.||Adshead F, Day Cody D, Pitt B. BASDEC: a novel screening instrument for depression in elderly medical inpatients. British Medical Journal 1992;305:397. Google Scholar CrossRef, Medline|
|11.||Schwartz JE, Jandorf L, Krupp LB. The measurement of fatigue: A new instrument. Journal of Psychosomatic Research. 1993;37:753–762. Google Scholar CrossRef, Medline|
|12.||Lerdal A, Bakken LN, Rasmussen EF, . Physical impairment, depressive symptoms and pre-stroke fatigue are related to fatigue in the acute phase after stroke. Disabil Rehabil. 2011;33:334–342. Google Scholar CrossRef, Medline|
|13.||Collen F, Wade DT, Robb GF, Bradshaw CM. The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. International Disability Studies. 1991;13:50–54. Google Scholar CrossRef, Medline|
|14.||Wade DT, Collin C. The Barthel ADL index: a standard measure of physical disability. International Disability Studies. 1988;11:89–92. Google Scholar CrossRef|
|15.||Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clinical Rehabilitation. 1987;1:301–305. Google Scholar Link|
|16.||Lam HS, Lau FW, Chan GK, Sykes K. The validity and reliability of a 6-Metre Timed Walk for the functional assessment of patients with stroke. Physiotherapy Theory and Practice: An International Journal of Physiotherapy 2010;26:251–255. Google Scholar|
|17.||Mastin DF, Bryson J, Corwyn R. Assessing sleep hygiene using the sleep hygiene index. Journal of Behavioral Medicine. 2006;29:223–363. Google Scholar CrossRef, Medline|
|18.||Beck AT, Steer RA. Beck Anxiety Inventory (BAI) Manual. Oxford: Pearson, 1990. Google Scholar|
|19.||Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosomatic Medicine. 1979;41:209–218. Google Scholar CrossRef, Medline|
|20.||Lincoln NB, Radford KA, Nouri FM. Stroke Drivers’ Screening Assessment Revised Manual. UK: University of Nottingham, 2012. Google Scholar|
|21.||Golden CJ. Stroop Color and Word Test: A Manual for Clinical and Experimental Uses Chicago, Illinois: Skoelting, 1978.|
|22.||Coughlan AK, Hollows SE. The Adult Memory and Information Processing Battery (AMIPB). Leeds: Psychology Department, St James University Hospital, 1985. Google Scholar|
|23.||Brott T, Adams HP, Olinger CP, . Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864–870. Google Scholar CrossRef, Medline|
|24.||Briggs DE, Felberg RA, Malkoff MD, Bratina P, Grotta JC. Should Mild or Moderate Stroke Patients Be Admitted to an Intensive Care Unit? Stroke. 2001;32:871–876. Google Scholar CrossRef, Medline|
|25.||Duncan F, Lewis SJ, Greig CA, . Exploratory Longitudinal Cohort Study of Associations of Fatigue After Stroke. Stroke. 2015;46:1052–1058. Google Scholar CrossRef, Medline|
|26.||Radman N, Staub F, Aboulafia-Brakha T, Berney A, Bogousslavsky J, Annoni JM. Poststroke fatigue following minor infarcts: a prospective study. Neurology. 2012;79:1422–1427. Google Scholar CrossRef, Medline|
|27.||Choi-Kwon S, Han SW, Kwon SU, Kim JS. Poststroke Fatigue: Characteristics and Related Factors. Cerebrovascular Disease. 2005;19:84–90. Google Scholar CrossRef, Medline|
|28.||Chen YK, Qu JF, Xiao WM, . Poststroke fatigue: risk factors and its effect on functional status and health-related quality of life. International Journal of Stroke. 2015;10:506–512. Google Scholar Link|
|29.||Glader EL, Stegmayr B, Asplund K. Poststroke Fatigue: A 2-Year Follow-Up Study of Stroke Patients in Sweden. Stroke. 2002;33:1327–1333. Google Scholar CrossRef, Medline|
|30.||Schepers V, Visser-Meily AM, Ketelaar M, Lindeman E. Poststroke Fatigue: Course and Its Relation to Personal and Stroke-Related Factors. Archives of Physical Medicine and Rehabilitation. 2006;87:184–188. Google Scholar CrossRef, Medline|
|31.||Zajicek JP, Ingram WM, Vickery J, Creanor S, Wright DE, Hobart JC. Patient-orientated longitudinal study of multiple sclerosis in south west England (The South West Impact of Multiple Sclerosis Project, SWIMS) 1: protocol and baseline characteristics of cohort. BMC Neurol. 2010;10:88. Google Scholar CrossRef, Medline|
|32.||van Steenbergen HW, Tsonaka R, Huizinga TWJ, Boonen A, van der Helm-van Mil AHM. Fatigue in rheumatoid arthritis; a persistent problem: a large longitudinal study. RMD Open. 2015;1:e000041. Google Scholar CrossRef|
|33.||Wu S, Barugh A, Mcleaod M, Mead G. Psychological associations of poststroke fatigue: a systematic review and meta-analysis. Stroke. 2014;45:893–898. Google Scholar CrossRef, Medline|
|34.||Melloni C, Berger JS, Wang TY, . Representation of women in randomized clinical trials of cardiovascular disease prevention. Circulation: Cardiovascular Quality and outcomes. 2010;3:135–42. Google Scholar CrossRef, Medline|
If your doctor diagnoses you with chronic fatigue syndrome, you’ll probably get two pieces of advice: Go to a psychotherapist and get some exercise. Your doctor might tell you that either of those treatments will give you a 60 percent chance of getting better and a 20 percent chance of recovering outright. After all, that’s what researchers concluded in a 2011 study published in the prestigious medical journal the Lancet, along with later analyses.
Problem is, the study was bad science.
And we’re now finding out exactly how bad.
Under court order, the study’s authors for the first time released their raw data earlier this month. Patients and independent scientists collaborated to analyze it and posted their findings Wednesday on Virology Blog, a site hosted by Columbia microbiology professor Vincent Racaniello.
The analysis shows that if you’re already getting standard medical care, your chances of being helped by the treatments are, at best, 10 percent. And your chances of recovery? Nearly nil.
The new findings are the result of a five-year battle that chronic fatigue syndrome patients — me among them — have waged to review the actual data underlying that $8 million study. It was a battle that, until a year ago, seemed nearly hopeless.
When the Lancet study, nicknamed the PACE trial, first came out, its inflated claims made headlines around the world. “Got ME? Just get out and exercise, say scientists,” wrote the Independent, using the acronym for the international name of the disease, myalgic encephalomyelitis. (Federal agencies now call it ME/CFS.) The findings went on to influence treatment recommendations from the CDC, the Mayo Clinic, Kaiser, the British National Institute for Health and Care Excellence, and more.
But patients like me were immediately skeptical, because the results contradicted the fundamental experience of our illness: The hallmark of ME/CFS is that even mild exertion can increase all the other symptoms of the disease, including not just profound fatigue but also cognitive deficits, difficulties with blood pressure regulation, unrestorative sleep, and neurological and immune dysfunction, among others.
Soon after I was diagnosed in 2006, I figured out that I had to rest the moment I thought, “I’m a little tired.” Otherwise, I would likely be semi-paralyzed and barely able to walk the next day.
The researchers argued that patients like me, who felt sicker after exercise, simply hadn’t built their activity up carefully enough. Start low, build slowly but steadily, and get professional guidance, they advised. But I’d seen how swimming for five minutes could sometimes leave me bedbound, even if I’d swum for 10 minutes without difficulty the day before. Instead of trying to continually increase my exercise, I’d learned to focus on staying within my ever-changing limits — an approach the researchers said was all wrong.
A disease ‘all in my head’?
The psychotherapy claim also made me skeptical. Talking with my therapist had helped keep me from losing my mind, but it hadn’t kept me from losing my health. Furthermore, the researchers weren’t recommending ordinary psychotherapy — they were recommending a form of cognitive behavior therapy that challenges patients’ beliefs that they have a physiological illness limiting their ability to exercise. Instead, the therapist advises, patients need only to become more active and ignore their symptoms to fully recover.
In other words, while the illness might have been triggered by a virus or other physiological stressor, the problem was pretty much all in our heads.
By contrast, in the American research community, no serious researchers were expressing doubts about the organic basis for the illness. Immunologists found clear patterns in the immune system, and exercise physiologists were seeinghighly unusual physiological changes in ME/CFS patients after exercise.
I knew that the right forms of psychotherapy and careful exercise could help patients cope, and I would have been thrilled if they could have cured me. The problem was that, so far as I could tell, it just wasn’t true.
A deeply flawed study
Still, I’m a science writer. I respect and value science. So the PACE trial left me befuddled: It seemed like a great study — big, controlled, peer-reviewed — but I couldn’t reconcile the results with my own experience.
So I and many other patients dug into the science. And almost immediately we saw enormous problems.
Before the trial of 641 patients began, the researchers had announced their standards for success — that is, what “improvement” and “recovery” meant in statistically measurable terms. To be considered recovered, participants had to meet established thresholds on self-assessments of fatigue and physical function, and they had to say they felt much better overall.
But after the unblinded trial started, the researchers weakened all these standards, by a lot. Their revised definition of “recovery” was so loose that patients could get worse over the course of the trial on both fatigue and physical function and still be considered “recovered.” The threshold for physical function was so low that an average 80-year-old would exceed it.
In addition, the only evidence the researchers had that patients felt better was that patients said so. They found no significant improvement on any of their objective measures, such as how many patients got back to work, how many got off welfare, or their level of fitness.
But the subjective reports from patients seemed suspect to me. I imagined myself as a participant: I come in and I’m asked to rate my symptoms. Then, I’m repeatedly told over a year of treatment that I need to pay less attention to my symptoms. Then I’m asked to rate my symptoms again. Mightn’t I say they’re a bit better — even if I still feel terrible — in order to do what I’m told, please my therapist, and convince myself I haven’t wasted a year’s effort?
Many patients worked to bring these flaws to light: They wrote blogs; they contacted the press; they successfully submitted carefully argued letters and commentaries to leading medical journals. They even published papers in peer-reviewed scientific journals.
They also filed Freedom of Information Act requests to gain access to the trial data from Queen Mary University of London, the university where the lead researcher worked. The university denied most of these, some on the grounds that they were “vexatious.”
Critics painted as unhinged
The study’s defenders painted critics as unhinged crusaders who were impeding progress for the estimated 30 million ME/CFS patients around the world. For example, Richard Horton, the editor of the Lancet, described the trial’s critics as “a fairly small, but highly organised, very vocal and very damaging group of individuals who have, I would say, actually hijacked this agenda and distorted the debate so that it actually harms the overwhelming majority of patients.”
Press reports also alleged that ME/CFS researchers had received death threats, and they lumped the PACE critics in with the purported crazies.
While grieving for my fellow patients, I seethed at both the scientists and the journalists who refused to examine the trial closely. I could only hope that, eventually, PACE would drown under a slowly rising tide of good science, even if the scientific community never recognized its enormous problems.
Compassion fatigue is a weariness of body and spirit, caused by the never-ending demands of caregiving. This form of burnout can come on quickly, and before you know it, you feel like you’ve hit the wall. You may even wonder if you can continue to be a caregiver. There are steps you can take to alleviate the symptoms of compassion fatigue. Your goal is to stop compassion fatigue before it stops you.
- Assess the situation. Exhaustion may cloud your judgment and things may not be as bad as they seem. If you are unable to do this on your own, ask for help.
- Consider your overall health. Do you have physical problems of your own, such as arthritis, or a sprained ankle? Illness can slow you down and change our outlook.
- Check your support system. Family members and friends may have moved away, and although you feel alone, you can shore up your support system. This takes time, and is worth your time.
- Be aware of your feelings and name them (impatience, anxiety, worry, etc.) Keep in mind that feelings can change quickly.
- Determine if you’re down or depressed. There’s a huge difference between the two and you need to know the differences. You’ll find helpful articles on the Internet and other resources at the public library.
- Talk to a trusted family member, friend, or colleague. One person can get you through a dark time. Venting your feelings makes you feel better, but don’t share too much at once. You don’t want to wear out the other person.
- Each day, try to have one meaningful conversation. This conversation may be with a health professional, another family caregiver, certified counselor, or religious leader. Contact a friend that you haven’t seen in weeks.
- Build “me time” into your days. A few minutes of doing something you enjoy, such as knitting, can boost your spirits. You may even wish to sign up for an adult education course.
- Stay physically active. A short walk, 15 minutes in your neighborhood, can change your outlook. Your loved one may belong to a health club and the two of you may exercise together.
- Take care of you. Don’t let others tell you how to do this. You’re the person who knows you best, and what makes you feel good.
- Retain selected social contacts. Options include going out for coffee, attending a meeting, or having dinner with friends. A few minutes away from the demands of caregiving can save your day.
- Monitor your self-talk. Once negative self-talk gets started, it’s hard to stop it, and will continue unless you take action. When a negative thought comes to mind, try to balance it with a positive one.
- Affirm your caregiving with words. Writing affirmations about caregiving can change your attitude in surprising ways. Keep your affirmations short. One-sentence affirmations are easier to write and remember.