What is fatigue? Pathological and nonpathological fatigue

Sociodemographic and psychosocial correlates of fatigue and chronic fatigue: A cross-sectional study from a South East London community survey

OBJECTIVE

A better understanding of fatigue and chronic fatigue symptoms in the community may lead to better targeted preventative interventions. This study aims to estimate the prevalence of fatigue and chronic fatigue and explore relationships with sociodemographic and psychosocial factors in a representative community population survey in London, UK.

METHODS

The first wave of the South East London Community Health study (2008 to 2010) surveyed face-to-face 1698 individuals aged 16 years and over from 1075 randomly selected households in the boroughs of Southwark and Lambeth. Self-reported fatigue and/or chronic fatigue was determined using the Chalder fatigue scale. Ordinal and binary logistic regression analyses were undertaken to assess the association of sociodemographic and psychosocial factors with higher levels of fatigue symptoms.

RESULTS

The point prevalence of fatigue was 23.5 % (95 % CI 21.5-25.7). After adjusting for age and sex, higher levels of fatigue were substantially associated with impacts on work and other activities due to physical (OR: 4.87 (95 % CI 3.44-6.88)) or emotional symptoms (OR: 4.52 (95 % CI, 3.16-6.48)). Higher levels of fatigue were also associated with seeking emotional help from professionals (OR: 2.73 (95 % CI, 1.91-3.92) or family or friends (OR: 2.37 (95 % CI,1.68-3.34) and reporting less perceived instrumental (OR: 2.01 (0.75-5.37)) and emotional support (OR: 3.76 (1.46-9.68)).

CONCLUSION

Our findings highlight the high prevalence of fatigue and chronic fatigue in a representative urban community sample. Higher levels of fatigue were significantly associated with greater disability and formal and informal help-seeking. The quality of perceived social support is an important protective factor.

Potential mechanisms underlying pathological fatigue-induced cardiac dysfunction

Pathological fatigue has emerged as a significant contributor to cardiac dysfunction. Unfortunately, suitable animal models to study cardiac dysfunction caused by fatigue are lacking, and the underlying mechanisms remain unclear. This study aimed to establish a pathological fatigue model induced by 5-week combined stress and explore the mechanisms of cardiac dysfunction triggered by fatigue. Five-week combined stress induced fatigue-like phenotypes, which included reluctance to move, reduced exercise endurance, and muscle strength. Moreover, the 5-week combined stress resulted in a significant reduction in both EF and FS, along with a marked upregulation of several myocardial injury biomarkers, thereby confirming the presence of abnormal cardiac function. Targeted metabolomics analysis indicated that 80% of the differential metabolites were downregulated, suggesting a hypometabolic profile in the heart. Interestingly, among the downregulated fatty acid metabolites, we identified two bacterial metabolites, namely acetate and butyrate. More importantly, we observed an inverse correlation between the levels of acetate and butyrate and the concentrations of certain cardiac injury markers. We then observed disturbances in gut bacteria, and group differences at the genus level revealed that all six differential bacteria, which ranked in the top 10 in terms of relative abundance, may directly or indirectly influence the production of acetic acid and butyric acid. Among them, the abundance of Akkermansia bacteria was positively correlated with reduced acetic acid levels. In summary, the present study provides a novel animal model of pathological fatigue-induced cardiac dysfunction and suggests that hypometabolic features and gut microbiota dysbiosis may be an important mechanism.

Effects of Acupuncture and Moxibustion on Heart Rate Variability in Chronic Fatigue Syndrome Patients: Regulating the Autonomic Nervous System in a Clinical Randomized Controlled Trial

BACKGROUND

This study investigates the effects of various acupuncture techniques, specific acupuncture points, and their combinations on symptom improvement in chronic fatigue syndrome (CFS) patients as well as their influence on heart rate variability (HRV) indicators.

METHODS

We recruited 35 healthy subjects as a healthy control group (Group A) and 175 patients with CFS, who were randomly divided into a fake acupuncture group (Group B), an acupuncture group targeting the Zusanli (ST36) point (Group C), an acupuncture group targeting the Guanyuan (CV4) point (Group D), a dual-acupoint acupuncture group (Group E), and a moxibustion group (Group F), with 35 patients in each group. Group B received fake acupuncture at both the bilateral Zusanli and Guanyuan points simultaneously. Group C received acupuncture at the bilateral Zusanli points along with fake acupuncture at the Guanyuan point. Group D received acupuncture at the Guanyuan point along with fake acupuncture at the bilateral Zusanli points. Group E received acupuncture at both the bilateral Zusanli and Guanyuan points simultaneously, and Group F received moxibustion at both the bilateral Zusanli and Guanyuan points simultaneously. Each group received a total of 10 treatments, administered every other day. Before treatment, the Qi-deficiency Syndrome Score, CFS Score, and SF36 Score were assessed for all subjects. HRV was measured before treatment, after the first treatment, after the fourth treatment, and at the end of treatment.

RESULTS

The results showed that both acupuncture and moxibustion can effectively alleviate fatigue symptoms in patients suffering from CFS, with combined acupuncture and moxibustion demonstrating greater effectiveness.

CONCLUSION

Acupuncture excelled in regulating the immediate effects of HRV, while moxibustion excelled in regulating long-term effects. Acupuncture targeting both the Zusanli and Guanyuan points proved more effective than acupuncture targeting a single point, with this difference reflected in the distinct regulatory effects on the sympathetic and parasympathetic nervous systems. The intervention mechanism of Zusanli may involve the parasympathetic nervous system, whereas Guanyuan may operate through the sympathetic nervous system.

TRIAL REGISTRATION

Approved by the Medical Ethics Committee of Hubei Provincial Hospital of Traditional Chinese Medicine (Approval number: HBZY2016-C24-01), and registered with the North American Clinical Trials Data Center (Clinical Trials.gov) (05/10/2016) (registration number: NCT02924831).

Integrated meta-analysis, network pharmacology, computational biology, and in vitro experimental verification to reveal the anti-fatigue mechanism of Lycium barbarum

This study aims to elucidate Lycium barbarum (LB)'s anti-fatigue mechanisms. Meta-analysis confirmed LB's anti-fatigue capacity, while network pharmacology, molecular docking, and molecular dynamics simulations identified key targets (SRC, HSP90AA1, EGFR, PRKACA, MAPK1). Furthermore, validation experiments in C2C12 cells demonstrated that LB mitigates H2O2-induced reactive oxygen species (ROS) accumulation and restores cell viability. qPCR analysis further revealed that LB downregulates the mRNA expression of CAT, IL-6 and TNF-α, while modulating the expression of these target genes. In summary, our data confirm the anti-fatigue effects of LB and elucidate that LB exerts multi-component, multi-target, and multi-pathway mechanisms in combating fatigue.

Long COVID for the Rheumatologist: Current Understanding and Approach to Management

There are estimated tens of millions of individuals throughout the world suffering from a variety of postinfectious sequela following infection with severe acute respiratory syndrome coronavirus 2 also commonly referred to as long coronavirus disease (COVID). Long COVID is providing an opportunity for the field of rheumatology to explore the relationship between similar syndromes including fibromyalgia seen in patients with underlying inflammatory and noninflammatory rheumatic diseases, as well as other postacute infectious sequela and bring our field's traditional skill sets to bear on improving our understanding of these disorders and the care of such patients.

Work intensification and occupational fatigue on nurses: a cross-sectional and correlational study

PURPOSE

This research aimed to determine the relationship between work intensification and occupational fatigue in nurses using a cross-sectional and correlational design.

METHODS

The sample included 597 nurses from public, private, and university hospitals in Istanbul, selected through convenience sampling. Data were collected using the "Nurse Information Form," the "Intensification of Job Demands Scale," and the "Occupational Fatigue Exhaustion/Recovery Scale." Analysis involved descriptive tests, correlation, and hierarchical linear regression.

RESULTS

Results showed higher-than-average levels of both chronic and acute fatigue, with acute fatigue being more prevalent. The mean intershift recovery score was below average. A significant positive correlation was found between chronic and acute fatigue, while a significant negative correlation was observed between both fatigue types and intershift recovery. Work intensification levels were above average and correlated positively with chronic and acute fatigue, except for intensified career-related planning. Conversely, a negative correlation was found with recovery, except for intensified skill-related learning demands. Regression analysis revealed that demographic and occupational characteristics of nurses other than age, work intensification, acute fatigue, and intershift recovery explained 59.8% of chronic fatigue. For acute fatigue, these factors explained 11.2%, and for intershift recovery, 12.8%.

CONCLUSIONS

This study highlights the correlation between work intensification and occupational fatigue in nurses, suggesting that increased work intensity leads to higher occupational fatigue. The findings contribute to the literature and assist nurse managers and decision-makers in preventing occupational fatigue by re-evaluating and regulating current working conditions where job demands are intensified.

Antioxidant and Anti-Fatigue Effects of a Standardized Botanical Extract Fraction (HemoHIM) in Forced-Exercised Aged Mice

HemoHIM is a standardized medicinal herbal preparation consisting of extracts of Angelica gigas Nakai, Cnidium officinale Makino, and Paeonia lactiflora Pallas that possesses immune regulatory activities. This study aimed to research the potential antioxidant effects of HemoHIM and its capacity for reducing fatigue in aged mice subjected to forced exercise. After administering HemoHIM 125 (500 mg/kg orally) for 4 weeks in 8-month-old female C57BL/6 mice (4 groups of 10 mice), various parameters were evaluated. The analyses revealed that HemoHIM enhanced swimming time and grip strength. In addition, it significantly reduced serum lactate levels and increased liver glutathione peroxidase (GPx) levels after exercise challenge. The expression levels of antioxidant enzymes and factors, including nuclear factor erythroid 2-related factor-2 (Nrf-2), heme oxygenase 1, superoxide dismutase, GPx, and glutathione reductase, were significantly higher in liver and muscle tissues of mice treated with HemoHIM. These results indicate that HemoHIM might function as an anti-fatigue and antioxidant agent by modulating the Nrf-2 signaling pathway.

The Utility of Methylphenidate for Fatigue in Long-Term Neurological Conditions: A Meta-analytical Review

OBJECTIVE

Fatigue is a chronic and debilitating symptom of many long-term neurological conditions (LTNCs). Although methylphenidate provides some promise in alleviating fatigue in other clinical groups, little work has explored its potential utility within LTNCs. The current systematic review and meta-analysis evaluates the utility of methylphenidate for symptoms of fatigue in LTNCs.

METHODS

Five databases (PsycINFO, MEDLINE, Embase, Scopus, and Cochrane Library) were searched for relevant articles from their inception to February 2022. A purpose-developed evaluation tool was used to assess each study's research quality (QuEST:F).

RESULTS

Of the 1698 articles identified, 11 articles were included within this review (n = 370). Meta-analytical findings reported an overall significant benefit of methylphenidate for symptoms of fatigue across a mixed neurological sample ( g = -0.44; 95% confidence interval, -0.77 to -0.11). Subgroup analyses identified a significantly greater benefit ( P < 0.001) of methylphenidate for fatigue in LTNCs with static pathogenic trajectories (eg, traumatic brain injury) (number needed to treat = 2.5) compared with progressive conditions (eg, multiple sclerosis) (number needed to treat = 40.2).

CONCLUSIONS

Methylphenidate may pose an effective intervention for the treatment of fatigue in a number of LTNCs. Nonetheless, given the quality of the current evidence base, there exists a clear need for further robust assessment of the utility of methylphenidate-with a focus on subgroup-specific variability.

Psychometric validation of the French Multidimensional Chronic Asthenia Scale (MCAS) in a sample of 621 patients with chronic fatigue

BACKGROUND

Psychometric validation of the Multidimensional Chronic Asthenia Scale (MCAS) was conducted in order to provide an effective tool for assessing the health-related quality of life of French-speaking patients with chronic asthenia (CA).

METHODS

Items resulting from the initial formulation of the self-reported MCAS (along with other materials) were completed by French-speaking volunteers with inactive or active inflammatory bowel disease (IBD-I vs. IBD-A) or chronic fatigue syndrome (CFS). Responses from 621 participants (180 patients with IBD-A, 172 with IBD-I, 269 with CFS) collected in a single online survey were divided into three subsamples to test the construct validity of the MCAS (Step 1, N = 240), to confirm its factorial structure (Step 2, N = 204) and to explore its convergent-discriminant validity with the Fatigue Symptoms Inventory (FSI) and revised Piper Fatigue Scale (r-PFS, Step 3, N = 177).

RESULTS

Steps 1 and 2 showed that, as expected, MCAS has four dimensions: feeling of constraint (FoC), physical (PC), life (LC) and interpersonal consequences (IC), which are also related to the duration of CA (i.e., the longer it lasts, the more the dimensions are impacted). The results further showed that the MCAS is sensitive enough to capture between-group differences, with the CFS group being the most impaired, followed by IBD-A and IBD-I. While convergent-discriminant validity between the 4 factors of MCAS and FSI and r-PFS, respectively, was satisfactory overall, Step 3 also pointed to some limitations that call for future research (e.g., shared variances between the PC and IC dimensions of MCAS and behavioral dimension of r-PFS).

CONCLUSION

Despite these limitations, the MCAS clearly constitutes a promising tool for measuring quantitative differences (i.e., severity/intensity) in CA associated with various diseases, but also, and importantly, the clinically important differences in domains of its expression (i.e., qualitative differences).

Characterization of exhaustion disorder and identification of outcomes that matter to patients: Qualitative content analysis of a Swedish national online survey

Fatigue is a common presenting problem in healthcare settings, often attributed to chronic psychosocial stress. Understanding of fatigue and development of evidence-based treatments is hampered by a lack of consensus regarding diagnostic definitions and outcomes to be measured in clinical trials. This study aimed to map outcome domains of importance to the Swedish diagnosis stress-induced exhaustion disorder (ED; ICD-10, code F43.8 A). An online survey was distributed nationwide in Sweden to individuals who reported to have been diagnosed with ED and to healthcare professionals working with ED patients. To identify outcome domains, participants replied anonymously to four open-ended questions about symptoms and expectations for ED-treatment. Qualitative content analysis was conducted of a randomized subsample of respondents, using a mathematical model to determine data saturation. Six hundred seventy participants (573 with reported ED, 97 healthcare professionals) completed the survey. Qualitative content analysis of answers supplied by 105 randomized participants identified 87 outcomes of importance to ED encompassing physical, cognitive, and emotional symptoms as well as functional disability. Self-rating scales indicated that many ED participants, beyond reporting fatigue, also reported symptoms of moderate to severe depression, anxiety, insomnia, poor self-rated health, and sickness behavior. This study presents a map of outcome domains of importance for ED. Results shed light on the panorama of issues that individuals with ED deal with and can be used as a step to further understand the condition and to reach consensus regarding outcome domains to measure in clinical trials of chronic stress and fatigue. Preregistration: Open Science Framework (osf.io) with DOI https://doi.org/10.17605/OSF.IO/4VUAG.

Symptom Patterns in Young Adults with Cancer: An App-Based Study

OBJECTIVES

To investigate symptom patterns in young adults with cancer using a smartphone-based app. The authors sought to explore symptom frequency and severity, cluster patients based on their symptom severity, investigate the co-occurrence of severe symptoms, and explore the relationship between symptoms and activities.

DATA SOURCES

Data were collected, using a mobile app, from 161 young adults with cancer (mean age 25.5 years, 75% female, 59% with solid cancer). Symptom frequency/severity was investigated with descriptive statistics. K-means clustering technique was used to cluster patients based on the average symptom severity. Co-occurrence of severe symptoms was investigated with the association rule technique. The relationship between symptom severity and likelihood of performing a physical/social activity was explored with mixed-effects logistic regression.

CONCLUSION

The most frequently reported symptom was mood disturbance, followed by fatigue, which was also the most severe one. Two clusters of patients were identified, experiencing higher and lower severity for all symptoms. Severe appetite disturbances were frequently reported together with severe lack of energy and nausea. Severe lack of energy, either alone or together with mood disturbance, was often reported together with severe fatigue. Higher mood disturbance was associated with lower probability of performing physical and social activities. This study provides new insights into the symptom experience of young adults with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Using a symptoms-tracking app may be a valid strategy for healthcare professionals, nurses, and researchers to support patients in symptom monitoring and, consequently, to identify and implement tailored symptom-management strategies.

Depressive Symptoms and Their Impact on Quality of Life in Parkinson's Disease: An Exploratory Network Analysis Approach

The clinical presentation of Parkinson's disease (PD) is often dominated by depressive symptoms, which can significantly impact the patients' quality of life (QoL). However, it is not clear how these depressive symptoms are interconnected, or if some symptoms are more influential in affecting QoL. In the Cohort of Patients with Parkinson's Disease in Spain (COPPADIS) study, 686 patients with PD were analyzed using network analyses. The patients completed the Beck Depression Inventory II (BDI-II) and provided their overall QoL (EUROHIS-QOL) at the beginning of the study. The study used centrality measures such as Expected Influence and Bridge Expected Influence to identify depressive symptoms that had the greatest impact on overall QoL. The results of exploratory network analyses indicate that the BDI-II items related to loss of energy, past failure, and tiredness or fatigue have the greatest impact on overall QoL as measured by the EUROHIS-QOL 8-item index. The loss of energy and tiredness or fatigue BDI-II items are also strongly associated with a number of different EUROHIS-QOL items, according to Bridge Expected Influences. For individuals suffering from PD, network analysis can aid in identifying significant non-motor symptoms that impact their QoL, thus paving the way for potential improvements.

Nonpharmacological interventions for treating fatigue in adolescents: A systematic review and narrative synthesis of randomised controlled trials

OBJECTIVE

Fatigue is common in adolescence and can be highly disabling if experienced persistently, with adverse psychosocial outcomes. There is a need to better understand what nonpharmacological treatments are available for adolescents suffering with persistent fatigue. The current review systematically identified, synthesised, and evaluated the evidence regarding nonpharmacological interventions for fatigue in adolescents, focusing on evaluating effectiveness, describing intervention components, and mapping interventions onto the behaviour change technique taxonomy (BCTT).

METHODS

CENTRAL, EMBASE, PsycINFO, PubMed, and Web of Science were systematically searched for articles including (1) adolescents aged 10-19 years old, (2) fatigue as a primary or secondary outcome, (3) nonpharmacological interventions, and (4) randomised controlled trials. Study screening, data extraction, quality assessment, and BCTT mapping were performed independently by two reviewers. Findings were presented as a narrative synthesis, with interventions ranked by promise.

RESULTS

5626 papers were identified and double-screened, resulting in the inclusion of 21 articles reporting 16 trials. Five interventions were classified as likely promising. Interventions often involved psychoeducation, cognitive behavioural therapy, and/or physical activity, incorporating various BCTT domains, most commonly shaping knowledge, repetition and substitution, and goals and planning. However, there did not seem to be any observable differences between fatigue-targeted and non-fatigue-targeted interventions. Overall study quality was mixed, particularly in relation to power and outcome measures.

CONCLUSION

There are several promising nonpharmacological interventions for adolescent fatigue, although further work is needed to determine effectiveness. Future trials need to ensure design rigour, focusing on adequate powering, validated outcome measures, and adhering to best practice reporting guidelines.

Investigating the influence of an effort-reward interaction on cognitive fatigue in individuals with multiple sclerosis

This study examined whether an alteration in the effort-reward relationship, a theoretical framework based on cognitive neuroscience, could explain cognitive fatigue. Forty persons with MS and 40 healthy age- and education-matched cognitively healthy controls (HC) participated in a computerized switching task with orthogonal high- and low-demand (effort) and reward manipulations. We used the Visual Analog Scale of Fatigue (VAS-F) to assess subjective state fatigue before and after each condition during the task. We used mixed-effects models to estimate the association and interaction between effort and reward and their relationship to subjective fatigue and task performance. We found the high-demand condition was associated with increased VAS-F scores (p < .001), longer response times (RT) (p < .001) and lower accuracy (p < .001). The high-reward condition was associated with faster RT (p = .006) and higher accuracy (p = .03). There was no interaction effect between effort and reward on VAS-F scores or performance. Participants with MS reported higher VAS-F scores (p = .02). Across all conditions, participants with MS were slower (p < .001) and slower as a function of condition demand compared with HC (p < .001). This behavioural study did not find evidence that an effort-reward interaction is associated with cognitive fatigue. However, our findings support the role of effort in subjective cognitive fatigue and both effort and reward on task performance. In future studies, more salient reward manipulations could be necessary to identify effort-reward interactions on subjective cognitive fatigue.

KangPiLao decoction modulates cognitive and emotional disorders in rats with central fatigue through the GABA/Glu pathway

Background: Central fatigue (CF) is a subjective sense of tiredness associated with cognitive and memory disorders, accompanied by reduced physical endurance and negative emotions, such as anxiety and depression. Disease progression and prognosis with regards to CF have been unfavorable and possibly contribute to dementia, schizophrenia, and other diseases. Additionally, effective treatments for CF are lacking. KangPiLao decoction (KPLD) has been widely applied in clinical treatment and is composed of six Chinese herbal medicines, some of which have confirmed anti-fatigue effects. While glutamic acid (Glu) is the main excitatory transmitter in the central nervous system (CNS), gamma-aminobutyric acid (GABA) is the major inhibitory transmitter. Both are involved in emotional, cognitive, and memory functions. This research was designed to explore how KPLD regulates cognitive and emotional disorders in rats with CF and to identify the relationship between the regulatory effect and the GABA/Glu pathway.

Methods: The compounds comprising KPLD were analyzed using high-performance liquid chromatography-mass spectrometry. Sixty Wistar rats were randomly divided into six groups. The modified multiple platform method was used to induce CF. Cognitive, emotional, and fatigue states were evaluated by performing behavioral tests (Morris water maze [MWM], open-field test [OFT], and grip strength test). Histomorphology, western blotting, immunohistochemistry, and RT-qPCR were performed to investigate protein and mRNA expression levels in the hippocampus and prefrontal cortexes involved in the GABA/Glu pathway.

Results: Rats with CF exhibited impaired spatial cognition and increased negative emotions in the MWM and OFT. KPLD enabled the improvement of these symptoms, especially in the high-concentration group. Western blotting and RT-qPCR demonstrated that the expression of GABAARα1, GABAARγ2, GABABR1, and GAD67 in rats with CF was higher, whereas GAT-1 and NMDAR2B were lower in the hippocampus and prefrontal cortex. KPLD decreased the expression of GABAARα1, GABABR1, GABAARγ2, and GAD67 in the hippocampus and prefrontal cortex and enhanced the expression of NR2B in the prefrontal cortex.

Conclusion: KPLD significantly improved cognitive and emotional disorders in rats with CF by regulating the GABA/Glu pathway. Overall, KPLD may be a promising candidate for developing a drug for treating CF.

Exhaustion disorder: scoping review of research on a recently introduced stress-related diagnosis

BACKGROUND

Symptoms related to chronic stress are prevalent and entail high societal costs, yet there is a lack of international consensus regarding diagnostics and treatment. A new stress-related diagnosis, exhaustion disorder, was introduced into the Swedish version of ICD-10 in 2005. Since then, use of the diagnosis has increased rapidly.

AIMS

To create the first comprehensive synthesis of research on exhaustion disorder to report on the current state of knowledge. Preregistration: Open Science Framework (http://www.w3.org/1999/xlink">osf.io), doi 10.17605/OSF.IO/VFDKW.

METHOD

A PRISMA-guided scoping review of all empirical studies of exhaustion disorder was conducted. Searches were run in the MEDLINE, PsycInfo and Web of Science databases. Data were systematically charted and thematically categorised based on primary area of investigation.

RESULTS

Eighty-nine included studies were sorted into six themes relating to lived experience of exhaustion disorder (n = 9), symptom presentation and course (n = 13), cognitive functioning (n = 10), biological measures (n = 24), symptom measurement scales (n = 4) and treatment (n = 29). Several studies indicated that individuals with exhaustion disorder experience a range of psychiatric and somatic symptoms beyond fatigue, but robust findings within most thematic categories were scarce. The limited number of studies, lack of replication of findings and methodological limitations (e.g. small samples and scarcity of specified primary outcomes) preclude firm conclusions about the diagnostic construct.

CONCLUSIONS

More research is needed to build a solid knowledge base for exhaustion disorder. International collaboration regarding the conceptualisation of chronic stress and fatigue is warranted to accelerate the growth of evidence.

Investigation of the Level and Factors Influencing Emergency Department Nurses Fatigue: A Case Study of the Saudi Arabian Context

Background: Work-related fatigue is a common health problem among nurses which can affect their performance and decision making. Significance and Aim: The study explores the levels of fatigue and its associated factors among emergency department (ED) nurses in Saudi Arabia. Methods: The study was developed through a cross-sectional quantitative study design. This included the collection of primary quantitative data with a questionnaire prepared and published on REDCap. The study questionnaire was adapted from two tools, namely the OFER 15 and the Copenhagen II tools, respectively. Results: The study established that the Saudi Arabian ED nurses have high acute fatigue (OFER 15 score = 81.11), moderate-high chronic fatigue (OFER 15 score = 74.17), and a high inter-shift recovery index (OFER 15 score = 78.01). In terms of the predictor factors, the study established that for the demographic factors, gender has an impact on chronic and acute fatigue, while work experience impacted acute fatigue and the number of dependents impacted on inter-shift recovery index. On the psycho-social factors, chronic fatigue is influenced by emotional demand (which is a variable used to evaluate the levels to which the nurse is invested, gaining education/skills thus increases job satisfaction) (−0.289), influence at work (−0.310), commitment at the workplace (0.376), rewards (−0.187), stress (0.420), and burnout (0.293), respectively. Acute fatigue is influenced by the emotional demands (0.336), role clarity (−0.128), and the nurses’ well-being and health (−0.034). Finally, the inter-shift recovery index is influenced by the ED nurses’ burnout levels (−0.877). Conclusions: The study indicates a high level of nursing fatigue among the Saudi Arabian ED nurses.

Exercise or physical activity-related adverse events in people receiving peritoneal dialysis: A systematic review

People receiving peritoneal dialysis (PD) may benefit from participation in exercise or physical activity. However, exercise therapy for people receiving PD is not typically included in routine care, in part, due to ongoing uncertainties about risk. The aim of this review was to systematically collate and explore data on adverse events experienced by people receiving PD while undertaking an exercise or physical activity intervention. Searches yielded 25 exercise or physical activity intervention studies involving people receiving PD. Of these 25 studies, 17 studies provided adverse event data and were included in the final review. No serious adverse events (e.g. death, hospitalisation) were found attributable to the intervention. From 50 reported adverse events during the intervention period, 32 were attributable to the exercise or physical activity intervention with most being musculoskeletal (e.g. muscle/joint pain, etc.) followed by fatigue. Most events were mild to moderate in severity and resolved by exercise programme modification, education, rest or medication. The results from this review did not uncover signals of harm for people receiving PD who engage in exercise with risk of adverse events appearing to be low, however, improved adverse events reporting and further interventional studies are required before robust guidelines can be produced.

The experience of cognitive behavioural therapy in depressed adolescents who are fatigued

OBJECTIVE

Fatigue is a common and debilitating symptom of major depressive disorder (MDD). Cognitive behavioural therapy (CBT) is a recommended psychological treatment for adolescents with moderate to severe depression. This study explored the experience of CBT in fatigued adolescents with MDD.

DESIGN

A qualitative study was conducted using existing data from the qualitative arm of a large randomized control trial, the IMPACT study.

METHODS

Data were obtained from semi-structured interviews conducted after therapy. Participants were 18 adolescents (aged 13-18 years) who reached the clinical threshold for fatigue on diagnostic assessment before starting treatment. The data were analysed using thematic framework analysis.

RESULTS

Three themes and seven sub-themes were developed. Adolescents appeared to find taking part in initial sessions, engaging in ongoing sessions and completing homework challenging. Perceiving the therapist as genuine seemed to provide a sense of safety which enabled adolescents to open up in sessions. When the therapist was not perceived as genuine, adolescents appeared to find CBT less helpful. The structure of CBT appeared to enable treatment goals to be set, and facilitated an increase in meaningful activity. Ensuring that tasks were perceived as manageable and goals as achievable seemed important for participation. Cognitive restructuring appeared useful, although some adolescents tended to engage in distraction from thoughts as an alternative strategy.

CONCLUSIONS

This study provides an initial insight into how fatigued adolescents with MDD experience CBT. Further research is required to establish whether the themes are pervasive and relatedly, how best to treat depression in fatigued adolescents receiving CBT.

PRACTITIONER POINTS

Fatigued adolescents with depression found engaging in CBT sessions and therapeutic homework demanding. Establishing a collaborative therapeutic relationship, where the therapist was perceived as genuine, appeared helpful for participation. The structured approach to therapy, combined with flexibility, was experienced as helpful. Adolescents who perceived the pace of sessions to be manageable and therapeutic goals as achievable seemed to find CBT helpful overall. These findings provide insight into how fatigued adolescents with depression experience CBT and highlight the importance of being aware of fatigue and adapting therapy accordingly.

Fatigue Symptoms Associated With COVID-19 in Convalescent or Recovered COVID-19 Patients; a Systematic Review and Meta-Analysis

BACKGROUND

The prevalence and prognosis of post-acute stage SARS-CoV-2 infection fatigue symptoms remain largely unknown.

AIMS

We performed a systematic review to evaluate the prevalence of fatigue in post-recovery from SARS-CoV-2 infection.

METHOD

Medline, Embase, PsycINFO, CINAHL, Web of Science, Scopus, trial registries, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for studies on fatigue in samples that recovered from polymerase chain reaction (PCR) diagnosed COVID-19. English, French, and Spanish studies were included. Meta-analyses were conducted separately for each recruitment setting.

RESULTS

We identified 41 studies with 9,362 patients that recovered from COVID-19. Post-COVID-19 patients self-report of fatigue was higher compared to healthy controls (risk ratio (RR) = 3.688, 95%CI [2.502, 5.436], p < .001). Over 50% of patients discharged from inpatient care reported symptoms of fatigue during the first (event rate [ER] = 0.517, 95%CI [0.278, 0.749]) and second month following recovery (ER = 0.527, 95%CI [0.337, 0.709]). Ten percent of the community patients reported fatigue in the first-month post-recovery. Patient setting moderated the association between COVID-19 recovery and fatigue symptoms (R2 = 0.11, p < .001). Female patients recovering from COVID-19 had a greater self-report of fatigue (odds ratio [OR] = 1.782, 95%CI [1.531, 2.870]). Patients recruited through social media had fatigue above 90% across multiple time points. Fatigue was highest in studies from Europe.

CONCLUSION

Fatigue is a symptom associated with functional challenges which could have economic and social impacts. Developing long-term planning for fatigue management amongst patients beyond the acute stages of SARS-CoV-2 infection is essential to optimizing patient care and public health outcomes. Further studies should examine the impact of sociodemographic, pandemic-related restrictions and pre-existing conditions on fatigue.

Chemical Characterization and Preliminary Evaluation of the Efficacy and Tolerability of a Food Supplement Based on Pomegranate Extract, B Vitamins, and Vitamin C against Prolonged Fatigue in Healthy Consumers

Fatigue, characterized by periods of exhaustion that interfere with normal activities and negatively affect quality of life, can be classified as prolonged fatigue (or short-term fatigue, SF) or chronic fatigue. Vitamin deficiency and chronic inflammation seem to be possible causes of fatigue. Due to the unavailability of effective remedies that attenuate fatigue and provide consumer satisfaction, the aim of this investigation is to assess whether a commercial food supplement consisting of pomegranate extract with known anti-inflammatory activity, B vitamins, and vitamin C can help fight SF. To this end, the chemical composition of whole fruit pomegranate dry extract was determined through a RP-UHPLC–HRMS method, which indicated the presence of ellagitannins, gallotannins, and organic and phenolic acids. In a survey of consumers of food supplements aimed at reducing fatigue, 78 subjects (21 men and 57 women) were recruited for one month to evaluate the efficacy and tolerability of this food supplement through validated questionnaires for assessing fatigue level and quality of life. The consumers reported a significant improvement in their conditions without adverse effects over this time period. Although further studies are needed, these preliminary data suggest the capacity of a combination of pomegranate extract and hydrosoluble vitamins to alleviate SF.

Approach to the child with fatigue: A focus for the general pediatrician

BACKGROUND

Fatigue is a common, nonspecific complaint commonly used to describe various conditions, ranging from a vague, subjective sense of weariness to muscular weakness, fatigability, exercise intolerance or excessive daytime somnolence. Despite its high frequency in the general population, literature addressing the approach to the child with fatigue from a general pediatrician perspective is poor. We herein propose a review of the available evidence on the topic, providing a practical framework to assist physicians in dealing with the issue.

METHODS

Data were identified by searches of MEDLINE, UpToDate, Google Scholar and references from relevant articles. Articles published between 1990 and 2021 were considered, prioritizing systematic reviews and meta-analyses. Then, an empirically-based model of approaching the tired child was proposed according to our center experience.

RESULTS

To correctly characterize the meaning of fatigue reporting, specific clues from history and physical examination should be emphasized. Duration, severity, and the age at onset are to be considered. Then, specific queries about everyday activities, sleep hygiene and social domain could be useful in reaching a specific diagnosis and offering an appropriate treatment.

CONCLUSIONS

We suggest a pragmatic approach to fatigue in children based on age assessment, targeted questions, physical examination clues, and some laboratory first-level tests. This could provide pediatricians with a useful tool to discriminate the broad etiology of such a complaint, disentangling between psychological and organic causes. Further studies are needed to investigate the predictive value, specificity and sensitivity of this diagnostic workflow in managing the child with fatigue.

Multi-Parameter Physiological State Monitoring in Target Detection Under Real-World Settings

Mental state changes induced by stimuli under experimental settings or by daily events in real life affect task performance and are entwined with physical and mental health. In this study, we developed a physiological state indicator with five parameters that reflect the subject's real-time physiological states based on online EEG signal processing. These five parameters are attention, fatigue, stress, and the brain activity shifts of the left and right hemispheres. We designed a target detection experiment modified by a cognitive attention network test for validating the effectiveness of the proposed indicator, as such conditions would better approximate a real chaotic environment. Results demonstrated that attention levels while performing the target detection task were significantly higher than during rest periods, but also exhibited a decay over time. In contrast, the fatigue level increased gradually and plateaued by the third rest period. Similar to attention levels, the stress level decreased as the experiment proceeded. These parameters are therefore shown to be highly correlated to different stages of the experiment, suggesting their usage as primary factors in passive brain-computer interfaces (BCI). In addition, the left and right brain activity indexes reveal the EEG neural modulations of the corresponding hemispheres, which set a feasible reference of activation for an active BCI control system, such as one executing motor imagery tasks. The proposed indicator is applicable to potential passive and active BCI applications for monitoring the subject's physiological state change in real-time, along with providing a means of evaluating the associated signal quality to enhance the BCI performance.

A mixed-methods systematic review of post-viral fatigue interventions: Are there lessons for long Covid?

OBJECTIVES

Fatigue syndromes have been widely observed following post-viral infection and are being recognised because of Covid19. Interventions used to treat and manage fatigue have been widely researched and this study aims to synthesise the literature associated with fatigue interventions to investigate the outcomes that may be applicable to 'long Covid'.

METHOD

The study was registered with PROSPERO (CRD42020214209) in October 2020 and five electronic databases were searched. Papers were screened, critically appraised and data extracted from studies that reported outcomes of fatigue interventions for post-viral syndromes. The narrative synthesis includes statistical analysis associated with effectiveness and then identifies the characteristics of the interventions, including identification of transferable learning for the treatment of fatigue in long Covid. An expert panel supported critical appraisal and data synthesis.

RESULTS

Over 7,000 research papers revealed a diverse range of interventions and fatigue outcome measures. Forty papers were selected for data extraction after final screening. The effectiveness of all interventions was assessed according to mean differences (MD) in measured fatigue severity between each experimental group and a control following the intervention, as well as standardised mean differences as an overall measure of effect size. Analyses identified a range of effects-from most effective MD -39.0 [95% CI -51.8 to -26.2] to least effective MD 42.28 [95% CI 33.23 to 51.34]-across a range of interventions implemented with people suffering varying levels of fatigue severity. Interventions were multimodal with a range of supportive therapeutic methods and varied in intensity and requirements of the participants. Those in western medical systems tended to be based on self- management and education principles (i.e., group cognitive behavioural therapy (CBT).

CONCLUSION

Findings suggest that the research is highly focussed on a narrow participant demographic and relatively few methods are effective in managing fatigue symptoms. Selected literature reported complex interventions using self-rating fatigue scales that report effect. Synthesis suggests that long Covid fatigue management may be beneficial when a) physical and psychological support, is delivered in groups where people can plan their functional response to fatigue; and b) where strengthening rather than endurance is used to prevent deconditioning; and c) where fatigue is regarded in the context of an individual's lifestyle and home-based activities are used.

Toward the unity of pathological and exertional fatigue: A predictive processing model

Fatigue is a common experience in both health and disease. Yet, pathological (i.e., prolonged or chronic) and transient (i.e., exertional) fatigue symptoms are traditionally considered distinct, compounding a separation between interested research fields within the study of fatigue. Within the clinical neurosciences, nascent frameworks position pathological fatigue as a product of inference derived through hierarchical predictive processing. The metacognitive theory of dyshomeostasis (Stephan et al., 2016) states that pathological fatigue emerges from the metacognitive mechanism in which the detection of persistent mismatches between prior interoceptive predictions and ascending sensory evidence (i.e., prediction error) signals low evidence for internal generative models, which undermine an agent’s feeling of mastery over the body and is thus experienced phenomenologically as fatigue. Although acute, transient subjective symptoms of exertional fatigue have also been associated with increasing interoceptive prediction error, the dynamic computations that underlie its development have not been clearly defined. Here, drawing on the metacognitive theory of dyshomeostasis, we extend this account to offer an explicit description of the development of fatigue during extended periods of (physical) exertion. Accordingly, it is proposed that a loss of certainty or confidence in control predictions in response to persistent detection of prediction error features as a common foundation for the conscious experience of both pathological and nonpathological fatigue.

Can COVID-19 be a risk for cachexia for patients during intensive care? Narrative review and nutritional recommendations

Although increased weight, and particularly obesity, has been associated with a more severe clinical course of COVID-19 and risk of fatality, the course of the illness can lead to prolonged length of stay. Changes in nutritional status and weight loss during hospitalisation are largely reported in some populations, but still not explored in COVID-19 patients. Considering that patients with COVID-19 show an increased inflammatory response, other signs and symptoms, which can lead to weight and muscle loss, should be monitored. The aim of this article was to establish possible connections between COVID-19, prolonged hospitalisation and muscle wasting, as well as to propose nutritional recommendations for the prevention and treatment of cachexia, through a narrative review. Identification of risk and presence of malnutrition should be an early step in general assessment of all patients, with regard to more at-risk categories including older adults and individuals suffering from chronic and acute disease conditions, such as COVID-19. The deterioration of nutritional status, and consequently cachexia, increases the risk of mortality and needs to be treated with attention as other complications. There is, however, little hard evidence of nutritional approaches in assisting COVID-19 treatment or its management including cachexia.

Stressful life events can predict post-stroke fatigue in patients with ischemic stroke

OBJECTIVE

To investigate whether stressful life events (SLEs) can predict post-stroke fatigue (PSF) in patients with acute ischemic stroke (AIS).

METHODS

This prospective cohort study included data from patients with AIS who were followed up to 2-year interview. PSF was assessed at admission and at 6 (n = 916), 12 (n = 880), and 24 (n = 857) months with the fatigue severity scale (FSS). SLEs were measured with the Social Readjustment Rating Scale questionnaire at 6, 12 and 24 months' interview.

RESULTS

A significant dose-response association was found between SLEs and FSS score across all examined time-points: compared with those did not experience SLEs, FSS score was higher for those experiencing SLEs ≥3 at 6 months (β 0.53, 95% CI 0.28-0.78), 12 months (β 0.54, 95% CI 0.30-0.78) and 24 months (β 0.48, 95% CI 0.29-0.68). Longitudinal analyses indicated a significantly positive relationship between the number of SLEs and FSS score (SLEs: ≥3 vs. 0, β 0.14, 95% CI 0.09-0.19). Moreover, a distinct interaction of follow-up time and SLE numbers on FSS score was observed (p < 0.05), which means elevated exposure to SLEs during follow-up was associated with a lower rate of fatigue decline. A similar association was found in SLE load analysis.

CONCLUSION

Patients with severe fatigue were more likely to report increased number of SLEs in the previous 6 months, which could suggest that a non-specific stressful event leads to an extra burden to an already vulnerable psychological system.

A systematic review of the association between fatigue and cognition in chronic noncommunicable diseases

OBJECTIVES

Fatigue is one of the most common symptoms associated with chronic noncommunicable diseases, and it may also increase cognitive impairment. However, associations between fatigue and cognitive impairment in chronic illnesses remain unclear. Therefore, the purpose of this systematic review was to examine research that investigated associations between level of fatigue and cognitive status.

METHODS

PubMed/Medline, PsycINFO, CINAHL, and Cochrane Database were searched for articles published between 2012 and 2018 using search terms fatigue, cognition, and various iterations of these terms. Study quality was assessed by the Joanna Briggs Institute Critical Appraisal Checklist tool.

RESULTS

Of 1799 citations, 10 studies in samples of individuals with cancer, multiple sclerosis, neurosarcoidosis, and chronic fatigue syndrome met the inclusion criteria. Fatigue was found to be significantly correlated with cognitive impairment in one cancer-related study (r = -.480, p < .001), one multiple sclerosis study (β= -0.52, p < .0001), and two chronic fatigue syndrome studies (r = 0.397, p < .001; r = 0.388, p < .001).

DISCUSSION

There is insufficient evidence examining the relationship between fatigue and cognitive impairment in patients with chronic illnesses. As a result, more studies are needed that examine potential relationships between these two symptoms in order to develop effective treatments for individuals living with a chronic noncommunicable disease.

Dietary and herbal supplements for fatigue: A quality assessment of online consumer health information

Background

The Internet is increasingly utilized by patients to acquire information about dietary and herbal supplements (DHSs). Previously published studies assessing the quality of websites providing consumer health information about DHSs have been found to contain inaccuracies and misinformation that may compromise patient safety.. The present study assessed the quality of online DHSs consumer health information for fatigue.

Methods

Six unique search terms were searched on Google, each relating to fatigue and DHSs, across four countries. Across 480 websites identified, 48 were deemed eligible and were quality assessed using the DISCERN instrument, a standardized index of the quality of consumer health information.

Results

Across 48 eligible websites, the mean summed score was 47.64 (SD = 10.38) and the mean overall rating was 3.06 (SD = 0.90). Commercial sites were the most numerous in quantity, but contained information of the poorest quality. In general, websites lacked discussion surrounding uncertainty of information, describing what would happen if no treatment was used, and how treatment choices affect overall quality of life.

Conclusion

Physicians and other healthcare professionals should be aware of the high variability in the quality of online information regarding the use of DHSs for fatigue and facilitate open communication with patients to guide them towards reliable online sources.

Fatigue is related to depression in idiopathic dystonia

INTRODUCTION

Dystonia is a movement disorder presented with involuntary muscle contraction causing abnormal posture, movement, or both. Besides motor symptoms, patients may also report non-motor symptoms such as pain, anxiety, apathy, depression, sleep problems, fatigue, and cognitive impairment. The etiology of fatigue in patients with dystonia is not yet well understood.

AIM

To evaluate the presence of fatigue, depression, anxiety, sleep disorders, and daily sleepiness in patients with focal and segmental dystonia and to determine which of these non-motor symptoms influence the occurrence and severity of fatigue.

PATIENTS AND METHODS

Patients were surveyed for symptoms of fatigue, depression, anxiety, night-time sleep problems, and daily sleepiness using the Fatigue Assessment Scale, Beck Depression Inventory II, Beck Anxiety Inventory, Pittsburgh Sleep Questionnaire Index, and Epworth Sleepiness Scale. Demographic data (sex, age, and disease duration) were collected from patient medical records. On statistical analysis, we used SPSS for Windows 10. The level of significance was set at p<0.05.

RESULTS

Sixty patients (43 female and 17 male) with focal or segmental dystonia were evaluated. Fatigue was reported by 67.2% of patients. Fatigue (general, physical, and mental fatigue) was found to correlate with depression, anxiety, and sleep problems. Daily sleepiness correlated only with mental fatigue. Disease duration, age, and gender did not influence the symptoms of fatigue. Multiple regression analysis showed that depression mostly predicted symptoms of general, physical, and mental fatigue.

CONCLUSION

Depression mostly predicted symptoms of general, physical, and mental fatigue in patients with focal and segmental dystonia.

Quantification of Neuromuscular Fatigue: What Do We Do Wrong and Why?

Neuromuscular fatigue (NMF) is usually assessed non-invasively in healthy, athletic or clinical populations with the combination of voluntary and evoked contractions. Although it might appear relatively straightforward to magnetically or electrically stimulate at different levels (cortical/spinal/muscle) and to measure mechanical and electromyographic responses to quantify neuromuscular adjustments due to sustained/repeated muscle contractions, there are drawbacks that researchers and clinicians need to bear in mind. The aim of this opinion paper is to highlight the pitfalls inevitably faced when NMF is quantified. The first problem might arise from the definition of fatigue itself and the parameter(s) used to measure it; for instance, measuring power vs. isometric torque may lead to different conclusions. Another potential limitation is the delay between exercise termination and the evaluation of neuromuscular function; the possible underestimation of exercise-induced neural and contractile impairment and misinterpretation of fatigue etiology will be discussed, as well as solutions recently proposed to overcome this problem. Quantification of NMF can also be biased (or not feasible) because of the techniques themselves (e.g. results may depend on stimulation intensity for transcranial magnetic stimulation) or the way data are analyzed (e.g. M wave peak-to-peak vs first phase amplitude). When available, alternatives recently suggested in the literature to overcome these pitfalls are considered and recommendations about the best practices to assess NMF (e.g. paying attention to the delay between exercise and testing, adapting the method to the characteristics of the population to be tested and considering the limitations associated with the techniques) are proposed.

Clinical and Preclinical Systematic Review of Panax ginseng C. A. Mey and Its Compounds for Fatigue

Background

Fatigue, as a complex, multidimensional symptom, is associated with many physical illnesses. Panax ginseng C. A. Mey (PG) is an important herbal drug which has been used for benefiting Qi for thousand years. Panax ginseng C. A. Mey and its compounds (PGC) possess various pharmacological activities, including anti-fatigue. Here, we conducted a systematic review of both randomized clinical trials (RCTs) and preclinical animal studies to investigate the efficacy and safety of PGC for fatigue.

Methods

Electronic searches were performed in 7 databases from the time of each database's inception to August 2019. The methodological quality of RCTs was assessed using 7-item checklist recommended by Cochrane Collaboration or by the CAMARADES 10-item quality checklist. All the data were analyzed using Rev-Man 5.3 and Stata SE software.

Results

Eight eligible RCTs and 30 animal studies were identified. The risk of bias scores in RCTs ranged from 4/7 to 7/7, and of animal studies varied from 4/10 to 7/10. Meta-analyses showed that PGC was superior to placebo according to their respective fatigue scales, heart rate recovery, and clinical effect (P < 0.05). There were a similar number of adverse effects between PGC and placebo group (P > 0.05). Meta-analyses showed that PGC can significantly decrease level of blood lactate, blood urea nitrogen, creatine kinase, malondialdehyde, and lactic dehydrogenase in serum, level of malondialdehyde in liver and level of gamma-aminobutyric acid, 5-hydroxytryptamine in brain tissue, and increase swimming time, level of glutathione peroxidase, glucose, superoxide dismutase in serum, level of glycogen and activity of superoxide dismutase, glutathione peroxidase, and catalase in skeletal muscle, level of hepatic glycogen in liver and level of dopamine, acetylcholine in brain tissue, compared with control (P < 0.05). Meta-analyses showed no significant difference in animal body weight between PGC and control (P > 0.05).

Conclusion

The present findings supported, to a certain degree, that PGC can be recommended for routine use in fatigue. The possible mechanism of PGC resists fatigue, mainly through antioxidant stress, regulating carbohydrate metabolism, delaying the accumulation of metabolites, promoting mitochondrial function, neuroprotection, antiapoptosis, and regulating neurotransmitter disorder in central nervous system.

Fatigue Profiles in Patients with Multiple Sclerosis are Based on Severity of Fatigue and not on Dimensions of Fatigue

Fatigue related to Multiple Sclerosis (MS) is considered a multidimensional symptom, manifesting in several dimensions such as physical, cognitive, and psychosocial fatigue. This study investigated in 264 patients with severe primary MS-related fatigue (median MS duration 6.8 years, mean age 48.1 years, 75% women) whether subgroups can be distinguished based on these dimensions. Subsequently, we tested whether MS-related fatigue consists of a single common unidimensional factor. Subscale scores on four self-reported fatigue questionnaires, including the Checklist of Individual Strength, the Modified Fatigue Impact Scale, the Fatigue Severity Scale and the SF36 vitality, were used in a cluster analysis to identify patients with similar fatigue characteristics. Next, all 54 items were included in exploratory factor analysis to test unidimensionality. Study results show that in patients with a treatment indication for primary MS-related fatigue, fatigue profiles are based on severity and not on the various dimensions of fatigue. The three profiles found, suggested one underlying fatigue dimension, but this could not be confirmed. Factor analysis of all 54 items resulted in 8 factors, confirming the multidimensional construct of the included fatigue questionnaires.

Self-Reported Fatigue Predicts Incident Stroke in a General Population: EPIC-Norfolk Prospective Population-Based Study

Background and Purpose- Fatigue is a common symptom among stroke survivors and in general practice. However, the clinical significance of fatigue and its relationship to incident stroke is unclear. The aim of this study was to examine the relationship between self-reported fatigue and the incidence of stroke in a general population. Methods- This was a prospective, population-based study. The study population was 15 654 men and women aged 39 to 79 years recruited in 1993 to 1997 and followed till March 2016. Fatigue was assessed at 18 months after baseline using the vitality domain of the Short Form 36 questionnaire. Cox proportional hazard models were constructed to describe the prospective relationship between baseline fatigue and incident stroke adjusting for age, sex, systolic blood pressure, cholesterol, physical activity, smoking status, alcohol consumption, fruit and vegetable consumption, diabetes mellitus, body mass index, vitamin supplement use, education level, Townsend deprivation index, and occupational social class. Incident stroke was ascertained using death certificates and hospital record linkage data. Results- Through 249 248 person-years of follow-up, 1509 incident strokes occurred. Participants who reported the highest level of fatigue (quartile 4) were more likely to be women, to be multimorbid, and to perceive their health as fair or poor. We observed ≈50% relative risk increase in stroke risk (hazard ratio, 1.49 [95% CI, 1.29-1.71]) in those who reported the highest level of fatigue compared with those who reported the lowest level of fatigue (Q4 versus Q1). This relationship remained unaltered regardless of anemia status, the presence or absence of chronic bronchitis, thyroid dysfunction, or depression. Conclusions- Self-report fatigue assessed by the vitality domain of the Short Form 36 questionnaire predicts the risk of future stroke at the general population level. Identifying and addressing stroke risk factors in those who report fatigue in general practice may have substantial benefit at the population level.

Non-Pharmacological Interventions for Post-Stroke Fatigue: Systematic Review and Network Meta-Analysis

Post-stroke fatigue (PSF) is one of the most serious sequelae, which often interferes with the rehabilitation process and impairs the functional recovery of patients. Due to insufficient evidence, it is unclear which specific pharmacological interventions should be recommended. Therefore, in this paper, we compare the effectiveness of non-pharmacological interventions in PSF. A systematic review and network meta-analysis of randomized controlled trials were performed using EMBASE, MEDLINE, CINAHL, Cochrane library, ClinicalTrials.gov, CNKI, and CQVIP, from inception to January 2018, in the English and Chinese languages. RCTs involving different non-pharmacological interventions for PSF with an outcome of fatigue measured using the Fatigue Severity Scale were included. Multiple intervention comparisons based on a Bayesian network are used to compare the relative effects of all included interventions. Ten RCTs with eight PSF non-pharmacological interventions were identified, comprising 777 participants. For effectiveness, most interventions did not significantly differ from one another. The cumulative probabilities of the best non-pharmacological intervention for fatigue reduction included Community Health Management (CHM), followed by Traditional Chinese Medicine (TCM) and Cognitive Behavioral Therapy (CBT). Network meta-analysis based on data from the selected RCTs indicated that the eight PSF non-pharmacological interventions shared equivalent efficacy, but CHM, TCM, and CBT showed potentially better efficacy. In the future, fatigue needs to be recognized and more accurate assessment methods for PSF are required for diagnosis and to develop more effective clinical interventions.

Effect of Lactobacillus plantarum TWK10 on Exercise Physiological Adaptation, Performance, and Body Composition in Healthy Humans

Probiotics have been rapidly developed for health promotion, but clinical validation of the effects on exercise physiology has been limited. In a previous study, Lactobacillus plantarum TWK10 (TWK10), isolated from Taiwanese pickled cabbage as a probiotic, was demonstrated to improve exercise performance in an animal model. Thus, in the current study, we attempted to further validate the physiological function and benefits through clinical trials for the purpose of translational research. The study was designed as a double-blind placebo-controlled experiment. A total of 54 healthy participants (27 men and 27 women) aged 20–30 years without professional athletic training were enrolled and randomly allocated to the placebo, low (3 × 10¹⁰ colony forming units (CFU)), and high dose (9 × 10¹⁰ CFU) TWK10 administration groups (n = 18 per group, with equal sexes). The functional and physiological assessments were conducted by exhaustive treadmill exercise measurements (85% VO_2max), and related biochemical indices were measured before and after six weeks of administration. Fatigue-associated indices, including lactic acid, blood ammonia, blood glucose, and creatinine kinase, were continuously monitored during 30 min of exercise and a 90 min rest period using fixed intensity exercise challenges (60% VO_2max) to understand the physiological adaptation. The systemic inflammation and body compositions were also acquired and analyzed during the experimental process. The results showed that TWK10 significantly elevated the exercise performance in a dose-dependent manner and improved the fatigue-associated features correlated with better physiological adaptation. The change in body composition shifted in the healthy direction for TWK10 administration groups, especially for the high TWK10 dose group, which showed that body fat significantly decreased and muscle mass significantly increased. Taken together, our results suggest that TWK10 has the potential to be an ergogenic aid to improve aerobic endurance performance via physiological adaptation effects.

Importance of fatigue and its measurement in chronic liver disease

The mechanisms of fatigue in the group of people with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are protean. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the storage, release and production of substrate for energy generation. It is exquisitely sensitive to the feedback controlling the uptake and release of these energy generation substrates. Metabolic contributors to fatigue, beginning with the uptake of substrate from the gut, the passage through the portal system to hepatic storage and release of energy to target organs (muscle and brain) are central to understanding fatigue in patients with chronic liver disease. Inflammation either causing or resulting from chronic liver disease contributes to fatigue, although inflammation has not been demonstrated to be causal. It is this unique combination of factors, the nexus of metabolic abnormality and the inflammatory burden of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis that creates pathways to different types of fatigue. Many use the terms central and peripheral fatigue. Central fatigue is characterized by a lack of self-motivation and can manifest both in physical and mental activities. Peripheral fatigue is classically manifested by neuromuscular dysfunction and muscle weakness. Therefore, the distinction is often seen as a difference between intention (central fatigue) versus ability (peripheral fatigue). New approaches to measuring fatigue include the use of objective measures as well as patient reported outcomes. These measures have improved the precision with which we are able to describe fatigue. The measures of fatigue severity and its impact on usual daily routines in this population have also been improved, and they are more generally accepted as reliable and sensitive. Several approaches to evaluating fatigue and developing endpoints for treatment have relied of biosignatures associated with fatigue. These have been used singly or in combination and include: physical performance measures, cognitive performance measures, mood/behavioral measures, brain imaging and serological measures. Treatment with non-pharmacological agents have been shown to be effective in symptom reduction, whereas pharmacological agents have not been shown effective.

A novel mutation in Slc2a4 as a mouse model of fatigue

Chronic fatigue is a debilitating disorder with widespread consequences, but effective treatment strategies are lacking. Novel genetic mouse models of fatigue may prove invaluable for studying its underlying physiological mechanisms and for testing treatments and interventions. In a screen of voluntary wheel-running behavior in N-ethyl-N-nitrosourea mutagenized C57BL/6J mice, we discovered two lines with low body weights and aberrant wheel-running patterns suggestive of a fatigue phenotype. Affected progeny from these lines had lower daily activity levels and exhibited low amplitude circadian rhythm alterations. Their aberrant behavior was characterized by frequent interruptions and periods of inactivity throughout the dark phase of the light-dark cycle and increased levels of activity during the rest or light phase. Expression of the behavioral phenotypes in offspring of strategic crosses was consistent with a recessive inheritance pattern. Mapping of phenotypic abnormalities showed linkage with a single locus on chromosome 1, and whole exome sequencing identified a single point mutation in the Slc2a4 gene encoding the GLUT4 insulin-responsive glucose transporter. The single nucleotide change (A-T, which we named "twiggy") was in the distal end of exon 10 and resulted in a premature stop (Y440*). Additional metabolic phenotyping confirmed that these mice recapitulate phenotypes found in GLUT4 knockout mice. However, to the best of our knowledge, this is the first time a mutation in this gene has been shown to result in extensive changes in general behavioral patterns. These findings suggest that GLUT4 may be involved in circadian behavioral abnormalities and could provide insights into fatigue in humans.

'Active'ating thoughts about affect: elicitation of physical activity judgements in insufficiently active women

OBJECTIVE

A growing body of evidence suggests that affective judgements are distinct from, and exert greater influence on, physical activity behaviours than instrumental judgements.

DESIGN

As part of a randomised controlled trial, 110 insufficiently active, female, university students were randomised to (a) an affective mental contrasting condition, (b) an instrumental mental contrasting condition, or (c) a 'standard' mental contrasting intervention (with no modifications). In the analyses concerning the trial's primary outcome, the affective mental contrasting condition was found to be more effective for increasing physical activity than the standard or instrumental conditions. The purpose of this study was to qualitatively examine the physical activity outcomes and obstacles elicited from participants as part of the three mental contrasting interventions within this trial.

RESULTS

32 lower-order physical activity judgement themes, categorised within seven high-order themes, were derived through the use of the mental contrasting intervention. In addition to identifying several affective and instrumental outcomes and obstacles that have previously been recognised, participants in this study also highlighted contextualised responses that describe complicated relationships that exist between affective and instrumental judgements.

CONCLUSIONS

This study provides fine-grained insight into cognitive processes derived from a novel intervention involving insufficiently active women.

Are sleep continuity disturbance and fatigue prodromal symptoms of cancer development?

Sleep continuity disturbance (also known as insomnia) and fatigue are common complaints of individuals diagnosed with cancer. Traditionally, many have believed that sleep continuity disturbance and fatigue are caused, in large measure, by the impact of the cancer diagnosis and treatment. Recent prospective research suggests however, that sleep continuity disturbance and fatigue may actually precede a cancer diagnosis. We suggest that sleep continuity disturbance and fatigue may in fact represent prodromal symptoms of cancer. We review the current perspectives of this sequence of events and present a revised schematic that accounts for the role of biological, behavioural, and cognitive factors that contribute to the development and maintenance of sleep continuity disturbances in cancer patients. Monitoring emergent and unexplained patient-reported fatigue, sleepiness, and insomnia may serve as early warning signs of new onset cancer, providing opportunity for early detection and early intervention.

Modified Si-Ni-San Decoction Ameliorates Central Fatigue by Improving Mitochondrial Biogenesis in the Rat Hippocampus

The traditional Chinese medicine (TCM) decoction Si-Ni-San (SNS) has been utilised for millennia to improve physiological coordination of the functions of the liver and spleen, which are regarded as the main pathological organs of central fatigue in TCM. This study evaluates the effect of a modified SNS (MSNS) formula on central fatigue in rats and explores molecular changes associated with hippocampal mitochondrial biogenesis. Central fatigue was induced through a 21-day sleep deprivation protocol. We assessed MSNS's effects on behaviour, blood and liver biomarkers, and mitochondrial ultrastructure. We found that MSNS could reverse various signs of central fatigue such as its effects on hippocampal gene and protein expression levels of sirtuin 1 (SIRT1), peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α), and nuclear respiratory factor 1 (NRF1). We also observed evidence of MSNS decreasing central fatigue, such as decreasing creatine kinase activity, decreasing levels of malondialdehyde and blood urea nitrogen, increasing lactate dehydrogenase and superoxide dismutase activities, increasing mitochondrial DNA copy number, and reversing mitochondrial ultrastructure changes. These findings suggest that MSNS can ameliorate central fatigue and that its molecular mechanism involves mitochondrial biogenesis enhancement mediated by hippocampal SIRT1, PGC-1α, and NRF1.

β-glucan Salecan Improves Exercise Performance and Displays Anti-Fatigue Effects through Regulating Energy Metabolism and Oxidative Stress in Mice

Fatigue induced by prolonged exercise not only leads to the decrease of exercise capacity, but also might be the cause of many diseases. In consideration of the side effects of pharmacological drugs, dietary supplements seem to be a better choice to ameliorate exercise-induced fatigue. The present study aimed to investigate the anti-fatigue effect of Salecan, a novel water-soluble β-glucan, during exercise and explore the underlying mechanisms. Male Institute of Cancer Research (ICR) mice were divided into five groups, including the Rest group and the other four Swim-groups treated with Salecan at 0, 25, 50, and 100 mg/kg/day for four weeks. Salecan treatment markedly increased the exhaustive swimming time of mice in the forced swimming test. Exercise fatigue and injury-related biochemical biomarkers including lactate, blood urea nitrogen (BUN), creatinine kinase (CK), alanine transaminase (ALT), and aspartate transaminase (AST) were ameliorated by Salecan. Salecan reversed the decreased serum glucose levels and glycogen contents caused by exercise. In addition, Salecan improved oxidative stress induced by exercise through regulating Nrf2/HO–1/Trx signaling pathway. Thus, the beneficial effects of Salecan against fatigue may be due to its positive effects on energy metabolism and antioxidation defence. Our results suggest that Salecan could be a novel potential candidate for anti-fatigue dietary supplements.

Efficacy of iron supplementation on fatigue and physical capacity in non-anaemic iron-deficient adults: a systematic review of randomised controlled trials

OBJECTIVE

Iron supplementation in iron-deficiency anaemia is standard practice, but the benefits of iron supplementation in iron-deficient non-anaemic (IDNA) individuals remains controversial. Our objective is to identify the effects of iron therapy on fatigue and physical capacity in IDNA adults.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

SETTING

Primary care.

PARTICIPANTS

Adults (≥18 years) who were iron deficient but non-anaemic.

INTERVENTIONS

Oral, intramuscular or intravenous iron supplementation; all therapy doses, frequencies and durations were included.

COMPARATORS

Placebo or active therapy.

RESULTS

We identified RCTs in Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health, SportDiscus and CAB Abstracts from inception to 31 October 2016. We searched the WHO's International Clinical Trials Registry Platform for relevant ongoing trials and performed forward searches of included trials and relevant reviews in Web of Science. We assessed internal validity of included trials using the Cochrane Risk of Bias tool and the external validity using the Grading of Recommendations Assessment, Development and Evaluation methodology. From 11 580 citations, we included 18 unique trials and 2 companion papers enrolling 1170 patients. Using a Mantel-Haenszel random-effects model, iron supplementation was associated with reduced self-reported fatigue (standardised mean difference (SMD) -0.38; 95% CI -0.52 to -0.23; I² 0%; 4 trials; 714 participants) but was not associated with differences in objective measures of physical capacity, including maximal oxygen consumption (SMD 0.11; 95% CI -0.15 to 0.37; I² 0%; 9 trials; 235 participants) and timed methods of exercise testing. Iron supplementation significantly increased serum haemoglobin concentration (MD 4.01 g/L; 95% CI 1.22 to 6.81; I² 48%; 12 trials; 298 participants) and serum ferritin (MD 9.23 µmol/L; 95% CI 6.48 to 11.97; I² 58%; 14 trials; 616 participants).

CONCLUSION

In IDNA adults, iron supplementation is associated with reduced subjective measures of fatigue but not with objective improvements in physical capacity. Given the global prevalence of both iron deficiency and fatigue, patients and practitioners could consider consumption of iron-rich foods or iron supplementation to improve symptoms of fatigue in the absence of documented anaemia.

PROSPERO REGISTRATION NUMBER

CRD42014007085.

Fatigue in Parkinson's disease: concepts and clinical approach

Parkinson's disease (PD) is a progressive neurological disorder characterized by a large number of motor and non-motor features. Fatigue is one of the most common and most disabling symptoms among patients with PD, and it has a significant impact on their quality of life. Although fatigue has been recognized for a long time, its pathophysiology remains poorly understood, and there is no evidence to support any therapeutic approach in PD patients. Expert consensus on case definition and diagnostic criteria for PD-related fatigue have been recently published, and although they still need to be adequately validated, they provide a great step forward in the study of fatigue. The goal of this article is to provide relevant information for the identification and management of patients with fatigue.

Fatigue is a relevant outcome in patients with myasthenia gravis

INTRODUCTION

Patients with myasthenia gravis often experience fatigue, but its effect on quality of life (QoL) is underestimated, and fatigue is rarely measured in clinical trials.

METHODS

Two hundred fifty-seven myasthenic patients completed the Neuro-QoL-Fatigue and measures of disease severity and QoL. We studied the relationship between fatigue and clinical and demographic variables. Finally, we studied the responsiveness of the Neuro-QoL-Fatigue in 95 patients receiving treatments for myasthenia and estimated the minimal important difference (MID).

RESULTS

Fatigue correlated with greater disease severity (r = 0.52-0.69, P < 0.0001) and worse QoL (r = 0.65-0.75, P < 0.0001). Patients in remission, with minimal manifestations, and pure ocular symptoms reported minimal fatigue. Regression modeling showed that, in addition to its relationship with disease severity, fatigue was worse in females, patients with generalized disease, and those with anxiety/depression. Fatigue improved after immunomodulation (P < 0.0001), and the MID was 5.3 points.

DISCUSSION

Fatigue in myasthenia correlates with disease severity, affects QoL, and can improve after treatment. Muscle Nerve 58: 197-203, 2018.