Similarities and differences in the experience of fatigue among people living with fibromyalgia, multiple sclerosis, ankylosing spondylitis and stroke

A Smartphone App to Support Self-Management for People Living With Sjögren's Syndrome: Qualitative Co-Design Workshops

BACKGROUND

Sjögren's syndrome (SS) is the second most common autoimmune rheumatic disease, and the range of symptoms includes fatigue, dryness, sleep disturbances, and pain. Smartphone apps may help deliver a variety of cognitive and behavioral techniques to support self-management in SS. However, app-based interventions must be carefully designed to promote engagement and motivate behavior change.

OBJECTIVE

We aimed to explore self-management approaches and challenges experienced by people living with SS and produce a corresponding set of design recommendations that inform the design of an engaging, motivating, and evidence-based self-management app for those living with SS.

METHODS

We conducted a series of 8 co-design workshops and an additional 3 interviews with participants who were unable to attend a workshop. These were audio recorded, transcribed, and initially thematically analyzed using an inductive approach. Then, the themes were mapped to the Self-Determination Theory domains of competency, autonomy, and relatedness.

RESULTS

Participants experienced a considerable demand in the daily work required in self-managing their SS. The condition demanded unrelenting, fluctuating, and unpredictable mental, physical, and social efforts. Participants used a wide variety of techniques to self-manage their symptoms; however, their sense of competency was undermined by the complexity and interconnected nature of their symptoms and affected by interactions with others. The daily contexts in which this labor was occurring revealed ample opportunities to use digital health aids. The lived experience of participants showed that the constructs of competency, autonomy, and relatedness existed in a complex equilibrium with each other. Sometimes, they were disrupted by tensions, whereas on other occasions, they worked together harmoniously.

CONCLUSIONS

An SS self-management app needs to recognize the complexity and overlap of symptoms and the complexities of managing the condition in daily life. Identifying techniques that target several symptoms simultaneously may prevent users from becoming overwhelmed. Including techniques that support assertiveness and communication with others about the condition, its symptoms, and users' limitations may support users in their interactions with others and improve engagement in symptom management strategies. For digital health aids (such as self-management apps) to provide meaningful support, they should be designed according to human needs such as competence, autonomy, and relatedness. However, the complexities among the 3 Self-Determination Theory constructs should be carefully considered, as they present both design difficulties and opportunities.

Patients experience of cognitive fatigue post-stroke: an exploratory study

PURPOSE

Cognitive fatigue is commonly reported and described as disabling by patients recovering from neurological conditions including stroke. However, cognitive fatigue is usually underdiagnosed among stroke survivors which leads to a lack of specific treatments for this condition. Therefore, the aim of this study was to explore post-stroke cognitive fatigue as it is experienced by stroke survivors.

METHODS

This qualitative research followed the principles of descriptive phenomenology within a constructivist paradigm. Individual semi-structured interviews were conducted with stroke survivors experiencing post-stroke cognitive fatigue recruited through the Heart and Stroke Foundation, the Canadian Partnership for Stroke Recovery, and social media posts. Data were analyzed through inductive content analysis.

RESULTS

Eleven stroke survivors participated. The analysis revealed five themes illustrating the experience and descriptions of post-stroke cognitive fatigue: (1) characteristics, (2) aggravating factors, (3) management, (4) effect of cognitive fatigue on daily life, and (5) social awareness and support.

CONCLUSION

This study highlights the complexity of post-stroke cognitive fatigue. Cognitive fatigue becomes more evident after discharge; therefore, clinicians should consistently screen for it and provide proper education to the patients and their carers.IMPLICATIONS FOR REHABILITATIONCognitive fatigue is a complex phenomenon that can negatively affect the daily life of stroke survivors.Sensory-overloaded environments, emotional distress, poor sleep, and engaging in complex cognitive tasks can trigger post-stroke cognitive fatigue.More education on the concept of cognitive fatigue should be provided to healthcare providers to be able to identify and manage this symptom properly.

Defining a Treatment Model for Self-Management of Fatigue in Rehabilitation of Acquired Brain Injury Using the Rehabilitation Treatment Specification System

Systematic treatment descriptions to standardize and evaluate management of fatigue after acquired brain injury (ABI) are lacking. The purpose of this multi-phase qualitative study was to formulate a treatment model for promoting self-management of fatigue in rehabilitation of ABI based on practice-based understandings and routines. The study was conducted in a community-based rehabilitation center in Denmark. The model was defined using the Rehabilitation Treatment Specification System. Phase 1 comprised co-production workshops with five service providers (occupational therapists, physiotherapists, and a neuropsychologist) to elicit preliminary treatment theories. In Phase 2, four case studies were conducted on management of fatigue in vocational rehabilitation. Interviews (n = 8) and treatment log entries (n = 76) were analyzed thematically to specify treatment targets and active ingredients. The treatment model comprised five main components: (i) Knowledge and understanding of fatigue, (ii) Interoceptive attention of fatigue, (iii) Acceptance of fatigue, (iv) Activity management, and (v) Self-management of fatigue. For each component, lists of targets and active ingredients are outlined. In conclusion, management of fatigue includes multiple treatment components addressing skills, habits, and mental representations such as knowledge and attitudes. The model articulates treatment theories, which may guide clinical reasoning and facilitate future theory-driven evaluation research.

Adaptation to poststroke fatigue in stroke survivors and their care partners: a scoping review

PURPOSE

Fatigue is a long-term symptom for stroke survivors. This scoping review synthesized how survivors achieve fatigue adaptation.

METHODS

Four databases were searched for studies between 2012 and 2021. Qualitative studies or qualitative findings from mixed-methods studies were included if they described survivors' experiences with fatigue and/or care partners' experiences in helping survivors adapt to fatigue. Studies were excluded if they were poster abstracts, reviews, or editorials.

RESULTS

Thirty-six articles were analyzed. Survivors with fatigue described different adaptive challenges - fatigue made them less productive, brought emotional distress, and was indiscernible to others. To respond to these challenges, stroke survivors did adaptive work including conserving energy, changing mindset, and restructuring normality. Care partners, employers, and colleagues showed adaptive leadership by adjusting daily routines or role responsibilities. Most survivors described that the current clinical practice did not meet their needs to address fatigue.

CONCLUSIONS

Stroke survivors had many types of challenges and strategies for fatigue adaptation. Survivors received family, employer, and colleague support but how care partners help survivors develop new skills is unknown. Stroke survivors expressed that healthcare professionals need to teach survivors and care partners basic knowledge of fatigue that meet their personal needs and provide adaptive interventions for survivors. Implications for rehabilitationThe challenges of poststroke fatigue are multifaceted because fatigue influences stroke survivors' physical, cognitive, mental, and social aspects of recovery.Stroke survivors need support from their care partners such as helping them adapt to the fatigue, adapt to new life routine, and adjust role responsibilities.Healthcare professionals, stroke survivors, and care partners need to work together to develop strategies about poststroke fatigue that meet stroke survivors' personal needs.

The Role of Walking in the Relationship between Catastrophizing and Fatigue in Women with Fibromyalgia

Walking is one of the most beneficial treatments for fibromyalgia patients. However, adherence to walking behavior is low due to the initially associated symptoms (including pain and fatigue). Although the association of catastrophism with greater symptoms is known, the results regarding fatigue have not always been consistent. Nevertheless, it is unknown whether the association between catastrophism and fatigue could, in turn, be conditioned by whether the patients walk or not. Therefore, our goal was to explore the moderating effect of walking on the association between catastrophizing and fatigue in patients with fibromyalgia. A cross-sectional study was carried out with 203 women with fibromyalgia. We used the Multidimensional Fatigue Inventory to assess fatigue and the Pain Catastrophizing Scale to assess pain catastrophizing (differentiating between its three dimensions). An ad hoc item was used to evaluate walking (moderator). Lower scores for fatigue and pain catastrophizing were found among patients who walked versus those who did not. Walking moderated the relationship between rumination and fatigue (Beta = 0.16, t = 1.96, p = 0.049) and between magnification and fatigue (Beta = 0.22, t = 21.83, p = 0.047). Helplessness showed no direct or interaction effect for fatigue. Nevertheless, higher rumination and magnification were associated with higher fatigue only in patients who walked. Therefore, to promote adherence to walking and reduce the effects of catastrophizing on fatigue, it seems necessary to manage rumination and magnification among patients who walk.

Qualitative interview study exploring the patient experience of living with axial spondyloarthritis and fatigue: difficult, demanding and draining

OBJECTIVE

To explore patients' lived experiences of axial spondyloarthritis (axSpA) and fatigue.

DESIGN

Interpretative phenomenological analysis (lived experience) was used as the study design. Analysis drew together codes with similar meaning to create superordinate and subordinate themes.

SETTING

Rheumatology departments in three National Health Service Foundation Trusts in the north, midlands and south of England.

PARTICIPANTS

A purposive sample of seventeen axSpA patients were recruited. The age range was 22-72 years (median age 46), nine were male and eight, female.

RESULTS

A central concept of achieving balance was identified as the active process of integrating axSpA symptoms and fatigue into daily life, working with and not against their condition to lead a fulfilled life. This was conveyed through three superordinate themes: struggling to find energy, engaging in everyday life and persevering through difficulties. Struggling to find energy was the challenge of retaining enough stamina to do things in daily life. Engaging in everyday life highlighted dedication to being active and organised, learning through experience and acceptance of a changed way of being. Persevering through difficulties identified the physical and emotional effort required to keep moving forward and the importance of feeling supported.

CONCLUSION

Achieving balance through finding energy, engaging and persevering everyday was fundamental to having the best possible life. The experience of energy emerged as a distinct but related component of fatigue. However, while energy could be maintained or replenished, fatigue was more difficult to overcome and required greater effort. Energy may be a useful indicator of an individual's current state and ability to sustain activities that supports their well-being, such as exercise. Awareness of the elements of achieving balance in axSpA may enable patients and clinicians to work together to tailor treatments to individual patient need.

Exploring the Preference for Fatigue-avoidance Goals as a Mediator Between Pain Catastrophizing, Functional Impairment, and Walking Behavior in Women With Fibromyalgia

OBJECTIVES

Along with the symptoms of pain and fatigue, pain catastrophizing and avoidance behaviors are highly prevalent and associated with functional impairment in fibromyalgia (FM) patients. Although pain and fatigue affect patients' quality of life, research has been exclusively focused on how pain affects physical activity and exercise. The aim of this study was to analyze the role of pain catastrophizing and preference for fatigue-avoidance goals in walking behavior and functional impairment in women with FM.

MATERIALS AND METHODS

In this cross-sectional study the sample was composed of 76 participants aged 18 years and older (mean age=55.05, SD=7.70). The study evaluated pain catastrophizing, preference for fatigue-avoidance goals, functional impairment, and walking behavior along with sociodemographic variables and clinical data.

RESULTS

Pain catastrophizing was associated with preference for fatigue-avoidance goals and this preference was associated with greater functional impairment and less distance walked. Path analysis supported the mediating role of preference for fatigue-avoidance goals in the relationship between pain catastrophizing and walking behavior and between pain catastrophizing and functional impairment. Furthermore, pain catastrophizing predicted greater preference for fatigue-avoidance goals which predicted more problems in functioning and less distance walked.

DISCUSSION

The present study may help clarify the connection between the factors that stop individuals with FM from implementing beneficial behaviors such as walking, and thus, allowing for the design of psychological interventions that seek to maintain physical functioning despite experiencing fatigue.

Rheumatic disease and fatigue: Participants' experiences of an activity-pacing group

BACKGROUND

Fatigue is a common symptom of inflammatory rheumatic disease and has a great impact on everyday life. Activity-pacing is proposed as an intervention to increase participation in meaningful activities.

AIMS

To explore participants' experiences with an activity-pacing group, how participants perceived self-managing everyday life after group attendance, and their reflections on unmet needs that could enhance self-management of everyday life with fatigue.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 10 participants who had attended an activity-pacing group. Thematic analyses were conducted.

FINDINGS

Prior to group attendance, the participants expressed an awareness of their lack of knowledge of fatigue. Through group attendance, they increased their understanding of fatigue and their ability to apply strategies to better manage everyday life. Participants found it difficult to balance their energy use and realised that implementing activity-pacing strategies takes time. Therefore, they requested follow-up sessions with the activity-pacing group. They also desire that rheumatologists pay more attention to and acknowledge fatigue.

CONCLUSIONS AND SIGNIFICANCE

Enhancing the understanding of fatigue and how to manage everyday life with fatigue, appears to be important. Group interventions led by occupational therapists and with a focus on activity-pacing may be a suitable approach. Follow-up sessions are recommended.

Evaluation of Response Processes to the Danish Version of the Dutch Multifactor Fatigue Scale in Stroke Using the Three-Step Test-Interview

Validated self-report measures of post-stroke fatigue are lacking. The Dutch Multifactor Fatigue Scale (DMFS) was translated into Danish, and response process evidence of validity was evaluated. DMFS consists of 38 Likert-rated items distributed on five subscales: Impact of fatigue (11 items), Signs and direct consequences of fatigue (9), Mental fatigue (7), Physical fatigue (6), and Coping with fatigue (5). Response processes to DMFS were investigated using a Three-Step Test-Interview (TSTI) protocol, and data were analyzed using Framework Analysis. Response processes were indexed on the following categories: (i) "congruent," response processes were related to the subscale construct; (ii) "incongruent," response processes were not related to the subscale construct; (iii) "ambiguous," response processes were both congruent and incongruent or insufficient to evaluate congruency; and (iv) "confused," participants did not understand the item. Nine adults were recruited consecutively 10-34 months post-stroke (median = 26.5) at an outpatient brain injury rehabilitation center in 2019 [five females, mean age = 55 years (SD = 6.3)]. Problematic items were defined as <50% of response processes being congruent with the intended construct. Of the 38 items, five problematic items were identified, including four items of Physical fatigue and one of Mental fatigue. In addition, seven items posed various response difficulties to some participants due to syntactic complexity, vague terms, a presupposition, and a double-barrelled statement. In conclusion, findings elucidate the interpretative processes involved in responding to DMFS post-stroke, strengthen the evidence base of validity, and guide revisions to mitigate potential problems in item performance.

Post-stroke fatigue: an exploratory study with patients and health professionals to develop a patient-reported outcome measure

BACKGROUND

Post-stroke fatigue (PSF) is commonly reported and described as disabling by patients recovering from stroke. However, a major challenge is how to accurately diagnose and assess PSF. Therefore, the aim of this study was to explore PSF as it is experienced by stroke survivors and described by health professionals to guide future development of a PSF-specific PROM.

METHODS

Individual semi-structured interviews were conducted with stroke survivors experiencing PSF (n = 9) and three focus groups were conducted with health professionals (n = 16). Data were analyzed through inductive content analysis.

RESULTS

The analysis revealed four themes illustrating the experience and descriptions of PSF: 1) PSF characteristics, 2) interfering and aggravating factors, 3) management, and 4) PSF awareness, which refers to stroke survivors first becoming aware of PSF after their initial hospital admission.

CONCLUSION

This study highlights the complexity and multidimensionality of PSF. The results from this study will guide future development of a PSF-PROM and support its content validity.

The Influence of Gayatri Mantra and Emotional Freedom Technique on Quality of Life of Post-Stroke Patients

PURPOSE

The quality of life in stroke patients is vital for survival. Nowadays, studies that show a decrease in quality of life in post-stroke patients are increasing. Various non-pharmacological modalities were explored in the past to improve rehabilitation. However, the study about the effects of religious mantra and its combination with the modern technique was lacking. Therefore, this study aimed to analyse the effects of Gayatri Mantra and Emotional Freedom Technique (EFT) on quality of life (QOL) of post-stroke patients.

METHODS

A quasi-experimental with pretest and posttest with the control group design was conducted. Forty-six post-stroke subjects with reduced quality of life based on Stroke Specific Quality of Life were consecutively recruited and divided into controls and intervention groups. The intervention group received additional treatment with Gayatri Mantra and EFT. In contrast, the control group attends and adheres only to the standard hospital rehabilitation program.

RESULTS

All indicators and the overall score of QOL in the intervention group showed significant improvement after treatment (p<0.05) compared with no improvement in the control group. Overall, a higher QOL score was observed in the intervention group at the end of the study. Mann-Whitney test shows significant differences between the final QOL score in intervention and control groups (p<0.001).

CONCLUSION

Gayatri Mantra and EFT are significantly increasing the quality of life of post-stroke patients.

The 4 U's Rule of Fibromyalgia: A Proposed Model for Fatigue in a Sample of Women with Fibromyalgia: A Qualitative Study

Although fatigue usually goes unnoticed, it is a symptom that poses great challenges to patients with fibromyalgia and is a strong limitation. The aim of this study is to identify and describe the variables involved in fatigue in nine different situations of the Goal Pursuit Questionnaire (GPQ) that may occur in the daily lives of women with fibromyalgia, according to an ABC (Antecedents–Behaviors–Consequences) model. This study followed a qualitative descriptive research method and a deductive–inductive hybrid approach based on a phenomenological paradigm. Twenty-six women with fibromyalgia participated in focus group discussions between February and March of 2018. Thematic content analysis was carried out from transcribed verbatim interviews. We identified nine major themes that emerged from the participants’ conversations: self-imposed duties, muscle fatigue, overwhelming feeling of tiredness, difficulty thinking, difficulty concentrating, negative emotions, lifestyle changes, affected everyday activities, and lack of motivation for daily activities and social interactions. We conclude that the ABC model allowed certain elements to emerge regarding the fatigue experience, highlighting its importance as a symptom in fibromyalgia. This additional analysis of the ABC model showed that fatigue can be described through the 4 U’s Rule, which is integrated by these four adjectives: (1) Unpredictable, (2) Uncontrollable, (3) Unseen, and (4) Unintelligible. Identifying these characteristics can contribute to a better understanding of fibromyalgia in addition to better treatment for these patients.

Fatigue in adults with primary antiphospholipid syndrome: findings from a mixed-methods study

Objective

This study aimed to explore the experience and impact of fatigue in adults with primary antiphospholipid syndrome (pAPS).

Methods

This sequential, explanatory mixed-methods study enrolled adults with a six-month or more history of pAPS. Consenting participants completed the Functional Assessment of Chronic Illness Therapy–Fatigue subscale (FS), Multi-Dimensional Perceived Social Support Scale, Patient Health Questionnaire (PHQ9), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire (IPAQMETS). Relationships between FS and other variables were explored with multiple linear regression. Interviews were conducted with a subgroup of participants, and the data were analysed thematically.

Results

A total of 103 participants were recruited (M_age = 50.3 years; standard deviation = 10.1 years; 18 males). Of these, 62% reported severe fatigue. Greater fatigue was associated with lower mood, physical inactivity, poorer sleep quality and lower perceived social support. The best-fit model explained 56% of the variance in FS (adjusted R² = 0.560, F(3, 74) = 33.65, p > 0.001) and included PHQ9 and IPAQMETS as significant predictors, and PSQI as a non-significant predictor. Twenty participants completed interviews. Three key themes were identified: characteristics of fatigue, impact on life and coping strategies.

Conclusion

Fatigue was a common symptom of pAPS and challenging to manage. Other factors, particularly mood and physical activity, influenced fatigue. Evidence-based self-management interventions are needed.

Insight into the Quality of Life of Patients with Ankylosing Spondylitis: Real-World Data from a US-Based Life Impact Survey

INTRODUCTION

We aim to assess the real-world, US patient-reported impact of ankylosing spondylitis (AS) on quality of life (QOL) across physical, discomfort, social, and emotional domains.

METHODS

Demographic and QOL data were collected from a random sample of patients associated with the Spondylitis Association of America (SAA) from July to December 2017. QOL measures were based on the Evaluation of Ankylosing Spondylitis Quality of Life (EASi-QoL) questionnaire. The survey evaluated AS impact on the physical domain on the day of survey participation and impact on the discomfort, social, and emotional domains within the week before participation. A 3:1 (male to female) weighting was performed to reflect the reported prevalence of AS in US adults.

RESULTS

Of 820 respondents who completed the survey, 716 self-reported receiving an AS diagnosis from their doctor and were included in this analysis (mean age, 55.5 years; 46.9% male). The mean total EASi-QoL score was 28.9 (weighted); overall, 33.7%, 31.7%, and 34.7% of respondents, respectively, reported a low (EASi-QoL score 0-17), a medium (18-35), and a high (≥ 36) impact of AS on QOL. The physical domain was most impacted; 41.9% of respondents had an EASi-QoL score ≥ 10 (weighted). Women were significantly more likely than men to report a high impact of AS on all QOL domains. Biologic users reported an impact on QOL comparable with the impact on QOL of nonsteroidal anti-inflammatory drug use. AS also impacted lifestyle characteristics, including career choice and sports participation.

CONCLUSION

AS negatively impacted all QOL domains analyzed. The incorporation of subjective measures of disease into disease evaluation should be considered.

FUNDING

Novartis Pharmaceuticals Corporation and UCB, Inc. Plain language summary available for this article.

Sleep disturbances in ankylosing spondylitis: a systematic review and meta-analysis

The aim of this meta-analysis was to compare sleep outcomes of AS patients and controls. Six electronic databases were searched: PubMed, Embase, IndMed, Cochrane Library, CNKI and Web of Science. Statistical analyses were executed using Revman 5.3 software. Nine studies and a total of 3169 participants were included in the meta-analysis. When sleep was assessed using PSQI, significant differences were observed in subjective sleep quality, sleep latency, sleep efficiency, sleep disorders, sleep medication use and total PSQI between patients with AS and controls, and subjective sleep quality was most severely affected. In PSG, eight variables of sleep quality (stage I sleep, stage II sleep, slow wave sleep, rapid eye movement, arousal index, periodic leg movement index, sleep latency, sleep efficiency) were lower in AS patients than in controls. Three variables of sleep quality assessed by USI (estimated sleep time, sleep sufficiency index, number of awakenings per night) and two variables of sleep quality assessed by MOS sleep scale (sleep disturbance scale, sleep problem index II) were lower in AS patients than in controls. It indicated that AS patients experience more serious sleep disorders. Early recognition and appropriate interventions are essential to improve patients' sleep quality.

Healthcare Provider Advice to Engage in Walking Regimens and Adherence in Women With Fibromyalgia

PURPOSE

The aim of the study was to analyze the profile of fibromyalgia patients receiving medical advice to walk and who complied with the advice according to a specific clinical pattern. A further aim has been to analyze the elements that increase adherence to walking.

DESIGN

A cross-sectional study with 920 women with fibromyalgia.

METHODS

Sociodemographic and clinical variables, walking behavior, and medical advice to walk were assessed.

FINDINGS AND CONCLUSIONS

Patients who adhere to walking have a lower likelihood of being tired. Regular walkers (patients who walk according to a specific clinical pattern) have a lower likelihood of comorbidity. Patients who receive medical advice to walk are more likely to walk more than 30 minutes and to take a break between bouts.

CLINICAL RELEVANCE

Nurses caring for people with fibromyalgia should include strategies to promote walking, especially in patients with low adherence profiles, paying attention to all elements of behavior.

Quality and acceptability of patient-reported outcome measures used to assess fatigue in axial spondyloarthritis (axSpA): a systematic review (protocol)

BACKGROUND

The prevalence of axial spondyloarthritis (axSpA) is estimated between 0.15 and 1.2%, with many of those patients experiencing severe fatigue. Current axSpA assessment guidance recommends use of a single-item visual analogue scale for fatigue severity. However, concerns have been raised about the ability of such a limited assessment to identify patients with major fatigue, to detect important change in fatigue or to reflect the multi-dimensional nature of fatigue. The proposed systematic review will identify and evaluate the quality and acceptability of single- and multi-item patient-reported outcome measures (PROMs) used to assess fatigue in axSpA, seeking to make recommendations for the 'best' measures for research and/or clinical practice.

METHODS/DESIGN

The review will seek to include published studies which report evidence of the development and/or measurement and/or practical properties of clearly defined and reproducible measures of fatigue following completion by patients with axSpA. Five major databases will be searched from 1980 to August 2017: MEDLINE (OVID), EMBASE (OVID), PsycINFO (OVID), World of Science and CINAHL. Study methodological quality will be assessed against the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The measurement and/or practical properties of reviewed measures will be assessed against current international standards. A short list of the 'best'-quality PROMs will be produced. The review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DISCUSSION

This study will provide the first robust and transparent evaluation of patient-reported measures of fatigue used in the axSpA population, synthesising evidence of quality, relevance and acceptability. The review will benefit patients, clinicians, health professionals and researchers wishing to enhance axSpA-fatigue assessment in routine practice, service evaluation and research. The findings will impact future research which seeks to better understand the nature of axSpA fatigue and evaluate the relative benefit of fatigue-management strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016042271.

Assessing fatigue in adults with axial spondyloarthritis: a systematic review of the quality and acceptability of patient-reported outcome measures

Objective

The aim was to evaluate the quality and acceptability of patient-reported outcome measures used to assess fatigue in patients with axial spondyloarthritis.

Methods

A two-stage systematic review of major electronic databases (1980–2017) was carried out to: (i) identify measures; and (ii) identify evaluative studies. Study and measurement quality were evaluated following international standards. Measurement content was appraised against a conceptual model of RA-fatigue.

Results

From 387 reviewed abstracts, 23 articles provided evidence for nine fatigue-specific measures: 6 multi-item and 3 single-item. No axial spondyloarthritis-fatigue-specific measure was identified. Evidence of reliability was limited, but acceptable for the Multi-dimensional Fatigue Inventory (internal consistency, test–retest) and Short Form 36-item Health Survey Vitality subscale (SF-36 VT; internal consistency). Evidence of construct validity was moderate for the Functional Assessment of Chronic Illness Therapy-Fatigue and 10 cm visual analog scale, limited for the SF-36 VT and not available for the remaining measures. Responsiveness was rarely evaluated. Evidence of measurement error, content validity or structural validity was not identified. Most measures provide a limited reflection of fatigue; the most comprehensive were the Multi-dimensional Assessment of Fatigue, Multi-dimensional Fatigue Inventory-20, Functional Assessment of Chronic Illness Therapy-fatigue and Fatigue Severity Scale.

Conclusion

The limited content and often poor quality of the reviewed measures limit any clear recommendation for fatigue assessment in this population; assessments should be applied with caution until further robust evidence is established. Well-developed, patient-derived measures can provide essential evidence of the patient’s perspective to inform clinical research and drive tailored health care. The collaborative engagement of key stakeholders must seek to ensure that future fatigue assessment is relevant, acceptable and of high quality.

The Experience of Persons With Multiple Sclerosis Using MS INFoRm: An Interactive Fatigue Management Resource

We aimed to understand participants' experiences with a self-guided fatigue management resource, Multiple Sclerosis: An Interactive Fatigue Management Resource ( MS INFoRm), and the extent to which they found its contents relevant and useful to their daily lives. We recruited 35 persons with MS experiencing mild to moderate fatigue, provided them with MS INFoRm, and then conducted semistructured interviews 3 weeks and 3 months after they received the resource. Interpretive description guided the analysis process. Findings indicate that participants' experience of using MS INFoRm could be understood as a process of change, influenced by their initial reactions to the resource. They reported experiencing a shift in knowledge, expectations, and behaviors with respect to fatigue self-management. These shifts led to multiple positive outcomes, including increased levels of self-confidence and improved quality of life. These findings suggest that MS INFoRm may have a place in the continuum of fatigue management interventions for people with MS.

Chronicity and use of health services: peer education of the School of Patients

OBJECTIVE

To evaluate the impact of the training strategy of the Escuela de Pacientes (School of Patients) on the use of health services among people with chronic diseases.

METHOD

Quantitative design study of pretest and posttest evaluation with a population of 3,350 chronic patients of the Escuela de Pacientes (Andalusia, 2013-2015). A questionnaire adapted from the Stanford University was used. It measured the self-perceived health, number of health visits, and level of trust and communication with health personnel. A descriptive and bivariate study, a correlation study and a pretest/posttest net gain analysis were performed.

RESULTS

Participation of 964 patients (28.8% of the population), of which 18.8% were men, mean age 56 years. Training increased trust in Primary Care (PC) and Hospital Care (HC) professionals (0.44 and 0.65 points), medical visits decreased by 25%, and hospital admissions fell by 51% with statistically significant differences by sex and disease. The correlation index between trust in professionals and use of health services was -0.215.

CONCLUSION

The training strategy had a positive impact on the use of health services and trust in health professionals, and were identified areas of improvement from which recommendations are established.

Exploring the patient perspective of fatigue in adults with visual impairment: a qualitative study

OBJECTIVES

Fatigue is an often mentioned symptom by patients with irreversible visual impairment. This study explored the patient perspective of fatigue in visually impaired adults with a focus on symptoms of fatigue, causes, consequences and coping strategies.

SETTING

Two large Dutch low vision multidisciplinary rehabilitation organisations.

PARTICIPANTS

16 visually impaired adults with severe symptoms of fatigue selected by purposive sampling.

METHODS

A qualitative study involving semistructured interviews. A total of four first-level codes were top-down predetermined in correspondence with the topics of the research question. Verbatim transcribed interviews were analysed with a combination of a deductive and inductive approach using open and axial coding.

RESULTS

Participants often described the symptoms of fatigue as a mental, daily and physical experience. The most often mentioned causes of fatigue were a high cognitive load, the intensity and amount of activities, the high effort necessary to establish visual perception, difficulty with light intensity and negative cognitions. Fatigue had the greatest impact on the ability to carry out social roles and participation, emotional functioning and cognitive functioning. The most common coping strategies were relaxation, external support, socialising and physical exercise and the acceptance of fatigue.

CONCLUSIONS

Our results indicate that low vision-related fatigue is mainly caused by population specific determinants that seem different from the fatigue experience described in studies with other patient populations. Fatigue may be central to the way patients react, adapt and compensate to the consequences of vision loss. These findings indicate a need for future research aimed at interventions specifically tailored to the unique aspects of fatigue related to vision loss.

Effect of the cooling suit method applied to individuals with multiple sclerosis on fatigue and activities of daily living

AIMS AND OBJECTIVES

To determine the effects of cooling suit on fatigue and activities of daily living of individuals with multiple sclerosis.

BACKGROUND

Fatigue is one of the most common symptoms in people with multiple sclerosis and adversely affects their activities of daily living. Studies evaluating fatigue associated with multiple sclerosis have reported that most of the fatigue cases are related to the increase in body temperature and that cooling therapy is effective in coping with fatigue.

DESIGN

This study used a two sample, control group design.

METHODS

The study sample comprised 75 individuals who met the inclusion criteria. Data were collected with study forms. After the study data were collected, cooling suit treatment was administered to the experimental group. During home visits paid at the fourth and eighth weeks after the intervention, the aforementioned scales were re-administered to the participants in the experimental and control groups.

RESULTS

The analyses performed demonstrated that the severity levels of fatigue experienced by the participants in the experimental group wearing cooling suit decreased. The experimental group also exhibited a significant improvement in the participants' levels of independence in activities of daily living.

CONCLUSIONS

The cooling suit worn by individuals with multiple sclerosis was determined to significantly improve the participants' levels of fatigue and independence in activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

The cooling suit therapy was found to be an effective intervention for the debilitating fatigue suffered by many multiple sclerosis patients, thus significantly improving their level of independence in activities of daily living.

A systematic review of quality-of-life domains and items relevant to patients with spondyloarthritis

OBJECTIVES

To summarize, from the literature, quality-of-life (QoL) domains and items relevant to patients with spondyloarthritis (SpA), and to determine if commonly used SpA patient-reported outcome (PRO) instruments include the identified domains.

METHODS

We used PRISMA statement for systematic review and searched Medline^® , Embase^®, and PsycInfo^® using relevant keywords. In addition, hand searches of references of the included articles were conducted. All articles were reviewed for inclusion by 2 independent reviewers. QoL domains and items relevant to patients with axial or peripheral SpA were extracted and presented using the adapted World Health Organization Quality-of-Life (WHOQOL) domain framework. SpA PROs were assessed to determine if they included the domains identified.

RESULTS

We retrieved 14,343 articles, of which 34 articles fulfilled inclusion criteria for review. Twenty-five articles were conducted in the European population. Domains such as negative feelings and activities of daily living were found to be present in 28 and 27 articles, respectively. SpA impacted QoL in all domains of the adapted WHOQOL framework. Domains that differed between types of SpA were financial resources, general levels of independence and medication side effects. Embarrassment, self-image, and premature ageing were items that differed by geographical setting. PROs to capture domains for peripheral SpA were similar for axial SpA.

CONCLUSIONS

We found that a wide range of domains and items of QoL were relevant to patients with SpA with minimal differences between patients with axial and peripheral SpA. Clinicians may consider using peripheral SpA PROs to measure QoL of patients with axial SpA.

Using health promotion guidelines for persons with disabilities to develop and evaluate a physical activity program for individuals with multiple sclerosis: A feasibility study

The Health Education for Persons with Multiple Sclerosis (HEMS) program was developed in response to the need for interventions aimed at increasing physical activity for individuals with Multiple Sclerosis (MS). It was developed and evaluated using Drum and colleagues (2009) guidelines for implementing health promotion programs for individuals with disabilities. The purpose of this feasibility study is to describe the development, implementation, and evaluation of the HEMS program. Thirteen individuals with MS completed the 8-week health education program. A mixed method approach for evaluation was implemented (i.e., survey and focus groups). Process and resource feasibility demonstrated that over half of the participants attended at least 80% of the weekly sessions. Focus group data provided valuable feedback for future iterations of the program including critiques on the delivery, content, and group support provided. Outcome evaluation showed increases in self-efficacy (survey), improvements in theoretical constructs (focus groups), and increased physical activity (focus groups). Results show that health promotion programs for persons with MS can improve physical activity and related constructs. Next steps will be to revise, implement, and reevaluate the HEMS program in a larger randomized control trial.

Prevalence and factors associated with disturbed sleep in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a systematic review

This review explores the prevalence and factors associated with disturbed sleep for patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis in order to clarify consistent findings in this otherwise disparate research field. The association of physical, demographic and psychological factors correlating with poor sleep was explored, and the effectiveness of interventions assessed. Ten electronic databases were searched: AMED, CINAHL, Embase, Medline, PsycINFO, PubMed, Scopus, Web of Science, OpenGrey and BASE. Following application of inclusion and exclusion criteria, 29 articles were critically assessed on the basis of methodology, experimental design, ethics and quality of sleep data, leading to the selection of 15 studies for final review. Poor sleep was reported in 35-90% of patients with axial spondyloarthritis and is more prevalent within this clinical population compared to healthy control subjects. Disturbed sleep is an important aspect of disease for patients and reflects the severity of disease activity, pain, fatigue and functional disability. However, the direction of this relationship is undetermined. Associations with age, gender, years spent in education, quality of life and depression have also been demonstrated. Anti-TNF medication is effective in reducing poor sleep, and exercise has also produced beneficial results. Future research into poor sleep should take account of its multifactorial nature. There is also a current lack of research investigating non-pharmacological interventions or combination therapies. A standardised, validated measurement of poor sleep, appropriate for regular patient screening, would be a useful first step for future research.

Clinical Utility of Mindfulness Training in the Treatment of Fatigue After Stroke, Traumatic Brain Injury and Multiple Sclerosis: A Systematic Literature Review and Meta-analysis

BACKGROUND

Fatigue is a common symptom following neurological illnesses and injuries, and is rated as one of the most debilitating sequela in conditions such as stroke, traumatic brain injury (TBI), and multiple sclerosis (MS). Yet effective treatments are lacking, suggesting a pressing need for a better understanding of its etiology and mechanisms that may alleviate the symptoms. Recently mindfulness-based interventions have demonstrated promising results for fatigue symptom relief.

OBJECTIVE

Investigate the efficacy of mindfulness-based interventions for fatigue across neurological conditions and acquired brain injuries.

MATERIALS AND METHODS

Systematic literature searches were conducted in PubMed, Medline, Web of Science, and PsycINFO. We included randomized controlled trials applying mindfulness-based interventions in patients with neurological conditions or acquired brain injuries. Four studies (N = 257) were retained for meta-analysis. The studies included patients diagnosed with MS, TBI, and stroke.

RESULTS

The estimated effect size for the total sample was -0.37 (95% CI: -0.58, -0.17).

CONCLUSION

The results indicate that mindfulness-based interventions may relieve fatigue in neurological conditions such as stroke, TBI, and MS. However, the effect size is moderate, and further research is needed in order to determine the effect and improve our understanding of how mindfulness-based interventions affect fatigue symptom perception in patients with neurological conditions.

Walking Beliefs in Women With Fibromyalgia: Clinical Profile and Impact on Walking Behavior

Although exercise is essential for the treatment of fibromyalgia, adherence is low. Walking, as a form of physical exercise, has significant advantages. The aim of this article is to describe, in 920 women with fibromyalgia, the prevalence of certain walking beliefs and analyze their effects both on the walking behavior itself and on the associated symptoms when patients walk according to a clinically recommended way. The results highlight the high prevalence of beliefs related to pain and fatigue as walking-inhibitors. In the whole sample, beliefs are associated with an increased perception that comorbidity prevents walking, and with higher levels of pain and fatigue. In patients who walk regularly, beliefs are only associated with the perception that comorbidity prevents them from walking. It is necessary to promote walking according to the established way (including breaks to prevent fatigue) and to implement interventions on the most prevalent beliefs that inhibit walking.

Patient-physician discordance in global assessment in early spondyloarthritis and its change over time: the DESIR cohort

Objective

To assess patient-physician discordance in global assessment of disease activity in early axial spondyloarthritis (axSpA) over time and determinants of discordance.

Methods

DESIR (Devenir des Spondyloarthropathies Indifférenciées Récentes) is a French, multicentre, longitudinal cohort of patients with early inflammatory back pain suggestive of axSpA. Patient global assessment (PGA) and physician global assessment (PhGA) were rated with a 0–10 numerical rating scale, every 6 months during 2 years then at 3 years. Discordance was defined by the absolute difference |PGA–PhGA|≥3 (range 0–10) and was analysed at each visit. Determinants of (PGA−PhGA) were assessed at the visit level by a generalised linear mixed model.

Results

A total of 702 patients were analysed at baseline (401 with complete data over 3 years): mean age 33.8±8.6 years, 379 (54.0%) female, mean symptom duration 18.1±10.5 months. Mean PGA values were always higher than mean PhGA values with a mean absolute difference of 1.8 points. At baseline, 202 (28.8%) patients had discordance mainly by PGA>PhGA; over 3 years the frequency of discordance was stable (range 25.5–28.8%). Discordance was not stable at the patient level, 118 (29.4%) patients were discordant once and 88 (22.0%) twice, and only 92 (22.9%) more than twice. Determinants of (PGA−PhGA) were spine pain (β=0.24, p<0.001) and fatigue (β=0.13, p<0.001).

Conclusions

Discordance concerned a quarter of patients with early axSpA. Over 3 years of follow-up, discordance did not decrease (no ‘reference shift’). Discordance was not a stable trait, indicating discordance is not a patient characteristic.

Exploring strategies used following a group-based fatigue management programme for people with multiple sclerosis (FACETS) via the Fatigue Management Strategies Questionnaire (FMSQ)

OBJECTIVES

To explore cross-sectional patterns of use of fatigue management strategies in people with multiple sclerosis (MS) who had attended a group-based fatigue management programme, Fatigue: Applying Cognitive behavioural and Energy effectiveness Techniques to lifeStyle ('FACETS'). In a multicentre randomised controlled trial (RCT) the FACETS programme was shown to reduce fatigue severity and improve self-efficacy and quality of life.

DESIGN

A questionnaire substudy within a RCT involving the self-completed Fatigue Management Strategies Questionnaire (FMSQ). The FMSQ includes: (1) closed questions about the use and helpfulness of fatigue management strategies taught in FACETS and (2) open items about changes to lifestyle, attitudes or expectations, barriers or difficulties encountered and helpful strategies not covered in FACETS.

PARTICIPANTS

All had a clinical diagnosis of MS, significant fatigue, were ambulatory and had attended at least 4 of 6 scheduled FACETS sessions.

METHODS

Participants (n=72) were posted the FMSQ with a prepaid return envelope 4 months after the end of the FACETS programme.

RESULTS

82% (59/72) of participants returned the FMSQ. The fatigue management strategies most frequently used since attending FACETS were prioritisation (80%), pacing (78%), saying no to others (78%), grading tasks (75%) and challenging unhelpful thoughts (71%). Adding in those participants who were already using the respective strategies prior to FACETS, the three most used strategies at 4 months were prioritisation (55/59), grading (54/59) and pacing (53/58). Free-text comments illustrated the complex interplay between attitudes/expectations, behaviours, emotions and the environment. Issues related to expectations featured strongly in participants' comments. Expectations (from self and others) were both facilitators and barriers to effective fatigue management.

CONCLUSIONS

Individuals' comments highlighted the complex, multifaceted nature of fatigue management. Revising expectations and a greater acceptance of fatigue were important shifts following the programme. Findings support the relevance of a cognitive behavioural approach for fatigue management. Booster sessions might be a useful addition to the FACETS programme.

TRIAL REGISTRATION NUMBER

Current controlled trials ISRCTN76517470; Results.