Conceptualising post-stroke fatigue: a cross-sectional survey of UK-based physiotherapists and occupational therapists

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.

Exploring experiences of people with stroke and health professionals on post-stroke fatigue guidance: getting the right people to the right care at the right time

PURPOSE

This focus group study aimed to explore experiences and perceptions on post-stroke fatigue guidance in Dutch rehabilitation and follow-up care among people/patients with stroke and health professionals.

METHODS

Ten persons with stroke and twelve health professionals with different professions within stroke rehabilitation or follow-up care in the Netherlands were purposively sampled and included. Eight online focus group interviews were conducted. We analysed the data using reflexive thematic analysis.

RESULTS

Three themes were identified. Guidance in fatigue management did not always match the needs of people/patients with stroke. Professionals were positive about the provided fatigue guidance (e.g. advice on activity pacing), but found it could be better tailored to the situation of people/patients with stroke. Professionals believe the right time for post-stroke fatigue guidance is when people/patients with stroke are motivated to change physical activity behaviour to manage fatigue - mostly several months after stroke - while people/patients with stroke preferred information on post-stroke fatigue well before discharge. Follow-up care and suggestions for improvement described that follow-up support after rehabilitation by a stroke coach is not implemented nationwide, while people/patients with stroke and professionals expressed a need for it.

CONCLUSIONS

The study findings will help guide improvement of fatigue guidance in stroke rehabilitation programmes and stroke follow-up care aiming to improve physical activity, functioning, participation, and health.

Managing Post-Stroke Fatigue Using a Mobile Health Called iHealth After Intracerebral Hemorrhage

Background

Post-stroke Fatigue (PSF) after Intracerebral Hemorrhage (ICH) is a long-term symptom in stroke survivors. However, the pathogenesis of PSF remains inadequately understood and sufficient evidence-based treatments are lacking. Mobile health (mHealth) technology offers a promising approach to expanding access to high-quality and culturally tailored evidence-based mental care.

Aim

This study examined the role of mHealth called iHealth in the management of PSF after ICH.

Methods

A total of 225 patients diagnosed with intracerebral hemorrhage (ICH) were included in the study and randomly assigned to either the Mobile Health Intervention Group (mHI Group) or the non-Mobile Health Intervention Group (non-mHI). The management involved the utilization of a digital healthcare application named iHealth, which incorporated digital questionnaires, fatigue scale tests, and online videos for the purpose of administering the Patient Fatigue Reporting Measurement Information System (PFRMIS) short form as part of the initial patient assessment following ICH. The study was conducted remotely via video conferencing over a 12-week period in mHI Group, with fatigue assessments being conducted 3 months post-ICH onset in two groups.

Results

Following the administration of PSF by iHealth, Univariate Logistic analyses indicated a significant association between fatigue and the type of activity, with patients who were sedentary or did nothing experiencing higher levels of fatigue (β=2.332, p<0.001; β=2.517, p<0.001). Multivariate Logistic analyses demonstrated a positive association between the intensity of physical activity and decreased emotional well-being and family support, as well as increased fatigue. (p=0.001, p=0.002, p=0.001). The FSS results demonstrated a significantly reduced incidence of PSF in the MHI group in comparison to non-mHI group following the conclusion of the programme. (13.1% vs 40%, p<0.001).

Conclusion

This study explored the effectiveness of the iHealth app for PSF following ICH, indicating that iHealth is a clinically valuable tool that warrants further dissemination.

Perceptions of Post-Stroke Fatigue among Health Care Practitioners: A Qualitative Interview Study

Background and Objectives: Post-Stroke Fatigue (PSF) is a complex, multidimensional, debilitating condition that affects almost half of all stroke survivors. This study explored the perceptions of physiatrists, physiotherapists, and occupational therapists about PSF and their experiences in managing patients with PSF in Saudi Arabia. Materials and Methods: Qualitative semi-structured interviews were conducted with participants from three different groups: eight physiotherapists (PTs), eight occupational therapists (OTs), and eight physiatrists (DRs). Using purposive sampling, participants with at least one year of experience in the field of PSF management were invited to take part. The data were analysed using inductive thematic analysis. Results: Twenty-four health care participants (eight PTs, eight OTs, eight DRs) were recruited. Five overarching themes encompassing various subthemes and sub-subthemes were generated: 'knowledge about post-stroke fatigue', 'diagnosing post-stroke fatigue', 'treatment approach', 'lack of awareness about post-stroke fatigue', and 'domains to improve'. The data indicated that participants used various strategies to manage PSF, including dietary changes, sleep hygiene, exercise, and energy conservation. Conclusions: Participants acknowledged that they lacked PSF-related management skills, despite possessing adequate knowledge about the management of stroke. Their openness to participating in activities that would improve their ability to diagnose and manage PSF was particularly striking.

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.

A New Wrist-Forearm Rehabilitation Protocol Integrating Human Biomechanics and SVM-Based Machine Learning for Muscle Fatigue Estimation

In this research, a new remote rehabilitation system was developed that integrates an IoT-based connected robot intended for wrist and forearm rehabilitation. In fact, the mathematical model of the wrist and forearm joints was developed and integrated into the main controller. The proposed new rehabilitation protocol consists of three main sessions: the first is dedicated to the extraction of the passive components of the dynamic model of wrist-forearm biomechanics while the active components are extracted in the second session. The third session consists of performing continuous exercises using the determined dynamic model of the forearm-wrist joints, taking into account the torque generated by muscle fatigue. The main objective of this protocol is to determine the state level of the affected wrist and above all to provide a dynamic model in which the torque generated by the robot and the torque supplied by the patient are combined, taking into account the constraints of fatigue. A Support Vector Machine (SVM) classifier is designed for the estimation of muscle fatigue based on the features extracted from the electromyography (EMG) signal acquired from the patient. The results show that the developed rehabilitation system allows a good progression of the joint's range of motion as well as the resistive-active torques.

Scoping review of molecular biomarkers associated with fatigue, stress, and depression in stroke survivors: A protocol

The prevalence of stroke increases each year and while mortality from stroke has decreased, the prevalence of comorbidities such as anxiety, depression and fatigue affects as many as 75% of stroke survivors. The aetiology of post-stroke fatigue is not clear, although it has been shown to be interrelated with comorbidities such as stress and depression. Due to the interconnected nature of these comorbidities, it is important to improve the specificity of diagnosis and identify novel therapeutic targets to improve the quality of life for stroke survivors. The investigation of molecular biomarkers associated with post-stroke stress, fatigue, and depression may shed light on the relationships between comorbidities and also contribute to the development of novel diagnostics and therapies. Several biomarkers have been identified for stress, depression, and fatigue, some of which are specific to stroke survivors. However, there remain several gaps in understanding, particularly in relation to the physiological mechanisms underlying these side effects and molecular biomarkers associated with post-stroke fatigue. The aim of this scoping review protocol is to outline the methodologies that will be used to provide a comprehensive understanding of the current literature on biomarkers associated with post-stroke fatigue, stress, and depression, informing future research questions.

Online advice for the symptomatic management of post-stroke fatigue: A scoping review

BACKGROUND

Limited medical evidence for managing post-stroke fatigue leads stroke survivors to seek information through other sources. This scoping review aimed to identify and assess the range and quality of web-based recommendations for managing post-stroke fatigue.

METHODS

Publicly accessible websites providing advice for post-stroke fatigue management were considered for review using the Joanna Briggs Institute's methodology. Using the search term "fatigue stroke", the first two pages of results from each search engine (Google, Yahoo, and Bing) were assessed against predetermined criteria. Findings were reported in accordance with PRISMA-ScR checklist. Quality and readability were also assessed.

RESULTS

Fifty-seven websites were identified; 16 primary and 11 linked websites met the inclusion criteria and demonstrated moderate to high quality and high readability. Primary websites were curated by non-government organizations (n = 10/16), companies (n = 4/16) or were media and blog websites (n = 2/16). Additional resources were provided on linked websites. All websites provided non-pharmacological advice, with four also describing pharmacological management. Many websites included advice related to physical activity modification (n = 18/27) and energy conservation strategies (e.g. activity prioritization, planning, pacing) (n = 26/27). Direction to seek health professional advice appeared frequently (n = 16/27).

CONCLUSIONS

The quality of publicly available web-based advice for people with post-stroke fatigue was moderate to high in most websites, with high readability. Energy conservation strategies and physical activity modification appear frequently. The general nature of the advice provided on most websites is supported by direction to healthcare professionals (i.e., clinical referral) who may assist in the practical individualization of strategies for managing post-stroke fatigue.

“I Give It Everything for an Hour Then I Sleep for Four.” The Experience of Post-stroke Fatigue During Outpatient Rehabilitation Including the Perspectives of Carers: A Qualitative Study

Background

Fatigue is a debilitating post-stroke symptom negatively impacting rehabilitation. Lack of acknowledgment from carers can be additionally distressing. The purpose of this study was to describe the experience of post-stroke fatigue during outpatient rehabilitation, including the perspectives of carers.

Methods

This qualitative study was guided by descriptive phenomenology within a constructivist paradigm. Semi-structured interviews were conducted with stroke survivors experiencing fatigue (Fatigue Assessment Scale >23) and attending outpatient rehabilitation. Carers were also interviewed where identified, providing insight into their own and stroke survivor experiences. Data were analyzed according to Colaizzi's analytic method.

Results

Fourteen stroke survivors (50% culturally and linguistically diverse), and nine carers participated. Six themes were identified: 1. The unpredictable and unprepared uncovering of fatigue; 2. Experience and adjustment are personal 3. Being responsible for self-managing fatigue; 4. The complex juggle of outpatient stroke rehabilitation with fatigue; 5. Learning about fatigue is a self-directed problem-solving experience; 6. Family and carers can support or constrain managing fatigue.

Conclusion

Despite engaging in outpatient rehabilitation, stroke survivors largely learnt to manage fatigue independent of healthcare professionals. Carers often facilitated learning, monitoring rehabilitation, daily routines and fatigue exacerbation. Conversely, family could be dismissive of fatigue and possess unrealistic expectations. Post-stroke fatigue must be considered by clinicians when delivering outpatient rehabilitation to stroke survivors. Clinicians should consistently screen for fatigue, provide flexible session scheduling, and educate about individual indicators and strategies for management. Clinicians should also explicitly engage carers who play a critical role in the management of fatigue.

UK clinical approaches to address post-stroke fatigue: findings from The Nottingham Fatigue after Stroke study

Background/Aims

Although post-stroke is common and debilitating, there is little published research on how it is managed by clinicians. The aim of this study was to document UK management of post-stroke fatigue and ascertain whether there are any differences in its management compared to fatigue arising from other conditions.

Methods

A cross-sectional survey was used with allied health professionals, psychologists, doctors and nurses working clinically in hospitals, the community or both, who routinely provided information, management or treatment to patients with fatigue. Questionnaires were designed and underwent pilot testing. Recruitment was conducted using healthcare professional networks, professional and condition special interest groups and social media, snowballing and personal emails targeting key professional experts.

Results

A total of 305 questionnaires were analysed; the majority of responses were from occupational therapists (56%, n=171). Although there were different opinions about whether post-stroke fatigue was the same as fatigue resulting from other conditions, the strategies suggested for both were similar. Post-stroke management included pacing (67%, n=204), which is spreading activities out during the day or week, keeping a fatigue diary (39%, n=119) and education (38%, n=117). There were variations in how support was offered, and marked variations in length of follow up; some services were flexible and could retain patients for up to 18 months, while others offered one session and no follow up.

Conclusions

People with post-stroke fatigue and fatigue arising from other conditions experience different levels of support to manage their fatigue, but the main strategies used in management are similar.

Managing post-stroke fatigue: A qualitative study to explore multifaceted clinical perspectives

Introduction

Post-stroke fatigue (PSF) is common and debilitating. However, while its effective management is a priority for clinicians and stroke survivors, there remains little evidence to provide guidance or underpin practice. Our aim, therefore, was to gain insights into the experiences of clinicians who routinely manage patients with fatigue.

Method

Qualitative interview study. The target was to recruit a purposeful sample of approximately 20 participants with expertise in managing PSF and fatigue arising from other conditions. Maximum variation sampling was used to ensure a balance of participants across different settings. Data were analysed using a framework approach, iteratively developed and refined by including emergent themes.

Results

We recruited 20 participants: nine occupational therapists (OTs), five physiotherapists, three nurses and three psychologists, which included three ‘fatigue experts’ from Europe and Australia. Analysis generated core themes around management and strategies used; these were similar regardless of professional background, clinical or geographical setting or condition treated. OTs felt a particular responsibility for fatigue management, although multidisciplinary teamwork was stressed by all.

Conclusion

There are clear similarities in clinicians’ experiences of managing PSF and fatigue across different conditions and also across professional groups. Clinicians rely predominantly on their own clinical knowledge for guidance.

Efficacy of Qigong Exercise for Treatment of Fatigue: A Systematic Review and Meta-Analysis

Objective: Several studies suggested that Qigong exercise (QE) can relieve fatigue in patients diagnosed with various diseases. Our review aimed to evaluate the efficacy of QE for alleviating fatigue. Methods: A related literature search was performed in the PubMed, Web of Science, Embase, Cochrane Library, China Biology Medicine disc (CBM), China National Knowledge Infrastructure (CNKI), Wanfang, and VIP data bases from inception to November 2020. Information on fatigue, malaise, tiredness, and Qigong research data was collected. Results: Sixteen randomized controlled trials (RCTs) were reported in patients with cancer (n = 4), chronic fatigue syndrome (n = 2), and other diseases (n = 10). The QE groups showed significant improvements in total fatigue intensity [15 RCTs, p < 0.00001; standard mean difference (SMD) -0.69 (-0.95 to -0.44)]. The QE groups did not show significant improvement in quality of life [4 RCTs, p = 0.08; SMD 0.53 (-0.07 to 1.14)]. The statistically significant difference of the subgroup analyses (different primary diseases, QE types, and study quality) also remained unchanged. Conclusion: The findings of this meta-analysis indicate that QE may be beneficial for improving fatigue in patients diagnosed with various diseases. Considering the limitations of the study, we draw a very cautious conclusion regarding the resulting estimate of the effect. Further studies are warranted to better understand the benefits of QE in primary medical care.

Developing a fatigue programme: Protocol for the Nottingham Fatigue After Stroke (NotFAST2) study

Introduction

Post-stroke fatigue is common and is one of the most distressing symptoms after stroke. It has a negative impact on physical, social and psychological functioning; it is also associated with poor outcomes and increased mortality. The effective management of post-stroke fatigue is therefore regarded as a clinical priority.

Method

This study will use a mixed-methods design with three overlapping phases. Phase 1 will be a survey of existing fatigue management within the United Kingdom. In phase 2, interviews and focus groups will be conducted with stroke survivors with fatigue, carers and clinicians to determine strategies used to manage fatigue successfully. In phase 3, data from phases 1 and 2 will contribute to the co-design of a fatigue management programme with the NotFAST2 study Patient and Public Involvement group. This will be further refined through subsequent focus groups, which will include those with fatigue associated with other health conditions.

Results

Survey data will be analysed using descriptive statistics. Interview and focus group data will be analysed using a framework approach.

Conclusion

Post-stroke fatigue requires a comprehensive management programme necessitating input from key stakeholders. A post-stroke fatigue programme will be developed which will be tested in a future randomised controlled trial.