Can the Fatigue Severity Scale 7-item version be used across different patient populations as a generic fatigue measure--a comparative study using a Rasch model approach

Comprehensive assessment and progression of health status during neurorehabilitation in survivors of critical illness: a prospective cohort study

BACKGROUND

Critical illness survivors frequently suffer from long-term impairments, often described as post-intensive care syndrome (PICS). PICS encompasses physical, cognitive, and mental impairments. Additionally, the term intensive care unit (ICU)-acquired weakness (ICUAW) was coined for muscle weakness after critical illness. Research on the progression and outcome of individuals affected by PICS and ICUAW is scant. Thus we aimed to assess the health status and its progression during neurorehabilitation in critically ill patients using comprehensive outcome measures, describe the prevalence of PICS, and evaluate factors associated with rehabilitation outcomes.

METHODS

Patients with mixed reasons for critical illness who received ≥ 5 days of mechanical ventilation on the ICU and who were admitted to neurorehabilitation, were eligible to be included in this prospective cohort study. A number of outcomes (patient-reported, clinician-reported, and performance) were assessed after discharge from the ICU (V1) and shortly before discharge from inpatient neurorehabilitation (V2). The prevalence of PICS, defined as having at least one impairment in any PICS dimension), was calculated at V1 and V2. Multiple logistic regressions were conducted to identify factors associated with rehabilitation outcome (poor outcome = modified Rankin Scale > 2) and ICUAW at V2 (MRC sum score < 48).

RESULTS

In total, 250 critical illness survivors (62 ± 14 years, 34% female, median stay on ICU 55 days, median inpatient rehabilitation 65 days) were included. 11 participants (4.4%) died before V2. All outcomes improved significantly during rehabilitation except sensory impairment and pain. PICS was present in 96% at V1 and in 85% at V2, whereby mainly the physical domain (V1: 87%, V2: 66%; ICUAW with MRC sum score < 48) and the cognitive domain (V1:65%, V2:55%; Montreal Cognitive Assessment < 26) were affected. Mental impairment was lower (V1:48%, V2:29%; Hospital Anxiety and Depression Scale > 7), but still affected a considerable number of participants. Accordingly, health-related quality of life was rather low at discharge (0.64 ± 0.28, index value of EQ-5D-5L). MRC sum score at V1, duration of mechanical ventilation, and female gender were significantly associated with a poor rehabilitation outcome. Grip strength in % of reference at V1, age, female gender, and comorbidities were significantly associated with persistent ICUAW at discharge.

CONCLUSIONS

Despite significant improvements during rehabilitation, survivors after critical illness experience a substantial burden of PICS and ICUAW at discharge from rehabilitation care. Survivors of critical illness require long-term follow-up, supportive structures, and tailored long-term multi-disciplinary therapies even after intensive rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00021753. Registered 03 September, 2020. https://drks.de/search/en/trial/DRKS00021753 .

Outcome, predictors and longitudinal trajectories of subjects with critical illness polyneuropathy and myopathy (CINAMOPS): study protocol of an observational cohort study in a clinical and post-clinical setting

INTRODUCTION

Critical illness polyneuropathy and myopathy (CIP/CIM) are frequent complications in the intensive care unit (ICU) with major consequences for the progress and outcome of subjects. CIP/CIM delays the weaning process, prolongs the hospital stay and increases the mortality rate. Additionally, it may have long-term consequences beyond the hospitalisation phase with prolonged disability. Even though there is growing interest in CIP/CIM, research about the clinical and post-clinical course as well as the middle-term and long-term outcomes of subjects with CIP/CIM is scarce. A large prospective study of critically ill subjects is needed with accurate diagnosis during the acute stage and comprehensive assessment during long-term follow-up.

METHODS AND ANALYSIS

This prospective observational cohort study aims to compare the clinical and post-clinical course of chronically critically ill subjects with and without the diagnosis of CIP/CIM and to determine predictors for the middle-term and long-term outcomes of subjects with CIP/CIM. In addition, the influence of the preclinical health status and the preclinical frailty on the long-term outcome of subjects with CIP/CIM will be investigated.This single-centre study will include 250 critically ill patients who were invasively ventilated for at least 5 days at the ICU and show reduced motor strength. At five study visits at admission and discharge to neurological rehabilitation, and 12, 18 and 24 months after disease onset, a comprehensive test battery will be applied including assessments of functioning and impairment, independence, health-related quality of life, activity and participation, cognition, gait and balance, fatigue, mental health and frailty.Secondary objectives are the documentation of therapy goals, therapy content and achieved milestones during the rehabilitation, to evaluate the clinimetric properties of the Mini-BESTest in critically ill patients, and to evaluate the time course and outcome of subjects with CIP/CIM after SARS-CoV-2 infection.

ETHICS AND DISSEMINATION

The study was approved by the ethical committee of the Ludwig-Maximilians University Munich. Participants will be included in the study after having signed informed consent.Results will be published in scientific, peer-reviewed journals and at national and international conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register (DRKS00021753).

Lesioned hemisphere-specific phenotypes of post-stroke fatigue emerge from motor and mood characteristics in chronic stroke

BACKGROUND AND PURPOSE

Post-stroke fatigue commonly presents alongside several comorbidities. The interaction between comorbidities and their relationship to fatigue is not known. In this study, we focus on physical and mood comorbidities, alongside lesion characteristics. We predict the emergence of distinct fatigue phenotypes with distinguishable physical and mood characteristics.

METHODS

In this cross-sectional observational study, in 94 first time, non-depressed, moderate to minimally impaired chronic stroke survivors, the relationship between measures of motor function (grip strength, nine-hole peg test time), motor cortical excitability (resting motor threshold), Hospital Anxiety and Depression Scale and Fatigue Severity Scale-7 (FSS-7) scores, age, gender and side of stroke was established using Spearman's rank correlation. Mood and motor variables were then entered into a k-means clustering algorithm to identify the number of unique clusters, if any. Post hoc pairwise comparisons followed by corrections for multiple comparisons were performed to characterize differences among clusters in the variables included in k-means clustering.

RESULTS

Clustering analysis revealed a four-cluster model to be the best model (average silhouette score of 0.311). There was no significant difference in FSS-7 scores among the four high-fatigue clusters. Two clusters consisted of only left-hemisphere strokes, and the remaining two were exclusively right-hemisphere strokes. Factors that differentiated hemisphere-specific clusters were the level of depressive symptoms and anxiety. Motor characteristics distinguished the low-depressive left-hemisphere from the right-hemisphere clusters.

CONCLUSION

The significant differences in side of stroke and the differential relationship between mood and motor function in the four clusters reveal the heterogenous nature of post-stroke fatigue, which is amenable to categorization. Such categorization is critical to an understanding of the interactions between post-stroke fatigue and its presenting comorbid deficits, with significant implications for the development of context-/category-specific interventions.

Reduced health-related quality of life, fatigue, anxiety and depression affect COVID-19 patients in the long-term after chronic critical illness

The term chronic critical illness describes patients suffering from persistent organ dysfunction and prolonged mechanical ventilation. In severe cases, COVID-19 led to chronic critical illness. As this population was hardly investigated, we evaluated the health-related quality of life, physical, and mental health of chronically critically ill COVID-19 patients. In this prospective cohort study, measurements were conducted on admission to and at discharge from inpatient neurorehabilitation and 3, 6, and 12 months after discharge. We included 97 patients (61 ± 12 years, 31% women) with chronic critical illness; all patients required mechanical ventilation. The median duration of ICU-treatment was 52 (interquartile range 36-71) days, the median duration of mechanical ventilation was 39 (22-55) days. Prevalences of fatigue, anxiety, and depression increased over time, especially between discharge and 3 months post-discharge and remained high until 12 months post-discharge. Accordingly, health-related quality of life was limited without noteworthy improvement (EQ-5D-5L: 0.63 ± 0.33). Overall, the burden of symptoms was high, even one year after discharge (fatigue 55%, anxiety 42%, depression 40%, problems with usual activities 77%, pain/discomfort 84%). Therefore, patients with chronic critical illness should receive attention regarding treatment after discharge with a special focus on mental well-being.Trial registration: German Clinical Trials Register, DRKS00025606. Registered 21 June 2021-Retrospectively registered, https://drks.de/search/de/trial/DRKS00025606 .

Effects of the royal jelly consumption on post-stroke complications in patients with ischemic stroke: results of a randomized controlled trial

Aims

There is a paucity of evidence regarding the benefit of royal jelly (RJ) on post-stroke complications in patients with ischemic stroke. To address this knowledge gap, this randomized, triple-blind, placebo-controlled clinical trial was carried out to determine the effects of RJ consumption on post-stroke clinical outcomes.

Methods

Of 64 eligible ischemic stroke patients (45-80 years), 32 were randomized to the RJ and 32 to the placebo groups and completed a 12-week intervention. The intervention group was advised to receive 1,000 mg of RJ dragee daily after breakfast. Post-stroke complications including cognition, fatigue, mental health, and appetite, along with serum levels of brain-derived neurotrophic factor (BDNF), and mid-upper arm circumference (MUAC) were assessed in groups pre-and post-intervention.

Results

After 12 weeks of RJ consumption, cognitive function [adjusted mean difference, 4.71; 95% confidence interval (CI), 1.75 to 7.67], serum levels of BDNF (adjusted mean difference, 0.36; 95% CI, 0.05 to 0.67), stress (adjusted mean difference, -3.33; 95% CI, -6.50 to -0.17), and appetite (adjusted mean difference, 1.38; 95% CI, 0.19 to 2.56) were significantly improved. However, the findings for fatigue (adjusted mean difference, -4.32; 95% CI, -10.28 to 1.63), depression (adjusted mean difference, -1.71; 95% CI, -5.58 to 2.16), anxiety (adjusted mean difference, -2.50; 95% CI, -5.50 to 0.49), and MUAC (adjusted mean difference, 0.36; 95% CI, -0.11 to 0.84) were less favorable.

Conclusion

Findings support the benefits of RJ consumption in improving post-stroke complications and clinical outcomes.Clinical trial registration: https://www.irct.ir/trial/59275, Identifier IRCT20180818040827N4.

Severe Post-COVID-19 Condition after Mild Infection: Physical and Mental Health Eight Months Post Infection: A Cross-Sectional Study

Severe acute COVID-19 infections requiring intensive care treatment are reported risk factors for the development of post-COVID-19 conditions. However, there are also individuals suffering from post-COVID-19 symptoms after mild infections. Therefore, we aimed to describe and compare the health status of patients who were initially not hospitalized and patients after critical illness due to COVID-19. The outcome measures included health-related quality of life (EQ-5D-5L, visual analogue scale (VAS)); mental health (hospital anxiety and depression scale (HADS)); general disability (WHODAS-12); and fatigue (Fatigue-Severity-Scale-7). Individuals were recruited at Schoen Clinic Bad Aibling, Germany. A total of 52 non-hospitalized individuals (47 ± 15 years, 64% female, median 214 days post-infection) and 75 hospitalized individuals (61 ± 12 years, 29% female, 235 days post-infection) were analyzed. The non-hospitalized individuals had more fatigue (87%) and anxiety (69%) and a decreased health-related quality of life (VAS 47 ± 20) compared to the hospitalized persons (fatigue 45%, anxiety 43%, VAS 57 ± 21; p < 0.010). Severe disability was observed in one third of each group. A decreased quality of life and disability were more pronounced in the females of both groups. After adjusting for confounding, hospitalization did not predict the burden of symptoms. This indicates that persons with post-COVID-19 conditions require follow-up services and treatments, independent of the severity of the acute infection.

Evaluating the psychometric properties of the fatigue severity scale using item response theory

BACKGROUND

Fatigue is a common daily experience and a symptom of various disorders. While scholars have discussed the use of the Fatigue Severity Scale (FSS) using item response theory (IRT), the characteristics of the Japanese version are not yet examined. This study evaluated the psychometric properties of the FSS using IRT and assessed its reliability and concurrent validity with a general sample in Japan.

METHODS AND MEASURES

A total of 1,007 Japanese individuals participated in an online survey, with 692 of them providing valid data. Of these, 125 participants partook in a re-test after approximately 18 days and had their longitudinal data analyzed. In addition, the graded response model (GRM) was used to assess the FSS items' characteristics.

RESULTS

The GRM's results recommended using seven items and a 6-point scale. The FSS's reliability was acceptable. Furthermore, the validity was adequate from the results of correlation and regression analyses. The synchronous effects models demonstrated that the Multidimensional Fatigue Inventory (MFI) enhanced depression, and depression enhanced FSS.

CONCLUSION

This study suggested that the Japanese version of the FSS should be a 7-item scale with a 6-point response scale. Further investigations may reveal the different aspects of fatigue assessed by the analyzed fatigue measures.

The effects of royal jelly supplementation on oxidative stress, inflammatory mediators, mental health, cognitive function, quality of life, and clinical outcomes of patients with ischemic stroke: study protocol for a randomized controlled trial

BACKGROUND

Stroke is a debilitating disease that affects over 15 million people worldwide each year, resulting in the death of one-third of those people and severe disability in two-thirds of survivors. Previous studies reported various health benefits of Royal jelly in the context of its anti-inflammatory properties. We will aim to investigate the effects of royal jelly supplementation on oxidative stress, inflammatory mediators, mental health, cognitive function, quality of life, and clinical outcomes of patients with ischemic stroke.

METHODS

The present study will be a triple-blind randomized placebo trial. Patients who meet our eligibility criteria will be assigned to the intervention or the control groups to receive allocated intervention for 12 weeks. Individuals of the intervention group will consume 1000 mg of Royal jelly dragee daily after breakfast. Subjects of the control group will receive a placebo dragee identical to the Royal jelly dragee. The severity of the stroke, cognitive function, mental health, quality of life, clinical outcomes, and biochemical measures will be assessed at baseline and post-intervention.

DISCUSSION

The current study is designed to investigate the effectiveness and safety of royal jelly supplementation in a randomized, parallel, two-arms, single-center, triple-blind, placebo-controlled manner. This study will provide evidence as a phase III clinical trial.

TRIAL REGISTRATION

IRCT20180818040827N4, registered on 16 October 2021. https://www.irct.ir/trial/59275.

Critical COVID-19 disease: Clinical course and rehabilitation of neurological deficits

BACKGROUND

The COVID-19 disease frequently causes neurological symptoms. Critically ill patients often require neurorehabilitation for manifestations like intensive care unit (ICU) acquired weakness or encephalopathy. The outcome of these patients, however, is largely unknown. Here we report the clinical course of critical affected COVID-19 patients from hospital admission to discharge from inpatient neurorehabilitation.

METHODS

Prospective cohort study. COVID-19 patients admitted to neurorehabilitation were included based on a laboratory-confirmed SARS-CoV-2 infection. Assessments [modified Rankin Scale (mRS), Barthel-Index, Fatigue-Severity-Scale-7 and health-related quality of life (EQ-5D-5L)] were conducted at admission and before discharge from inpatient care. Data were compared to the preclinical health status.

RESULTS

Sixty-one patients (62 ± 13 years, 16 female) were included in the analysis. Most patients had been treated on ICU (n = 58; 57 ± 23 days) and had received invasive ventilation (n = 57; 46 ± 21 days). After discharge from ICU, patients spent on average 57 ± 26 days in neurorehabilitation. The most frequent neurological diagnoses were ICU-acquired weakness (n = 56) and encephalopathy (n = 23). During rehabilitation overall disability improved [mRS median (IQR) 4.0 (1.0) at inclusion and 2.0 (1.0) at discharge]. However, the preclinical health state [mRS 0.0 (0.0)] was not regained (p < 0.001). This was also reflected by the Barthel-Index [preclinical 100.0 (0.0), at inclusion 42.5 (35.0), at discharge 65.0 (7.5); p < 0.001]. Patients had only minor fatigue during inpatient care. Quality of life generally improved but was still low at discharge from hospital.

CONCLUSION

Patients with neurological sequelae after critical COVID-19 disease showed substantial deficits at discharge from inpatient care up to 4 months after the initial infection. They were restricted in activities of daily living and had reduced health-related quality of life. All patients needed continued medical support and physical treatment.

The Silhouettes Fatigue Scale: a validity study with individuals with physical disabilities and chronic pain

PURPOSE

Fatigue is known to interfere with function in individuals with physical disabilities. In order to monitor changes in fatigue over time and evaluate the efficacy of treatments, psychometrically sound measures of fatigue are needed. The aim of this work was to evaluate the validity of the Silhouettes Fatigue Scale with English instructions (SFS-EN) in a sample of adults with physical disabilities living in the USA.

METHODS

Individuals with medical conditions associated with physical disabilities responded to an online survey that included the SFS-EN as well as another validated measure of fatigue (PROMIS short form-4a Fatigue Scale), and measures of pain intensity and pain catastrophizing.

RESULTS

523 individuals participated (mean age = 59.1 years; SD = 11.4). Most participants were Caucasian (89%), women (59%) and unemployed (71%). Results showed strong positive correlations between both measures of fatigue, supporting the convergent validity of the SFS-EN. In addition, the magnitude of this association was significantly greater than the association between the scores of the SFS-EN and the measures of pain intensity and pain catastrophizing, supporting the former's discriminant validity.

CONCLUSIONS

The findings extend previous results supporting the SFS as a brief, easy to administer and understand, and valid measure of fatigue.IMPLICATIONS FOR REHABILITATIONFatigue is common in adults with physical disabilities and chronic pain.The Silhouettes Fatigue Scale (SFS) is a new single-item measure of general fatigue.Findings show that the SFS with English instructions (SFS-EN) is an easy to understand measure.Results support the convergent and discriminant validity of the SFS-EN score in adults with physical disabilities and chronic pain.

Resilience and Its Association With Activities of Daily Living 3 Months After Stroke

Independence in basic activities of daily living (ADL) is an important outcome after stroke. Identifying factors associated with independence can contribute to improve post-stroke rehabilitation. Resilience, which is the ability of coping with a serious event, might be such a factor. Still, the impact of resilience and its role in rehabilitation after stroke is poorly investigated. Hence, the purpose of this study was to assess whether resilience assessed early after stroke can be associated with independence in basic ADL 3 months later. Hospitalized patients with a diagnosed acute stroke and a modified Rankin Scale score ≤ 4 were included. Bivariate and multivariate linear regression were applied to assess whether resilience as measured by the Brief Resilience Scale within the first 2 weeks after stroke was associated with basic ADL measured by Barthel Index at 3-month follow-up. Age, sex, fatigue, stroke severity at admission and pre-stroke disability were added as covariates. Sixty-four participants (35 (54.7%) male), aged 75.9 (SD 8.6) years were included 4.3 (SD 2.8) days after stroke. There was no significant change in resilience from baseline 3.1 (SD 0.3) to 3 months later 3.2 (SD 0.5). Resilience was not associated with basic ADL in neither the bivariate (b = 2.01, 95% CI −5.21, 9.23, p = 0.580) nor in the multivariate regression models (b = 0.50, 95% CI −4.87, 6.88, p = 0.853). Our results showed that resilience remained stable during follow-up. Early measurement of resilience was not associated with independence in basic activities of daily living 3 months after stroke. These results, indicate that resilience is a personal trait not associated with the outcome of physical adversity. However, future research should investigate whether resilience is related to the outcomes of psychosocial adversity after a stroke.

Rasch analysis of fatigue severity scale in patients with epilepsy

OBJECTIVE

To utilize the Rasch model to validate and assess the psychometric properties of the Fatigue Severity Scale (FSS) in patients with epilepsy.

METHODS

A total of 307 patients (age > 18 years) with a confirmed diagnosis of epilepsy were consented to participate. Exclusion criteria included patients with psychogenic nonepileptic events, cognitive disabilities, and patients who did not speak/understand English. The nine-step FSS was programmed into software administered to patients on electronic tablets, and patient responses were auto-scored. The Rasch rating scale model (RSM) was used to evaluate the unidimensionality, reliability, and targeting of the FSS. To assess unidimensionality, we examined infit and outfit mean squares. We also assessed unidimensionality of the FSS using a principal component analysis of Rasch residuals, where residuals are understood as the difference between observed and expected data values. We evaluated the internal consistency of person and item performance by examining separation reliability estimates and separation ratio. Differential Item Functioning (DIF) was calculated for gender.

RESULTS

There was mixed evidence regarding the extent to which the FSS fit the Rasch model. Outfit values ranged from 0.52 to 2.72 and infit values were 0.60 to 2.18, strongly suggesting the presence of misfitting items: Item 1 ("My motivation is lower when I am fatigued") and Item 2 ("Exercise brings on my fatigue").

SIGNIFICANCE

The nine-item FSS showed fair psychometric properties in this sample of patients with epilepsy. Our study provides unique, supportive information for the use of a modified version of the FSS, omitting the first two items, in patients with epilepsy. Given the prevalence of fatigue and other neuropsychiatric comorbidities of epilepsy, having a validated fatigue scale can aid healthcare providers to identify moderate-to-severe fatigue levels in patients with epilepsy and address the plausible risk factors.

Neural effective connectivity explains subjective fatigue in stroke

Persistent fatigue is a major debilitating symptom in many psychiatric and neurological conditions, including stroke. Post-stroke fatigue has been linked to low corticomotor excitability. Yet, it remains elusive as to what the neuronal mechanisms are that underlie motor cortex excitability and chronic persistence of fatigue.

In this cross-sectional observational study, in two experiments we examined a total of 59 non-depressed stroke survivors with minimal motoric and cognitive impairments using ‘resting-state’ MRI and single- and paired-pulse transcranial magnetic stimulation.

In the first session of Experiment 1, we assessed resting motor thresholds—a typical measure of cortical excitability—by applying transcranial magnetic stimulation to the primary motor cortex (M1) and measuring motor-evoked potentials in the hand affected by stroke. In the second session, we measured their brain activity with resting-state MRI to assess effective connectivity interactions at rest. In Experiment 2 we examined effective inter-hemispheric connectivity in an independent sample of patients using paired-pulse transcranial magnetic stimulation. We also assessed the levels of non-exercise induced, persistent fatigue using Fatigue Severity Scale (FSS-7), a self-report questionnaire that has been widely applied and validated across different conditions. We used spectral dynamic causal modelling in Experiment 1 and paired-pulse transcranial magnetic stimulation in Experiment 2 to characterize how neuronal effective connectivity relates to self-reported post-stroke fatigue. In a multiple regression analysis, we used the balance in inhibitory connectivity between homologue regions in M1 as the main predictor, and have included lesioned hemisphere, resting motor threshold and levels of depression as additional predictors.

Our novel index of inter-hemispheric inhibition balance was a significant predictor of post-stroke fatigue in Experiment 1 (β = 1.524, P = 7.56 × 10⁻⁵, confidence interval: 0.921 to 2.127) and in Experiment 2 (β = 0.541, P = 0.049, confidence interval: 0.002 to 1.080). In Experiment 2, depression scores and corticospinal excitability, a measure associated with subjective fatigue, also significantly accounted for variability in fatigue.

We suggest that the balance in inter-hemispheric inhibitory effects between primary motor regions can explain subjective post-stroke fatigue. Findings provide novel insights into neural mechanisms that underlie persistent fatigue.

The effects of spirulina (Arthrospira platensis) supplementation on anthropometric indices, blood pressure, sleep quality, mental health, fatigue status and quality of life in patients with ulcerative colitis: A randomised, double-blinded, placebo-controlled trial

BACKGROUND

An emerging body of evidence has highlighted the protective role of spirulina in human health. Thus, we conducted a randomised controlled trial to discern the effects of spirulina supplementation on anthropometric indices, blood pressure, sleep quality, mood, fatigue status and quality of life among ulcerative colitis patients.

METHODS

Eighty participants with ulcerative colitis were randomly allocated to receive, either, 1 g/day (two 500 mg capsules) spirulina (n = 40) or placebo (n = 40), in a clinical trial for eight weeks. Dietary intake, physical activity, sleep quality, mental health, fatigue status and quality of life were assessed for each participant at baseline and trial cessation. Anthropometric indices and blood pressure were also assessed.

RESULTS

Seventy-three participants completed the intervention. Our results revealed that spirulina supplementation significantly reduced sleep disturbances (P = .03), while no significant changes occurred in the sleep quality score or other sleep parameters, vs the placebo group (P > .05). Furthermore, a significant reduction in stress score (P = .04) and increase in quality of life (P = .03) was detected; but not anxiety, depression or fatigue scores (P > .05). Additionally, anthropometric indices and blood pressure did not significantly change (P > .05).

CONCLUSION

An improved quality of life was observed among ulcerative colitis patients following spirulina supplementation, which could be attributed to improved sleep disturbance and stress status. Further clinical studies, with longer duration interventions and suitably powered sample sizes, are necessary to elucidate the veracity of our findings.

Nursing management of fatigue in cancer patients and suggestions for clinical practice: a mixed methods study

Background

Fatigue is a complex and frequent symptom in cancer patients, influencing their quality of life, but it is still underestimated and undertreated in clinical practice. The aims of this study were to detect the presence of fatigue in cancer patients, describe how patients and nurses perceived it and how nurses managed fatigue.

Methods

This is a mixed methods study. Data were collected in two oncological wards using the Brief Fatigue Inventory (BFI), an ad hoc questionnaire, patient interviews, focus groups with nurses and the review of nursing records. Interviews and focus groups were analysed through thematic analysis. We used SPSS 22.0 for quantitative data and Nvivo 10 for qualitative data analysis.

Results

A total of 71 questionnaires were analysed (39 males, mean age 65.7 years). Fatigue was reported 5 times (7%) in nursing records, while in 17 cases (23.9%) problems associated to it were reported. Twelve patients were interviewed. Five themes were identified: feeling powerless and aggressive, my strategies or what helps me, feeling reassured by the presence of family members, feeling reassured by nurses’ gestures, and being informed. Three themes were identified through the focus groups: objectivity and subjectivity in the assessment of fatigue, nurses’ contribution to the multidisciplinary management of fatigue, and difficulty in evaluating outcomes.

Conclusions

The approach to the management of fatigue was unstructured. Patients were satisfied with the care they received but needed more information and specific interventions. Useful aspects were identified that could be used to change health professionals’ approach towards the management of fatigue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00699-9.

The Pulmonary Fibrosis Foundation Patient Registry. Rationale, Design, and Methods

Detailed understanding of longitudinal behavior, response to therapy, and applicable biomarkers for interstitial lung diseases (ILDs) is lacking. There is a need for a large multicenter registry that provides researchers and clinicians access to well-characterized data not limited to patients with idiopathic pulmonary fibrosis. The Pulmonary Fibrosis Foundation Patient Registry (PFF-PR) is a database that collects baseline and longitudinal demographic and clinical information about patients with ILDs in the United States. The objective of this study is to describe the patient population, data collection process, and opportunities for retrospective and prospective research with the PFF-PR. Individuals 18 years or older who had ILD diagnosed and who were seen at PFF-PR centers who provided informed consent were eligible to participate. Baseline and longitudinal demographic, spirometric, radiographic, morbidity, and mortality data are recorded into a secure electronic data capture system. Starting in 2016, the PFF-PR has collected data on 2,003 patients at 42 clinical sites in the United States. At the time of enrollment, the mean age of participants was 68 years old. Most (62%) of participants were male, and 58% had a positive smoking history. The mean forced vital capacity was 69% predicted, and the mean diffusing capacity of the lung for carbon monoxide was 43% predicted. Forty-one percent of patients were using supplemental oxygen, and 39% were on antifibrotic therapy. Reasons for attrition were mostly death or transplant, with low rates of loss to follow-up or withdrawal. The PFF-PR is a large multicenter United States-based registry that provides researchers and clinicians access to well-characterized ILD patient data.

Validation of a three-item Fatigue Severity Scale for patients with substance use disorder: a cohort study from Norway for the period 2016-2020

BACKGROUND

Little attention has been paid to customising fatigue questionnaires for patients with Substance Use Disorders (SUDs). The present study aims to validate and shorten the nine-item Fatigue Severity Scale (FSS-9) and Visual Analogue Fatigue Scale (VAFS) for use with this population.

METHODS

We used data from a nested cohort with annual health assessments with responses on the FSS-9 and VAFS. During the period 2016-2020, 917 health assessments were collected from 655 patients with SUD in Bergen and Stavanger, Norway. A total of 225 patients answered the health assessment at least twice. We defined baseline as the first annual health assessment when the health assessments were sorted chronologically per patient. We checked for internal consistency, and we used longitudinal confirmatory factor analysis (CFA) and linear mixed model (LMM) analysis to validate and shorten the FSS-9 and VAFS.

RESULTS

The internal consistency of the FSS-9 was excellent with a Cronbach's α of 0.94 at baseline and 0.93 at the second annual health assessment. When shortening the FSS-9 to a three-item FSS (FSS-3, items 5-7), the Cronbach's α was 0.87 at baseline and 0.84 at the second health assessment. The internal consistency was not affected when the VAFS was added to the FSS-3 and the FSS-9. The longitudinal CFA model showed a well-fitting model for the FSS-3 (χ² = 13.33, degree of freedom = 8, P = 0.101). The LMM analysis showed equal linear changes at the individual level for the FSS-3 (slope: 0.00, P > 0.05) and FSS-9 (slope: 0.01, P > 0.05) between the health assessments.

CONCLUSION

The FSS-9 could be shortened to the FSS-3 with high validity and reliability for patients with SUDs and the addition of VAFS did not provide much added variability.

Prediction of evening fatigue severity in outpatients receiving chemotherapy: less may be more

Background

Fatigue is the most common and debilitating symptom experienced by oncology patients undergoing chemotherapy. Little is known about patient characteristics that predict changes in fatigue severity over time.

Purpose

To predict the severity of evening fatigue in the week following the administration of chemotherapy using machine learning approaches.

Methods

Outpatients with breast, gastrointestinal, gynecological, or lung cancer (N=1217) completed questionnaires one week prior to and one week following administration of chemotherapy. Evening fatigue was measured with the Lee Fatigue Scale (LFS). Separate prediction models for evening fatigue severity were created using clinical, symptom, and psychosocial adjustment characteristics and either evening fatigue scores or individual fatigue item scores. Prediction models were created using two regression and three machine learning approaches.

Results

Random forest (RF) models provided the best fit across all models. For the RF model using individual LFS item scores, two of the 13 individual LFS items (i.e., "worn out", "exhausted") were the strongest predictors.

Conclusion

This study is the first to use machine learning techniques to predict evening fatigue severity in the week following chemotherapy from fatigue scores obtained in the week prior to chemotherapy. Our findings suggest that the language used to assess clinical fatigue in oncology patients is important and that two simple questions may be used to predict evening fatigue severity.

Outcome measures for physical fatigue in individuals with multiple sclerosis: a systematic review

INTRODUCTION

Physical fatigue can be a common reason for early retirement or sick leave since it appears in the earliest stages of multiple sclerosis (MS). Therefore, a prompt and accurate diagnosis is essential. This systematic review aims to identify and describe the instruments used to assess physical fatigue in MS patients with consideration for the languages used to validate the instruments and their methodological qualities.

AREA COVERED

This study has been carried out through 'Medline,' 'Scopus,' 'Cinhal,' and 'Web of Science' databases for all the papers published before 24 January 2020. Three independent authors have chosen the eligible studies based upon pre-set criteria of inclusion. Data collection, data items, and assessment of the risk of bias: the data extraction approach was chosen based on the Cochrane Methods. For data collection, the authors followed the recommendations from the COSMIN initiative. Study quality and risk of bias were assessed using the COSMIN Check List.

EXPERT OPINION

119 publications have been reviewed. The 45 assessment scales can be divided into specific scales for physical fatigue and specific scales for MS. The most popular tools are the Fatigue Severity Scale and the Modified Fatigue Impact Scale.

Exploring the relationship between effort perception and poststroke fatigue

OBJECTIVE

To test the hypothesis that poststroke fatigue, a chronic, pathologic fatigue condition, is driven by altered effort perception.

METHODS

Fifty-eight nondepressed, mildly impaired stroke survivors with varying severity of fatigue completed the study. Self-reported fatigue (trait and state), perceived effort (PE; explicit and implicit), and motor performance were measured in a handgrip task. Trait fatigue was measured with the Fatigue Severity Scale-7 and Neurologic Fatigue Index. State fatigue was measured with a visual analog scale (VAS). Length of hold at target force, overshoot above target force, and force variability in handgrip task were measures of motor performance. PE was measured with a VAS (explicit PE) and line length estimation, a novel implicit measure of PE.

RESULTS

Regression analysis showed that 11.6% of variance in trait fatigue was explained by implicit PE (R = 0.34; p = 0.012). Greater fatigue was related to longer length of hold at target force (R = 0.421, p < 0.001). A backward regression showed that length of hold explained explicit PE in the 20% force condition (R = 0.306, p = 0.021) and length of hold and overshoot above target force explained explicit PE in the 40% (R = 0.399, p = 0.014 and 0.004) force condition. In the 60% force condition, greater explicit PE was explained by higher force variability (R = 0.315, p = 0.017). None of the correlations were significant for state fatigue.

CONCLUSION

Trait fatigue, but not state fatigue, correlating with measures of PE and motor performance, may suggest that altered perception may lead to high fatigue mediated by changes in motor performance. This finding furthers our mechanistic understanding of poststroke fatigue.

Psychometric properties of a short version of Lee Fatigue Scale used as a generic PROM in persons with stroke or osteoarthritis: assessment using a Rasch analysis approach

BACKGROUND

Fatigue is a common symptom associated with a wide range of diseases and needs to be more thoroughly studied. To minimise patient burden and to enhance response rates in research studies, patient-reported outcome measures (PROM) need to be as short as possible, without sacrificing reliability and validity. It is also important to have a generic measure that can be used for comparisons across different patient populations. Thus, the aim of this secondary analysis was to evaluate the psychometric properties of the Norwegian 5-item version of the Lee Fatigue Scale (LFS) in two distinct patient populations.

METHODS

The sample was obtained from two different Norwegian studies and included patients 4-6 weeks after stroke (n = 322) and patients with osteoarthritis on a waiting list for total knee arthroplasty (n = 203). Fatigue severity was rated by five items from the Norwegian version of the LFS, rating each item on a numeric rating scale from 1 to 10. Rasch analysis was used to evaluate the psychometric properties of the 5-item scale across the two patient samples.

RESULTS

Three of the five LFS items ("tired", "fatigued" and "worn out") showed acceptable internal scale validity as they met the set criterion for goodness-of-fit after removal of two items with unacceptable goodness-of-fit to the Rasch model. The 3-item LFS explained 81.6% of the variance, demonstrated acceptable unidimensionality, could separate the fatigue responses into three distinct severity groups and had no differential functioning with regard to disease group. The 3-item version of the LFS had a higher separation index and better internal consistency reliability than the 5-item version.

CONCLUSIONS

A 3-item version of the LFS demonstrated acceptable psychometric properties in two distinct samples of patients, suggesting it may be useful as a brief generic measure of fatigue severity.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02338869; registered 10/04/2014 (stroke study).

The effects of garlic (Allium sativum) supplementation on inflammatory biomarkers, fatigue, and clinical symptoms in patients with active rheumatoid arthritis: A randomized, double-blind, placebo-controlled trial

Based on the antiinflammatory properties of garlic, current study was conducted to evaluate the garlic supplement effects on serum levels of some inflammatory biomarkers, clinical symptoms, and fatigue in women with active rheumatoid arthritis. In this randomized, double-blind, placebo-controlled trial study, 70 women with RA were randomly divided into two groups: The intervention group was supplemented with 1,000 mg of garlic, and the control group received placebo for 8 weeks. At baseline and at the end of the study, clinical symptoms, fatigue, serum level of C-reactive protein (CRP), tumor necrosis factor-a (TNF-a), and erythrocyte sedimentation rate (ESR) were determined. After intervention, serum levels of CRP (p = .018) and TNF-a (p < .001) decreased significantly in the garlic group as compared with the placebo group. Also, pain intensity, tender joint count, disease activity score (DAS-28), and fatigue were significantly decreased in the intervention group compared with the control group (p < .001; for all). Swollen joint count was significantly decreased in the garlic group (p < .001), but not in the placebo group (p = .123). No significant changes were observed for ESR. Garlic supplementation by improving inflammatory mediators and clinical symptoms can be considered as a potential adjunct treatment in patients with RA. However, further studies with larger duration are needed.

Autonomic and Cognitive Function Response to Normobaric Hyperoxia Exposure in Healthy Subjects. Preliminary Study

Background and objective: This is the first study to investigate the effect of high-flow oxygen therapy, using a normobaric chamber on cognitive, biochemical (oxidative stress parameters and the level of neurotrophins), cardiovascular and autonomic functioning. Materials and methods: 17 healthy volunteers, eight males and nine females, with a mean age of 37.5 years, were examined. The experimental study involved ten two-hour exposures in a normobaric chamber with a total pressure of 1500 hPa (32–40 kPa partial pressure of oxygen, 0.7–2 kPa of carbon dioxide and 0.4–0.5 kPa of hydrogen). Cognitive function was assessed by using Trail Making Test parts A, B and difference in results of these tests (TMT A, TMT B and TMT B-A); California Verbal Learning Test (CVLT); Digit symbol substitution test (DSST); and Digit Span (DS). Fatigue (Fatigue Severity Scale (FSS)), cardiovascular, autonomic and baroreceptor functioning (Task Force Monitor) and biochemical parameters were measured before and after intervention. Results: After 10 sessions in the normobaric chamber, significant decreases in weight, caused mainly by body fat % decrease (24.86 vs. 23.93%, p = 0.04 were observed. TMT part A and B results improved (p = 0.0007 and p = 0.001, respectively). In contrast, there was no statistically significant influence on TMT B-A. Moreover, decrease in the number of symbols left after a one-minute test in DSST was noted (p = 0.0001). The mean number of words correctly recalled in the CVLT Long Delay Free Recall test improved (p = 0.002), and a reduction in fatigue was observed (p = 0.001). Biochemical tests showed a reduction in levels of malondialdehyde (p < 0.001), with increased levels of Cu Zn superoxide dismutase (p < 0.001), Neurotrophin 4 (p = 0.0001) and brain-derived neurotrophic factor (p = 0.001). A significant increase in nitric oxide synthase 2 (Z = 2.29, p = 0.02) and Club cell secretory protein (p = 0.015) was also noted. Baroreceptor function was significantly improved after normobaric exposures (p = 0.003). Significant effect of normobaric exposures and BDNF in CVLT Long Delay Free Recall was noted. Conclusions: This study demonstrates that 10 exposures in a normobaric chamber have a positive impact on visual information and set-shifting processing speed and increase auditory-verbal short-term memory, neurotrophic levels and baroreceptor function. A response of the respiratory tract to oxidative stress was also noted. There is a need to rigorously examine the safety of normobaric therapy. Further studies should be carried out with physician examination, both pre and post treatment.

Inpatient Step Counts, Symptom Severity, and Perceived Health Status After Lung Resection Surgery

BACKGROUND

The clinical relevance of inpatient step counts after lung surgery remains unknown.

OBJECTIVE

The aim of this study was to identify those factors related to physical activity measured by step count, during the inpatient stay, and its relationship with symptom severity and perceived health status at hospital admission, discharge, and 1 month after discharge.

METHODS

We studied the inpatient step count of 73 participants who underwent lung resection surgery. The number of steps was measured using a triaxial accelerometer. The health status and the severity of symptoms were examined at hospital admission, discharge, and 1 month after discharge.

RESULTS

Of the 73 participants, 35 were active and 38 were sedentary during the hospitalization. The mean number of steps walked during 3 inpatient days was 6689 ± 3261 and 523 ± 2273 (P < .001) for the active and sedentary groups, respectively. The dyspnea and fatigue scores in the sedentary group across data collection points (hospital admission, discharge, and follow-up) were significantly worse (P < .01). In regard to pain, the sedentary group presented worse results, than the active group, at discharge and follow-up (P < .01). The correlation analysis indicated significant but weak correlations (r < 0.500) between inpatient steps per day and symptom severity at 1-month follow-up (T2) after surgery.

CONCLUSION

Inpatient step count may be a risk factor for symptom severity and perceived health status during hospitalization and within the first month after lung resection surgery.

IMPLICATIONS FOR PRACTICE

Nurses should consider recommending physical activity during hospitalization for patients after lung resection.

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.

Onset Patterns and Course of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Background: Epidemiologic studies of myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS) have examined different aspects of this disease separately but few have explored them together. Objective: Describe ME/CFS onset and course in one United States-based cohort. Methods: One hundred and fifty subjects fitting Fukuda 1994 CFS criteria completed a detailed survey concerning the initial and subsequent stages of their illness. Descriptive statistics, graphs, and tables were used to illustrate prevalence and patterns of characteristics. Results: The most common peri-onset events reported by subjects were infection-related episodes (64%), stressful incidents (39%), and exposure to environmental toxins (20%). For 38% of subjects, more than 6 months elapsed from experiencing any initial symptom to developing the set of symptoms comprising their ME/CFS. Over time, the 12 most common symptoms persisted but declined in prevalence, with fatigue, unrefreshing sleep, exertion-related sickness, and flu-like symptoms declining the most (by 20-25%). Conversely, cognitive symptoms changed the least in prevalence, rising in symptom ranking. Pregnancy, menopause, and menstrual cycles exacerbated many women's symptoms. Fatigue-related function was not associated with duration of illness or age; during the worst periods of their illness, 48% of subjects could not engage in any productive activity. At the time of survey, 47% were unable to work and only 4% felt their condition was improving steadily with the majority (59%) describing a fluctuating course. Ninety-seven percent suffered from at least one other illness: anxiety (48%), depression (43%), fibromyalgia (39%), irritable bowel syndrome (38%), and migraine headaches (37%) were the most diagnosed conditions. Thirteen percent came from families where at least one other first-degree relative was also afflicted, rising to 27% when chronic fatigue of unclear etiology was included. Conclusions: This paper offers a broad epidemiologic overview of one ME/CFS cohort in the United States. While most of our findings are consistent with prior studies, we highlight underexamined aspects of this condition (e.g., the evolution of symptoms) and propose new interpretations of findings. Studying these aspects can offer insight and solutions to the diagnosis, etiology, pathophysiology, and treatment of this condition.

A Survey of Assistive Technologies for Assessment and Rehabilitation of Motor Impairments in Multiple Sclerosis

Multiple sclerosis (MS) is a disease that affects the central nervous system, which consists of the brain and spinal cord. Although this condition cannot be cured, proper treatment of persons with MS (PwMS) can help control and manage the relapses of several symptoms. In this survey article, we focus on the different technologies used for the assessment and rehabilitation of motor impairments for PwMS. We discuss sensor-based and robot-based solutions for monitoring, assessment and rehabilitation. Among MS symptoms, fatigue is one of the most disabling features, since PwMS may need to put significantly more intense effort toward achieving simple everyday tasks. While fatigue is a common symptom across several neurological chronic diseases, it remains poorly understood for various reasons, including subjectivity and variability among individuals. To this end, we also investigate recent methods for fatigue detection and monitoring. The result of this survey will provide both clinicians and researchers with valuable information on assessment and rehabilitation technologies for PwMS, as well as providing insights regarding fatigue and its effect on performance in daily activities for PwMS.

Why do some ME/CFS patients benefit from treatment with sodium dichloroacetate, but others do not?

Myalgic Encephalopathy/Chronic Fatigue Syndrome (ME/CFS) is an enigmatic disease the pathogenesis of which remains elusive. Pragmatic proof-of-principle of the hypothetical mechanisms causing the clinical symptoms has been delivered, but it is hard to explain why some patients do respond favourably to treatment with sodium dichloroacetate (DCA), which enhances the activity of the mitochondrial enzyme pyruvate dehydrogenase, but other patients experience no benefit from this substance. In a prospective trial including 35 ME/CFS patients, logistic regression analysis with stepwise elimination has identified 6 pre-treatment characteristics allowing for the differentiation between responders (n = 13) and non-reponders (n = 22) with high accuracy (P < 0.0001; area under the ROC-curve = 0.92). A formula was derived generating the probability of belonging to the group of responders. This finding may assist in selecting ME/CFS patients suitable for treatment with DCA, but requires further studies as to the predictive capacity of the derived formula.

Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-CompassTM

BACKGROUND

Unmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic "Rehab-Compass," a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice.

METHODS

A new graphic overview of broad unmet rehabilitation needs covers deficits in functioning, daily activity, participation, and quality of life. It was constructed by using 5 patient-oriented, well-validated, and reliable existing instruments with converted data into a 0 (worst outcome) to 100 (best outcome) scale but unchanged in terms of variable properties. Satisfaction of the Rehab-Compass^TM was studied by a qualitative interview of 9 patients with stroke and 3 clinicians. Practical feasibility and capacity of the instrument were evaluated in a cross-sectionalstudy with 48 patients at 5-month follow-ups after subarachnoid hemorrhage.

RESULTS

The Rehab-Compass^TM identified and graphically visualized a panoramic view of the multidimensional needs over time which was completed before clinical consultation. The Rehab-Compass^TM appeared to be feasible and time-efficientin clinical use. The interviews of both patients and clinicians showed high satisfaction when using the Rehab-Compass^TM graph. In the studied stroke patients, the Rehab-Compass^TM identified memory and processing information, fatigue, mood, and pain after subarachnoid hemorrhage as the most common problems.

CONCLUSIONS

The graphic Rehab-Compass^TM seems to be a feasible, useful, and time-saving tool for identification of unmet rehabilitation needs among stroke survivors in clinical practice. Further research is needed to make the Rehab-Compass^TM more concise and evaluate the instrument among different stroke subgroups.

Influence of Biological Therapeutics, Cytokines, and Disease Activity on Depression in Rheumatoid Arthritis

Purpose

Rheumatoid arthritis (RA) is an often debilitating autoinflammatory disease. Patients with rheumatoid arthritis are often troubled by co-occurring depression or other psychological manifestations. RA patients have a variety of treatment options available, including biologicals that inhibit cytokines or immune cells. If these cytokines influence the psychological symptoms, then the use of cytokine inhibitors should modulate these symptoms.

Methods

A cohort of 209 individuals was recruited. This group included 82 RA patients, 22 healthy subjects, 32 depressed control subjects, and 73 subjects with systemic lupus erythematosus. Of the RA patients, 51% were on a biological therapeutic. ELISA was used to measure cytokine levels. A variety of psychological assessments were used to evaluate depression, anxiety, sleep, fatigue, and relationship status. Clinical values were obtained from medical records.

Results

IL-10 concentration was associated with depressive symptoms in the RA patients, healthy controls, and the lupus patients. In the patients with primary depression, depressive symptoms were associated with IL-6 and TNF-alpha. In RA patients, Tocilizumab use was associated with decreased depressive symptoms. 14 RA patients who were not using biologicals began using them by a one-month follow-up. In these patients, there was no significant change to any value except for fatigue.

Conclusions

A variety of both biological and social factors influences depressive symptoms in RA. IL-10 and IL-6 are likely to be involved, since IL-10 concentration was associated with depression and Tocilizumab decreased depressive symptoms in the RA patients. The roles of these cytokines are different in RA and lupus, as high IL-10 in RA is associated with increased depressive symptoms, but high IL-10 in the lupus patients is associated with decreased depression. IL-6 was also associated with depressive symptoms in the patients with primary depression. These results strongly indicate that disease activity, including cytokine levels, has a strong impact on depressive symptoms.

Depression and anxiety in systemic lupus erythematosus: The crosstalk between immunological, clinical, and psychosocial factors

Depression and anxiety cause severe loss of quality of life for patients with systemic lupus erythematosus. The causes and factors that contribute to these psychological manifestations in lupus are difficult to disentangle. This study compared clinical, psychological, and demographic factors between lupus patients, depressed patients, and rheumatoid arthritis patients to discover lupus-specific contributors to depression. Lupus-specific manifestations of depression were also investigated.Physiological, clinical, and psychosocial data were collected from 77 patients. ELISA was used to measure cytokine levels. Univariate and Multivariate analyses were used to compare the patient populations and identify correlations between key physical and psychological indicators.The prevalence of depression in the SLE cohort was 6 times greater than the healthy control subjects. Pain, IL-6, and Pittsburgh Sleep Quality index values were all significantly higher in SLE patients compared with the healthy control group (P < .001, P = .038, and P = .005, respectively). Anxiety levels were significantly higher in SLE patients compared to healthy and RA control patients (P = .020 and .011, respectively). Serum IL-10 concentrations, relationship assessment scale, and fatigue severity scale values were found to be correlated with depression among the SLE patients (P = .036, P = .007, and P = .001, respectively). Relationship assessment and fatigue severity scale scores were found to be the best indicators of depression for the SLE patients (P = .042 and .028, respectively).Fatigue Severity, relationship satisfaction, and IL-10 concentrations are indicators of depression in lupus patients. Despite also suffering from the pain and disability that accompanies chronic autoimmune disease, the rheumatoid arthritis patients had less anxiety and better relationship scores.

Comparison of the Effects of Benson Muscle Relaxation and Nature Sounds on the Fatigue in Patients With Heart Failure: A Randomized Controlled Clinical Trial

This study was conducted with the aim of comparing the effects of Benson muscle relaxation and nature sounds on fatigue in patients with heart failure. Fatigue and exercise intolerance as prevalent symptoms experienced by patients with heart failure can cause the loss of independence in the activities of daily living. It can also damage self-care and increase dependence to others, which subsequently can reduce the quality of life. This randomized controlled clinical trial was conducted in an urban area of Iran in 2016. Samples were consisted of 105 hospitalized patients with heart failure chosen using a convenience sampling method. They were assigned to relaxation, nature sounds, and control groups using a randomized block design. In addition to routine care, the Benson muscle relaxation and nature sounds groups received interventions in mornings and evenings twice a day for 20 minutes within 3 consecutive days. A 9-item questionnaire was used to collect data regarding fatigue before and after the interventions. Relaxation and nature sounds reduced fatigue in patients with heart failure in comparison to the control group. However, no statistically significant difference was observed between the interventions. Benson muscle relaxation and nature sounds are alternative methods for the reduction of fatigue in patients with heart failure. They are inexpensive and easy to be administered and upon patients' preferences can be used by nurses along with routine nursing interventions.

Mechanisms of poststroke fatigue

Poststroke fatigue is a debilitating symptom and is poorly understood. Here we summarise molecular, behavioural and neurophysiological changes related to poststroke fatigue and put forward potential theories for mechanistic understanding of poststroke fatigue.

Validation of Fatigue Impact Scale with various item sets - a Rasch analysis

PURPOSE

Fatigue is a symptom in patients with chronic gastrointestinal (GI) and liver diseases. Different instruments have been developed to assess the severity of fatigue and the 40-item Fatigue Impact Scale (FIS) is among the most widely used. Shorter versions of FIS include the 21-item Modified Fatigue Impact Scale (MFIS), and an eight-item version for everyday use. The study aimed to assess construct validity, reliability, and sufficiency of the raw score of the original FIS with 40 items, and examine the sufficiency of the 21 items from the Modified scale and the eight items of the Daily Fatigue Impact Scale (D-FIS), all of which are embedded in the 40-item scale.

METHODS

Patients with chronic GI or liver disease (n = 354) completed the FIS with 40 items. The majority (57%) was under the age of 55 years and approximately half were females (48%). Various item sets of FIS were derived which showed fit to the Rasch model.

RESULTS

Local dependency and multidimensionality in FIS and the 21-item Modified scale were resolved with a testlet solution but the D-FIS showed local dependency and multidimensionality and differential item functioning (DIF) still remained. Two new item sets fulfilling unidimensionality and no DIF are suggested, one with 15 items and a six-item scale for daily use. The transformation table shows score-interval scale estimates for all these item sets.

CONCLUSIONS

Both the FIS and the Modified scale can be used to measure fatigue albeit requiring some adjustment for DIF. The eight-item D-FIS is more problematic, and its summed score is not valid. Alternative 15- and 6-item versions presented in this paper can offer valid summed scores, and the transformation table allows transformation of raw scores and comparisons across all versions. Implications for rehabilitation The Fatigue Impact Scale and the Modified Fatigue Impact Scale can be used to measure fatigue after adjustments for differential item functioning. Alternative 15- and 6-item versions of Fatigue Impact Scale offer valid summed scores. The summed score for the Daily Fatigue Impact Scale is not valid. A transformation table with raw scores and Rasch transformed interval scale metric makes it possible to compare scores derived from the Fatigue Impact Scale, the Modified Fatigue Impact Scale and the proposed 15- and 6-item versions of Fatigue Impact Scale for research and/or clinical use.

Psychometric limitations of the 13-item Sense of Coherence Scale assessed by Rasch analysis

BACKGROUND

A person's sense of coherence (SOC) reflects their perception that the world is meaningful and predictable, and impacts their ability to deal with stressors in a health-promoting manner. A valid, reliable, and sensitive measure of SOC is needed to advance health promotion research based on this concept. The 13-item Sense of Coherence Scale (SOC-13) is widely used, but we reported in a previous evaluation its psychometric limitations when used with adults with morbid obesity. To determine whether the identified limitations were specific to that population or also generalize to other populations, we have replicated our prior study design and analysis in a new sample of adults with inflammatory bowel disease (IBD).

METHODS

A sample of 428 adults with IBD completed the SOC-13 at a routine clinic visit in Norway between October 1, 2009 and May 31, 2011. Using a Rasch analysis approach, the SOC-13 and its three subscales were evaluated in terms of rating scale functioning, internal scale validity, person-response validity, person-separation reliability and differential item functioning.

RESULTS

Collapsing categories at the low end of the 7-category rating scale improved its overall functioning. Two items demonstrated poor fit to the Rasch model, and once they were deleted from the scale, the remaining 11-item scale (SOC-11) demonstrated acceptable item fit. However, neither the SOC-13 nor the SOC-11 met the criteria for unidimensionality or person-response validity. While both the SOC-13 and SOC-11 were able to distinguish three groups of SOC, none of the subscales could distinguish any such groups. Minimal differential item functioning related to demographic characteristics was also observed.

CONCLUSIONS

An 11-item version of the sense of coherence scale has better psychometric properties than the original 13-item scale among adults with IBD. These findings are similar to those of our previous evaluation among adults with morbid obesity and suggest that the identified limitations may exist across populations. Further refinement of the SOC scale is therefore warranted.

A Rasch Analysis of Assessments of Morning and Evening Fatigue in Oncology Patients Using the Lee Fatigue Scale

CONTEXT

To accurately investigate diurnal variations in fatigue, a measure needs to be psychometrically sound and demonstrate stable item function in relationship to time of day. Rasch analysis is a modern psychometric approach that can be used to evaluate these characteristics.

OBJECTIVES

To evaluate, using Rasch analysis, the psychometric properties of the Lee Fatigue Scale (LFS) in a sample of oncology patients.

METHODS

The sample comprised 587 patients (mean age 57.3 ± 11.9 years, 80% women) undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer. Patients completed the 13-item LFS within 30 minutes of awakening (i.e., morning fatigue) and before going to bed (i.e., evening fatigue). Rasch analysis was used to assess validity and reliability.

RESULTS

In initial analyses of differential item function, eight of the 13 items functioned differently depending on whether the LFS was completed in the morning or in the evening. Subsequent analyses were conducted separately for the morning and evening fatigue assessments. Nine of the morning fatigue items and 10 of the evening fatigue items demonstrated acceptable goodness-of-fit to the Rasch model. Principal components analyses indicated that both morning and evening assessments demonstrated unidimensionality. Person-separation indices indicated that both morning and evening fatigue scales were able to distinguish four distinct strata of fatigue severity.

CONCLUSION

Excluding four items from the morning fatigue scale and three items from the evening fatigue scale improved the psychometric properties of the LFS for assessing diurnal variations in fatigue severity in oncology patients.

Prior physical exertion modulates allocentric distance perception: a demonstration of task-irrelevant cross-modal transfer

Physical exertion has been previously shown to influence distance perception in the egocentric framework. In this study, we show that physical exertion influences allocentric distance perception. Twenty healthy volunteers made allocentric line length estimates following varying levels of physical exertion. Each participant was presented with 30 different line lengths ranging from 1 to 12 cm, and each length was presented three times. Each line presentation was preceded by the participant exerting one of the following three levels of their maximal voluntary force (MVF): 20, 50, or 80 % MVF using their hand in the pinch force task. Psychometric curves were obtained for the lines perceived as ‘long’ following each of the three force levels. Lines that were perceived as ‘short’ following 20 and 50 % MVF were perceived as ‘long’ following 80 % MVF; that is, there was a significant leftward shift in the psychometric curve following 80 % MVF when compared to 20 and 50 % MVF. Here, we demonstrate that physical exertion influences perception of distances in the allocentric framework. We discuss our findings with respect to cross-modal interactions, fatigue physiology, peri- and extra-personal space interactions.

Examining the relationship between fatigue and cognition after stroke: A systematic review

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

Reliability, validity and responsiveness of the Chinese version of Liver Disease Quality of Life Questionnaire in viral hepatitis patients

AIM: To determine the reliability, validity and responsiveness of the Chinese version of Liver Disease Quality of Life Questionnaire (LDQOL1.0) in viral hepatitis patients.

METHODS: The questionnaire was administered to 100 patients with viral hepatitis and 91 returned the questionnaire. Cronbach α, ceiling effect and flooring effect were calculated to test the reliability of this questionnaire. Relationship coefficients between liver disease specific dimensions and SF-36 were calculated to test the standard validity of the questionnaire. Exploring factor analysis was used to test the questionnaire's construct validity. Responsiveness was tested by comparing scores of patients with different Child Pugh scores. Pearson coefficient was used to show the relationship and ANOVA analysis was used to test responsiveness.

RESULTS: Cronbach α ranged from 0.33 (95%CI: 0.08-0.52) to 0.9 (95%CI: 0.90-0.99), and 80% of domains had a Cronbach α value higher than 0.7. Ceiling effects ranged from 0% to 39.6%, and flooring effects ranged from 0% to 34.1%, with most domains having the values less than 20%. Six of twelve domains were related closely with SF-36 (Pearson coefficient > 0.5, P < 0.05). Exploring factor analysis showed that 7 of 12 domains concurred with original imagination. Responsiveness showed that 6 of 12 domains were good (F: 0.353-21.29, P < 0.05).

CONCLUSION: Most domains of LDQOL1.0 had good reliability, validity and responsiveness when it was used to test quality of life in Chinese patients with viral hepatitis.

Cognitive functions, fatigue, depression, anxiety, and sleep disturbances: assessment of nonmotor features in young patients with essential tremor

There is a growing amount of evidence to suggest that besides motor features, patients with essential tremor (ET) may exhibit significant nonmotor features, such as mild cognitive deficits, fatigue, neuropsychiatric symptoms, and sleep disturbances. The goal of this study was to examine nonmotor features in young patients with ET and their impact on quality of life. 45 patients (24.55 ± 7.16 years old) with ET and 35 controls were evaluated using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Beck Depression Inventory, Beck Anxiety Scale, Fatigue Severity Scale, and Short Form-36. Cognitive functions were evaluated using the Turkish version of the Montreal Cognitive Assessment Battery (MoCA). We ruled out other possible causes of the tremor. The tremor rate was evaluated using the Fahn-Tolosa-Marin Tremor Rating Scale. Poor sleep quality, fatigue, anxiety, and depressive symptoms were more common, and MoCA total scores were lower in the patient group. Fatigue, depressive symptoms, and higher anxiety levels were seen to have a negative effect on physical and mental health. Excessive daytime sleepiness had a negative effect on physical health. There is an emerging interest in nonmotor features of ET. This study showed that even young patients have nonmotor features that decrease their quality of life. This might tell us that nonmotor symptoms could be a part of the disease in the early stages.

Post-stroke fatigue: a problem of altered corticomotor control?

OBJECTIVES

We recently showed that diminished motor cortical excitability is associated with high levels of post-stroke fatigue. Motor cortex excitability impacts movement parameters such as reaction and movement times. We predicted that one or both would be influenced by the presence of post-stroke fatigue.

METHODS

41 first-time stroke survivors (high fatigue n=21, Fatigue Severity Scale 7 (FSS-7) score >5; low fatigue n=20, FSS-7 score <3) participated in the study. Movement times, choice and simple reaction times were measured in all participants.

RESULTS

A three way ANOVA with fatigue (high and low), task (movement time, simple reaction time and choice reaction time) and hand (affected and unaffected) as the three factors, revealed a significant difference between affected (but not unaffected) hand movement times in the high compared to low fatigue groups. Reaction times, however, were not different between the high-fatigue and low-fatigue groups in either the affected or unaffected hand.

CONCLUSIONS

Previously, we showed that motor cortex excitability is lower in patients with high post-stroke fatigue. Our current findings suggest that post-stroke fatigue (1) is a problem of movement speed (possibly a consequence of diminished motor cortex excitability) and not movement preparation, and (2) may have a focal origin confined to the lesioned hemisphere. We suggest that low motor cortex excitability in the lesioned hemisphere is a viable therapeutic target in post-stroke fatigue.

Cognitive function in chronic rhinosinusitis: a controlled clinical study

BACKGROUND

Cognitive dysfunction in patients with chronic rhinosinusitis (CRS) has previously received little attention. Cognitive data generally includes only subjective measures and lack appropriate controls when cognition is considered. The purpose of this study was to characterize dimensions of cognitive function that are affected in patients with CRS compared to a control sample using subjective and objective measures of cognitive function.

METHODS

Patients fulfilling diagnostic criteria for CRS and non-CRS controls were recruited from the same clinical reference population. Patient-reported cognitive dysfunction was assessed using the Cognitive Failures Questionnaire (CFQ) and fatigue via the Fatigue Severity Scale (FSS). Objective cognitive function was assessed using a battery of tests from the Automated Neuropsychological Assessment Metrics (ANAM) computerized platform.

RESULTS

A total of 100 subjects were enrolled, including 50 patients with active CRS and 50 control subjects. Patients with CRS scored significantly worse in subjective cognition as measured by total CFQ scores (38.3 ± 16.5 vs 30.9 ± 12.5; p = 0.009) and the FSS (4.2 ± 1.6 vs 3.0 ± 1.5; p = 0.001). Patients with CRS were also found to have worse simple reaction time scores compared to controls without CRS (162.4 ± 56.2 vs 193.0 ± 44.6; p = 0.003). These differences persisted regardless of polyp status. Performance differences for FSS and SRT measures remained significant after controlling for age, gender, race/ethnicity, education, allergic rhinitis, asthma, obstructive sleep apnea, depression, and antihistamine usage.

CONCLUSION

Patients with CRS report significantly more cognitive dysfunction and fatigue on validated instruments and had worse reaction times on computerized testing. Further study is necessary to determine whether available treatments impact these measures.

Multidimensional fatigue inventory and post-polio syndrome - a Rasch analysis

BACKGROUND

Fatigue is a common symptom in post-polio syndrome (PPS) and can have a substantial impact on patients. There is a need for validated questionnaires to assess fatigue in PPS for use in clinical practice and research. The aim with this study was to assess the validity and reliability of the Swedish version of Multidimensional Fatigue Inventory (MFI-20) in patients with PPS using the Rasch model.

METHODS

A total of 231 patients diagnosed with PPS completed the Swedish MFI-20 questionnaire at post-polio out-patient clinics in Sweden. The mean age of participants was 62 years and 61% were females. Data were tested against assumptions of the Rasch measurement model (i.e. unidimensionality of the scale, good item fit, independency of items and absence of differential item functioning). Reliability was tested with the person separation index (PSI). A transformation of the ordinal total scale scores into an interval scale for use in parametric analysis was performed. Dummy cases with minimum and maximum scoring were used for the transformation table to achieve interval scores between 20 and 100, which are comprehensive limits for the MFI-20 scale.

RESULTS

An initial Rasch analysis of the full scale with 20 items showed misfit to the Rasch model (p < 0.001). Seven items showed slightly disordered thresholds and person estimates were not significantly improved by rescoring items. Analysis of MFI-20 scale with the 5 MFI-20 subscales as testlets showed good fit with a non-significant x (2) value (p = 0.089). PSI for the testlet solution was 0.86. Local dependency was present in all subscales and fit to the Rasch model was solved with testlets within each subscale. PSI ranged from 0.52 to 0.82 in the subscales.

CONCLUSIONS

This study shows that the Swedish MFI-20 total scale and subscale scores yield valid and reliable measures of fatigue in persons with post-polio syndrome. The Rasch transformed total scores can be used for parametric statistical analyses in future clinical studies.

Post-stroke fatigue: a deficit in corticomotor excitability?

The pathophysiology of post-stroke fatigue is poorly understood although it is thought to be a consequence of central nervous system pathophysiology. In this study we investigate the relationship between corticomotor excitability and self-reported non-exercise related fatigue in chronic stroke population. Seventy first-time non-depressed stroke survivors (60.36 ± 12.4 years, 20 females, 56.81 ± 63 months post-stroke) with minimal motor and cognitive impairment were included in the cross-sectional observational study. Fatigue was measured using two validated questionnaires: Fatigue Severity Scale 7 and Neurological Fatigue Index - Stroke. Perception of effort was measured using a 0-10 numerical rating scale in an isometric biceps hold-task and was used as a secondary measure of fatigue. Neurophysiological measures of corticomotor excitability were performed using transcranial magnetic stimulation. Corticospinal excitability was quantified using resting and active motor thresholds and stimulus-response curves of the first dorsal interosseous muscle. Intracortical M1 excitability was measured using paired pulse paradigms: short and long interval intracortical inhibition in the same hand muscle as above. Excitability of cortical and subcortical inputs that drive M1 output was measured in the biceps muscle using a modified twitch interpolation technique to provide an index of central activation failure. Stepwise regression was performed to determine the explanatory variables that significantly accounted for variance in the fatigue and perception scores. Resting motor threshold (R = 0.384; 95% confidence interval = 0.071; P = 0.036) accounted for 14.7% (R(2)) of the variation in Fatigue Severity Scale 7. Central activation failure (R = 0.416; 95% confidence interval = -1.618; P = 0.003) accounted for 17.3% (R(2)) of the variation in perceived effort score. Thus chronic stroke survivors with high fatigue exhibit high motor thresholds and those who perceive high effort have low excitability of inputs that drive motor cortex output. We suggest that low excitability of both corticospinal output and its facilitatory synaptic inputs from cortical and sub-cortical sites contribute to high levels of fatigue after stroke.