The Experience of Fatigue Across Long-Term Conditions: A Qualitative Meta-Synthesis

A systematic mapping review of clinical guidelines for the management of fatigue in long-term physical health conditions

PURPOSE

Despite a high prevalence of fatigue and its importance to patients, many people with long-term conditions do not receive fatigue management as part of their treatment. This review is aimed to identify clinical guidance for the management of fatigue in long-term physical health conditions.

METHODS

A systematic mapping review was conducted in accordance with Social Care Institute for Excellence systematic review guidance. Bibliographic databases and guideline repositories were searched for clinical guidelines for long-term conditions, published between January 2008 and July 2018, with a search for updates conducted in May 2023. Data were extracted on the recommendations made for managing fatigue and, where cited, the underlying research evidence used to support these recommendations was also extracted.

RESULTS

The review included 221 guidelines on 67 different long-term conditions. Only 30 (13.6%) of the guidelines contained recommendations for managing fatigue. These were categorised as clinical (e.g. conduct further investigations), pharmacological, behavioural (e.g. physical activity), psychological, nutritional, complementary, environmental, and multicomponent. The guidelines rated much of the evidence for fatigue management as fairly low quality, highlighting the need to develop and test fatigue-management strategies in high-quality trials.

CONCLUSION

This review highlights that management of fatigue is a very important neglected area in the clinical guidelines for managing long-term conditions.

The relationship between self-perceived fatigue, muscle endurance, and circulating markers of inflammation in participants of the Copenhagen aging and Midlife Biobank (CAMB)

BACKGROUND

Fatigue, low muscle endurance, muscle weakness and low-grade inflammation are strongly related to frailty at higher age. When signs of self-perceived fatigue and low muscle endurance are interrelated with low-grade inflammation at midlife, they might be used as early markers for frailty. This study investigated whether the interrelationships among self-perceived fatigue, muscle endurance and inflammation can be observed at midlife.

METHODS

A total of 965 participants of the Copenhagen Aging and Midlife Biobank (aged 52 ± 4 years, 536 males, 426 females) were assessed for self-perceived fatigue (20-item multidimensional fatigue inventory), muscle endurance (grip work), circulating markers of inflammation (hsCRP, IL-6, IL-10, TNF-alpha and IFN-γ), daily physical activity (PAS-2), body composition (%body fat assessed by bio-impedance) and self-reported health status. Participants were categorised (correcting for age and gender) according to high fatigue and/or low muscle endurance, differences in inflammatory profile between fatigue categories were assessed by ANCOVA (corrected for PAS-2, %body fat and presence of inflammatory conditions).

RESULTS

Overall, muscle endurance, fatigue and inflammatory markers were significantly interrelated. Higher levels of hsCRP (p < 0.001), IL-6 (p < 0.001), IL-10 (p = 0.035) and TNF-alpha (p = 0.028) were observed in participants presenting both low muscle endurance and high fatigue. IFN-γ was highest in those with high fatigue but normal muscle endurance (p = 0.015).

CONCLUSIONS

Middle-aged participants with higher fatigue in combination with low muscle endurance show higher levels of inflammation, independently from physical activity, body fat and inflammatory pathology. The underlying mechanisms should be identified and future studies should also investigate whether these individuals show early signs of reduced physiological reserve capacity, which in later life come to full expression by means of frailty.

Day-to-day fluctuations of fatigue severity in individuals with knee osteoarthritis: an ecological momentary assessment approach

Objective

The variable course of fatigue adds to the disease burden of patients with OA yet it has been poorly understood. This study aimed to describe within-person fluctuations of fatigue severity and explore its associations with pain, positive affect, negative affect, sleep, and perceived exertion of physical activity.

Methods

Individuals with chronic knee pain or a clinical diagnosis of knee OA ≥40 years of age completed daily assessments about fatigue, pain, positive affect, negative affect, sleep, perceived exertion of physical activity (numeric rating scale 0-10), and overwhelming fatigue (yes/no) on a smartphone over 14 days. Within-person fluctuations of fatigue severity were described by the probability of acute changes (PACs) and s.d.s. Associations with pain, positive affect, negative affect, sleep, and perceived exertion of physical activity were explored using multilevel models.

Results

Forty-nine individuals were included (mean age 63.4 years; 82% female). PACs and s.d.s of within-person daily fatigue fluctuations ranged from 0.00 to 0.80 and 0.35 to 2.95, respectively. Within-person associations of fatigue severity were moderate for positive affect [β = -0.57 (95% CI -0.67, -0.47)], weak for pain [β = 0.41 (95% CI 0.29, 0.53)] and negative affect [β = 0.40 (95% CI 0.21, 0.58)], and negligible for sleep [β = -0.13 (95% CI -0.18, -0.08)] and perceived exertion of physical activity [β = 0.18 (95% CI 0.09, 0.26)].

Conclusion

Some individuals showed almost stable day-to-day levels of fatigue severity, whereas others experienced a substantial number of clinically relevant fluctuations. To reduce the burden of daily fatigue fluctuations, our results suggest that pain, positive and negative affect rather than sleep and perceived exertion of physical activity should be considered as potential targets.

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.

The Cognitive and Behavioural Responses to Symptoms Questionnaire (CBRQ): Development, reliability and validity across several long-term conditions

OBJECTIVES

Cognitive and behavioural responses to symptoms can worsen or maintain the severity of symptoms across long-term conditions (LTCs). Although the Cognitive and Behavioural Responses Questionnaire (CBRQ) has been used in research, its original development and psychometric properties as a transdiagnostic measure have not been reported. Our aim was to evaluate the psychometric properties of the CBRQ and a recently proposed short version, across different LTCs.

DESIGN

Psychometric validation study.

METHODS

Confirmatory factor analysis (CFA) tested the factor structure of the CBRQ in two datasets from the CBRQ's original development; (chronic fatigue syndrome, N = 230; and multiple sclerosis, N = 221) and in additional groups: haemodialysis (N = 174), inflammatory bowel disease (N = 182) and chronic dizziness (N = 185). Scale reliability and construct validity were assessed. The factor structure of the shortened CBRQ (CBRQ-SF) was also assessed.

RESULTS

CFA revealed that a 7-or 8-factor structure had generally appropriate fit supporting the originally proposed 7 factors (Fear avoidance, Damage beliefs, Catastrophising, Embarrassment avoidance, Symptom focusing, All-or-nothing behaviour and Avoidance/Resting behaviour). Omega coefficients indicated satisfactory internal reliability. Correlations with related constructs suggested construct validity. The scale appeared sensitive to change. The CBRQ-SF also displayed good psychometric quality, with a better model fit than the CBRQ.

CONCLUSIONS

The CBRQ and the shortened version were shown to be reliable and valid at assessing a range of cognitive and behavioural responses to symptoms, highlighting the multi-symptom, transdiagnostic properties of this questionnaire. Further research is necessary to determine the test-retest reliability and sensitivity to change of the CBRQ and CBRQ-SF and a thorough evaluation of the content validity of the items.

Cancer and Non-cancer Fatigue Treated With Bupropion: A Systematic Review

CONTEXT

Fatigue is a predominant and distressing symptom in cancer and non-cancer conditions for which there is a paucity of recommendations for pharmacological interventions. Bupropion is a novel treatment whose efficacy and safety in the treatment of fatigue are unknown.

OBJECTIVES

This study aimed to systematically assess the evidence on the efficacy and safety of bupropion in the treatment of fatigue in people with cancer and non-cancer conditions.

METHODS

PubMed, EMBASE, and Ovid Medline databases were searched up to July 26, 2022. Studies were included if they reported bupropion as an intervention for cancer and non-cancer-related fatigue and used an objective scale to assess symptom outcomes. Experimental and quasi-experimental studies in adult patients published in English were included.

RESULTS

This review reports on seven studies (three randomized studies, three non-randomized studies, and one case series) that enrolled a total of 584 patients. Bupropion was tested in five studies for treating cancer-related fatigue and in two studies for treating fatigue in non-cancer conditions. The reviewed studies were heterogeneous in relation to the scales used to assess fatigue. Six out of seven studies reported that bupropion significantly reduced the fatigue burden without causing major adverse effects. These positive results must be taken with caution caused by the small sample sizes and low quality of the studies reviewed.

CONCLUSION

Bupropion may prove to be an effective and safe intervention for fatigue in cancer and non-cancer conditions. A high-quality randomized trial is warranted to test current preliminary results.

A Mobile Phone Text Messaging Intervention to Manage Fatigue for People With Multiple Sclerosis, Spinal Cord Injury, and Stroke: Development and Usability Testing

BACKGROUND

Fatigue significantly affects daily functioning in persons with disabilities. Fatigue management can be challenging, and the information provided during routine physician visits to manage fatigue can be overwhelming. One way to address fatigue is to increase knowledge, skills, and confidence for self-management (ie, patient activation). Self-management programs have shown promising effects in targeting fatigue in persons with disabilities. However, satisfaction with self-management programs is low for persons with disabilities, and tailoring interventions to personalized needs has been recommended. SMS text messaging is increasingly being used to implement health behavior change interventions in a person's natural environment. Little has been done to link mobile health approaches with patient activation and self-management to address fatigue in persons with disabilities.

OBJECTIVE

This study aimed to develop and test a mobile phone-based fatigue self-management SMS text messaging intervention targeting patient activation in 3 groups of persons with disabilities: persons with multiple sclerosis, persons who had a stroke, and persons with a spinal cord injury.

METHODS

We used evidence-based resources and input from a consumer advisory board (CAB; composed of 2 participants from each of the 3 disability groups) and a neurologist to develop the intervention. The study was conducted using a 4-step process: development of the initial SMS text messaging library and categorization of the content into 9 content areas, review and modification of the SMS text messages by the neurologist and CAB, integration of the content library into a digital platform, and utility testing by CAB members.

RESULTS

A total of 6 CAB participants rated SMS text messages covering 9 domain areas of fatigue self-management with good clarity (mean ratings=3.5-5.0 out of 5) and relevance (mean ratings=3.2-5.0 out of 5). Overall, SMS text messaging content was reported by CAB participants as helpful, clear, and well suited for a mobile health intervention. The CAB reached consensus on the time of day that SMS text messages should be sent (morning) and their frequency (once per day). This feedback led the research team to narrow down the program to deliver 48 SMS text messages, 1 per day, Monday through Thursday only, a total of 4 SMS text messages per week, over a 12-week period. The final set of SMS text messages was programmed into a digital platform with a predefined delivery schedule. The usability of the intervention was high, with 55 (83%) out of 66 responses endorsing the highest rating.

CONCLUSIONS

This study demonstrates a step-by-step process for developing a fatigue self-management SMS text messaging intervention for persons with disabilities. For this population, whose access to health services is often limited, this intervention provides an alternative delivery model to increase access to fatigue information and deliver content that aligns with the person's needs.

Physical and mental fatigue in people with non-communicable chronic diseases

BACKGROUND

Fatigue is frequently reported in people with a non-communicable chronic disease. More insight in the nature of this symptom may enhance targeted treatment of fatigue. In this study, we aimed to gain more insight in the prevalence of different types of fatigue and in current prescribed treatment strategies to reduce fatigue in non-communicable chronic diseases.

METHODS

People with non-communicable chronic diseases were contacted via public, non-profit, disease-specific health funds and patient associations and invited to complete a web-based survey. The survey included a general question about the experience ("Do you now or have you ever had complaints of fatigue?") and nature of fatigue (physically/mentally/combination), the Checklist Individual Strength-subscale subjective fatigue (CIS-Fatigue; 8-56 points), self-constructed questions for the distinction between physical and mental fatigue (both 3-21 points) and questions on prescribed treatments for fatigue.

RESULTS

In total, 4199 participants (77% females) completed the online survey. 3945 participants (94.0%) reported experiencing fatigue, of which 64.4% reported a combination of both physical and mental fatigue. Median CIS-Fatigue score was 41 (32-48) points, with 68% of the participants reporting severe fatigue (≥36 points). Median scores for physical and mental fatigue were 15 (11-18) and 12 (8-16) points, respectively. In 55% of the participants, fatigue was only occasionally or never discussed with the healthcare professional, and only 23% of the participants were prescribed a treatment for fatigue. Participants often reported no effect or even an increase in fatigue after treatment.

CONCLUSIONS

Findings indicate that both physical and mental fatigue are often experienced simultaneously in people with non-communicable chronic diseases, but can also occur separately. Fatigue is often only occasionally or never discussed, let alone treated, highlighting the need to raise awareness among healthcare professionals. Future studies are needed to gain more insight in underlying factors of fatigue in non-communicable chronic diseases, its impact on daily life and development and evaluation of targeted treatment strategies.Key messages:Both physical and mental fatigue are frequently present in people with non-communicable chronic diseases.Fatigue is often only occasionally or never discussed during consultation with the physician, highlighting the need to raise awareness among healthcare professionals for adequate screening and evaluating of fatigue in people with non-communicable chronic diseases.Only less than a quarter of the people with non-communicable chronic diseases who reported to experience fatigue were prescribed a treatment for fatigue, which was often experienced as ineffective.

Fatigue severity and avoidance among individuals with chronic disease: A meta-analysis

OBJECTIVE

Fatigue is a common, debilitating symptom experienced by individuals with chronic disease. Avoidance, or the act of evading unwanted experiences, is associated with fatigue across chronic disease samples. The current study sought to determine the strength of association between fatigue severity and avoidance in individuals with chronic disease.

METHODS

PubMed, PsycINFO, CINAHL, and ProQuest Dissertations and Theses databases were searched. Eligible studies measured fatigue and avoidance in chronic disease samples. Sixty-six studies were included. Data analyses were conducted in Rstudio. A random effects model was employed, and a weighted mean effect size was computed for fatigue severity and avoidance. Mixed-effects meta-regression analyses were conducted to examine moderating variables, including patient, clinical, and measurement characteristics. Publication bias was examined using funnel plot, trim-and-fill, and p-curve.

RESULTS

The meta-analysis comprised of 71 unique patient samples from 66 studies. The total number of included participants was 13,024. A small, positive association was found between fatigue severity and avoidance, r(71) = 0.22, p < .001, 95% CI [0.18-0.27], SE = 0.02. There was also significant heterogeneity, Q(70) = 349.96, p < .001. Moderator analyses examining age, sex, illness duration, avoidance type, and disease sample were all non-significant. Regarding publication bias, trim-and-fill resulted in a modified weighted mean effect size (r(83) = 0.18, p < .001) and a p-curve analysis supported the evidential value of the current analysis.

CONCLUSION

Findings support that among individuals with chronic disease, fatigue severity and avoidance are positively associated, which has implications for behavioral interventions in this population.

Response Shift After Cognitive Behavioral Therapy Targeting Severe Fatigue: Explorative Analysis of Three Randomized Controlled Trials

Background

Cognitive behavioral therapy (CBT) is an evidence-based intervention for severe fatigue. Changes in patients’ fatigue scores following CBT might reflect not only the intended relief in fatigue but also response shift, a change in the meaning of patients’ self-evaluation. Objectives were to (1) identify the occurrence of response shift in patients undergoing CBT, (2) determine the impact of response shift on the intervention effect, and (3) investigate whether changes in fatigue-related cognitions and perceptions, targeted during CBT, are associated with response shift.

Methods

Data of three randomized controlled trials testing the efficacy of CBT in individuals with chronic fatigue syndrome (CFS, n = 222), cancer (n = 123), and diabetes (n = 107) were re-analyzed. Fatigue severity was measured with 8 items from the Checklist Individual Strength, a valid and widely used self-report questionnaire. Structural equation modelling was applied to assess lack of longitudinal measurement invariance, as indication of response shift.

Results

As expected, in all three trials, response shift was indicated in the CBT groups, not the control groups. Response shift through reprioritization was indicated for the items “Physically, I feel exhausted” (CFS) and “I tire easily” (cancer, diabetes), which became less vs. more important to the measurement of fatigue, respectively. However, this did not affect the intervention effects. Some changes in cognitions and perceptions were associated with the response shifts.

Conclusions

CBT seems to induce response shift through reprioritization across patient groups, but its occurrence does not affect the intervention effect. Future research should corroborate these findings and investigate whether patients indeed change their understanding of fatigue.

Experiences of a cognitive behavioural therapy (CBT) intervention for fatigue in patients receiving haemodialysis

BACKGROUND

A feasibility randomised-controlled trial found that a cognitive-behavioural therapy intervention for renal fatigue has the potential to reduce fatigue in patients receiving haemodialysis, but uptake was low.

OBJECTIVES

Nested in the randomised-controlled trial (RC) qualitative interviews were undertaken to understand the acceptability of renal fatigue, the facilitators of, and barriers to, engagement, and the psychosocial processes of change.

DESIGN

The trial included 24 participants at baseline. Semi-structured interviews were conducted with nine participants from the intervention arm (n = 12). Approach Interviews were carried out immediately following treatment (3 months post-randomisation). Data were analysed using inductive thematic analysis.

FINDINGS

Five main themes were formulated. The overarching theme was a sense of coherence (whether the illness, symptoms and treatment made sense to individuals), which appeared to be central to acceptability and engagement. Two themes captured the key barriers and facilitators to engagement, cognitive and illness/treatment burdens and collaboration with the therapist. Participants described changes related to their activity, thoughts and social identity/interactions, which shaped perceptions of change in fatigue. Lastly, participants discussed the optimal delivery of the intervention.

CONCLUSIONS

This study revealed the importance of patients' understanding of fatigue and acceptance of the treatment model for the acceptability of and engagement with a cognitive-behavioural therapy-based intervention for fatigue. Overall, there was an indication that such an intervention is acceptable to patients and the mechanisms of change align with the proposed biopsychosocial model of fatigue. However, it needs to be delivered in a way that is appealing and practical to patients, acknowledging the illness and treatment burdens.

Defining routine fatigue care in Multiple Sclerosis in the United Kingdom: What treatments are offered and who gets them?

Background

Fatigue is common and disabling in Multiple Sclerosis (MS). A recent meta-analytic systematic review reported 113 trials of exercise and behavioural interventions for fatigue, yet patients consistently describe fatigue being under-treated. The extent of the research-to-practice gap is yet to be documented.

Objective

To describe what fatigue treatments people with MS (pwMS) in the United Kingdom (UK) have been offered.

Methods

A cross-sectional survey of pwMS on the UK MS Register (UKMSR). Data on fatigue treatments offered were collected using an online questionnaire developed with patient input and summarised using descriptive statistics. Sociodemographic, MS-related, and psychological factors associated with treatment offered were evaluated using a logistic regression model.

Results

4,367 respondents completed the survey, 90.3% reported experiencing fatigue. Of these, 30.8% reported having been offered at least one type of pharmacological/non-pharmacological treatment for fatigue. Pharmacological treatments were more commonly offered (22.4%) compared to non-pharmacological treatments (12.6%; 2.9% exercise and 5.9% behavioural therapy). In the logistic regression model, older age, working, shorter time since MS diagnosis, and lower fatigue were associated with lower odds of having been offered treatment for fatigue.

Conclusion

This study accentuates the extent of the unmet need for fatigue treatment in MS in the UK.

Experienced fatigue in people with rare disorders: a scoping review on characteristics of existing research

BACKGROUND

Experienced fatigue is an under-recognized and under-researched feature in persons with many different rare diseases. A better overview of the characteristics of existing research on experienced fatigue in children and adults with rare diseases is needed. The purpose of this review was to map and describe characteristics of existing research on experienced fatigue in a selection of rare diseases in rare developmental defects or anomalies during embryogenesis and rare genetic diseases. Furthermore, to identify research gaps and point to research agendas.

METHODS

We applied a scoping review methodology, and performed a systematic search in March 2020 in bibliographic databases. References were sorted and evaluated for inclusion using EndNote and Rayyan. Data were extracted on the main research questions concerning characteristics of research on experienced fatigue (definition and focus on fatigue, study populations, research questions investigated and methods used).

RESULTS

This review included 215 articles on ten different rare developmental defects/anomalies during embryogenesis and 35 rare genetic diseases. Of the 215 articles, 82 had investigation of experienced fatigue as primary aim or outcome. Included were 9 secondary research articles (reviews) and 206 primary research articles. A minority of articles included children. There were large differences in the number of studies in different diseases. Only 29 of 215 articles gave a description of how they defined the concept of experienced fatigue. The most common research-question reported on was prevalence and/ -or associations to fatigue. The least common was diagnostics (development or validation of fatigue assessment methods for a specific patient group). A large variety of methods were used to investigate experienced fatigue, impeding comparisons both within and across diagnoses.

CONCLUSION

This scoping review on the characteristics of fatigue research in rare diseases found a large variety of research on experienced fatigue. However, the minority of studies had investigation of experienced fatigue as a primary aim. There was large variation in how experienced fatigue was defined and also in how it was measured, both within and across diagnoses. More research on experienced fatigue is needed, both in children and adults with rare diseases. This review offers a basis for further research.

Perceptions of fatigue in patients with idiopathic pulmonary fibrosis or sarcoidosis

Background

Fatigue is highly prevalent in patients with idiopathic pulmonary fibrosis (IPF) or sarcoidosis. However, the difference in fatigue perceptions for these patients is unknown and this may be important to better understand what fatigue means to the individual patient.

Methods

This cross-sectional quantitative study aims to determine the different perceptions of fatigue as 'frustrating', 'exhausting', 'pleasant', 'frightening' using the Fatigue Quality List and to assess determinants related to these perceptions of fatigue. Beside the fatigue quality connotations, demographics, lung function, fatigue severity (Checklist Individual Strength subscale Fatigue), dyspnea (modified-Medical Research Council), fatigue catastrophizing (Fatigue Catastrophizing Scale), anxiety/depression (Hospital Anxiety and Depression Scale) and general health status (EuroQoL 5-dimension 5-level) were assessed.

Results

Mean frequency score of fatigue-related perceptions in patients with IPF was 3.4 points and in patients with sarcoidosis 4.0 points. Severely fatigued patients with IPF reported their fatigue less 'pleasant' significantly more often than patients without severe fatigue. Fatigue severity, dyspnea, catastrophizing and general health were significantly correlated with the negative connotation categories of the Fatigue Quality List in patients with IPF. Severely fatigued sarcoidosis patients reported their fatigue perceptions significantly more often as 'frustrating', 'exhausting', 'frightening' and less 'pleasant' than patients without severe fatigue. Moreover, in patients with sarcoidosis fatigue severity, dyspnea, catastrophizing and depression were significantly associated with all four categories of the Fatigue Quality List that describe the experienced fatigue (P<0.05).

Conclusions

The current findings of experiences of fatigue in patients with IPF or pulmonary sarcoidosis provide insights for professionals treating these patients. Although similarities were found in the several experiences of fatigue across non-severely and severely fatigued patients, differences were also evident and could be mapped for IPF and sarcoidosis.

Perceptions of fatigue and fatigue management interventions among people with multiple sclerosis: a systematic literature review and narrative synthesis

Background/Aims

Fatigue is the most common symptom of multiple sclerosis. Evidence supports the effectiveness of fatigue management interventions for people with multiple sclerosis. This review aimed to identify how people with multiple sclerosis experience fatigue and to examine their perceptions of fatigue management interventions.

Methods

The review was conducted systematically, searching the following electronic databases: AMED, CINAHL Complete, eBook Nursing Collection, ERIC, Health Source: Nursing/Academic Edition, MEDLINE, APA PsycArticles, and APA PsycInfo for original peer-reviewed empirical research published in English between January 2000 and June 2020. Qualitative and mixed-methods studies that captured the perspectives of people with multiple sclerosis on their fatigue and/or their perceptions of fatigue management interventions were included. A narrative synthesis was used to synthesise the findings.

Results

A total of 23 qualitative and eight mixed-methods studies were extracted comprising a total of 662 people with multiple sclerosis (relapsing remitting n=293; secondary progressive n=129; primary progressive n=73; relapsing progressive n=3; benign n=2; fulminant n=1; type of multiple sclerosis not reported n=161). Fatigue was perceived by people with multiple sclerosis as a debilitating symptom of the condition and which they felt impacted adversely on their lives. A lack of understanding from others about multiple sclerosis fatigue was challenging for people with multiple sclerosis. People with multiple sclerosis valued the physical and psychosocial-based content of fatigue management interventions and felt fatigue management interventions enabled them to legitimise their fatigue and feel more in control of their fatigue.

Conclusions

From the perspective of people with multiple sclerosis, fatigue is a central and debilitating feature of the everyday experience of living with multiple sclerosis. Research on the potential of fatigue management interventions to foster control for people with multiple sclerosis to help them manage their fatigue is warranted. Healthcare professionals should consider how they can empower people with multiple sclerosis to educate others about their fatigue. Some evidence being generated for practice might not be sufficiently contextualised to different forms of multiple sclerosis.

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

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

Caught up in Care: Crafting Moral Subjects of Chronic Fatigue

Patients with chronic fatigue receive advice to improve symptom management and well-being. This advice is based on ideas of self-management and is conveyed during clinical assessment as "activity regulation." Based on ethnographic fieldwork in a hospital clinic in Norway, we show how these patients attempt to demonstrate their competences and everyday concerns, and how the ideology of self-management frames the hope for recovery and crafts a subject with the ability to improve. Patients, however, linger between everyday social predicaments and ideals of healthy living, and are caught up in cultural models of care that deflect everyday concerns and agency.

The Neurobiology of Pathological Fatigue: New Models, New Questions

The last decade has seen the emergence of new theoretical frameworks to explain pathological fatigue, a much neglected, yet highly significant symptom across a wide range of diseases. While the new models of fatigue provide new hypotheses to test, they also raise a number of questions. The primary purpose of this essay is to examine the predictions of three recently proposed models of fatigue, the overlap and differences between them, and the evidence from diseases that may lend support to the models of fatigue. I also present expansions for the sensory attenuation model of fatigue. Further questions examined here are the following: What are the neural substrates of fatigue? How can sensory attenuation, which underpins agency also explain fatigue? Are fatigue and agency related?

Brief Psychosocial Intervention to Address Poststroke Depression May Also Benefit Fatigue and Sleep-Wake Disturbance

PURPOSE

This study aimed to determine if brief psychosocial/behavioral therapy directed to reduce poststroke depression would decrease fatigue and improve sleep-wake disturbance.

DESIGN

A preplanned secondary data analysis from a completed clinical trial was conducted.

METHODS

One hundred participants received usual care, in-person intervention, or telephone intervention. Depression, fatigue, and sleep-wake disturbance were measured at entry, 8 weeks, 21 weeks, and 12 months following the intervention.

FINDINGS

Fatigue (within: p = .042, between: p = .394), sleep disturbance (within: p = .024, between: p = .102), and wake disturbance (within: p = .004, between: p = .508) decreased over the 12 months in the intervention groups, but not in the control group. This difference was clinically meaningful for wake disturbance and approached the clinically important difference for fatigue.

CONCLUSIONS/CLINICAL RELEVANCE

Reduction in wake disturbance was consistent with clinically meaningful difference standards for patient-reported outcomes, warranting further research in larger samples.

Characterization of Post-exertional Malaise in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Background: Myalgic encephalomyelitis/chronic fatigue syndrome is characterized by persistent and disabling fatigue, exercise intolerance, cognitive difficulty, and musculoskeletal/joint pain. Post-exertional malaise is a worsening of these symptoms after a physical or mental exertion and is considered a central feature of the illness. Scant observations in the available literature provide qualitative assessments of post-exertional malaise in patients with myalgic encephalomyelitis/chronic fatigue syndrome. To enhance our understanding, a series of outpatient focus groups were convened. Methods: Nine focus groups totaling 43 patients who reported being diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome were held between November 2016 and August 2019. Focus groups queried post-exertional malaise in daily life and participants' retrospective memory of post-exertional malaise that followed an exercise provocation with a cardiopulmonary exercise test. Data analysis followed the grounded theory method to systematically code and categorize the data to find meaningful patterns. A qualitative software package was used to move text into categories during data coding. Results: A wide range of symptoms were attributed to exertion both in daily lives and following cardiopulmonary exercise testing. While three core symptoms emerged (exhaustion, cognitive difficulties, and neuromuscular complaints), participants' descriptions were notable for their unique individual variations. Of 18 participants who responded to questions centered around symptoms following a cardiopulmonary exercise test, 17 reported that symptoms started within 24 h and peaked in severity within 72 h following the cardiopulmonary exercise test. Patients described post-exertional malaise as interfering with their ability to lead a "normal" life. Conclusion: The experience of post-exertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome varies greatly between individuals and leads to a diminished quality of life. myalgic encephalomyelitis/chronic fatigue syndrome patients describe post-exertional malaise as all-encompassing with symptoms affecting every part of the body, difficult to predict or manage, and requiring complete bedrest to fully or partially recover. Given the extensive variability in patients, further research identifying subtypes of post-exertional malaise could lead to better targeted therapeutic options.

A Qualitative Metasynthesis of the Experience of Fatigue Across Five Chronic Conditions

CONTEXT

Fatigue is a symptom reported by patients with a variety of chronic conditions. However, it is unclear whether fatigue is similar across conditions. Better understanding its nature could provide important clues regarding the mechanisms underlying fatigue and aid in developing more effective therapeutic interventions to decrease fatigue and improve quality of life.

OBJECTIVES

To better understand the nature of fatigue, we performed a qualitative metasynthesis exploring patients' experiences of fatigue across five chronic noninfectious conditions: heart failure, multiple sclerosis, rheumatoid arthritis, chronic kidney disease, and chronic obstructive pulmonary disease.

METHODS

We identified 34 qualitative studies written in the last 10 years describing fatigue in patients with one of the aforementioned conditions using three databases (Embase, PubMed, and CINAHL). Studies with patient quotes describing fatigue were synthesized, integrated, and interpreted.

RESULTS

Across conditions, patients consistently described fatigue as persistent overwhelming tiredness, severe lack of energy, and physical weakness that worsened over time. Four common themes emerged: running out of batteries, a bad life, associated symptoms (e.g., sleep disturbance, impaired cognition, and depression), and feeling misunderstood by others, with a fear of not being believed or being perceived negatively.

CONCLUSION

In adults with heart failure, multiple sclerosis, rheumatoid arthritis, chronic kidney disease, and chronic obstructive pulmonary disease, we found that fatigue was characterized by severe energy depletion, which had negative impacts on patients' lives and caused associated symptoms that exacerbated fatigue. Yet, fatigue is commonly misunderstood and inadequately acknowledged.

Psychometric Properties of the Multidimensional Fatigue Inventory (MFI-20), Derived From Seven Samples

CONTEXT

Fatigue is a frequent symptom in patients suffering from chronic diseases. The Multidimensional Fatigue Inventory (MFI-20) is often used to measure fatigue. The aim of this article was to test the scale structure of the questionnaire.

METHODS

The MFI-20 data were obtained from seven samples, including general population samples and samples of patients with different diseases (N between 122 and 1993). Five confirmatory factor analysis (CFA) models were tested for each sample.

RESULTS

The scale structure postulated by the original test authors could not be confirmed by the CFAs. The inclusion of a method factor which considers the positive versus the negative orientation of the items yielded a better model fit. Cronbach's alpha was acceptable for most of the samples and scales: the total score of the MFI-20 reached alpha coefficients above 0.89. A short form of the MFI-20 which is restricted to the 10 positively oriented items (MFI-10) showed relatively good CFA indices.

CONCLUSION

The factorial validity of the MFI-20 is insufficient, an issue which is due, at least in part, to the inclusion of positively and negatively oriented items. Nevertheless, we recommend maintaining the scale structure of the MFI-20 and not searching for alternative structures.

Accelerated aging in breast cancer survivors and its association with mortality and cancer recurrence

PURPOSE

To prospectively investigate accelerated aging and its association with total mortality and breast cancer-specific mortality/recurrence among breast cancer survivors.

METHODS

This study included 4218 female breast cancer patients enrolled into a population-based cohort study approximately 6-month post-diagnosis. Information on aging-related symptoms (i.e., self-rated overall health condition, energy level, depression, sleep difficulty, and quality) was collected at 18- and 36-month post-diagnosis surveys. Information on overall health, daily function impairments, survival status, and recurrence was collected at 10-year post-diagnosis survey. Record linkages with vital statistics were conducted to collect mortality information. Cox proportional hazards model was applied.

RESULTS

Among 3041 10-year survivors with a mean age of 63.7 ± 9.7 years, respectively, 52.3%, 19.0%, and 27.6% reported poor health, limitation in daily activity, and climbing floors. Age-specific prevalence revealed that breast cancer survivors reached similar prevalence of the functional limitations 5-10 years earlier than cancer-free women. At the 18-month post-diagnosis survey, respectively, 47.0%, 72.5%, and 25.1% of survivors reported unsatisfied overall health condition, reduced energy level, and depression symptoms. After a median follow-up of 10.9 years, low self-rated overall health, low energy level, and depression were significantly associated with increased total mortality, with hazard ratios (HRs; 95% confidence intervals [CI]) of 3.14 (2.43, 4.06), 1.49 (1.20, 1.84), and 1.59 (1.21, 2.09), respectively. Low self-rated health was associated with breast cancer-specific mortality/recurrence (HR  1.85, 95% CI 1.30, 2.65). No significant association was found for sleep difficulty and quality.

CONCLUSION

Aging-related physical changes/symptoms are commonly presented at 18 months after breast cancer diagnosis and are associated with worse prognosis.

IMPACT

Our findings highlight the concern of accelerated aging among breast cancer survivors.

Experiencing and responding to chronic cancer-related fatigue: A meta-ethnography of qualitative research

Objective

One of the most prevalent and disrupting symptoms experienced by cancer patients is chronic cancer‐related fatigue (CCRF). A better understanding of the chronic nature of CCRF can provide valuable insights for theory and practice. The purpose of this meta‐ethnography was to derive an overarching interpretative narrative on patients' experiences and responses to CCRF.

Methods

We conducted a comprehensive systematic literature search in five databases (05‐03‐2018). In addition, papers from reference lists were retrieved. Two researchers independently screened the papers for eligibility and appraised quality (CASP‐criteria). We followed the seven phases of meta‐ethnography to extract, translate, and synthesise first‐order constructs (ie, patients' views) and second‐order constructs (ie, authors' views) from the selected studies into third‐order constructs (ie, new interpretations).

Results

Of the 1178 collected articles, 16 articles were included. Through synthesis, a new figure of six interrelated third‐order constructs was developed: (1) embodied experience entails the dominating presence of the body; (2) (mis)recognition includes lack of recognition of CCRF by patients, relatives, and health providers; (3) small horizon describes a resultant narrowed world; (4) role change encompasses adopting other life roles; (5) loss of self refers to the impact on one's identity; and (6) regaining one's footing describes the struggle against CCRF, adaptation to CCRF and finally acceptance of a “new normal with CCRF.”

Conclusion

A new embodiment figure of CCRF with social (eg, (mis)recognition), spatial (eg, small horizon) and temporal dimensions (eg, regaining one's footing) was developed. This figure can help professionals to recognise CCRF, inform patients, and personalise treatment.

The holistic management of fatigue within palliative care

BACKGROUND

Fatigue is a common symptom experienced by people with cancer and other long-term, non-malignant conditions. It can be disease-related or caused by treatments such as chemotherapy or radiotherapy. Patients frequently report this as a distressing symptom and, while some international guidelines for its management exist, evidence suggests that these are not always implemented.

METHOD

This article reviews the evidence basis for fatigue management, looking at exercise, education, psychological interventions, complementary therapies and pharmacological therapy, and finds that a one-size fits all approach to fatigue management is unrealistic.

FINDINGS

Research appears to support different interventions at various points in the disease trajectory and this is of importance for service design as palliative care is increasingly introduced earlier in the patient's pathway.

CONCLUSION

Although the body of research is growing, management of fatigue caused by non-malignant conditions remains poorly evidenced, making comprehensive recommendations for these patient groups even more challenging.

Seeing the quality improvement forest through the quality improvement trees: A meta-synthesis of case studies in Florida and Georgia

Objectives

To identify important characteristics of quality improvement applications for population health and healthcare settings and to explore the use of quality improvement as a model for implementing and disseminating evidence-based or best practices.

Methods

A meta-synthesis was used to examine published quality improvement case studies. A total of 10 published studies that were conducted in Florida and Georgia were examined and synthesized using meta-synthesis (a qualitative research methodology) for meaningful insights and lessons learned using defined meta-synthesis inclusion criteria. The primary focus of the analysis and synthesis were the reported processes and findings that included responses to structured questioning in addition to emergent results from direct observation and semi-structured open-ended interviewing.

Results

The key insights for the use of quality improvement in public health and healthcare settings included (1) the essential importance of data monitoring, analysis, and data-based decision making; (2) the need to focus on internal mutable factors within organizations; (3) the critical role of quality improvement team group dynamics; (4) the value of using a quality improvement collaborative or multi-clinic quality council/committee for sharing and comparing performance on key metrics; and (5) the need to identify a quality improvement approach and methods for clarification as a structured quality improvement intervention.

Conclusion

In addition to the advantages of using quality improvement to enhance or improve healthcare and public health services, there is also potential for quality improvement to serve as a model for enhancing the adoption of evidence-based practices within the context of dissemination and implementation research.

The development and initial validation of the Fatigue Sensitivity Questionnaire

Currently, there is poor understanding of fatigue and the possible psychological conditions that may underlie chronic fatigue. Although substantial work has been directed to better clinically address fatigue, no work has explored individual differences in expectations or perceptions of the negative consequences associated with fatigue-related symptoms. The goals of this study were to (a) develop and (b) validate a measure of expectations or perceptions of the negative consequences associated with fatigue-related symptoms (e.g. fatigue sensitivity) across two independent samples (N = 1,827; 73.1% female; M_age = 21.68; SD = 4.54) of young adults. Results supported a 10-item measure of fatigue sensitivity, entitled the Fatigue Sensitivity Questionnaire (FSQ). The FSQ demonstrated unidimensionality, excellent internal consistency, and strong convergent and discriminant validity. Overall, the 10-item scale offers a single score that can be employed to measure fatigue sensitivity. Clinically, the FSQ may be a brief, informative, and easily disseminated measure in better understanding and capturing expectations or perceptions about the negative consequences of fatigue. As a research tool, the use of the FSQ may provide broader understanding of vulnerability factors that may influence fatigue-related health outcomes. Future research is needed to test the validity of the FSQ in other samples.

Using intervention mapping to design a self-management programme for older people with chronic conditions

Self-management programmes provide strategies to optimise health while educating and providing resources for living with enduring illnesses. The current paper describes the development of a community-based programme that combines a transdiagnostic approach to self-management with mindfulness to enhance psychological coping for older people with long-term multimorbidity. The six steps of intervention mapping (IM) were used to develop the programme. From a needs assessment, the objectives of the programme were formulated; the theoretical underpinnings then aligned to the objectives, which informed programme design, decisions on implementation, programme adoption and evaluation steps. Bandura's social cognitive theory informed the methods and practical strategies of delivery. Among the features addressed with participants are transdiagnostic dimensions such as fatigue, pain, breathlessness, sleep disturbances. The programme utilises mindfulness to aid coping and ameliorate the psychological distresses associated with chronicity. Findings from an initial feasibility study and subsequent pilot assisted in conceptualising our programme. In conclusion, applying IM gave the planners confidence the programme is robust and evidence-based with clearly articulated links between the behavioural goals and design elements to obtain the desired outcomes.

Comorbid conditions and health-related quality of life in long-term cancer survivors-associations with demographic and medical characteristics

PURPOSE

Our study provides a detailed overview of comorbid conditions and health-related quality of life of long-term cancer survivors and analyses the impact of demographic, disease- and treatment-related characteristics.

METHODS

We present data obtained from 1000 survivors across mixed tumour entities 5 and 10 years after cancer diagnosis in a cross-sectional study. We analyse the prevalence of physical symptoms and health conditions via self-report and health-related quality of life using the EORTC QLQ-C30 in comparison to gender- and age-matched reference values of the general population.

RESULTS

Cancer survivors reported on average 5 comorbidities; 23% had 7 or more comorbid conditions. Cancer survivors reported higher physical symptom burden than the population-especially fatigue, insomnia and pain. Type and prevalence of long-term and late effects differ with disease-related factors (e.g. cancer type, treatment) and characteristics of the patient. Cancer survivors also reported lower quality of life than the population, especially in everyday activities, social life, psychological well-being and financial difficulties. There was a positive association between high quality of life and a low level of morbidity.

CONCLUSIONS

The specific knowledge about physical long-term consequences for the individual types of cancer could raise awareness in health care professionals for high-risk patients and help to develop adequate prevention and survivorship-programs.

IMPLICATIONS FOR CANCER SURVIVORS

Limitations in the mental health area underlines the importance of psycho-oncological survivorship-care-plans, which go beyond the time of rehabilitation. Special attention should be given to the financial situation of patients in long-term follow-up care.

Fatigue in the general population: German normative values of the EORTC QLQ-FA12

PURPOSE

Fatigue is a frequent symptom in patients suffering from chronic diseases, especially cancer patients. A new fatigue questionnaire was recently developed to better assess this condition, the EORTC QLQ-FA12. The aims of this study were to test the psychometric properties of this fatigue questionnaire and to provide normative values.

METHODS

A total of 2411 individuals (53.5% women), representatively selected from the German general population, responded to the EORTC QLQ-FA12 questionnaire.

RESULTS

Women reported more fatigue than men on all three scales of the EORTC QLQ-FA12 with the following effect sizes: d = 0.29 (physical fatigue), d = 0.22 (emotional fatigue), and d = 0.11 (cognitive fatigue). There were no linear age trends. Confirmatory factorial analysis confirmed the latent structure of the questionnaire. The correlations among the latent scales were between 0.71 and 0.84. The internal consistency coefficients were alpha = 0.92 (physical fatigue), 0.86 (emotional fatigue), 0.79 (cognitive fatigue), and 0.94 (sum score).

CONCLUSIONS

The study proved the psychometric quality of the EORTC QLQ-FA12 in the general population. Gender differences should be accounted for when comparing groups of patients. The normative scores can be used to qualify the assessment of the degree of patients' fatigue.

Psychometric Properties of the Fatigue Questionnaire EORTC QLQ-FA12 in a Sample of Female Cancer Patients

CONTEXT

Cancer patients frequently suffer from fatigue. Recently, the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life group developed a new 12-item fatigue assessment instrument.

OBJECTIVES

The aim of this study was to psychometrically test this questionnaire in comparison with the three-item fatigue scale of the EORTC QLQ-C30.

METHODS

A sample of 354 patients who were being treated for breast cancer or gynecologic cancer were examined using the new fatigue questionnaire EORTC QLQ-FA12 and the EORTC QLQ-C30 during their hospital stay (t1) and three months after hospital discharge (t2). Confirmatory factorial analyses, item analyses, test-retest reliability analyses, and correlation analyses were performed.

RESULTS

The analyses roughly supported the three-factorial structure of the FA12, which comprised the subscales physical, emotional, and cognitive fatigue. The fit indices of the confirmatory factorial analysis were worse than those of the original article but nevertheless acceptable. Cronbach alpha of the total scale was 0.92; the coefficients of the subscales were between 0.79 and 0.93. The correlation between the EORTC QLQ-FA12 total scale and the fatigue scale of the EORTC QLQ-C30 was 0.69 and the correlation between the t1 and t2 scores was 0.45 for the EORTC QLQ-FA12 total scale and between 0.37 and 0.47 for the subscales.

CONCLUSION

The psychometric coefficients justify the calculation of a sum score, which can be used by clinicians to assess the general degree of fatigue. Although the three-item fatigue scale of the EORTC QLQ-C30 stresses the physical aspect of fatigue, the new EORTC QLQ-FA12 covers its emotional and cognitive aspects as well.