A theory of postoperative fatigue: an interaction of biological, psychological, and social processes

An Interactive Pain Application (MServ) Improves Postoperative Pain Management

Background

Most patients have moderate or severe pain after surgery. Opioids are the cornerstone of treating severe pain after surgery but cause problems when continued long after discharge. We investigated the efficacy of multifunction pain management software (MServ) in improving postoperative pain control and reducing opioid prescription at discharge.

Methods

We recruited 234 patients to a prospective cohort study into sequential groups in a nonrandomised manner, one day after major thoracic or urological surgery. Group 1 received standard care (SC, n = 102), group 2 were given a multifunctional device that fed back to the nursing staff alone (DN, n = 66), and group 3 were given the same device that fed back to both the nursing staff and the acute pain team (DNPT, n = 66). Patient-reported pain scores at 24 and 48 hours and patient-reported time in severe pain, medications, and satisfaction were recorded on trial discharge. Findings. Odds of having poor pain control (>1 on 0–4 pain scale) were calculated between standard care (SC) and device groups (DN and DNPT). Patients with a device were significantly less likely to have poor pain control at 24 hours (OR 0.45, 95% CI 0.25, 0.81) and to report time in severe pain at 48 hours (OR 0.62, 95% CI 0.47–0.80). Patients with a device were three times less likely to be prescribed strong opioids on discharge (OR 0.35, 95% CI 0.13 to 0.95). Interpretation. Using an mHealth device designed for pain management, rather than standard care, reduced the incidence of poor pain control in the postoperative period and reduced opioid prescription on discharge from hospital.

Comparison of ED95 of Butorphanol and Sufentanil for gastrointestinal endoscopy sedation: a randomized controlled trial

Background

Butorphanol, a synthetic opioid partial agonist analgesic, has been widely used to control perioperative pain. However, the ideal dose and availability of butorphanol for gastrointestinal (GI) endoscopy are not well known. The aim of this study was to evaluated the 95% effective dose (ED₉₅) of butorphanol and sufentanil in GI endoscopy and compared their clinical efficacy, especially regarding the recovery time.

Methods

The study was divided into two parts. For the first part, voluntary patients who needed GI endoscopy anesthesia were recruited to measure the ED₉₅ of butorphanol and sufentanil needed to achieve successful sedation before GI endoscopy using the sequential method (the Dixon up-and-down method). The second part was a double-blind, randomized study. Two hundred cases of painless GI endoscopy patients were randomly divided into two groups (n = 100), including group B (butorphanol at the ED₉₅ dose) and group S (sufentanil at the ED₉₅ dose). Propofol was infused intravenously as the sedative in both groups. The recovery time, visual analogue scale (VAS) score, hand grip strength, fatigue severity scores, incidence of nausea and vomiting, and incidence of dizziness were recorded.

Results

The ED₉₅ of butorphanol for painless GI endoscopy was 9.07 μg/kg (95% confidence interval: 7.81–19.66 μg/kg). The ED₉₅ of sufentanil was 0.1 μg/kg (95% CI, 0.079–0.422 μg/kg). Both butorphanol and sufentanil provided a good analgesic effect for GI endoscopy. However, the recovery time for butorphanol was significantly shorter than that for sufentanil (P < 0.05, group B vs. group S:21.26 ± 7.70 vs. 24.03 ± 7.80 min).

Conclusions

Butorphanol at 9.07 μg/kg was more effective than sufentanil for GI endoscopy sedation and notably reduced the recovery time.

Trial registration

Chinese Clinical Trail Registry (Registration number # ChiCTR1900022780; Date of Registration on April 25rd, 2019).

Multi-modal prehabilitation: addressing the why, when, what, how, who and where next?

Just as there is growing interest in enhancing recovery after surgery, prehabilitation is becoming a recognised means of preparing the patient physically for their operation and/or subsequent treatment. Exercise training is an important stimulus for improving low cardiovascular fitness and preserving lean muscle mass, which are critical factors in how well the patient recovers from surgery. Despite the usual focus on exercise, it is important to recognise the contribution of nutritional optimisation and psychological wellbeing for both the adherence and the response to the physical training stimulus. This article reviews the importance of a multi-modal approach to prehabilitation in order to maximise its impact in the pre-surgical period, as well as critical future steps in its development and integration in the healthcare system.

Benefits of direct patient discharge to outpatient physical therapy after total knee arthroplasty

Purpose: To investigate the effectiveness of home health physical therapy followed by outpatient physical therapy as compared to patients discharged directly to outpatient physical therapy in improving functional performance, strength/activation and residual knee pain outcomes among patients who received a total knee arthroplasty.Materials and methods: A secondary analysis of longitudinal data in which patients with total knee arthroplasty underwent home health physical therapy or were discharged directly to outpatient physical therapy. Main outcome measures included the stair climb test, timed up and go, 6-min walk test, quadriceps and hamstring strength, quadriceps activation and residual knee pain.Results: Patients referred to home health physical therapy prior to outpatient physical therapy demonstrated significantly greater declines in stair climb test (10.3; 95% CI [6.5, 14.1]; t = 5.41; p < 0.0001), timed up and go (2.0; 95% CI [1.0, 3.0]; t = 4.10; p < 0.0001), 6-min walk (53.8; 95% CI [29.4, 78.2]; t = 4.35; p < 0.0001), quadriceps strength (21.7%; 95% CI [19.3%, 24.9%]; t = 2.53; p = 0.01), hamstring strength (44.7%; 95% CI [43.4%, 45.7%], t = 3.17; p = 0.002) and higher residual knee pain (0.53; 95% CI [0.04, 1.03]; t = 2.17; p = 0.03) 1 month after total knee arthroplasty compared to those referred directly to outpatient physical therapy.Conclusions: These findings suggest that patients discharged directly to outpatient physical therapy had a more rapid recovery 1 month after total knee arthroplasty. Additional research is needed to investigate the potential causal relation between care pathways and clinical outcomes following total knee arthroplasty.Implications for rehabilitationTotal knee arthroplasty, typically performed to alleviate end-stage knee osteoarthritis, is the most commonly performed elective surgery in the United States.Despite improvement in pain, objective measurements of functional performance and strength often remain at preoperative levels one year after total knee arthroplasty.Patients discharged directly to higher intensity outpatient physical therapy have a more rapid recovery after total knee arthroplasty compared with those patients who received two weeks of home health prior to undergoing outpatient physical therapy.

Social roles and long-term illness: is it time to rehabilitate convalescence?

The total extent of sickness in the population has increased while disease has decreased. Being sick is a role that offers the patient many advantages both directly, in terms of being absolved from undertaking many daily activities if necessary, and indirectly, through additional financial and other resources that may be offered. Because of these advantages, it is usual for any persistent sickness to be validated by health care professionals. Moreover sick people are expected to make every effort to leave the sick state, especially to make every effort using offered advice and resources such as rehabilitative treatments. However some people are sick longer than anticipated or apparently justified. The sick role developed based on assumptions that may no longer be valid, and the extended World Health Organization's International Classification of Functioning (WHO ICF) model of illness provides a new analysis of the problem, emphasizing that sometimes sickness is caused or perpetuated by factors other than disease. Among other factors, the lack of a way out of the sick role might be one reason for increasing sickness. Therefore re-establishing convalescence as a role might facilitate people in leaving the sick role, and rehabilitation should consider promoting convalescence.

Optimization of surgical outcomes with prehabilitation

The concept of preparing surgical candidates with various modalities designed to increase physical, physiological, metabolic, and psychosocial reserves is known as prehabilitation. Prehabilitation has garnered significant attention in recent years as evidence grows describing benefits to clinical and quality of life outcomes. Recent research examining hospital length of stay and readmission rates provides promising findings with respect to the value of prehabilitation in economic and sustainable healthcare models. The role of prehabilitation across the surgical experience exploits common surgical wait-times and the teachable moment that many patients experience upon the identification of a surgical requirement to improve the pre-, peri-, and postoperative experience. Prehabilitation incorporates numerous systemic and regional approaches to conditioning the surgical candidate. These include exercise, nutrition, education, and/or psychosocial approaches that are intended to improve preoperative fitness and preparedness. Importantly, this also promotes and facilitates health behaviour changes not only preoperatively but during the postoperative period and over the long-term. In this paper, we briefly review the historical and current perspectives on prehabilitation and comment on opportunities for greater clinical and empirical understanding in this field.

Prehabilitation to enhance perioperative care

Patients who are elderly, malnourished, anxious, and have a low physical function before surgery are likely to have suboptimal recovery from cancer surgery. A multimodal prehabilitation program is proposed, consisting of exercise training and nutritional and psychological support, which increases physiologic reserve before the stress of surgery. This interventional approach seems to improve ability to undergo the stress of surgery and faster recovery. The integration of exercise, adequate nutrition, and psychosocial components, with medical and pharmacologic optimization in the presurgical period, deserves to receive more attention by clinicians to elucidate the most effective interventions.

Review article: Perioperative care in enhanced recovery for total hip and knee arthroplasty

Enhanced recovery pathways for total hip and knee arthroplasty can reduce length of hospital stay and perioperative morbidity. 22 studies were reviewed for identification of perioperative care interventions, including preoperative (n=4), intra-operative (n=8), and postoperative (n=4) care interventions. Factors that improve outcomes included use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status and provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems and tranexamic acid, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery.

Association between the transcriptional levels of Htr-1a and tryptophan hydroxylase-1 in the hippocampus and the antifatigue effects of leucine on rats with postoperative fatigue

Leucine (Leu), a branched-chain amino acid (BCAA), is widely used in clinical practice following severe burns, gastrointestinal surgery, trauma and sepsis. In the present study, the antifatigue effects of BCAAs on a postoperative fatigue (POF) rat model, induced by 70% intestinal resection, were investigated. Leu (16.5 g/l) was administered intraperitoneally at a dose of 18 ml/kg/day. The fatigue level and antifatigue effects of Leu were evaluated by open-field testing on day 1, 3, 5 and 7 after surgery. In addition, mRNA specimens were extracted and measured using a quantitative polymerase chain reaction method. The open-field test results indicated that Leu exhibited a significant antifatigue effect. The total distance travelled and the number of times the rats passed from the outermost grids of an open-top case were greatly improved in the Leu treatment group when compared with the POF model group. With the exception of the normal group, the mRNA expression levels of Htr-1a exhibited a similar trend in all other groups, reaching a climax on day 3 and 5, while being restored to a normal level on day 7. With regard to the Leu intervention group, the mRNA expression level of Htr-1a decreased significantly on day 3 and 5 following surgery. The mRNA expression levels of tryptophan hydroxylase-1 were unchanged in this short time period; however, the levels were increased gradually in the Leu treatment group. Therefore, Leu exhibited an apparent antifatigue effect on various 5-hydroxytryptamine-associated genes.

Ginsenoside Rb1 improves energy metabolism in the skeletal muscle of an animal model of postoperative fatigue syndrome

BACKGROUND

Postoperative fatigue syndrome (POFS) is a common clinical complication followed by almost every major abdominal surgery. Ginsenoside Rb1 (GRb1), a principle ginsenoside in ginseng, could exert a potent anti-fatigue effect on POFS. However, the mechanism is still unknown. Previous studies revealed that alterations in the energy metabolism in the skeletal muscle may play a vital role in the development and progression of fatigue. In the present study, we investigate the effect of GRb1 on energy metabolism in the skeletal muscle of a rat model of POFS induced by major small intestinal resection.

METHODS

GRb1 (10 mg/kg) was intraperitoneally administrated once daily for 1, 3, 7, and 10 d from the operation day, respectively. The locomotor activity was recorded every day, and total food intake was calculated starting from 24 h after surgery. After GRb1 treatment was completed, blood and skeletal muscle were sampled. The level of blood glucose was determined by an automatic biochemical analyzer. The content of adenosine triphosphate (ATP) in skeletal muscle was determined by high-performance liquid chromatography. The activity of energy metabolic enzymes Na(+)-K(+)-ATPase, pyruvate kinase, and succinate dehydrogenase (SDH) was assessed by commercially available kits.

RESULTS

The results revealed that GRb1 could increase locomotor activity of POFS rats and significantly increase their total food intake postoperatively (P < 0.05). Furthermore, GRb1 also significantly increased ATP content in the skeletal muscle of POFS rats (P < 0.05). Meanwhile, the activity of Na(+)-K(+)-ATPase and SDH in the skeletal muscle of POFS rats was enhanced by GRb1 (P < 0.05). However, no significant differences in blood glucose and pyruvate kinase were found between the POFS and GRb1 treatment rats (P > 0.05).

CONCLUSIONS

These results suggest that GRb1 may improve skeletal muscle energy metabolism in POFS, and the underlying mechanism may be associated with an increase in the content of ATP and an enhancement in the activity of energy metabolic enzymes such as Na(+)-K(+)-ATPase ATPase and SDH in the skeletal muscle.

The effect of perioperative psychological intervention on fatigue after laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Fatigue is one of the main complaints after surgery and may last longer than physical symptoms. It prevents return to normal function and activity. Relaxation interventions, performed prior to abdominal surgery, have been shown to reduce pain, wound erythema, and systemic cortisol levels. However, there is a lack of data on the impact of this intervention on patient well-being, functional recovery, activities of daily living, and fatigue after discharge from hospital.

METHODS

The study was a randomised single-blinded trial. Patients who were to undergo elective laparoscopic cholecystectomy for any indication between April 2008 and May 2010 were screened for inclusion. Those in the intervention group attended a standardised 45 min relaxation session with a health psychologist and were given relaxation exercise CDs to take home. The control group did not have the intervention. Patients were followed for 30 days. Fatigue was measured using the identity-consequence fatigue scale.

RESULTS

Seventy-five patients were randomised. Fifteen patients were excluded after randomization for various reasons; hence, 60 patients were followed up and analysed. Both groups had similar fatigue at baseline. There was improved fatigue and consequence of fatigue on postoperative day 30 in the intervention group. There was no difference in fatigue at any other time point postoperatively.

CONCLUSION

This was the first interventional study targeting fatigue after laparoscopic cholecystectomy by using a brief psychological relaxation intervention. It has shown a reduction of fatigue and impact of fatigue at 30 days postoperatively in the intervention group.

The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis

BACKGROUND

The local and systemic humoral response after colorectal surgery is thought to affect postoperative recovery. It is commonly claimed that laparoscopic surgery elicits a diminished inflammatory response than equivalent open surgery. Despite these claims, the evidence is conflicting. Therefore, we aimed to systematically review the results from randomized controlled clinical trials comparing the humoral response associated with laparoscopic versus open colorectal surgery.

MATERIALS AND METHODS

A high-sensitivity search was conducted independently by two of the authors with no language restriction. Studies were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline (January 1966 to January 2009), PubMed (1950 to January 2009), and Embase (1947 to January 2009). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager ver. 5.0.

RESULTS

Thirteen randomized controlled trials were included. Meta-analysis demonstrated a significantly higher serum IL-6 on d 1 after open colorectal resection for neoplasia (n = 97) compared with laparoscopic resection (n = 76, P = 0.0008) without significant heterogeneity. Data for plasma IL-6 were heterogeneous, with no apparent difference between groups. No other significant differences were identified, and there were not enough data on local peritoneal humoral factors to allow meta-analysis.

CONCLUSION

Open colorectal resection for neoplasia is associated with higher postoperative serum levels of IL-6 on d 1 than equivalent laparoscopic surgery. The aetiology and clinical significance of this finding is uncertain, and further studies are required to elucidate any differences in the local humoral response which may be more clinically relevant in surgery for this indication.

Peritoneal damage: the inflammatory response and clinical implications of the neuro-immuno-humoral axis

BACKGROUND

The peritoneum is a bilayer serous membrane that lines the abdominal cavity. We present a review of peritoneal structure and physiology, with a focus on the peritoneal inflammatory response to surgical injury and its clinical implications.

METHODS

We conducted a nonsystematic clinical review. A search of the Ovid MEDLINE database from 1950 through January 2009 was performed using the following search terms: peritoneum, adhesions, cytokine, inflammation, and surgery.

RESULTS

The peritoneum is a metabolically active organ, responding to insult through a complex array of immunologic and inflammatory cascades. This response increases with the duration and extent of injury and is central to the concept of surgical stress, manifesting via a combination of systemic effects, and local neural pathways via the neuro-immuno-humoral axis. There may be a decreased systemic inflammatory response after minimally invasive surgery; however, it is unclear whether this is due to a reduced local peritoneal reaction.

CONCLUSIONS

Interventions that dampen the peritoneal response and/or block the neuro-immuno-humoral pathway should be further investigated as possible avenues of enhancing recovery after surgery, and reducing postoperative complications.

The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay

OBJECTIVE

To compare outcomes from hip arthroplasty between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to the comparison sites.

DESIGN

Prospective cohort study.

SUBJECTS

Consecutive consenting patients receiving primary hip arthroplasty during 12 months beginning July 2006 in three UK National Health Service surgical units. One has shortened postoperative stay to median three days; one was a new treatment centre with median stay of five days; the third was a traditional unit with median stay of six days (N = 316, 119, 87, respectively).

METHODS

Patients were assessed preoperatively and six weeks postoperatively. The primary indicator of function was the Oxford Hip Score. Additional secondary measures included further self-report indicators of function and quality of life and health service costs.

RESULTS

Patient outcome in the unit with rapid discharge was not impaired by comparison with the other sites on any measure: Oxford Hip Score decreased from 49 to 27 in the short-stay unit, from 40 to 30 in the treatment centre and from 43 to 32 in the traditional unit. Cost of arthroplasty was least in the short-stay unit, although there was potential for cost savings in each.

CONCLUSION

Short postoperative stay after hip arthroplasty can be achieved without intensive patient preparation or post-discharge care and without compromising short-term patient outcome or increasing health care costs. Longer term follow-up is needed.

Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy

Background

Recent data have suggested a relationship between postoperative fatigue and the peritoneal cytokine response after surgery. The aim of this study was to test the hypothesis that preoperative administration of glucocorticoids before surgery would decrease fatigue and enhance recovery, by reducing the peritoneal production of cytokines.

Methods

In a double-blind randomized controlled study, patients undergoing elective, open colonic resection were administered 8 mg dexamethasone or normal saline. Patients were treated within an enhanced recovery after surgery programme. Primary outcomes were cytokine levels in peritoneal drain fluid and fatigue as measured by the Identity–Consequence Fatigue Scale (ICFS).

Results

Baseline parameters were similar for 29 patients in the dexamethasone group and 31 in the placebo group. Patients who received dexamethasone had lower ICFS scores on days 3 and 7. Dexamethasone was associated with significantly lower peritoneal fluid interleukin (IL) 6 and IL-13 concentrations on day 1, and these correlated with changes in the ICFS score. There was no significant increase in adverse events in the dexamethasone group.

Conclusion

Preoperative administration of dexamethasone resulted in a significant reduction in early postoperative fatigue, associated with an attenuated early peritoneal cytokine response. Peritoneal production of cytokines may therefore be important in postoperative recovery. Registration number: ACTRN12607000066482 (http://www.anzctr.org.au/).

Early discharge following hip arthroplasty: patients' acceptance masks doubts and concerns

OBJECTIVE

To describe patients' experience of accelerated discharge after hip arthroplasty in order to test the acceptability to patients of economically driven shortening of post-operative stay.

METHODS

Patients (n = 35) who had received primary total hip replacement up to 12 weeks previously were recruited from two UK orthopaedic units, one of which has pioneered short post-operative stay (3-4 days), and another one of which retains a traditional regimen of discharge after 6-7 days. Patients were interviewed about their experience of care, focusing particularly on their views related to length of stay and with particular attention to patients' well-known tendency to mask critical views of their care. Transcripts were analysed thematically to identify the ways that patients evaluated their care and whether these differed between sites.

RESULTS

Patients were primarily concerned with how attentive and informative hospital staff had been and did not refer to length of stay spontaneously. When prompted about this, they did not question their discharge time, although those in the more traditional unit could not countenance more rapid discharge. Patients in the unit with accelerated discharge described concerns about the consequences of early discharge for them or their family, particularly managing pain and mobility problems at home and needing more support.

CONCLUSIONS

Patients' traditional beliefs about the necessity of prolonged convalescence are not a barrier to early discharge after hip arthroplasty. Nevertheless, some patients' acceptance of early discharge masks doubts and concerns. More intensive post-operative management may be needed if clinical care is not to suffer.

Pathophysiology of cancer-related fatigue

Cancer-related fatigue (CRF) is influenced and modulated by a number of critical factors, and the mechanism that is both necessary and sufficient to induce development of severe fatigue in patients with cancer has not yet been identified. Specific research efforts to understand the factors that may contribute to CRF development have been made, including studies of the direct effects of tumor burden, the effects of cancer treatment, and other pathophysiologic and psychosocial conditions. Compelling new hypotheses regarding CRF pathophysiology have been proposed, such as the pro-inflammatory hypothesis, the serotonin hypothesis, the vagal-afferent-activation hypothesis, the anemia hypothesis, and the adenosine triphosphate hypothesis; some of these have been tested in both animal models and humans and some in animals only. Gaining an understanding of the specific mechanisms related to the development of fatigue in patients with cancer and survivors requires further investigation. Pathophysiologic research in CRF could be applied in the clinic to improve CRF diagnosis and to enable administration of mechanism-driven interventions. A targeted intervention study with CRF as a primary end point also would be useful.

A prospective study on the influence of a fast-track program on postoperative fatigue and functional recovery after major colonic surgery

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery; however, their impact on long-term outcomes, such as postoperative fatigue (POF), has not been fully established.

AIM

To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery.

METHOD

In a prospective study, 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program.

RESULTS

Demographic and clinical characteristics were comparable at baseline. The median duration of total hospital stay (4 versus 7 d, P < 0.001), rates of urinary tract infections (P = 0.028) and ileus (P = 0.042) were significantly smaller in the ERAS group. Postoperatively, POF significantly increased in both groups. However, peak POF score was significantly lower in the ERAS group (P = 0.001). In the first 30 d after surgery, Fatigue Consequence scores were also significantly smaller in the ERAS group. Overall, the total fatigue experience (P = 0.035) and the total fatigue impact (P = 0.005) were significantly smaller in the ERAS group.

CONCLUSION

The impact of ERAS programs may extend beyond the commonly reported short-term outcomes, and ERAS may accelerate overall recovery and return to normal function.

Sample size planning for the coefficient of variation from the accuracy in parameter estimation approach

The accuracy in parameter estimation approach to sample size planning is developed for the coefficient of variation, where the goal of the method is to obtain an accurate parameter estimate by achieving a sufficiently narrow confidence interval. The first method allows researchers to plan sample size so that the expected width of the confidence interval for the population coefficient of variation is sufficiently narrow. A modification allows a desired degree of assurance to be incorporated into the method, so that the obtained confidence interval will be sufficiently narrow with some specified probability (e.g., 85% assurance that the 95 confidence interval width will be no wider than to units). Tables of necessary sample size are provided for a variety of scenarios that may help researchers planning a study where the coefficient of variation is of interest plan an appropriate sample size in order to have a sufficiently narrow confidence interval, optionally with somespecified assurance of the confidence interval being sufficiently narrow. Freely available computer routines have been developed that allow researchers to easily implement all of the methods discussed in the article.

Predictors of expectancies for post-surgical pain and fatigue in breast cancer surgical patients

Expectancies for post-surgical pain and fatigue have previously been found to predict pain and fatigue among breast cancer surgery patients. However, the study of predictors of these expectancies has been neglected. The present study was designed to investigate predictors of expectancies for post-surgical pain and fatigue among breast cancer surgery patients.Four hundred and eighteen women (M = 48.3 years, SD = 13.66 years) scheduled to undergo excisional breast biopsy or lumpectomy completed questionnaires assessing demographics/medical history, pre-surgical distress, stable personality characteristics, pre-surgical pain and fatigue, and expectancies for post-surgical pain and fatigue.Path analysis revealed: expectancies for post-surgical pain were significantly predicted by trait anxiety, acute pre-surgical distress, and age; and expectancies for post-surgical fatigue were significantly predicted by acute pre-surgical distress, acute pre-surgical fatigue, previous experience with the same surgical procedure, and education (all ps < .05). Examination of an alternative model revealed that the effects of the aforementioned predictors on expectancies were not mediated by acute pre-surgical distress, clarifying the directionality of the distress-expectancy relationship.Expectancies for post-surgical pain and fatigue are influenced by distress, treatment history, stable personality characteristics, extant symptoms, and demographic factors. These variables should be considered in designing clinical interventions to manipulate expectancies for patient benefit.

The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study

OBJECTIVES

This study was a prospective investigation of the extent to which psychologic variables could be predictive of postoperative pain. Study aims were: 1) to evaluate whether an assessment of pre-operative distress factors could predict the intensity of postoperative pain; and 2) to characterize the unique pattern in which anxiety and pain catastrophizing scores relate to postoperative pain.

METHODS

The Pain Catastrophizing Scale and the State-Trait Anxiety Inventory were administered to 38 patients scheduled for elective abdominal surgery. The questionnaires were completed on the day of admission, a day before the operation. On day 1 and day 2 following the operation, perception of pain intensity at the surgical wound was assessed by visual analog scale.

RESULTS

The Pain Catastrophizing Scale and State-Trait Anxiety Inventory scores were significantly correlated with the postoperative pain scores. A linear regression analysis showed that Pain Catastrophizing Scale predicted the level of postoperative pain intensity even after controlling for state anxiety and that trait anxiety was not a significant predictor. In addition, analysis of the unique pattern of each predictor related to postoperative pain intensity indicated a linear curve for the Pain Catastrophizing Scale and curvilinear curve for the state anxiety.

DISCUSSION

The results are discussed in light of appraisal and coping theories. It is suggested that a simple assessment of preoperative catastrophizing tendency and anxiety scores may assist medical teams in postoperative pain management.

Salivary cortisol as a predictor of postoperative fatigue

OBJECTIVE

Some patients with chronic fatigue syndrome (CFS) exhibit low basal cortisol levels, but it is not known whether low cortisol is a cause of CFS, predates the onset of CFS symptoms, or is an epiphenomenon caused by the behavioral changes typical of CFS. Because elective surgery is one of the few predictable risk factors for chronic fatigue, in this study, we followed a cohort of surgery patients from before to 6 months after their operation to test these theories.

METHOD

One hundred sixty-one patients completed fatigue questionnaires and provided salivary cortisol samples before undergoing an elective inpatient surgical procedure, and then 2 days, 3 weeks, and 6 months afterward.

RESULTS

Controlling for relevant demographic and surgical variables and for preoperative fatigue, low preoperative cortisol did not predict postoperative fatigue severity on any occasion (p > .05). Similarly, there was no correlation between low postoperative cortisol and postoperative fatigue severity at 3 weeks or 6 months (p > .05). Although 16 patients met our case definition for "chronic fatigue" at the 6-month follow up, low preoperative and low postoperative cortisol did not significantly predict fatigue caseness (p > .05).

CONCLUSIONS

Any association between chronic fatigue and low cortisol would seem to develop after the onset of fatigue symptoms. Low cortisol is therefore unlikely to be the primary cause of chronic fatigue states.

Psychological factors in postoperative fatigue

OBJECTIVE

To assess whether the fatigue commonly reported by patients following surgery is partly a result of somatization and/or cognitive-behavioral factors.

METHODS

One hundred eighty-three patients completed questionnaires before surgery and then 2 days, 3 weeks and 6 months afterward. Multiple regressions were used to assess which of the following factors were important in predicting self-reported postoperative fatigue, controlling for preoperative fatigue and for various demographic and surgical variables: negative mood, history of mood disorder, preoperative expectations of fatigue, preoperative worry or optimism about surgery, preoperative beliefs about the benefits of activity or rest, self-reported postoperative activity, self-reported cardiovascular deconditioning, and availability of social support.

RESULTS

Controlling for demographic and surgical variables and preoperative fatigue, postoperative fatigue showed significant associations with negative mood at each stage of follow-up (p < .001) and was significantly predicted by history of mood disorder at 2 days postoperatively (p = .02). Higher fatigue expectations were self-fulfilling at 3 weeks after surgery (p = .02), whereas preoperative belief in physical activity as being beneficial to recovery predicted reduced fatigue at 6 months (p < .001). Finally, self-reported breathlessness after exercise, an indicator of cardiovascular deconditioning, was also significantly associated with greater fatigue at 6 months (p = .02).

CONCLUSION

The results indicate that psychological processes may well be relevant in the etiology of postoperative fatigue. In particular, the results relating to mood and expectations suggest that somatization may be particularly important in the first few weeks following surgery, whereas cognitive-behavioral factors and cardiovascular deconditioning may be more important in determining later-stage recovery.

A systematic review and meta-analysis of the incidence and severity of postoperative fatigue

OBJECTIVE

Postoperative fatigue is common following major abdominal surgery. Less is known about its prevalence in other surgical subgroups, and about its long-term prognosis. A systematic review of prospective cohort studies was conducted to clarify these issues.

METHOD

Studies were identified from an extensive literature search. Overall estimates of pre- to postoperative change in fatigue severity and the incidence of clinically significant postoperative fatigue were calculated using meta-analyses.

RESULTS

Eighty-one cohorts were identified. Type of surgery was found to be a possible predictor of fatigue severity, with major abdominal, gynaecological, cardiac and minor surgery apparently associated with greater fatigue than orthopaedic surgery. Limited data were available regarding the long-term persistence of postoperative fatigue.

CONCLUSION

Postoperative fatigue appears to be an important problem following only certain forms of surgery. Why this is so remains unclear, and further work using better fatigue questionnaires is now required to confirm these differences.

Glucocorticoids and glucocorticoid receptors: mediators of fatigue?

Fatigue is a common problem; when chronic and disabling, subjects can be categorized as having chronic fatigue syndrome (CFS). Whilst it is most likely a multifactorial condition of biopsychosocial origin, the nature of the pathophysiological component remains unclear. There has been a wealth of interest in the possible hypothalamo-pituitary-adrenal (HPA) axis dysfunction in CFS, and whether such changes may mediate fatigue. On balance, there appears to be reduced cortisol output in a proportion of patients, together with heightened negative feedback and glucocorticoid receptor function. There is evidence for impaired adrenocorticotropic hormone (ACTH) and cortisol responses to a variety of challenges. However, there is no evidence for a specific or uniform dysfunction of the HPA axis. Evidence that these changes may be related to symptom production comes from randomized controlled trials of glucocorticoid replacement therapy, which have shown improvements in fatigue and disability. Given the many factors that may impinge on the HPA axis in CFS, such as inactivity, sleep disturbance, psychiatric comorbidity, medication and ongoing stress, it seems likely that there is not a single or specific change to the HPA axis in CFS and that the observed HPA axis disturbances are of multifactorial etiology. This is further supported by a comparison of neuroendocrine findings in other conditions in which fatigue is prominent, showing both similarities and differences with the pattern in CFS.

The neuroendocrinology of chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a common and disabling problem; although most likely of biopsychosocial origin, the nature of the pathophysiological components remains unclear. There has been a wealth of interest in the endocrinology of this condition, which will be reviewed in this article. Most studied has been the hypothalamic-pituitary-adrenal (HPA) axis; although the quality of many studies is poor, the overall balance of evidence points to reduced cortisol output in at least some patients, with some evidence that this is linked to symptom production or persistence. There is evidence for heightened negative feedback and glucocorticoid receptor function and for impaired ACTH and cortisol responses to a variety of challenges. However, there is no evidence for a specific or uniform dysfunction of the HPA axis. Given the many factors that may impinge on the HPA axis in CFS, such as inactivity, sleep disturbance, psychiatric comorbidity, medication, and ongoing stress, it seems likely that HPA axis disturbance is heterogeneous and of multifactorial etiology in CFS. Studies assessing GH, dehydroepiandrostenedione and its sulfate, melatonin, leptin, and neuroendocrine-monoamine interactions are also reviewed. There is some evidence from these studies to suggest alterations of dehydroepiandrostenedione sulfate function and abnormal serotonin function in CFS, but whether these changes are of functional importance remains unclear. To obtain a clearer assessment of the etiological and pathophysiological relevance of endocrine changes in CFS, it is suggested that more prospective cohort studies be undertaken in groups at high risk for CFS, that patients with CFS are followed up into recovery, and that multidimensional assessments are undertaken to unravel the influence of the various confounding factors on the observed endocrine changes in CFS.

Physiological and psychological influences on postoperative fatigue

Fatigue is common after major surgery and delays recovery. We studied the role of physiological and psychological factors in determining fatigue and physical well being after surgery in 102 patients undergoing primary hip arthroplasty. Self-administered questionnaires were used to measure the intensity of feelings of fatigue, vigor, depression, and subjective physical well being on the day before surgery, on the third and seventh postoperative days, and 1 and 6 mo after surgery. The physiological response to surgery was determined by sequential measurements of circulating norepinephrine, epinephrine, cortisol, interleukin-6, and C-reactive protein during the 7 days after surgery. The peak value of each variable was used for statistical analysis. Physical well being decreased significantly at 3 and 7 days but increased significantly at 1 and 6 mo. Fatigue decreased significantly at 1 and 6 mo. Multiple regression analysis showed that the main predictor of worse physical well being at 3 days was the size of the C-reactive protein response. Subsequently, the main predictor was the level of preoperative well being. The severity of fatigue and vigor after surgery were predicted mostly by the preoperative levels of the respective variable. We conclude that fatigue after hip arthroplasty was not predicted by physiological variables but was largely predicted by preoperative levels of fatigue.

IMPLICATIONS

Fatigue is common after major surgery and delays recovery. It is usually attributed to the physiological response to surgery. We studied patients undergoing hip arthroplasty and found that the severity of postoperative fatigue was not predicted by physiological changes. Instead, it was predicted by the preoperative level of fatigue.

Systematic review and meta-analysis of interventions for postoperative fatigue

BACKGROUND

Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques.

METHODS

Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed.

RESULTS

Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom.

CONCLUSION

While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive-behavioural, sleep and activity-based interventions also needs to be addressed.

Anxiety and surgical recovery. Reinterpreting the literature

OBJECTIVE

To critically evaluate the interpretation of the findings reported in the peer-reviewed literature concerning the association of state and trait anxiety with surgical recovery and response to surgery.

METHODS

The Social Science Citation Index (SSCI), Science Citation Index (SCI), Medline and Psychological Abstracts (PsycInfo) databases were searched for studies published since 1981. Reference lists from previous reviews were also searched for additional references. Studies that were not in the public domain were not searched for.

RESULTS

Twenty-seven studies were identified by the search strategy, met the inclusion criteria and contributed to the review.

CONCLUSIONS

Associations between preoperative measures of anxiety and postoperative mood and pain have been consistently reported. Associations with regard to other recovery variables are less consistent. The existing evidence does not rule out an interpretation of the results as reflecting consistent self-reporting bias rather than causal association.

Influence of the emotional response to surgery on functional recovery during 6 months after hip arthroplasty

We examined whether the emotional response to hip arthroplasty predicted functional recovery after controlling for preoperative function and surgical trauma. Mood and fatigue were measured in 102 consecutive patients preoperatively and 3 days postoperatively. Time of achievement of functional milestones indicated recovery in hospital, and functional status was measured preoperatively and 1 and 6 months postoperatively. Circulating C-reactive protein and interleukin-6 levels indicated trauma. Recovery in hospital was slower in patients with greater trauma. Recovery at follow-up was slower in patients with poorer preoperative function and with greater anxiety and fatigue, but the apparent influence of anxiety was explained by its association with preoperative function and fatigue. Whereas short-term recovery is predicted by surgical trauma, long-term recovery is predicted by preexisting function and the emotional response to surgery. However, the influence of the emotional response is small and the important aspect of emotion is fatigue rather than anxiety.

Postoperative fatigue is a component of the emotional response to surgery: results of multivariate analysis

OBJECTIVE

To test the theory that postoperative fatigue is an aspect of the emotional, not physiological, response to surgery, we examined whether fatigue is a component of subjective experience after surgery and whether it is related to subjective physical or emotional state.

METHODS

Patients (N=160) undergoing hip or knee arthroplasty were assessed preoperatively, 1 and 7 days and 1 and 6 months postoperatively using multiple indicators of fatigue and subjective emotional and physical state. Covariance structure modeling was used to find out the structure of patients' experience on each occasion.

RESULTS

At each time, data indicated four latent variables: negative mood, positive mood, dysfunction and pain. Scales measuring fatigue indicated negative or positive mood but were unrelated to dysfunction and pain.

DISCUSSION

In surgical patients, the language of fatigue and energy describes empirically distinct components of emotional state. Explanations for postoperative fatigue should therefore be sought in emotional, not physiological, mechanisms.

Recovery from hip and knee arthroplasty: Patients' perspective on pain, function, quality of life, and well-being up to 6 months postoperatively

OBJECTIVE

To provide a more detailed description from patients' perspectives than is yet available of recovery from hip and knee arthroplasty and to use this information to test 2 assumptions about recovery from these procedures: that recovery from knee arthroplasty, as assessed by patients, routinely reaches the level achieved by hip arthroplasty; and that fatigue is prolonged after major orthopedic surgery.

DESIGN

A cohort study.

SETTING

University teaching hospitals.

PARTICIPANTS

Consecutive patients undergoing hip (n = 107) or knee (n = 53) arthroplasty.

INTERVENTIONS

Unilateral hip or knee arthroplasty.

MAIN OUTCOME MEASURES

Standardized self-rated measurements of pain, function, quality of life, and well-being from preoperatively to 6 months follow-up.

RESULTS

Pain and function improved significantly less after knee arthroplasty than after hip arthroplasty, but the 2 procedures led to similar improvements in life evaluation, mood, and subjective health. Fatigue was only transiently increased.

CONCLUSION

The findings were inconsistent with both assumptions. Nevertheless, despite poorer recovery in pain and function, patients receiving knee arthroplasty felt that life had improved as much as did patients with hip arthroplasty. Detailed information about how major joint arthroplasty in routine practice affects patients' lives can be used to advise patients and clinicians and can invalidate influential, but inaccurate, assumptions.

Fatigue in the Danish general population. Influence of sociodemographic factors and disease

OBJECTIVE

To measure the levels of fatigue in the general population, and to examine how disease and sociodemographic factors influence fatigue.

DESIGN

Cross sectional questionnaire study in the Danish general population.

SUBJECTS

A random, age stratified sample of 1608 people aged 20-77 with an equal gender distribution (response rate 67%).

MAIN OUTCOME MEASURES

Five fatigue scales from the questionnaire Multidimensional Fatigue Inventory: General Fatigue, Physical Fatigue, Reduced Activity, Reduced Motivation and Mental Fatigue.

RESULTS

Fatigue scores were skewed towards absence of fatigue. The General Fatigue and Physical Fatigue scales showed the highest fatigue levels while the Reduced Motivation scale showed lowest levels. Gender differences in fatigue scores were small, but the variability among women was higher-that is, more women had high scores. A multiple linear regression analysis showed that respondents of low social status and respondents with a depression had high fatigue scores on all scales, independent of other factors. Chronic somatic disease had an independent direct effect on Mental Fatigue, but for the rest of the scales, the effect of somatic disease depended on age, gender and/or whether the person was living alone. For example, General and Physical Fatigue decreased with age among healthy people, whereas scores on these scales increased with age among those with a somatic disease.

CONCLUSIONS

Physical and mental diseases play essential parts for the level of fatigue and as modulators of the associations between sociodemographic factors and fatigue. These interactions should be taken into account in future research on fatigue and sociodemographic factors and when data from clinical studies are compared with normative data from the general population.

The systematic assessment of short-term functional recovery after major joint arthroplasty

Despite extensive information about long-term recovery from major joint arthroplasty, little attention has been given to the measurement of functional recovery in the immediate postoperative period. Therefore assumptions about the importance of physical therapy during this period remain untested. We devised a way of recording functional recovery before discharge, based primarily on the achievement of objective milestones. This was incorporated into routine physiotherapy practice and applied to sequential patients undergoing elective hip (n = 163) or knee (n = 66) replacement. Six months later, we followed up 160 patients, of whom 145 completed questionnaires to assess subjective physical and emotional state and functional recovery. The method was sensitive to known influences on pace of recovery, including type of arthroplasty (hip vs knee) and surgeons' differing requirements for mobilization. In addition, we were able to confirm and quantify sources of variation in functional recovery which previously were suspected but unconfirmed: in particular, the timing of early mobilization. Outcome at 6 months was unrelated to objective functional recovery in hospital, although fatigue and wellbeing at this time were predicted by physiotherapists' subjective assessment of patients' motivation before discharge. The findings can be used to inform patients and as a source of comparison data for the assessment of functional recovery in other centres. More importantly, the procedure reported may be applied to quantify functional recovery in routine practice and thereby expose variability in recovery to scientific scrutiny.

Psychological adjustment after cardiac transplantation

Psychosocial function improves after cardiac transplantation but the extent of improvement is not established. Neither are the factors established that account for variability in function between patients following successful transplantation. We therefore compared illness-related dysfunction in patients following orthotopic cardiac transplantation (OCT) with that in angina-free patients following coronary artery bypass graft (CABG) and stable patients in heart failure awaiting transplantation (HF). We also measured two factors that might contribute to variation in function: emotional distress and concern with physical symptoms. Psychosocial function was as good in OCT as in CABG patients and, in both, was better than in HF patients. Differences in emotional distress and in physical symptoms showed a similar pattern and contributed to, but did not completely account for, differences in function. Concern with physical symptoms contributed to variability in functional impairment in HF but not CABG patients; transplantation strengthened this relationship. The results show that successful cardiac transplantation enhances psychosocial function to a level comparable with that after CABG, and suggest targets for psychological or educational intervention to improve quality of life after transplantation in patients whose recovery is inhibited by concern about physical symptoms.