Fatigue in persons who have lived with spinal cord injury for >20 years

Factors Associated With Fatigue in People With Spinal Cord Injury: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the association between fatigue and clinical and demographic variables in people with spinal cord injury (SCI).

DATA SOURCES

Five databases (MEDLINE, Physiotherapy Evidence Database, Cochrane, Google Scholar, Cumulative Index to Nursing and Allied Health) were searched up to November 2021.

STUDY SELECTION

Observational studies that reported the association between fatigue and clinical and demographic variables in English or Spanish were eligible. Reviews, qualitative research studies, and nonoriginal articles were excluded. Twenty-three of the 782 identified studies met the inclusion criteria for the meta-analysis.

DATA EXTRACTION

Two researchers independently extracted the data. The strength of the association between each factor and fatigue was determined by the effect size. When the results of the effect size were expressed with different statistics, the correlation coefficient was the preferred estimation. The risk of bias was assessed using the Appraisal Tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale.

DATA SUMMARY

A pooled analysis of the associations between fatigue and 17 factors was performed. A direct association was found between fatigue and 9 factors (sorted by effect size): anxiety (r=0.57; 95% CI, 0.29-0.75), stress (r=0.54; 95% confidence interval [CI], 0.26-0.74), depression (r=0.47; 95% CI, 0.44-0.50), pain (r=0.34; 95% CI, 0.16-0.50), analgesic medication (r=0.32; 95% CI, 0.28-0.36), assistive devices (r=0.23; 95% CI, 0.17-0.29), lesion level (r=0.15; 95% CI, 0.07-0.23), incomplete SCI (r=0.13; 95% CI, 0.05-0.22), and medication (r=0.12; 95% CI, 0.01-0.23). An inverse association was found with 3 factors (sorted by effect size): self-efficacy (r=-0.63; 95% CI, -0.81 to -0.35), participation (r=-0.32; 95% CI, -0.58 to -0.001), and physical activity (r=-0.17; 95% CI, -0.28 to -0.05). No association was found with age, sex, educational level, time since injury, and spasticity.

CONCLUSIONS

Several factors were associated with fatigue in people with SCI, with those related to mental health showing the strongest associations. These results should be interpreted with caution because of the high heterogeneity observed in some factors.

Anxiety, depression, and fatigue in middle-aged and older persons with spina bifida: a cross-sectional study

PURPOSE

To study psychological distress and fatigue among persons with spina bifida (SB) 50 years or older and living in Norway.

METHODS

In 2017, cross-sectional data were collected (n = 30). The Hospital Anxiety and Depression Scale (HADS) and the Fatigue Severity Scale (FSS) were used. Descriptive statistics, non-parametric tests, and Spearman correlations were performed. Relevant information from previous studies on adults with chronic spinal cord injury (SCI) and the general population, were collected for comparison.

RESULTS

Participants were 18 women and 12 men, mean age 57.5 (SD 5.6), 26 with myelomeningocele, and six with hydrocephalus. Thirty percent scored above the HADS-A- and 20% above the HADS-D thresholds, thus in the same range as previous studies of SB, but higher compared to persons with SCI and norms. HADS-D correlated with pain and FSS scores. Forty percent reported fatigue symptoms (9/15 without hydrocephalus, 3/6 with hydrocephalus).

CONCLUSIONS

The study revealed a high prevalence of fatigue symptomatology among middle-aged and older adults with SB. Symptoms of anxiety and depression were more common than among persons with chronic SCI and norms. SB follow-ups should include awareness of psychological distress and fatigue, and investigate pain and medication side effects among possible influencing factors.IMPLICATIONS FOR REHABILITATIONClinicians treating adult persons with SB should be aware of possible psychological distress and fatigue symptomatology among these patients.We suggest an initial screening for psychological distress and fatigue in persons with SB during follow-up visits and rehabilitation.Interventions to reduce pain may influence levels of psychological distress and/or fatigue in patients with SB.Clinicians should enquire about the effects of medication on fatigue when assessing and prescribing new medications; a thorough medication review helps to assess the benefits and risks.

Therapists' perspectives on using brain-computer interface-triggered functional electrical stimulation therapy for individuals living with upper extremity paralysis: a qualitative case series study

BACKGROUND

Brain computer interface-triggered functional electrical stimulation therapy (BCI-FEST) has shown promise as a therapy to improve upper extremity function for individuals who have had a stroke or spinal cord injury. The next step is to determine whether BCI-FEST could be used clinically as part of broader therapy practice. To do this, we need to understand therapists' opinions on using the BCI-FEST and what limitations potentially exist. Therefore, we conducted a qualitative exploratory study to understand the perspectives of therapists on their experiences delivering BCI-FEST and the feasibility of large-scale clinical implementation.

METHODS

Semi-structured interviews were conducted with physical therapists (PTs) and occupational therapists (OTs) who have delivered BCI-FEST. Interview questions were developed using the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change. COM-B components were used to inform deductive content analysis while other subthemes were detected using an inductive approach.

RESULTS

We interviewed PTs (n = 3) and OTs (n = 3), with 360 combined hours of experience delivering BCI-FEST. Components and subcomponents of the COM-B determined deductively included: (1) Capability (physical, psychological), (2) Opportunity (physical, social), and (3) Motivation (automatic, reflective). Under each deductive subcomponent, one to two inductive subthemes were identified (n = 8). Capability and Motivation were perceived as strengths, and therefore supported therapists' decisions to use BCI-FEST. Under Opportunity, for both subcomponents (physical, social), therapists recognized the need for more support to clinically implement BCI-FEST.

CONCLUSIONS

We identified facilitating and limiting factors to BCI-FEST delivery in a clinical setting according to clinicians. These factors implied that education, training, a support network or mentors, and restructuring the physical environment (e.g., scheduling) should be targeted as interventions. The results of this study may help to inform future development of new technologies and interventions.

Evidence on definitions, concepts, outcome instruments, and interventions for chronic fatigue in spinal cord injury: a scoping review protocol

OBJECTIVE

The objective of this review is to review the existing evidence on definitions, concepts, measurement instruments, and interventions for chronic fatigue in spinal cord injury.

INTRODUCTION

Chronic fatigue in people with spinal cord injury is an under-studied issue that affects between 25% and 56.6% of people with spinal cord injury. There are questions about how it is defined and managed due to its complex, multifactorial nature and relationship with related conditions. No overview of chronic fatigue in spinal cord injury exists and we are in need of a shared definition of chronic fatigue, as well as a comprehensive review of concepts and evidence supporting outcome instruments and interventions.

INCLUSION CRITERIA

This review will include empirical and non-empirical studies that focus on definitions, concepts, measurement instruments, and interventions for chronic fatigue in spinal cord injury. Studies that focus on peripheral muscle fatigue will only be included if they include chronic fatigue as a secondary outcome.

METHODS

This review will be done in three phases. Phase I will provide an overview of definitions of chronic fatigue in spinal cord injury and will include a qualitative analysis of concept attributes and characteristics. Phase II will focus on factors related to chronic fatigue and measurement instruments used to measure chronic fatigue, and phase III will focus on interventions. Full texts will be screened by two independent reviewers against inclusion criteria. Results will be presented in tabular form with a narrative summary.

Relationship between pain, fatigue, and physical activity levels during a technology-based physical activity intervention

Objective: The majority of individuals with spinal cord injury (SCI) experience chronic pain. Chronic pain can be difficult to manage because of variability in the underlying pain mechanisms. More insight regarding the relationship between pain and physical activity (PA) is necessary to understand pain responses during PA. The objective of this study is to explore possible relationships between PA levels and secondary conditions including pain and fatigue.Design: Prospective cohort analysis of a pilot study.Setting: Community.Participants: Twenty individuals with SCI took part in the study, and sixteen completed the study.Interventions: Mobile-health (mHealth) based PA intervention for two-months during the three-month study.Outcome measures: Chronic Pain Grade Scale (CPGS) questionnaire, The Wheelchair User's Shoulder Pain Index (WUSPI), Fatigue Severity Scale (FSS), and PA levels measured by the mHealth system.Results: A positive linear relationship was found between light-intensity PA and task-specific pain. However, the relationship between moderate-intensity PA and pain interference was best represented by a curvilinear relationship (polynomial regression of second order). Light-intensity PA showed positive, linear correlation with fatigue at baseline. Moderate-intensity PA was not associated with fatigue during any phase of the study.Conclusion: Our results indicated that PA was associated with chronic pain, and the relationship differed based on intensity and amount of PA performed. Further research is necessary to refine PA recommendations for individuals with SCI who experience chronic pain.Trial registration: ClinicalTrials.gov identifier: NCT03773692.

Lifestyle modifications and pharmacological approaches to improve sexual function and satisfaction in men with spinal cord injury: a narrative review

STUDY DESIGN

A narrative review describing various components of sexual dysfunction in men with spinal cord injury (SCI), as well as addressing potential therapeutic approaches.

OBJECTIVES

Restoration of sexual function is considered one of the most important health priorities for individuals with SCI. The purpose of this review is to provide information regarding the factors that are less appreciated when considering changes to sexual function in men with SCI. We also propose therapeutic approaches, with a focus on lifestyle modifications, which have been shown to improve sexual function.

METHODS

A literature search was performed and limited evidence for therapeutic approaches in individuals with SCI was supplemented by consistent findings from the able-bodied population.

RESULTS

We evaluated the less addressed factors known to contribute to sexual dysfunction in men with SCI, including hormonal influences (i.e., testosterone deficiency, thyroid hormone, and cortisol), psychological factors (i.e., pain, fatigue, depression, and body image), and secondary SCI complications (i.e., urinary tract infection, pressure sores, and autonomic dysreflexia). To address these factors beyond standard medical treatments for sexual dysfunction, options include physical activity/exercise, diet, and specific medications for symptom relief (i.e., testosterone replacement therapy and selective serotonin reuptake inhibitors for depression).

CONCLUSIONS

Physical activity's potential application, efficacy across multiple aspects of sexuality, and the lack of side effects, suggests that long-term exercise is a viable solution to directly or indirectly improve sexual function in males with SCI. Diet and supplemental medications may further promote body composition changes, which more broadly affect sexuality.

Fractures and musculoskeletal ailments in persons 20+ years after a traumatic spinal cord injury in Norway

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To gain insights into fracture rate and musculoskeletal ailments among Norwegians with a spinal cord injury (SCI) acquired more than 20 years ago.

SETTINGS

Sunnaas Hospital, Nesoddtangen, Norway.

METHODS

165 persons with SCI were interviewed in 2004-2005 by questionnaires and clinical examination. Descriptive statistics and a logistic regression analysis were performed to identify variables associated with bone fractures and musculoskeletal ailments.

RESULTS

Around half of the participants experienced a fracture after injury and excessive use of alcohol increased the odds (OR 0.09; CI 0.01-0.74) of suffering a post-injury fracture (p = 0.03). Sixty percent experienced shoulder ailments after the SCI and the use of orthosis to the knee and hip increased the odds (OR 4.4; CI 1.4-13) of experiencing shoulder ailment (p = 0.01).

CONCLUSION

Around half of the 165 participants reported to have suffered a fracture and over 100 to experience musculoskeletal ailment 20 years after injury. We suggest that prevention strategies and symptom management must be embedded in follow-up visits after SCI.

Prevalence of depression, fatigue, and sleep disturbances in patients with myelopathy: Their relation with functional and neurological recovery

OBJECTIVES

To observe the prevalence of fatigue, depression, and sleep disturbance in patients with myelopathy and their correlation with neurological and functional recovery.

PATIENTS AND METHODS

Study conducted in a university tertiary research hospital with 127 patients with myelopathy (92 males) admitted to neurorehabilitation unit between January 2010 and December 2013. Mean age was 32.71 ± 13.08 years (range 15-65 years), and mean duration of injury was 76.22 ± 82.5 days (range 14-365 days). Functional status and impairments were assessed using Barthel Index and Spinal Cord Independence Measures. Depression, fatigue, and sleep disturbances were assessed using Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and Pittsburgh Sleep Quality Index scales, respectively. Neurological recovery was assessed using American Spinal Injury Association's impairment scale.

RESULTS

Forty-four out of 104 (42%) patients had borderline or confirmed depression, 36/108 (33%) had significant fatigue, and 62/106 (58%) had significant sleep disturbances at admission. Significant correlation was observed between change in fatigue and depression scores with change in functional status scores (P < 0.05) but no correlation (P > 0.05) between change in sleep disturbance scores and functional status score and neurological recovery (P > 0.05). Similarly, change in fatigue and depression scores had no correlation with neurological status improvement. Fatigue, depression, and sleep disturbance scores showed significant improvement, that is, admission vs. discharge scores (P < 0.05) with significant correlation between improvement in all three variables (P < 0.05).

CONCLUSIONS

Study variables showed significant improvement in the present study with myelopathy patients but not necessarily correlating with functional and neurological recovery.

Differences in bone mineral density, markers of bone turnover and extracellular matrix and daily life muscular activity among patients with recent motor-incomplete versus motor-complete spinal cord injury

Spinal cord injury (SCI) leads to severe bone loss, but the associated mechanisms are poorly described in incomplete SCI individuals. The purpose of the study is to compare alterations in bone mineral density (BMD) and serum biomarkers of bone turnover in recent motor-incomplete to -complete SCI men, as well as to describe their physical activity and spasticity. We studied 31 men with acute SCI. Whole-body DXA scans, serum biomarkers and self-reported activity and spasticity were examined 1 and/or 3 and 12 months after the injury. We observed a decrease in proximal femur BMD (p < 0.02) in both the groups. Serum phosphate and carboxy-terminal-collagen crosslinks were significantly lower in motor-incomplete versus complete SCI men, whereas albumin-corrected Ca(2+) (p = 0.02) were lower only 3 months after injury. When data from all 31 SCI participants were pooled, we observed increased serum matrix metalloproteinase-2 (MMP-2) and tissue inhibitors of MMP-2 (TIMP-2) (p < 0.02) whereas TIMP-1 decreased (p = 0.03). BMD correlated positively with self-reported activity (r = 0.59, p = 0.04) and negatively with spasticity (r = 0.74, p = 0.02) 12 months after injury. As a summary, men with motor-incomplete SCI developed significant proximal femur bone loss 12 months after injury and exhibited increased bone resorption throughout the first year after the injury. Compared with complete SCI men, incomplete SCI men show attenuated bone resorption. Our pooled data show increased turnover of extracellular matrix after injury and that increased exercise before and after injury correlated with reduced bone loss.

Comparison of mental health between individuals with spinal cord injury and able-bodied controls in Neiva, Colombia

Although research has investigated the mental health of individuals with spinal cord injury (SCI), an overwhelming majority of this research has been conducted in the United States, Western Europe, and other developed countries. The purpose of this study was to compare the mental health of individuals with SCI with able-bodied controls in Neiva, Colombia, South America. Subjects included 40 Colombians with SCI and 42 age- and sex-matched controls (N = 82). The groups did not differ based on age, sex, years of education, or socioeconomic status. However, controls were twice as likely to be married. Four measures assessed mental health, including satisfaction with life (Satisfaction with Life Scale), depressive symptoms (Patient Health Questionnaire-9), self-esteem (Rosenberg Self-Esteem Scale), and anxiety (State-Trait Anxiety Inventory). In comparison with able-bodied controls, individuals with SCI reported significantly lower mental health on both depressive symptoms and satisfaction with life. These effect sizes were medium and large, respectively. The groups did not differ significantly on measures of self-esteem or anxiety. Mental health of individuals with SCI should be considered a central part of SCI rehabilitation interventions, particularly in Latin America.