The meaning of fatigue for women with multiple sclerosis

Investigating Relationships Among Interoceptive Awareness, Emotional Susceptibility, and Fatigue in Persons With Multiple Sclerosis

BACKGROUND

Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS). Although personality traits and MS have been studied, interoception and emotional susceptibility and their links to fatigue have not yet been explored.

METHODS

Study participants provided demographic information and completed standardized patient-reported outcomes of walking function, physical activity, subjective fatigue, interoceptive awareness, and emotional susceptibility. A subset of participants participated in semistructured interviews discussing fatigue, body sensations, emotions, and their effects on exercise. Quantitative data were analyzed using multiple regression. Qualitative data were analyzed using thematic analysis.

RESULTS

Mean ± SD Fatigue Severity Scale scores (5.0 ± 1.3) indicated that fatigue was a problematic symptom. Mean ± SD Multidimensional Assessment of Interoceptive Awareness, Version 2 (2.8 ± 0.6) and Emotional Susceptibility Scale (3.0 ± 1.0) scores indicated lower levels of interoceptive awareness and emotional susceptibility. Quantitative data indicated no relationship between fatigue and interoceptive awareness (β = -0.20; P = .88) and emotional susceptibility (β = 0.03; P = .83), and neither were these related to physical activity (β = -0.07; P = .64). Qualitative themes indicated strong fatigue experiences involving the whole body and individual limbs, anger and frustration, and effects on physical activity.

CONCLUSIONS

Physically active people with MS report strong sensations of fatigue closely linked to frustration and helplessness. There was agreement between qualitative and quantitative assessments of fatigue but dissonance regarding interoceptive awareness and physical activity. The practice of clinicians, particularly those involved with facilitating or planning physical activity for persons with MS, would benefit from these findings about fatigue.

Characterizing fatigue phenotypes with other symptoms and clinically relevant outcomes among people with multiple sclerosis

PURPOSE

Fatigue is a common symptom of multiple sclerosis (MS) and can adversely affect all aspect of quality of life. The etiology of fatigue remains unclear, and its treatments are suboptimal. Characterizing the phenotypes of fatigued persons with MS may help advance research on fatigue's etiology and identify ways to personalize fatigue interventions to improve quality of life. The purpose of this study was to identify fatigue phenotypes; examine phenotype stability overtime; and characterize phenotypes by health and function, social and environmental determinants, psychosocial factors, and engagement in healthy behaviors.

METHODS

We conducted a longitudinal study over a 3-month period with 289 fatigued participants with MS. To identify fatigue phenotypes and determine transition probabilities, we used latent profile and transition analyses with valid self-report measures of mental and physical fatigue severity, the mental and physical impact of fatigue, depression, anxiety, and sleep quality. We used ANOVAs and effect sizes to characterize differences among phenotypes.

RESULTS

The best fitting model included six subgroups of participants: Mild Phenotype, Mild-to-Moderate Phenotype, Moderate-to-Severe Phenotype, Severe Phenotype, Fatigue-dominant Phenotype, and Mental Health-dominant Phenotype. The transition analysis indicated that phenotypic membership was highly stable. Variables with a large eta squared effect size included environmental barriers, self-efficacy, and fatigue catastrophizing.

CONCLUSION

These results indicate that the magnitude of fatigue experienced may be more important to consider than the type of fatigue when characterizing fatigue phenotypes. Future research should explore whether tailoring interventions to environmental barriers, self-efficacy, and fatigue catastrophizing reduce the likelihood of transitioning to a more severe phenotype.

Understanding quality of life across different clinical subtypes of multiple sclerosis: a thematic analysis

PURPOSE

Multiple sclerosis (MS) is a neurological disease that has different clinical presentations and illness trajectories. The aim of this study was to explore factors that are important for quality of life (QoL) of people with MS (pwMS), and to understand how they may differ across three subtypes.

METHODS

Both convenience and purposive sampling were employed. Semi-structured interviews were conducted with people with relapsing-remitting MS (n = 16), secondary progressive MS (n = 14), and primary progressive MS (n = 13). All interviews were audio recorded and then transcribed verbatim for thematic analysis involving both inductive and deductive processes. A separate analysis for each subtype was made during the inductive process before examining for similarities and differences across the three subtypes in the deductive process.

FINDINGS

Four factors were identified to have an important influence on QoL of pwMS: restricted and disrupted enjoyment, disturbed future, challenged sense of self, and well-being of significant others. The themes reflect how pwMS commonly perceived enjoyment as a purpose of life, while also illustrating how their QoL may be questioned because of new perspectives going forward with MS, challenges to their sense of self, and increased concerns for their significant others as a result of MS. Subtype differences were attributed to different illness trajectories: relapsing or progressive.

CONCLUSIONS

There are subtype differences in the negative impact of MS on QoL. Clinicians are encouraged to understand the challenges of different illness trajectories, in particular the traumatic nature of relapses and steady worsening of symptoms among those with progressive subtypes of MS.

The "Managing Fatigue" programme - experiences shared by MS participants

BACKGROUND

The "Managing Fatigue" (MF) programme can help people living with Multiple sclerosis (MS) manage fatigue in their everyday lives. The programme has been proven feasible with Swedish occupational therapists, but there is a lack of knowledge of how MS participants experience the programme, and what they learned from participating in the programme.

AIM

To describe how Swedish MS participants experience the content and structure of the Swedish MF programme, as well as what they learned from participating in the programme.

MATERIAL AND METHODS

Qualitative interviews were performed with nine MS participants, and data were analysed according to direct content analysis.

RESULTS

Participants experienced programme material was relevant, and they valued the structured sessions that utilised different teaching forms. Participants described the group format and the experienced course leader nurtured their learning process. They learned occupational skills to save energy, to re-value daily occupations, and initiated a process of change, but individual support is needed after programme completion.

CONCLUSION AND SIGNIFICANCE

Findings support programme feasibility among MS participants, and show the importance of being able to practice skills to handle fatigue in everyday life. Future studies should consider adding outcome measures focussing on engagement in occupations when evaluating programme effectiveness.

REFRESH protocol: a non-inferiority randomised clinical trial comparing internet and teleconference to in-person 'Managing Fatigue' interventions on the impact of fatigue among persons with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. It is considered a major cause of non-traumatic disability in young adults. One of the most common and disabling symptoms of MS is fatigue. MS fatigue can impact all aspects of quality of life, including physical, mental and social function. Fortunately, fatigue self-management interventions, such as 'Managing Fatigue: A 6 week energy conservation course', can decrease the impact of fatigue and improve health-related quality of life. The purpose of this study is to compare three modes of delivering the Managing Fatigue intervention-two remote delivery formats (teleconference and internet) and one in-person format-on perceptions of fatigue and its impact on physical, mental and social function.

METHODS AND ANALYSIS

A non-inferiority randomised clinical trial is being conducted to compare the three delivery formats (1:1:1 allocation ratio) among 582 participants with MS living in the Midwestern and Northeastern United States. The hypothesis is that teleconference and internet versions of the intervention are non-inferior to the traditional mode of clinical service delivery (ie, one to one, in person) in terms of the primary outcome of self-reported fatigue impact (ie, Fatigue Impact Scale) and the secondary outcome of health-related quality of life (ie, Multiple Sclerosis Impact Scale). Outcomes are being measured at baseline, 2 months, 3 months and 6 months. The primary analysis tool will be linear mixed effects model. The prespecified inferiority margin for the primary outcome is 10 points. We will also examine whether baseline characteristics (eg, sociodemographic) moderate outcomes of the Managing Fatigue intervention and whether changes in self-efficacy and fatigue self-management behaviours mediate changes in outcomes.

ETHICS AND DISSEMINATION

The protocol is approved centrally by the institutional review board at Case Western Reserve University. Eligible participants give consent before being enrolled and randomised into the study. The study results will be disseminated through relevant advocacy organisations, newsletters to participants, publication in peer-reviewed journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03550170; Pre-results.

The notion of "invisibility" in people's experiences of the symptoms of multiple sclerosis: a systematic meta-synthesis

Purpose: Invisible symptoms have a negative impact on people living with Multiple Sclerosis (MS), related to the very notion that they are "unseen." It is important to understand the notion of "invisibility" in MS, as invisible symptoms are particularly distressing, and there is a paucity of research focussing on their invisible nature and its specific impact. We aimed to systematically identify, appraise and synthesise qualitative research regarding the notion of "invisibility" in relation to people's lived experience of symptoms of MS.Methods and materials: Articles meeting inclusion criteria were critically appraised and synthesised using a meta-ethnographic approach.Results: 17 articles were identified from six electronic databases. Three third-order themes were presented as a line of argument. "Invisibility" was conceptualised by people with MS as a discrepancy between the internal experience of symptoms and what is observed externally. "Invisibility" of MS symptoms was found to have numerous impacts, including not feeling understood or validated by others, issues around the perceived legitimacy of the illness, and living with needs which are hidden. We found that "invisibility" by its nature offers people a choice of strategies they use to navigate it. This choice introduces a dilemma: disclose the diagnosis to be "seen," or remain "invisible."Conclusions: This review revealed the manner in which people with MS are affected by the invisibility of their symptoms and the various adaptations used to navigate these lived experiences. We highlight the need to improve clinician and public understanding, and to better respond to these experiences. Future research focusing on the exploration of people's experiences of "invisibility" in MS, including the ways in which "invisibility" is managed on a day-to-day basis could raise clinical and public awareness of the impact of "invisibility" and how to provide support for this, thus easing the dilemmas faced by those with MS.IMPLICATIONS FOR REHABILITATIONPeople with Multiple Sclerosis (MS) experience symptoms that are not overtly visible to others, impacting their emotional and social wellbeing negatively.It is important for healthcare professionals to validate MS patients' experiences around "invisibility" and provide appropriate support.Healthcare professionals should address with MS patients any issues around disclosure of their diagnosis to those around them and support them to navigate these decisions.Raising awareness about the impact of "invisibility" for people with MS may help to lessen patient burden and promote understanding amongst healthcare professionals and the general public.

An interpretative phenomenological analysis of dignity in people with multiple sclerosis

BACKGROUND

Dignity is a fundamental concept in healthcare. The symptoms of multiple sclerosis have a negative effect on dignity. Understanding of lived experience of dignity in people with multiple sclerosis is crucial to support dignity in practice.

RESEARCH AIM

The aim was to explore the sense of dignity experienced by people with multiple sclerosis.

RESEARCH DESIGN AND PARTICIPANTS

An interpretative phenomenological analysis design was adopted, using data collected through face-to-face interviews with 14 participants.

ETHICAL CONSIDERATIONS

The study was approved by the faculty Ethical Committee (No. EC 1828/2016).

FINDINGS

Four interconnected superordinate themes emerged from analysis: Loss of a fully-fledged life: Violating the dignity-of-self; To accept and fight: Promoting the dignity-of-self; Contempt and rudeness: Indignity-in-relation; and Those who know and see, help: Promoting dignity-in-relation. The loss of former fully-fledged life has a dramatic impact on integrity and impaired dignity-of-self. Accepting illness and changed identity impaired by multiple sclerosis was the step that the participants considered to be important for reacquiring the sense of dignity. The participants encountered misunderstandings, prejudices, embarrassment, insensitive remarks, labelling, unwillingness and impersonal treatment as indignities. Acceptance of their condition, needed support, the feeling of being part of a group, sensitivity and the sharing of problems had a positive effect on their dignity.

DISCUSSION

Continual changes in functional ability threaten an individual's identity and were experienced as violations of dignity. Based on this, participant's dignity-of-self was not a moral, but much more existential value. Acceptance of changed identity and fighting spirit were important for restoring their dignity-of-self. The misunderstandings, prejudices and unwillingness had a negative impact on their dignity-in-relation. On the other side, support from others in fighting promoted their dignity-in-relation.

CONCLUSION

Dignity is manifested as a complex phenomenon of lived experience of people with multiple sclerosis and also an umbrella concept for providing good quality of person-centred care.

The Relational Impact of Multiple Sclerosis: An Integrative Review of the Literature Using a Cognitive Analytic Framework

This integrative literature review uses cognitive analytic therapy (CAT) theory to examine the impact of a chronic illness, multiple sclerosis (MS), on relationships and mental health. Electronic searches were conducted in six medical and social science databases. Thirty-eight articles met inclusion criteria, and also satisfied quality criteria. Articles revealed that MS-related demands change care needs and alter relationships. Using a CAT framework, the MS literature was analysed, and five key patterns of relating to oneself and to others were identified. A diagrammatic formulation is proposed that interconnects these patterns with wellbeing and suggests potential “exits” to improve mental health, for example, assisting families to minimise overprotection. Application of CAT analysis to the literature clarifies relational processes that may affect mental health among individuals with MS, which hopefully will inform how services assist in reducing unhelpful patterns and improve coping. Further investigation of the identified patterns is needed.

Understanding and living with multiple sclerosis fatigue

Introduction

Fatigue substantially affects the lives of many people with multiple sclerosis. This study aimed to further our understanding of the experience of living with multiple sclerosis fatigue by exploring how people became aware of and understood their multiple sclerosis fatigue and how they accommodate it in their daily lives.

Method

The study used an existential approach to thematic analysis. Thirteen in-depth, semi-structured interviews with people who experienced multiple sclerosis fatigue were conducted and analysed.

Results

Participants developed an understanding of multiple sclerosis fatigue through gaining awareness of its effect on their lives, seeking information themselves and being informed by health professionals. Participants described how they began to understand the effect of fatigue in their lives and make decisions about how to accommodate it. They discussed the challenges associated with helping others to understand their multiple sclerosis fatigue.

Conclusion

Lay and expert explanations, the phenomenological notions of lived experience, self-identity and embodiment and stigma associated with invisible disability were useful concepts for understanding the results. Clinicians should consider these concepts when supporting people with multiple sclerosis fatigue to understand the effect of fatigue in their daily lives and use fatigue management strategies to make effective lifestyle changes to accommodate it.

Exploring Occupational Adaptation through the Lives of Women with Multiple Sclerosis

Multiple sclerosis (MS) affects people's physical capabilities and the lives of people with MS are constantly changing (Finlayson et al 2005), yet how people adapt to the disease from an occupational perspective has received little attention. This study explored the occupational adaptation of women with MS.

Seven women with MS were recruited from the Multiple Sclerosis Society of Ireland. Each participant completed the Modified Interest Checklist (Kielhofner and Neville 1983), the Role Checklist (Oakley et al 1985) and the Occupational Questionnaire (Smith et al 1986). Qualitative data were also collected, using the Occupational Performance History Interview – II (Kielhofner et al 2004).

The findings from all four tools were amalgamated and analysed. Three main themes emerged: the impact of MS on (i) performance capacity, (ii) roles and (iii) interests. The participants adapted by performing interests and roles differently and developing new meaningful interests and roles that were congruent with their performance capacity.

The findings highlight the importance of having an understanding of the impact of different types of MS on the occupational adaptation process. A greater understanding will facilitate occupational therapists in enabling people with MS to adapt to their condition by engaging in meaningful occupations throughout the lifespan.

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

CONTEXT

Fatigue is a common and debilitating symptom associated with many long-term conditions and is reported to cause significant levels of distress for those individuals. There is a substantial body of literature related to the nature of fatigue; however, this has not been drawn together and compared across conditions.

OBJECTIVES

The aim of this review was to synthesize data on the nature of fatigue across long-term conditions.

METHODS

The review was designed as a qualitative meta-synthesis and followed the Joanna Briggs Institute guidelines for synthesizing qualitative research. The following databases were searched for the period January 1980 to January 2016, Ovid (Medline, Embase, CINAHL, and PsycINFO) and manual searching from the reference lists from articles identified by electronic search. Fifty-seven studies were included in the review, and findings related to the nature of fatigue were extracted and findings meta-synthesized.

RESULTS

The perceived nature of fatigue across long-term conditions was encompassed in one synthesis; the fatigue experience is without precedent, with four categories: a different fatigue to any experienced before, the intensity of fatigue is overwhelming, the trajectory of fatigue, and impact on sleep and sleep disturbance. Just over half of the participants in the included studies were diagnosed with cancer. Patterns in the experience of fatigue by condition were found for cancer-related fatigue and post-stroke fatigue where data were able to be synthesized.

CONCLUSION

Although similarities in the nature of the fatigue experienced were found across conditions, differences were also evident and could be mapped for cancer-related fatigue and post-stroke fatigue. Further qualitative research on the experience of fatigue across a wide range of chronic conditions would further contribute to understanding similarities and differences across conditions and inform both research and practice in relation to assessment and management.

Similarities and differences in the experience of fatigue among people living with fibromyalgia, multiple sclerosis, ankylosing spondylitis and stroke

AIMS AND OBJECTIVES

To elucidate the experience of fatigue across several long-term illnesses, focusing on the similarities and differences.

BACKGROUND

Fatigue is common to many long-term illnesses, but it has been studied mainly within the context of a single illness; qualitative studies comparing the experience and its impact on daily life across different long-term illnesses are lacking.

DESIGN

Qualitative design.

METHODS

A secondary analysis was conducted of five original interview studies involving 95 persons with ankylosing spondylitis, fibromyalgia, multiple sclerosis or stroke.

RESULTS

Similarities and differences concerning experiences of fatigue were found across the studied long-term illnesses. All patients expressed the perception of having an unfamiliar body. Fatigue was also commonly expressed as unpredictable, uncontrollable and invisible to others. Differences were related to a constant versus a varying condition, a sudden and an uncontrollable sleepiness, a mutual reinforcement with pain and increased stress sensitivity. A lack of energy and a need for sleep and rest were common experiences, as was the impact on social relationships. There were also similarities regarding how the patients managed their daily life. The search for practical solutions and attitude adjustment differed with the fatigue characteristics. All patients felt a lack of understanding and disbelief from others.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

Fatigue is commonly expressed by patients with long-term illnesses. Variations in experience are related to the type of diagnosis. The disparity between experiences influences how patients managed and adjusted to the conditions of everyday life. The illness-specific characteristics of fatigue warrant increased clinical awareness and may allow professionals to offer adequate information and establish effective methods of managing the condition. The feeling of invisibility and difficulty describing the experience of fatigue in particular highlights this need.

What are the support needs of men with multiple sclerosis, and are they being met?

BACKGROUND

Multiple sclerosis (MS) is a chronic, degenerative condition of the central nervous system that can lead to high levels of disability and a range of psychological and social problems. Although considerable research has been conducted on the experience of living with MS and the disease's psychosocial consequences, much of this has focused on women, with the male perspective seldom considered. It is possible, therefore, that men differ from women in how they experience MS and the type of support or interventions that meet their needs.

METHODS

A literature review was undertaken to identify the specific support needs of men with MS, describe current support available to men with MS, and evaluate the extent to which these needs are met by current service provision.

RESULTS

The literature reviewed suggests that the needs of men with MS are different from those of women in terms of psychological factors such as well-being and mental health and support.

CONCLUSIONS

If interventions are to be evidence based, health-care professionals need to take into account the needs, desires, and capabilities of men with MS in the development of services. Further qualitative and quantitative research is required to address the gaps in the evidence base of support needs for men with MS.

Narratives reflecting the lived experiences of people with brain disorders: common psychosocial difficulties and determinants

BACKGROUND

People with brain disorders - defined as both, mental disorders and neurological disorders experience a wide range of psychosocial difficulties (PSDs) (e.g., concentrating, maintaining energy levels, and maintaining relationships). Research evidence is required to show that these PSDs are common across brain disorders.

OBJECTIVES

To explore and gain deeper understanding of the experiences of people with seven brain disorders (alcohol dependency, depression, epilepsy, multiple sclerosis, Parkinson's disease, schizophrenia, stroke). It examines the common PSDs and their influencing factors.

METHODS

Seventy seven qualitative studies identified in a systematic literature review and qualitative data derived from six focus groups are used to generate first-person narratives representing seven brain disorders. A theory-driven thematic analysis of these narratives identifies the PSDs and their influencing factors for comparison between the seven disorders.

RESULTS

First-person narratives illustrate realities for people with brain disorders facilitating a deeper understanding of their every-day life experiences. Thematic analysis serves to highlight the commonalities, both of PSDs, such as loneliness, anger, uncertainty about the future and problems with work activities, and their determinants, such as work opportunities, trusting relationships and access to self-help groups.

CONCLUSIONS

The strength of the methodology and the narratives is that they provide the opportunity for the reader to empathise with people with brain disorders and facilitate deeper levels of understanding of the complexity of the relationship of PSDs, determinants and facilitators. The latter reflect positive aspects of the lives of people with brain disorders. The result that many PSDs and their influencing factors are common to people with different brain disorders opens up the door to the possibility of using cross-cutting interventions involving different sectors. This strengthens the message that 'a great deal can be done' to improve the lived experience of persons with brain disorders when medical interventions are exhausted.

Myalgic encephalomyelitis/chronic fatigue syndrome and encephalomyelitis disseminata/multiple sclerosis show remarkable levels of similarity in phenomenology and neuroimmune characteristics

BACKGROUND

'Encephalomyelitis disseminata' (multiple sclerosis) and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are both classified as diseases of the central nervous system by the World Health Organization. This review aims to compare the phenomenological and neuroimmune characteristics of MS with those of ME/CFS.

DISCUSSION

There are remarkable phenomenological and neuroimmune overlaps between both disorders. Patients with ME/CFS and MS both experience severe levels of disabling fatigue and a worsening of symptoms following exercise and resort to energy conservation strategies in an attempt to meet the energy demands of day-to-day living. Debilitating autonomic symptoms, diminished cardiac responses to exercise, orthostatic intolerance and postural hypotension are experienced by patients with both illnesses. Both disorders show a relapsing-remitting or progressive course, while infections and psychosocial stress play a large part in worsening of fatigue symptoms. Activated immunoinflammatory, oxidative and nitrosative (O+NS) pathways and autoimmunity occur in both illnesses. The consequences of O+NS damage to self-epitopes is evidenced by the almost bewildering and almost identical array of autoantibodies formed against damaged epitopes seen in both illnesses. Mitochondrial dysfunctions, including lowered levels of ATP, decreased phosphocreatine synthesis and impaired oxidative phosphorylation, are heavily involved in the pathophysiology of both MS and ME/CFS. The findings produced by neuroimaging techniques are quite similar in both illnesses and show decreased cerebral blood flow, atrophy, gray matter reduction, white matter hyperintensities, increased cerebral lactate and choline signaling and lowered acetyl-aspartate levels.

SUMMARY

This review shows that there are neuroimmune similarities between MS and ME/CFS. This further substantiates the view that ME/CFS is a neuroimmune illness and that patients with MS are immunologically primed to develop symptoms of ME/CFS.

Meanings of fatigue for women with Parkinson's disease

The existing knowledge of women's experiences of living with Parkinson's disease and fatigue is limited. To gain first-hand knowledge, we interviewed 11 women using a phenomenological hermeneutic interpretation. The results indicate that the familiar daily routines of women with Parkinson's disease had changed in the sense that their bodily attachment to the world had been altered. The body no longer provided smooth access to the surrounding world; rather, the body served as a barrier to daily living. In practice, understanding this barrier can be significant in recognizing how to create positive conditions that support the women's experiences and how to formulate their care in congruence with their needs.

Experiences living with fatigue in Iranian veterans chemically injured by sulfur mustard gas: a phenomenological study

PURPOSE

Fatigue affects the quality of life. Evidence shows that the phenomenon of fatigue is experienced differently depending on the type of disease and its consequences. The aim of the study was to explicate the meanings of the experience of living with fatigue in chemically injured veterans.

METHODS

The hermeneutic phenomenology approach was used in this study, with an emphasis on Van Mennen's viewpoint and approach. According to Van Mennen, six overlapping dynamic activities are recommended to conduct a phenomenological study. During unstructured interviews, the participants were asked to describe their daily living experiences with fatigue. The participants were individuals who were chemically injured due to exposure to mustard gas. After examining every statement in the interview text, extractions of the meaning units, clustering, and themes were performed.

RESULTS

The data explication was based on the third to sixth stages of Van Mennen's approach. The experience living with fatigue was classified into four essential themes: fatigue as a chronic condition, as an unstable and affected situation, as a physical condition of the entire individual, and as a mental condition of the entire individual.

CONCLUSION

Due to unique social interactions and pathogenicity, victims of mustard gas experience fatigue differently than patients with other chronic diseases.

Fatigue in multiple sclerosis - a brief review

Fatigue is the most common and debilitating symptom in multiple sclerosis (MS) and is believed to be distinctly different from fatigue seen in other chronic conditions. It can affect a patient's mood, sleep and have a detrimental effect on their quality of life. In the recent years much literature has emerged in an attempt to elucidate the potential causes and treatment of this common symptom. This review article aims to examine the most recent theories on the pathophysiology of fatigue in MS as well as its association with sleep and depression. We describe the pharmacological and non-pharmacological approaches to its treatment and propose a multidisciplinary, patient enabled and individualised manner to the management of fatigue in MS.

Living with a double burden: Meanings of pain for women with fibromyalgia

Living with fibromyalgia (FM) means living with a chronic pain condition that greatly influences daily life. The majority of people with FM are middle-aged women. The aim of this study was to elucidate meanings of pain for women with FM. Fifteen women with FM were interviewed about their pain experiences and a phenomenological hermeneutic interpretation was used to analyse the interview texts. The findings show that meanings of pain for women with FM can be understood as living with a double burden; living with an aggressive, unpredictable pain and being doubted by others in relation to the invisible pain. The ever-present pain was described as unbearable, overwhelming, and dominated the women's whole existence. Nevertheless, all the women tried to normalize life by doing daily chores in an attempt to alleviate the pain. In order to support the women's needs and help them to feel well despite their pain, it is important that nurses and health care personnel acknowledge and understand women with FM and their pain experiences.

How does fatigue influence community-based exercise participation in people with multiple sclerosis?

PURPOSE

Regular exercise is considered important for long-term health outcomes and fatigue management in persons with multiple sclerosis (MS); however, little is known about the experiences of individuals with MS-related fatigue, who participate in community-based exercise activities. The aim of this study was to describe the experiences of people with MS-related fatigue, who engaged in community-based exercise activities in order to discover how fatigue influenced their exercise participation.

METHOD

In this study, we used qualitative methodology based on the interpretive description approach to collect and analyse data. Individuals with MS, who experienced fatigue and regularly participated in community-based exercise activities, were interviewed. Interviews were audiotaped and transcribed verbatim. Data were analysed using an inductive thematic approach with multi-step verification strategies.

RESULTS

We found that perceived control over MS-related fatigue influenced exercise choices in our participants. Furthermore, perceived control over fatigue was influenced by seven factors: wellness philosophy, a related goal, belief that control was possible, feeling safe and supported, ability to manage limits, being satisfied with trade-offs and positive definition of self.

CONCLUSION

Identification of factors influencing perceived control over fatigue will assist health care providers when facilitating community exercise choices for people with MS.

Meanings of being received and met by others as experienced by women with MS

In order to elucidate meanings of being received and met by others as experienced by women with multiple sclerosis (MS) we conducted a qualitative inquiry. We interviewed 15 women with MS and analysed the interviews with a phenomenological hermeneutic interpretation. The findings were presented in two themes: experiencing oneself as a valuable person and experiencing oneself as diminished. Meanings of being received and met by others, as experienced by women with MS, can be understood as containing two dimensions where treatment from others can mean recognising oneself through confirmation, as well as being ignored due to missing togetherness with others.

Monitoring my multiple sclerosis: a patient-administered health-assessment scale

Optimal health of people with multiple sclerosis (MS) can be promoted by patients' sharing of health information gained through periodic self-monitoring with their health-care providers. The purpose of this study was to develop a valid and reliable self-administered scale to obtain information about MS patients' health status and the impact of the disease on their daily lives. We named this scale "Monitoring My Multiple Sclerosis" (MMMS). A cross-sectional survey was conducted of 171 MS patients who completed the MMMS and Patient-Determined Disease Steps (PDDS) scales and provided information on their MS disease classification and demographic characteristics. Data analysis included several parametric procedures. Factor analysis of the 26-item MMMS resulted in four factors with satisfactory α reliability coefficients for the total scale (0.90) and factored subscales: Physical (0.85), Relationships (0.80), Energy (0.70), and Cognitive/Mental (0.67). Analysis of variance demonstrated that the total scale and the Physical subscale, but not the Relationships subscale, showed significantly worse functioning for patients with either moderate or severe disability as measured by the PDDS than for patients with mild disability (P < .001). The Cognitive/Mental subscale showed significantly worse functioning for patients with moderate disability than for patients with mild disability (P < .05). However, the Energy subscale showed significantly worse functioning among moderately disabled patients than among severely disabled patients (P < .01). Independent t tests demonstrated that patients classified as having secondary progressive multiple sclerosis had significantly worse scores on the total MMMS (P < .05) and the Physical subscale (P < .001) than those classified as having relapsing-remitting multiple sclerosis. The MMMS demonstrated satisfactory reliability and validity and is recommended for use by MS patients and their health-care providers as a mechanism to promote the sharing of health information, to the benefit of both patients and providers.

Life strain-related tiredness and illness-related fatigue in individuals with ankylosing spondylitis

OBJECTIVE

To examine the nature of fatigue and how it is managed in daily life situations by individuals with ankylosing spondylitis (AS).

METHODS

Twelve informants, 8 women and 4 men ages 30-59 years, who had lived with the diagnosis of AS for 6 months to 36 years, participated in qualitative interviews. They were asked to describe their daily life during good and bad days of AS, and to give examples of everyday situations where they experienced fatigue and what they did to recover. The text analysis consisted of identifying and coding meaningful statements, sorting the codes into categories, and condensing themes.

RESULTS

Two separate conditions of fatigue were identified. One consisted of comprehensible, manageable tiredness related to a life strain that was exacerbated by having AS. Life strain-related tiredness indicated to the respondents that they should rest or temporarily slow down, and this protected them from overexertion. The other condition was an unfamiliar and unmanageable fatigue that was related to their illness. Illness-related fatigue was accompanied by unbearable pain, severe stiffness, and heaviness of the body that could not be alleviated by the individual. This condition was considered a sign of the onset or a flare up of inflammation.

CONCLUSION

Fatigue in the individuals with AS varied over time, and took the form of 2 different conditions. Life strain-related tiredness had a positive aspect in that it protected against overstrain and guided life strain regulation. In contrast, illness-related fatigue was nonpurposive for the individuals and seems to call for medical therapy.

The lonely battle for dignity: individuals struggling with multiple sclerosis

Much is known about the phenomenon of dignity, yet there is still a need for implementing this understanding in clinical practice. The main purpose of this study was to find out how persons suffering from multiple sclerosis experience and understand dignity and violation in the context of a rehabilitation ward. A phenomenological-hermeneutic approach was used to extract the meaningful content of narratives from 14 patients with multiple sclerosis. Data were collected by personal research interviews. The findings revealed three main themes: (1) 'invisibly captured in fatigue'; (2) 'fighters' law: one who does not ask will not receive'; and (3) 'dignity is humanity'. The essence of the findings in this study is that dignity is humanity. According to the participants, dignity requires time and is experienced only in a context of empathy and mutual confidence.

Meanings of feeling well for women with multiple sclerosis

In research concerning multiple sclerosis (MS), the factors that impact on people's well-being and quality of life have been studied, but little has been written about what it means to feel well for women with MS. Therefore, in this study our aim was to describe meanings of feeling well for women with MS. We interviewed 15 women with MS, and a phenomenological hermeneutic interpretation was utilized to analyze the interviews. Through this study it can be understood that finding a pace where daily life goes on means that women with MS feel well when the illness is kept in check and is not the dominant experience. The findings of this study can be used to confirm women's experiences of feeling well, despite living with the consequences of MS. Health care professionals will find the results of this study useful when they reflect on and formulate the care of women with MS when attempting to support the latter's desire to feel well in their daily lives.

Women's experience of SLE-related fatigue: a focus group interview study

OBJECTIVE

The aim of this study was to describe women's experience of SLE-related fatigue, how they express the feeling of fatigue, impact on life and strategies developed to manage fatigue in daily living.

METHOD

Seven, semi-structured focus group discussions with 33 women were audio-taped, transcribed verbatim and analysed according to qualitative content analysis.

RESULTS

Perceptions of SLE-related fatigue were sorted into four themes. Nature of Fatigue, involved the sensation, occurrence and character. Aspects Affected by Fatigue described emotions that arose together with fatigue as well as aspects of work, family life, social contacts and leisure activities that were affected by fatigue. Striving Towards Power and Control concluded the array of ways used to manage daily life and were categorized into the mental struggle, structure, restrict and provide. Factors Influencing the Perception of Fatigue described understanding from their surroundings and pain as strongly influencing the experience and perception of fatigue.

CONCLUSION

SLE-related fatigue was portrayed as an overwhelming phenomenon with an unpredictable character, resulting in the feeling that fatigue dominates and controls most situations in life. The choice of strategies was described as a balance with implications for how fatigue limited a person's life. Health care professionals are advised to take a more active role to empower people with SLE to find their own balance as a way to achieve a feeling of being in control.

Chronic Fatigue

Because of the widespread nature of chronic fatigue, health care providers need a common understanding of chronic fatigue to enable effective communication. To aid this understanding a concept analysis was undertaken using a modified version of Rodger’s evolutionary method of concept analysis. The literature review yielded many resources focused on defining fatigue and relating it to many diverse chronic conditions. This article also discusses the differences between chronic fatigue and acute episodes of fatigue. Chronic fatigue is a subjective, unpleasant, changeable, and exhausting experience that adversely affects quality of life. Whereas rest or sleep often relieves acute fatigue, chronic fatigue is unrelenting. Chronic fatigue has multiple antecedents and is a component of a diverse array of chronic diseases.

Exploring physical activity behaviour of persons with multiple sclerosis: a qualitative pilot study

PURPOSE

Identify facilitators and barriers to physical activity (PA), and explore the utility of Social Cognitive Theory (SCT) and Transactional Model of Stress and Coping (TMSC) in understanding PA behaviour among persons with multiple sclerosis (MS).

METHODS

Thirteen participants from a clinical trial were interviewed and classified as physically active, sometimes active or inactive based on the Health-Promoting Lifestyle Profile-II. Interviews were analysed using analytical induction, which consisted of coding data into pre-established categories and then exploring similarities and differences between groups. Pre-established coding categories were constructs from SCT (i.e. environment, expectations, self-efficacy and self-regulation) and TMSC (i.e. stress appraisal and coping style).

RESULTS

Inactive and active participants differed in their self-regulation skills, self-efficacy and coping styles. Common barriers to PA included symptoms and the physical and social environment. Facilitators of PA included strong self-regulation skills, confidence to overcome symptoms to engage in PA (i.e. barrier self-efficacy) and positive coping styles.

CONCLUSION

Results from this pilot study suggest that PA interventions will need to implement multiple strategies that target self-efficacy, social environment and coping styles. We found SCT and TMSC useful in understanding PA behaviour among persons with MS; however, a limitation to these theories is that they are not explicit in the relationship between health and cognitions. Future research will need to explore how to incorporate models of health and function into existing behaviour change theories.

Fatigue in relation to perceived health: people with multiple sclerosis compared with people in the general population

Fatigue is not only a complex phenomenon accompanying different illness conditions but is also a common complaint among individuals in the general population. Among individuals diagnosed with the chronic neurological disease multiple sclerosis (MS), one-third describe fatigue as the very first symptom, however it is invisible to others. When adopting an action-theoretic approach to health, fatigue may be considered to influence the individual's goals of life and subjectively perceived health. The aim of this study was to describe perceived fatigue in relation to perceived health among working-aged individuals diagnosed with MS (n = 155), and in a comparative group of individuals randomly selected from the general population living in the same geographical area (n = 190). A self-report questionnaire including the Fatigue Impact Scale, a checklist of six symptoms, questions covering perceived health and levels of and perceptions of fatigue was used for the data collection. The responses on perceived health were dichotomized into two categories: 'good health' and 'ill health'. Of the individuals with MS, 50% graded their perceived health as ill compared with 18% in the reference group (p < 0.001), and 68% graded fatigue as one of their worst symptoms compared with 21% in the reference group. In both groups, higher presence of symptoms and impact of fatigue in daily activities correlated negatively to perceived health. Compared with the individuals in the reference group, the individuals with MS reported higher impact of fatigue in physical areas in both the category of 'good health' (p < 0.001) and 'ill health' (p < 0.01). The perceived impact of fatigue was mirrored in increased problems in social and family activities. In conclusion, individuals with MS perceive fatigue as one of their worst symptoms three times as often as individuals in the general population. However, individuals with MS probably also adapt themselves or shift in their response to fatigue more than individuals in the general population.

Women experience higher levels of fatigue than men at the end of life: a longitudinal home palliative care study

Few studies have evaluated sex differences in the prevalence, severity, and correlates of fatigue at the end of life. The Brief Fatigue Inventory, McGill Quality of Life (MQOL) Questionnaire, and Karnofsky Performance Scale were administered at two-week intervals to 102 patients in a home palliative program. Outcomes in the sample and a regional palliative database (n=3,096) were analyzed. Cancer was the diagnosis in 96% of patients enrolled. Prevalence (P=0.0091) and severity of fatigue (P<0.001) were higher in women at entry and in a repeated measures analysis over time (severity, P=0.0048). Performance status did not explain this difference. MQOL scores were inversely correlated to fatigue (Spearman coefficient=-0.48, P<0.0001), but did not differ by sex. There was no difference in fatigue interference with MQOL in women and men. Although depression was higher in women (P=0.042) and related to fatigue at entry, it did not explain the sex difference in fatigue scores. Of the sociodemographic variables examined, neither education nor living situation contributed to the fatigue difference. This study shows a sex effect in the fatigue experienced by patients with advanced illnesses, which is not explained by baseline differences in performance, depression, MQOL, education, or living situation. That fatigue interference with MQOL is the same for men and women suggests that higher fatigue scores in women reflect not only a difference in the dimension of fatigue severity, but are also relevant in relation to impact on QOL. Assessment of fatigue should include the dimension of QOL important for both women and men.

A phenomenological study of fatigue in patients with primary biliary cirrhosis

AIM

This paper reports the findings of research on the lived experience of fatigue in patients with primary biliary cirrhosis - a type of chronic liver disease.

BACKGROUND

Fatigue is a universal phenomenon, commonly associated with both acute and chronic illness, but also seen in healthy individuals. However, it is not often addressed in healthcare encounters despite its disabling nature, perhaps because of the multitude of contributing factors and the lack of effective treatments. It is a common and debilitating symptom in patients with primary biliary cirrhosis. Despite the prevalence of fatigue in this condition, patients' experiences of this symptom have not been researched.

METHOD

An interpretive-phenomenological approach developed by van Manen was chosen and this combines features of descriptive and interpretive phenomenology. Eight participants were interviewed during 2005 about their fatigue experience. Thematic analysis was conducted.

FINDINGS

Five themes were identified: an unreliable body, fatigue as always present yet insidious, planning a life to conserve energy, struggling to maintain normality and emotional consequences. These themes reflected the unrelenting, intrusive nature of fatigue into the lives of those affected.

CONCLUSION

This research will provide empathic insight into the fatigue experience in this condition and generate communication about coping strategies. It will add to the body of research on fatigue in chronic conditions and may generate ideas for intervention research.