Fatigue after stroke: manifestations and strategies

Exploring core and bridge symptoms in patients recovering from stroke: a network analysis

Background

Patients recovering from stroke experience a variety of symptoms that present as a synergistic and mutually reinforcing "symptom cluster," rather than as singular symptoms. In this study, we researched and systematic analyzed these symptom clusters, including core and bridge symptoms, to help determine the relationships between symptoms and to identify key symptom targets, providing a new approach for formulating precise symptom management interventions.

Methods

Convenience sampling was applied to select 432 stroke recovery patients treated in the Seventh People's Hospital of Changzhou City from August 1, 2023 to April 14, 2024. Subsequently, a cross-sectional survey was conducted using the General Information Questionnaire and Stroke Symptom Experience Scale to extract symptom clusters via exploratory factor analysis. Finally, the "qgraph" and "bootnet" packages in the R language were used to construct a network layout to describe the relationships between symptoms and calculate the centrality index.

Results

The average age of the 432 enrolled recovering stroke patients was 68.17 ± 12.14 years, including 268 males (62.04%) and 164 females (37.96%), none of whom underwent surgical intervention. Among this cohort, the 3 symptoms with the highest incidence rates were "limb weakness" (A2, 80.56%), "fatigue" (A5, 77.78%), and "limitations of limb movement" (A1, 68.06%). A total of 5 symptom clusters were extracted: the somatic activity disorder, mood-disorder-related, cognitive-linguistic dysfunction, somatic-pain-related, and foot dysfunction symptom clusters. In the symptom network, the 2 most common symptoms in terms of intensity and expected impact were "fatigue" (A5, rs = 1.14, re = 1.00) and "pessimism about the future" (B3, rs = 1.09, re = 1.02). The symptom with the strongest bridge intensity was "limb pain" (D1, rs = 2.64).

Conclusion

This study uses symptom network analysis to explore the symptoms of stroke patients during recovery, identifying core symptoms and bridge symptoms. Based on these findings, we can develop more targeted management plans to improve the accuracy and efficiency of interventions. Through this management approach, we can enhance treatment effectiveness, reduce unnecessary medication, lower adverse drug reactions, and optimize the allocation of medical resources.

Increased risk of depression and associated symptoms in poststroke aphasia

Poststroke aphasia hinders patients' emotional processing and social adaptation. This study estimated the risks of depression and related symptoms in patients developing or not developing aphasia after various types of stroke. Using data from the US Collaborative Network within the TriNetX Diamond Network, we conducted a retrospective cohort study of adults experiencing their first stroke between 2013 and 2022. Diagnoses were confirmed using corresponding International Classification of Diseases, Tenth Revision, Clinical Modification codes. Patients were stratified by poststroke aphasia status and stroke type, with propensity score matching performed to control for confounders. The primary outcome was depression within one year post-stroke; secondary outcomes included anxiety, fatigue, agitation, emotional impact, and insomnia. Each matched group comprised 12,333 patients. The risk of depression was significantly higher in patients with poststroke aphasia (hazard ratio: 1.728; 95% CI 1.464-2.038; p < 0.001), especially those with post-hemorrhagic-stroke aphasia (hazard ratio: 2.321; 95% CI 1.814-2.970; p < 0.001). Patients with poststroke aphasia also had higher risks of fatigue, agitation, and emotional impact. Anxiety and insomnia risks were higher in those with post-hemorrhagic-stroke aphasia. Poststroke aphasia, particularly post-hemorrhagic-stroke aphasia, may increase the risks of depression and associated symptoms, indicating the need for comprehensive psychiatric assessments.

Exploring post-stroke fatigue from the perspective of stroke survivors: what strategies help? A qualitative study

PURPOSE

Post-stroke fatigue is a research priority for stroke survivors and health professionals but there is limited evidence to guide management. We aimed to explore (1) the experience of post-stroke fatigue from the perspective of stroke survivors and their caregivers and (2) fatigue management strategies that are used.

MATERIALS AND METHODS

This was a qualitative study using semi-structured interviews. People with self-reported post-stroke fatigue and caregivers were recruited using maximum variation sampling. Analysis was done via the framework approach.

RESULTS

We recruited 17 stroke survivors, nine male (53%), most under 65 years (n = 12, 76%), and greater than 1-year post-stroke (n = 16, 94%, range 10-months to 22-years). One-third of participants self-reported having aphasia (n = 5, 36%). We also recruited eight caregivers, most of whom were female (n = 7, 88%). We identified four themes: (1) fatigue is unexpected after stroke and symptoms vary; (2) the individual experience of fatigue is complex, influenced by multifactorial and biopsychosocial factors; (3) learning to adapt and accept fatigue; and (4) Strategies to manage fatigue and personal approaches to rest.

CONCLUSIONS

Post-stroke fatigue experience varies presenting cognitively, physically, and psychologically according to a complex interplay of biopsychosocial factors and personal triggers. Self-management strategies are individualised and include organisation, medications, lifestyle modifications, and peer support.

Factors associated with fatigue among people who have returned to work after stroke: an exploratory study

OBJECTIVE

To explore the associations between fatigue impact and (a) personal and stroke-related characteristics, (b) functional impairments and (c) work-related factors among individuals who have returned to work after stroke.

DESIGN

A cross-sectional exploratory study.

SUBJECTS

87 working stroke survivors.

METHODS

This study comprises data from a postal survey targeting work ability and perceived stroke-related consequences 1 year after stroke. Fatigue was evaluated using the Fatigue Severity Scale (FSS). Factors associated with having fatigue (FSS total score ≥ 4) were identified using univariable and multivariable logistic regression analyses. Three domain-specific multivariable models and 1 final combined model were created.

RESULTS

Fatigue was reported by 43% of the participants. Several factors representing all the investigated domains were associated with fatigue. In the final combined regression model, self-perceived low cognitive functioning, low decision control at work and high quantitative job demands had the strongest independent effects on the odds of having fatigue.

CONCLUSION

Among people who were working 1 year after stroke, fatigue was associated with both personal and stroke-related characteristics as well as functional impairments and work-related factors. This highlights the complex nature of post-stroke fatigue. Fatigue management interventions should have a comprehensive approach and also consider the work environment.

Development of a tailored intervention targeting sedentary behavior and physical activity in people with stroke and diabetes: A qualitative study using a co-creation framework

Purpose

Type 2 diabetes and sedentary behavior pose serious health risks in stroke survivors. Using a co-creation framework, this study aimed to develop an intervention in collaboration with stroke survivors with type 2 diabetes, relatives, and cross-sectoral health care professionals to reduce sedentary behavior and increase physical activity.

Materials and methods

This qualitative explorative study used a co-creation framework consisting of a workshop and focus group interviews with stroke survivors with type 2 diabetes (n = 3), relative (n = 1), and health care professionals (n = 10) to develop the intervention. A content analysis was used to analyze data.

Results

The developed "Everyday Life is Rehabilitation" (ELiR) intervention consisted of a tailored 12-week home-based behavior change intervention with two consultations of action planning, goal setting, motivational interviewing, and fatigue management including education on sedentary behavior, physical activity, and fatigue. The intervention has a minimalistic setup using a double-page paper "Everyday Life is Rehabilitation" (ELiR) instrument making it implementable and tangible.

Conclusions

In this study, a theoretical framework was used to develop a tailored 12-week home-based behavior change intervention. Strategies to reduce sedentary behavior and increase physical activity through activities of daily living along with fatigue management in stroke survivors with type 2 diabetes were identified.

Handling fatigue in everyday activities at five years after stroke: A long and demanding process

BACKGROUND

Fatigue is common and can be challenging after stroke.

AIM

To explore how post-stroke fatigue (PSF) was experienced and handled among people with stroke in their performance of everyday activities and in participation in social activities five years after stroke.

METHODS

Nine persons who perceived PSF one year after stroke onset were interviewed five years later. The interviews were analysed using qualitative content analysis.

RESULTS

Most participants experienced PSF even five years after stroke and reported longstanding difficulties in everyday activities. Handling fatigue-a long slow process with invisible adjustments in everyday life emerged as the theme. By implementing new strategies in everyday life their PSF lessened over time. Understanding among significant others as to how PSF appears and providing information about PSF early after stroke was perceived important.

CONCLUSION

This study adds new knowledge regarding experiences of PSF and long-term support needs. Even if PSF still was reported the participants experienced improvements in everyday life through the application of new strategies. Information about PSF and strategies for managing everyday life should be provided during rehabilitation.

SIGNIFICANCE

This study is one out of only a few focussing on long-term PSF and adjustment to its consequences in everyday life.

Prior employment status and obesity do not predict post-stroke fatigue

Aim: To investigate whether prior employment status or obesity pose as risk factors for post stroke fatigue in patients following an ischemic stroke. Materials & methods: A total of 121 patients with a confirmed diagnosis of ischemic stroke in the past 3 years were enrolled into the study. Post-stroke fatigue (PSF) was assessed using the fatigue assessment scale (no PSF ≤21, PSF 22–50). Patients were then identified based on their employment status (previously worked) or obesity (BMI) and compared with the presence of PSF. Results: A Fisher’s exact test was applied to determine the association between PSF and obesity (p = 1.000). A Fisher’s exact test was applied to show the association between PSF and employment status (p = 0.384). In logistic regression, employment status did not independently predict dichotomized fatigue assessment scale (adjusted odds ratio 1.34, 95% CI: 0.51–3.50, p = 0.557). Conclusion: Previous employment status and obesity did not independently predict PSF in an urban, minority community.

Adaptation to poststroke fatigue in stroke survivors and their care partners: a scoping review

PURPOSE

Fatigue is a long-term symptom for stroke survivors. This scoping review synthesized how survivors achieve fatigue adaptation.

METHODS

Four databases were searched for studies between 2012 and 2021. Qualitative studies or qualitative findings from mixed-methods studies were included if they described survivors' experiences with fatigue and/or care partners' experiences in helping survivors adapt to fatigue. Studies were excluded if they were poster abstracts, reviews, or editorials.

RESULTS

Thirty-six articles were analyzed. Survivors with fatigue described different adaptive challenges - fatigue made them less productive, brought emotional distress, and was indiscernible to others. To respond to these challenges, stroke survivors did adaptive work including conserving energy, changing mindset, and restructuring normality. Care partners, employers, and colleagues showed adaptive leadership by adjusting daily routines or role responsibilities. Most survivors described that the current clinical practice did not meet their needs to address fatigue.

CONCLUSIONS

Stroke survivors had many types of challenges and strategies for fatigue adaptation. Survivors received family, employer, and colleague support but how care partners help survivors develop new skills is unknown. Stroke survivors expressed that healthcare professionals need to teach survivors and care partners basic knowledge of fatigue that meet their personal needs and provide adaptive interventions for survivors. Implications for rehabilitationThe challenges of poststroke fatigue are multifaceted because fatigue influences stroke survivors' physical, cognitive, mental, and social aspects of recovery.Stroke survivors need support from their care partners such as helping them adapt to the fatigue, adapt to new life routine, and adjust role responsibilities.Healthcare professionals, stroke survivors, and care partners need to work together to develop strategies about poststroke fatigue that meet stroke survivors' personal needs.

“I Give It Everything for an Hour Then I Sleep for Four.” The Experience of Post-stroke Fatigue During Outpatient Rehabilitation Including the Perspectives of Carers: A Qualitative Study

Background

Fatigue is a debilitating post-stroke symptom negatively impacting rehabilitation. Lack of acknowledgment from carers can be additionally distressing. The purpose of this study was to describe the experience of post-stroke fatigue during outpatient rehabilitation, including the perspectives of carers.

Methods

This qualitative study was guided by descriptive phenomenology within a constructivist paradigm. Semi-structured interviews were conducted with stroke survivors experiencing fatigue (Fatigue Assessment Scale >23) and attending outpatient rehabilitation. Carers were also interviewed where identified, providing insight into their own and stroke survivor experiences. Data were analyzed according to Colaizzi's analytic method.

Results

Fourteen stroke survivors (50% culturally and linguistically diverse), and nine carers participated. Six themes were identified: 1. The unpredictable and unprepared uncovering of fatigue; 2. Experience and adjustment are personal 3. Being responsible for self-managing fatigue; 4. The complex juggle of outpatient stroke rehabilitation with fatigue; 5. Learning about fatigue is a self-directed problem-solving experience; 6. Family and carers can support or constrain managing fatigue.

Conclusion

Despite engaging in outpatient rehabilitation, stroke survivors largely learnt to manage fatigue independent of healthcare professionals. Carers often facilitated learning, monitoring rehabilitation, daily routines and fatigue exacerbation. Conversely, family could be dismissive of fatigue and possess unrealistic expectations. Post-stroke fatigue must be considered by clinicians when delivering outpatient rehabilitation to stroke survivors. Clinicians should consistently screen for fatigue, provide flexible session scheduling, and educate about individual indicators and strategies for management. Clinicians should also explicitly engage carers who play a critical role in the management of fatigue.

Risk Factors and Imaging Mechanisms of Fatigue After Mild Ischemic Stroke: An Exploratory Study From a Single Chinese Center

Objective: To explore the biochemical risk factors and imaging mechanisms of post fatigue after mild ischemic stroke among a Chinese population. Methods: Forty consecutive patients with mild ischemic stroke within onset of 14 ± 2 days were enrolled between March and June 2018. The clinical information, scale data, biomarkers in peripheral venous blood, and imaging data during hospitalization and follow-up period were collected. Results: Patient age (range 34-78) was positively correlated with the prevalence of fatigue (p = 0.009). Both blood norepinephrine and serotonin levels during hospitalization were negatively correlated to the prevalence of post-stroke fatigue (model 1 p = 0.009 and model 2 P = 0.043, respectively). Infarct of right cerebral hemisphere is positively correlated with the occurrence of fatigue after mild ischemic stroke (p = 0.020). Compared to non-fatigue patients, amplitude of low-frequency fluctuation (ALFF) was lower in several areas of brain in stroke patients with fatigue, including the right orbital inferior frontal, right inner orbital frontal, right frontal, right triangular frontal inferior, right anterior and lateral cingulate, and right medial frontal gyruses. Analysis of the difference in functional connectivity between the fatigue and non-fatigue groups found no cluster. Conclusions: Frontal lobe-related neural pathways may play an essential role in the regulation of fatigue after mild ischemic stroke. Abnormal neural circuits may reduce the levels of neurotransmitters such as serotonin and norepinephrine and lead to post-stroke fatigue.

Post-stroke fatigue: an exploratory study with patients and health professionals to develop a patient-reported outcome measure

BACKGROUND

Post-stroke fatigue (PSF) is commonly reported and described as disabling by patients recovering from stroke. However, a major challenge is how to accurately diagnose and assess PSF. Therefore, the aim of this study was to explore PSF as it is experienced by stroke survivors and described by health professionals to guide future development of a PSF-specific PROM.

METHODS

Individual semi-structured interviews were conducted with stroke survivors experiencing PSF (n = 9) and three focus groups were conducted with health professionals (n = 16). Data were analyzed through inductive content analysis.

RESULTS

The analysis revealed four themes illustrating the experience and descriptions of PSF: 1) PSF characteristics, 2) interfering and aggravating factors, 3) management, and 4) PSF awareness, which refers to stroke survivors first becoming aware of PSF after their initial hospital admission.

CONCLUSION

This study highlights the complexity and multidimensionality of PSF. The results from this study will guide future development of a PSF-PROM and support its content validity.

Methodology of the fatigue after stroke educational recovery group randomized controlled trial

RATIONALE

Post-stroke fatigue affects up to 92% of stroke survivors, causing significant burden. Educational cognitive behavioral therapy fatigue groups show positive results in other health conditions.

AIMS

FASTER will determine if educational cognitive behavioral therapy fatigue management group reduces subjective fatigue in adults post-stroke.

DESIGN

Prospective, multi-centre, two-arm, single-blind, phase III RCT (parallel, superiority design), with blinded assessments at baseline, six weeks, and three months post-program commencement. With n = 200 (100 per group, 20% drop-out), the trial will have 85% power (2-sided, p = 0.05) to detect minimally clinically important differences of 0.60 (SD = 1.27) in fatigue severity scale and 1.70 points (SD = 3.6) in multidimensional fatigue inventory-20 at three months.

OUTCOMES

Primary outcomes are self-reported fatigue severity and dimensionality (i.e. types of fatigue experienced - physical, psychological and/or cognitive) post-intervention (six weeks). Secondary outcomes include subjective fatigue at three months, and health-related quality of life, disability, sleep, pain, mood, service use/costs, and caregiver burden at each follow-up.

DISCUSSION

FASTER will determine whether fatigue management group reduces fatigue post-stroke.Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000626167).

Stroke survivors’ experiences and perceptions of post-stroke fatigue education in the subacute phase of stroke. The FASE qualitative study

Introduction

Post-stroke fatigue significantly impacts stroke survivors’ rehabilitation, morbidity and quality of life. The evidence-base of post-stroke fatigue education is scarce and inconsistently translated to practice. Research is necessary to understand the current provision, impact and perceptions of post-stroke fatigue education from the stroke survivor’s perspective. The aim of this study is to develop an understanding of stroke survivors’ current experiences and perceptions of fatigue and the role of post-stroke fatigue education in subacute stroke.

Methods

A United Kingdom-based qualitative inquiry using semi-structured interviews involving 10 participants who had experienced subacute stroke was conducted using thematic data analysis.

Findings

The overarching theme of acceptance and adaptation reflected possible mechanisms in how stroke survivors manage post-stroke fatigue. Theme one highlighted the individual and diverse nature of post-stroke fatigue. Theme two, the variability of stroke survivors’ current experiences, reflected variability in content and context of post-stroke fatigue education. Theme three, the role of stroke services, described perceived responsibility and ability of stroke services to provide post-stroke fatigue education.

Conclusions

Post-stroke fatigue education is variable in practice. The results suggest further investigation of a stroke pathway approach for post-stroke fatigue education, involving core aspects suitable for a spectrum of stroke survivors with additional components tailored to individual needs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Lack of content overlap and essential dimensions - A review of measures used for post-stroke fatigue

INTRODUCTION

Post-stroke fatigue (PSF) is a highly prevalent and disabling condition. A major obstacle in PSF research is the lack of consensus on how to assess and diagnose fatigue after stroke. A wide variety of patient reported outcome measures (PROMs) are currently being used, none of which are developed specifically for stroke patients. The objectives of this study are to evaluate content validity in individual fatigue PROMs, and to identify similarities and differences through cross-comparison of PROMs.

METHODS

We used a novel mixed-methods approach to evaluate content validity in fatigue PROMs. First, we performed a qualitative content analysis of items in eleven fatigue PROMs used in stroke populations, and then we used descriptive statistics and a similarity coefficient to investigate similarities and differences across instruments.

RESULTS

The analysis of 156 items in eleven PROMs revealed 83 different items each representing a distinct attribute of fatigue. The results show that currently used fatigue PROMs omit important PSF-specific items, do not take into account the multidimensional nature of PSF and lack content overlap.

SUMMARY

The wide variety of items and lack of overlap between fatigue PROMs illuminates the need for researchers to report why a specific PROM was used. PROMs that capture the specific experiences of patients with PSF are also needed to advance research on PSF and its etiology and treatment.

Chronic post-stroke fatigue: It may no longer be about the stroke itself

OBJECTIVE

Post-stroke fatigue (PSF) is a debilitating complication of stroke recovery. Contributing risk factors, whether they are modifiable, and if they change over time remain understudied. We determine factors associated with PSF and how they evolve from the subacute through chronic phases of recovery.

PATIENTS AND METHODS

A consecutive series of patients presenting to our comprehensive stroke center with acute stroke were seen in follow-up within 6 months of infarct and administered the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue scale to evaluate for PSF. It was re-administered >6 months post-infarct. Demographics, stroke characteristics (NIH Stroke Scale [NIHSS], infarct size and location), medical comorbidities, and outcomes (modified Rankin Scale [mRS]) were also recorded. Regression analyses were used to determine factors associated with FACIT scores and PSF at each time point.

RESULTS

203 patients were administered the FACIT a mean 1.6 months post-stroke; 128 underwent re-administration (mean 13.9 months post-event). In adjusted models, stroke severity (follow-up NIHSS [p < 0.001], mRS [p = 0.005]) and posterior circulation localization (p = 0.012) were associated with lower FACIT scores (increased fatigue) in the subacute setting, while medical comorbidities (hypertension [p = 0.024], obstructive sleep apnea [p = 0.020]) and medication use (anticonvulsants [p = 0.021]) were associated with lower scores chronically. Baseline depression (p < 0.001, p = 0.029) was associated with lower scores at both time points.

CONCLUSION

Early PSF appears to be largely attributable to stroke severity, while chronic fatigue occurs in the setting of medical comorbidities and medication use. This has significant clinical implications when considering management strategies at different stages of recovery.

Mechanisms of poststroke fatigue

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

Tiredness and fatigue during processes of illness and recovery: A qualitative study of women recovered from fibromyalgia syndrome

Fibromyalgia syndrome (FMS), a chronic musculoskeletal pain condition, is often accompanied by fatigue. In this study, inspired by narrative approaches to health and illness, we explore how women who have regained their health after FMS describe tiredness along a storyline from before they fell ill, through their illness, recovery process, and present-day health. The data derive from qualitative interviews with eight Norwegian women who previously suffered from FMS but who no longer had the condition at the time of interview. We undertook a narrative analysis to understand the complexity of the stories about tiredness and fatigue and on this basis identified a storyline based on four sub-narratives: 1) Alarming but ignored tiredness (before illness); 2) paralyzing fatigue (during illness); 3) making sense of fatigue (recovery process); and 4) integrating tiredness into life (today). The findings highlight participants' different understandings and meanings of tiredness and fatigue and the ways in which these link past, present, and future. Significantly, a clear distinction between tiredness and fatigue was not always found. Overall, the storyline that emerges from the narratives is about balancing tiredness/fatigue with everyday life, and how this unfolds in different ways across the span of FMS, from falling ill to recovering and regaining health.

Self-Reported Fatigue and Associated Factors Six Years after Stroke

Several studies have found that fatigue is one of the most commonly reported symptoms after stroke and the most difficult to cope with. The present study aimed to investigate the presence and severity of self-reported fatigue six years after stroke onset and associated factors. The cohort “Life After Stroke Phase I” (n = 349 persons) was invited at six years to report fatigue (Fatigue Severity Scale 7-item version), perceived impact of stroke and global recovery after stroke (Stroke Impact Scale), anxiety and depression (Hospital Anxiety and Depression Scale), life satisfaction (Life Satisfaction Checklist) and participation in everyday social activities (Frenchay Activities Index). At six years 37% of the 102 participants in this cross-sectional study reported fatigue. The results showed that in nearly all SIS domains the odds for post-stroke fatigue were higher in persons with a higher perceived impact. Furthermore, the odds for post-stroke fatigue were higher in those who had experienced a moderate/severe stroke and had signs of depression and anxiety. Fatigue is still present in one-third of persons as long as six years after stroke onset and is perceived to hinder many aspects of functioning in everyday life. There is an urgent need to develop and evaluate interventions to reduce fatigue.

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.

Exploring the experience of sleep and fatigue in male and female adults over the 2 years following traumatic brain injury: a qualitative descriptive study

OBJECTIVES

To explore the experience of fatigue and sleep difficulties over the first 2 years after traumatic brain injury (TBI).

DESIGN

Longitudinal qualitative descriptive analysis of interviews completed as part of a larger longitudinal study of recovery following TBI. Data relating to the experience of fatigue and/or sleep were extracted and coded by two independent researchers.

SETTING

Community-based study in the Hamilton and Auckland regions of New Zealand.

PARTICIPANTS

30 adult participants who had experienced mild, moderate or severe brain injury within the past 6 months (>16 years of age). 15 participants also nominated significant others to take part. Interviews were completed at 6, 12 and 24 months postinjury.

RESULTS

Participants described feeling unprepared for the intensity, impact and persistent nature of fatigue and sleep difficulties after injury. They struggled to learn how to manage their difficulties by themselves and to adapt strategies in response to changing circumstances over time. Four themes were identified: (1) Making sense of fatigue and sleep after TBI; (2) accepting the need for rest; (3) learning how to rest and; (4) need for rest impacts on ability to engage in life.

CONCLUSIONS

Targeted support to understand, accept and manage the sleep and fatigue difficulties experienced may be crucial to improve recovery and facilitate engagement in everyday life. Advice needs to be timely and revised for relevance over the course of recovery.

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

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

Managing Poststroke Fatigue Using Telehealth: A Case Report

OBJECTIVE. The objective of this study was to examine the effectiveness of delivering Managing Fatigue: A Six-Week Course for Energy Conservation via telehealth for a 70-yr-old man with poststroke fatigue (PSF).

METHOD. For this pilot case study, a questionnaire developed by the authors and the Patient-Reported Outcomes Measurement Information System Fatigue Short Form 7a were used for screening. The study was implemented via teleconference over an 8-wk period. The Fatigue Impact Scale (FIS) and the Canadian Occupational Performance Measure (COPM) were used to gather pretest and posttest data.

RESULTS. After the participant completed the course, decreased fatigue impact was noted on the FIS, and modestly improved occupational performance and satisfaction were evidenced by the COPM.

CONCLUSION. For this single participant experiencing PSF, performance and satisfaction on the COPM guardedly improved and fatigue impact decreased after participation in the energy conservation course offered by teleconference, a form of telehealth delivery. Further research is recommended with larger sample sizes.

Cognitive-linguistic effort in multidisciplinary stroke rehabilitation: Decreasing vs. increasing cues for word retrieval

Approximately 24% of stroke survivors experience co-occurring aphasia and hemiparesis. These individuals typically attend back-to-back therapy sessions. However, sequentially scheduled therapy may trigger physical and mental fatigue and have an adverse impact on treatment outcomes. The current study tested a hypothesis that exerting less effort during a therapy session would reduce overall fatigue and enhance functional recovery. Two stroke survivors chronically challenged by non-fluent aphasia and right hemiparesis sequentially completed verbal naming and upper-limb tasks on their home computers. The level of cognitive-linguistic effort in speech/language practice was manipulated by presenting verbal naming tasks in two conditions: Decreasing cues (i.e., most-to-least support for word retrieval), and Increasing cues (i.e., least-to-most support). The participants completed the same upper-limb exercises throughout the study periods. Both individuals showed a statistically significant advantage of decreasing cues over increasing cues in word retrieval during the practice period, but not at the end of the practice period or thereafter. The participant with moderate aphasia and hemiparesis achieved clinically meaningful gains in upper-limb functions following the decreasing cues condition, but not after the increasing cues condition. Preliminary findings from the current study suggest a positive impact of decreasing cues in the context of multidisciplinary stroke rehabilitation.

Factors Associated with Poststroke Fatigue: A Systematic Review

Background. Poststroke fatigue (PSF) is a frequent, disabling symptom that lacks a consensual definition and a standardized evaluation method. The (multiple) causes of PSF have not been formally characterized. Objective. To identify factors associated with PSF. Method. A systematic review of articles referenced in MEDLINE. Only original studies having measured PSF and potentially associated factors were included. Data was extracted from articles using predefined data fields. Results. Although PSF tends to be more frequent in female patients and older patients, sociodemographic factors do not appear to have a major impact. There are strong associations between PSF and emotional disturbances (such as depression and anxiety). PSF may also be linked to attentional disturbances (mainly slowing in processing speed). The literature data have failed to demonstrate a clear impact of the type and severity of stroke. It has been suggested that PSF results from alterations in the frontothalamostriatal system and/or inflammatory processes. Pain, sleep disorders, and prestroke fatigue also appeared to be associated with PSF. Implications. A better understanding of PSF may improve stroke patient care and facilitate the development of effective treatments.

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.

Difference in Motor Fatigue between Patients with Stroke and Patients with Multiple Sclerosis: A Pilot Study

Fatigue is often reported in stroke patients. However, it is still unclear if fatigue in stroke patients is more prominent, more frequent or more "typical" than in patients with multiple sclerosis (MS) and if the pathophysiology differs between these two populations. The purpose of this study was to compare motor fatigue and fatigue-induced changes in kinematic gait parameters between stroke patients, MS patients, and healthy persons. Gait parameters at the beginning and end of a treadmill walking test were assessed in 10 stroke patients, 40 MS patients, and 20 healthy subjects. The recently developed Fatigue index Kliniken Schmieder (FKS) based on change of the movement's attractor and its variability was used to measure motor fatigue. Six stroke patients had a pathological FKS. The FKS (indicating the level of motor fatigue) in stroke patients was similar compared to MS patients. Stroke patients had smaller step length, step height and greater step width, circumduction with the right and left leg, and greater sway compared to the other groups at the beginning and at the end of test. A severe walking impairment in stroke patients does not necessarily cause a pathological FKS indicating motor fatigue. Moreover, the FKS can be used as a measure of motor fatigue in stroke and MS and may also be applicable to other diseases.

Life changed existentially: a qualitative study of experiences at 6-8 months after mild stroke

PURPOSE

To explore experiences of mild-stroke survivors in the context of early supported discharge. The meanings patients attributed to activities and participation in the home recovery process were our main interest.

METHODS

Eight participants (45-80 years) from a randomised controlled study were selected for this sub-study. This purposive sample had received rehabilitation in their homes in the post-stroke acute phase of recovery as part of the larger study. Extensive interview data were analysed using an interpretive strategy and systematic text condensation. Coping theory was included in later stages of analysis.

FINDINGS

The mild-stroke survivors' stories revealed that life had changed profoundly. Differences and similarities in experienced changes were related to: self-perceived health, the body, practical activities, taking part in society, and self-perception. The findings showed the ways in which life changed for mild-stroke survivors, experienced challenges, and survivors' thoughts about the future.

CONCLUSIONS

Mild-stroke rehabilitation should focus more strongly on basic concerns related to self-perceived health, self-perception, and body, since these dimensions seem to complicate daily activities and close relationships. Professionals should also be aware of patients who experience an uncertain situation and unresolved rehabilitation needs, which still can be present 6-8 months after the stroke.

IMPLICATIONS FOR REHABILITATION

When living with mild stroke, entrance to practical and social activities seemed founded on the patients' perception of the body and self as comprehensible or not. Comprehending their own changed body and sense of self seem to be a long-term process when living with mild stroke. It is suggested that long-term follow-up be incorporated in home rehabilitation service, also in the context of early supported discharge. This may contribute to help patient cope more optimally with activities and participation of importance to them.

Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

BACKGROUND

Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.

METHODS AND FINDINGS

The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.

CONCLUSIONS

Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems.

Stroke rehabilitation: recent advances and future therapies

Despite advances in the acute management of stroke, a large proportion of stroke patients are left with significant impairments. Over the coming decades the prevalence of stroke-related disability is expected to increase worldwide and this will impact greatly on families, healthcare systems and economies. Effective neuro-rehabilitation is a key factor in reducing disability after stroke. In this review, we discuss the effects of stroke, principles of stroke rehabilitative care and predictors of recovery. We also discuss novel therapies in stroke rehabilitation, including non-invasive brain stimulation, robotics and pharmacological augmentation. Many trials are currently underway, which, in time, may impact on future rehabilitative practice.