Fatigue as an Understudied Barrier to Participation in Life Roles

Fatigue is one of the most burdensome and disabling symptoms in numerous acute and chronic conditions and is associated with reduced participation in all aspects of daily life, for example, parenting, employment, and socialization. Historically, occupational practitioners played key roles in fatigue management by creating and implementing interventions. The American Occupational Therapy Foundation convened a Planning Grant Collective workshop with the goal to develop collaborative research ideas and proposals to advance the understanding and management of fatigue. Participants from occupational therapy and other disciplines, with expertise with fatigue or who were conducting research on fatigue, participated in a 3-day virtual workshop. Four main topics emerged: implementation science, treatment taxonomy, trial design and comparative effectiveness, and phenotyping. This white paper describes the proceedings, summarizes the discussions, and outlines recommendations from the PGC workshop on fatigue.

Myalgic Encephalomyelitis-Chronic Fatigue Syndrome Common Data Element item content analysis

INTRODUCTION

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a multisystem chronic disease estimated to affect 836,000-2.5 million individuals in the United States. Persons with ME/CFS have a substantial reduction in their ability to engage in pre-illness levels of activity. Multiple symptoms include profound fatigue, post-exertional malaise, unrefreshing sleep, cognitive impairment, orthostatic intolerance, pain, and other symptoms persisting for more than 6 months. Diagnosis is challenging due to fluctuating and complex symptoms. ME/CFS Common Data Elements (CDEs) were identified in the National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS) Common Data Element Repository. This study reviewed ME/CFS CDEs item content.

METHODS

Inclusion criteria for CDEs (measures recommended for ME/CFS) analysis: 1) assesses symptoms; 2) developed for adults; 3) appropriate for patient reported outcome measure (PROM); 4) does not use visual or pictographic responses. Team members independently reviewed CDEs item content using the World Health Organization International Classification of Functioning, Disability and Health (ICF) framework to link meaningful concepts.

RESULTS

119 ME/CFS CDEs (measures) were reviewed and 38 met inclusion criteria, yielding 944 items linked to 1503 ICF meaningful concepts. Most concepts linked to ICF Body Functions component (b-codes; n = 1107, 73.65%) as follows: Fatiguability (n = 220, 14.64%), Energy Level (n = 166, 11.04%), Sleep Functions (n = 137, 9.12%), Emotional Functions (n = 131, 8.72%) and Pain (n = 120, 7.98%). Activities and Participation concepts (d codes) accounted for a smaller percentage of codes (n = 385, 25.62%). Most d codes were linked to the Mobility category (n = 69, 4.59%) and few items linked to Environmental Factors (e codes; n = 11, 0.73%).

DISCUSSION

Relatively few items assess the impact of ME/CFS symptoms on Activities and Participation. Findings support development of ME/CFS-specific PROMs, including items that assess activity limitations and participation restrictions. Development of psychometrically-sound, symptom-based item banks administered as computerized adaptive tests can provide robust assessments to assist primary care providers in the diagnosis and care of patients with ME/CFS.

Appraisal of Long COVID: Lessons to be Learned from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Objective(s)

Little is known regarding after-effects of Long-COVID-19 (LC), while ME/CFS has been extensively researched. We performed a rigorous scoping review to inform a better definition of symptomatology of LC and cross-cutting similarities with ME/CFS. Our objective was to review the National Institutes of Health (NIH) ME/CFS Common Data Elements (CDEs), identify Patient Reported Outcome Measures (PROMs) and link items to the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) codes to inform efforts to define LC.

Data Sources

NIH ME/CFS CDEs (Jan. 2020), Google Scholar, PubMed - search terms: Long COVID and ME/CFS.

Study Selection

A review of 119 NIH ME/CFS CDEs applied the following inclusion criteria: 1) PROM based; 2) assess symptomatology; 3) specific to adults 18 years and over; 4) no visual or pictographic scales.

Data Extraction

Of the 119 NIH ME/CFS CDEs, 38 met review criteria; items were entered into an Excel spreadsheet. Five researchers independently coded items using ICF linking rules and resolved discrepancies using a consensus-based process.

Data Synthesis

Six articles specifically compared LC and ME/CFS for symptom overlap. Similarities between ME/CFS and Long COVID symptoms include: fatigue, post exertional malaise (PEM), cognitive symptoms, sleep dysfunction, pain, noise and light hypersensitivity, orthostatic intolerance, cardiac, gastrointestinal and immune pathologies. The 944 items from 38 PROM CDEs were coded based on common ME/CFS and LC symptoms. The percent of items linked to one or more ICF categories (1288 codes) was as follows: Body Function (b codes) 73%: Fatigability, N=252 (20%); Cognitive functions, N=234 (18%); Sleep functions, N=139, 11%; and Pain, N=119, (9%). Activity and Participation (d codes), N=332, (26%). Environment (e codes), N=11, 0.9%.

Conclusions

The ICF provides a common language to assess ME/CFS and LC cross-cutting symptoms and their impact on body function, activity and participation. This review of ME/CFS CDE's can help identify common symptoms, such as PEM, and encourage appropriate symptom management to prevent cycles of overexertion and relapse for those with LC.

Author(s) Disclosures

The authors have no conflicts of interest to declare.

Efficacy of Computer-Based Telephone Counseling on Long-Term Adherence to Strength Training in Elderly Patients With Knee Osteoarthritis: A Randomized Trial

OBJECTIVE

To determine whether the Boston Overcoming Osteoarthritis through Strength Training Telephone-Linked Communication (BOOST-TLC) program, a novel telephone-based, motivational, strength-training exercise-adherence counseling intervention, improved adherence to a strength-training exercise program over 2 years.

METHODS

Participants were recruited for this 2-year, single-blind, parallel-arm randomized controlled trial from knee osteoarthritis patient registries, community newspapers, and online websites in Massachusetts. Eligibility criteria included age 50 years or older, painful knee osteoarthritis, and ability to use a telephone. Exclusion criteria included medical conditions precluding exercise, inflammatory arthritis, current regular strength training, planned knee replacement surgery, dementia, inability to follow exercise instructions, and inability to use the TLC system. After participating in a group exercise class, participants were randomized to receiving motivational telephone calls through the BOOST-TLC program for 24 months or the control. Both control and intervention participants received a monthly automated phone message reminder to continue the program. Exercise adherence was ascertained by a single self-report item scored 0-10, where 10 represented complete adherence. Outcomes were evaluated at 6, 12, 18, and 24 months.

RESULTS

A total of 104 subjects were randomized, and 89 subjects (44 control, 45 TLC) completed the 24-month follow-up. There was no significant difference in adherence at 24 months between groups (mean for control group 4.01 [95% confidence interval (95% CI) 3.03, 4.99], mean for TLC subjects 3.63 [95% CI 2.70, 4.56]; P = 0.57).

CONCLUSION

In those with knee osteoarthritis who had participated in an exercise program, frequent motivational telephone reminders did not increase adherence to strength-training exercise.

Exercise adherence: beliefs of adults with knee osteoarthritis over 2 years

Exercise is an established treatment to alleviate pain and improve function among adults with knee osteoarthritis (KOA). However, long-term adherence to exercise is poor and effective approaches to support adherence are limited. Here, we report on an ancillary study to a randomized controlled trial (RCT) where the primary outcome was 2-year adherence to a home based strength-training program. The aims of this current study were to (i) explore experiences, feelings, and perspectives related to long-term adherence to exercise among adults with painful KOA participating in a 2-year RCT, and (ii) identify factors that influenced long-term adherence to exercise. Methods: We purposively recruited 25 subjects and conducted in-depth interviews at the 2-year RCT assessment. In the RCT participants completed a 6-week group exercise program followed by automated telephone calls. Findings: Three conceptual categories describing beliefs about exercise were identified: (1) monitoring; (2) knowledge of how to manage their exercise behaviors; and (3) benefits of exercise. Monitoring provided by peers and instructors during group exercise, and telephone technology were valued by participants. Participants who reported low adherence expressed ambivalence about the benefits of exercise and a desire for more social support. Those who reported high adherence exhibited self-determination and self-efficacy. Conclusions: A novel finding is the conceptual link of self-determination to high adherence to strength-training exercises over 2 years among adults with KOA. Implications for physical therapists include identifying patients' autonomy, competence, and relatedness needs to foster intrinsic control for exercise behavior.