Clinical Utility of Mindfulness Training in the Treatment of Fatigue After Stroke, Traumatic Brain Injury and Multiple Sclerosis: A Systematic Literature Review and Meta-analysis

Well we still know nothing about stroke fatigue and mindfulness training just seems like dealing with the symptoms, not the causes. A good placebo, but not the actual solution.
http://journal.frontiersin.org/article/10.3389/fpsyg.2016.00912/full?

Kristine M. Ulrichsen^1*, Tobias Kaufmann², Erlend S. Dørum^1,2,3, Knut K. Kolskår^1,2,3, Geneviève Richard^1,2,3, Dag Alnæs², Tone J. Arneberg⁴, Lars T. Westlye^2,3* and Jan E. Nordvik¹

• ¹Sunnaas Rehabilitation Hospital HT, Nesodden, Norway
• ²KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, NORMENT: Norwegian Centre for Mental Disorders Research, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
• ³Department of Psychology, University of Oslo, Oslo, Norway
• ⁴Department of Behavioural Sciences, Oslo and Akershus University College of Applied Sciences, Oslo, Norway

Background: Fatigue is a common symptom following neurological illnesses and injuries, and is rated as one of the most debilitating sequela in conditions such as stroke, traumatic brain injury (TBI), and multiple sclerosis (MS). Yet effective treatments are lacking, suggesting a pressing need for a better understanding of its etiology and mechanisms that may alleviate the symptoms. Recently mindfulness-based interventions have demonstrated promising results for fatigue symptom relief.
Objective: Investigate the efficacy of mindfulness-based interventions for fatigue across neurological conditions and acquired brain injuries.
Materials and Methods: Systematic literature searches were conducted in PubMed, Medline, Web of Science, and PsycINFO. We included randomized controlled trials applying mindfulness-based interventions in patients with neurological conditions or acquired brain injuries. Four studies (N = 257) were retained for meta-analysis. The studies included patients diagnosed with MS, TBI, and stroke.
Results: The estimated effect size for the total sample was -0.37 (95% CI: -0.58, -0.17).
Conclusion: The results indicate that mindfulness-based interventions may relieve fatigue in neurological conditions such as stroke, TBI, and MS. However, the effect size is moderate, and further research is needed in order to determine the effect and improve our understanding of how mindfulness-based interventions affect fatigue symptom perception in patients with neurological conditions.

Introduction

Fatigue is a prevalent condition associated with a number of diseases (Hofman et al., 2007; Kluger et al., 2013). Curative pharmacologic or non-pharmacologic treatments have not yet been identified (Lee et al., 2008; Cantor et al., 2014; Wu et al., 2015). In some cases, like cancer-related fatigue, mindfulness-based interventions have resulted in significant reduction of fatigue symptoms (Pachman et al., 2014). However, the mechanisms of fatigue are poorly understood (Kutlubaev et al., 2012; Wu et al., 2015). Neurological diseases cause harm to the central nervous system, and fatigue associated with these kinds of diagnoses may have another etiology and respond differently to treatment than other types of fatigue. The objective of this systematic review is to investigate the effect of mindfulness-based interventions on fatigue symptoms following neurological conditions and acquired brain injuries.

Fatigue and increased fatigability are reported in a range of neurological conditions, like Parkinson’s, traumatic brain injury (TBI), myasthenia gravis, stroke, and multiple sclerosis (MS; Chaudhuri and Behan, 2004; DeLuca, 2005; Colle et al., 2006; Barker-Collo et al., 2007; Cantor et al., 2008; Friedman et al., 2011; Kluger et al., 2013). Often manifested as a mental and physical lack of energy, increased tiredness and reduced initiative (Glader et al., 2002; Choi-Kwon and Kim, 2011), fatigue can be persistent (Duncan et al., 2012; Ponsford et al., 2014) and pose a serious barrier to rehabilitation (Michael, 2002). Moreover, fatigue is associated with negative outcomes such as lower levels of functioning (Juengst et al., 2013), reduced quality of life, increased institutionalization and mortality (Glader et al., 2002; Lerdal et al., 2009).

Self-reports confirm fatigue as a distressing condition, and it is rated as the worst or one of the worst symptoms by 55, 50, and 40% of MS, TBI, and stroke patients, respectively (Fisk et al., 1994; LaChapelle and Finlayson, 1998; Ingles et al., 1999). Adding to the impact of the symptoms, nearly half of the stroke patients suffering from fatigue felt that they were offered insufficient help managing the fatigue (McKevitt et al., 2010). Due to the debilitating consequences, and incomplete understanding of the mechanisms and treatments of fatigue, the topic was listed among the top ten research priorities in a consensus report from UK stroke survivors, caregivers, and health professionals (Pollock et al., 2014). Such reports are in line with the literature on fatigue in other neurological conditions, often emphasizing the substantial limitations in our comprehension and treatment of this symptom (Chaudhuri and Behan, 2004).

Agreeing on a universally accepted definition of fatigue has proven problematic (Chaudhuri and Behan, 2004; Immink, 2014). Although the search for biological correlates of fatigue is ongoing, the experience of fatigue is fundamentally subjective (Chaudhuri and Behan, 2004; Dittner et al., 2004), and common not only to ill health but also in draining physical activities. The feeling of fatigue is thus both intimate, yet universal, and the experience has proven difficult to quantify and measure objectively (Dittner et al., 2004; Belmont et al., 2006; Mollayeva et al., 2013). However, it is generally accepted to differentiate “normal” fatigue from “pathological” fatigue (de Groot et al., 2003). While normal fatigue is considered to reflect a state of weariness associated with strain that can be lessened by rest, serving a protective and restorative function (Choi-Kwon and Kim, 2011), the pathological fatigue seen in many patients with acquired brain injury and MS tends to be more persistent, less related to strain, abnormal, excessive, and problematic (de Groot et al., 2003).

Fatigue is frequently measured by self-report questionnaires (Belmont et al., 2006; Lerdal et al., 2009). A multitude of scales are available [see Krupp et al., 1989, Fatigue Severity Scale (FSS); Schwartz et al., 1993, Fatigue Assessment Instrument (FAI); Smets et al., 1995, Modified Fatigue Impact Scale (MFIS)], and the same tools are often used across conditions (Dittner et al., 2004). Besides self-report measures, performance-based tests are sometimes also applied (Lerdal et al., 2009), presumably measuring more objective aspects of fatigue, but no objective “gold standard” or litmus test is currently available (Dittner et al., 2004).

Why some people develop fatigue in the face of neurological injury or disease, whereas others do not, is yet to be answered. Several factors have been found to be associated with or predict post-stroke fatigue (PSF), including functional impairment severity, depression, pain, sleep disturbances, cognitive impairments, physical deconditioning, pre-stroke fatigue, sedative medications, coronary heart disease, and increasing age (Mead et al., 2011; Wang et al., 2014). The variety of predictors suggests a complex etiology, further complicating treatment and diagnostic assessments. As fatigue is a pivotal part of both depression and sleep disturbances, these conditions have been posed as alternative or supplementing explanations (Kos et al., 2007). There are, however, many patients experiencing fatigue without reporting depression (van der Werf et al., 2001; Glader et al., 2002), and some studies fail to find associations between fatigue and sleep problems (Schepers et al., 2006). Findings like this may indicate that fatigue can be a partly independent symptom, and neurological fatigue in the absence of conditions such as depression or sleep problems has been referred to as “primary fatigue” (Forwell et al., 2008).

Owing to the multidimensionality of fatigue, the construct is often conceptualized as reflecting different subcategories. An applicable categorization is the division between peripheral (predominantly physical/muscular) and brain-derived central (more psychologically rooted, the sense of complete exhaustion) fatigue (Chaudhuri and Behan, 2000, 2004), in which mental fatigue constitutes an important dimension of the latter (Chaudhuri and Behan, 2000, 2004). The coping hypothesis offers one explanation for this experience, stating that increased fatigue is rooted in the continuous effort needed in order to compensate for cognitive impairments caused by the brain injury (Van Zomeren et al., 1984). Indeed, a few studies have reported that individuals with TBI and MS are showing increased brain activation compared to healthy controls while performing cognitive tasks (McAllister et al., 1999, 2001; DeLuca et al., 2008; Kohl et al., 2009) possibly indicating increased mental effort, while yet other studies have identified reduced sustained attention (McAvinue et al., 2005), selective attention deficits (Ziino and Ponsford, 2006), and a tendency to stimulus over-selectivity (McHugh and Wood, 2013) in patients with TBI. These findings are in line with the hypothesis of a central, brain-derived fatigue in neurological conditions, which might be associated with disruptions in circuits involving basal ganglia, frontal cortex thalamus (Chaudhuri and Behan, 2000). As pointed out by Chaudhuri and Behan (2004), (central) fatigue is “consistently seen with lesions in pathways associated with arousal and attention, reticular and limbic systems and basal ganglia” (pp. 979–980).

The models, hypotheses and correlates reviewed above are by no means offering an exhaustive account of the mechanisms of fatigue in neurological conditions. Still, by highlighting relevant aspects of the condition, such accounts may provide clues about potentially effective treatment strategies. Attentional impairments seem to be a recurrent and relevant aspect. Thus, in order to improve attentional regulation and control, a treatment procedure that has been suggested, among others, is mindfulness-based training (Chen et al., 2011; McHugh and Wood, 2013).

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