http://stroke.ahajournals.org/content/48/7/e159.long
Abstract
At
least half of all stroke survivors experience fatigue; thus, it is a
common cause of concern for patients, caregivers, and clinicians after
stroke. This scientific statement provides an international perspective
on the emerging evidence surrounding the incidence, prevalence, quality
of life, and complex pathogenesis of poststroke fatigue. Evidence for
pharmacological and nonpharmacological interventions for management are
reviewed, as well as the effects of poststroke fatigue on both stroke
survivors and caregivers.
Fatigue
is a common and often debilitating sequela of both ischemic and
hemorrhagic stroke. Globally, there are ≈33 million stroke survivors,1 and at least half of these individuals experience fatigue.2
The goal of this scientific statement is to provide an international
perspective on the current understanding of the incidence, prevalence,
quality of life (QOL), and complex pathogenesis of poststroke fatigue
(PSF). Potential pharmacological and nonpharmacological approaches to
management are explored, as well as the effects of PSF on both stroke
survivors and caregivers.
Methods
A
critical analysis of published quantitative research and guidelines on
fatigue after stroke was conducted. Databases searched included PubMed,
CINAHL, MEDLINE, and PsycINFO. Search terms included poststroke fatigue, fatigue, chronic fatigue, incidence, prevalence, caregiver, biomarker, etiology, intervention, patient education materials, and pharmacological interventions.
Analysis involved reviewing titles, abstracts, and full-text articles
for relevance to the topic with the following inclusion criteria: (1)
written in the English language; (2) involved human subjects; (3)
published from January 2000 through March 2016; (4) used a
quasi-experimental, experimental, observational research or randomized
clinical trial (RCT) design; (5) involved the subject of fatigue after
ischemic or hemorrhagic stroke; and (6) was conducted during any part of
the stroke continuum of care (acute hospitalization, inpatient
rehabilitation, homecare, long-term care). Additional quantitative
research was identified from the reference lists of publications found
with the search criteria listed above.
Overview of PSF
There
are many ways in which fatigue is defined and measured. These varying
definitions affect the estimates of the incidence and prevalence of PSF.
None of the current definitions of PSF are specific to stroke. The most
commonly used definitions include the following:
- “Subjective lack of physical and/or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities.”3
- “A feeling of early exhaustion developing during mental activity, with weariness, lack of energy, and aversion to effort.”4
- “Sense of exhaustion, lack of perceived energy or tiredness, distinct from sadness or weakness.”5
These
definitions may include both physical and mental energy or be limited
only to mental activity. In recent years. fatigue has come to be
distinguished from symptoms of depression. but there is no consensus
among clinicians or researchers on one definition of PSF.
Given
the many and differing definitions of fatigue, estimates of its
incidence (first reported fatigue related to stroke onset) and
prevalence (number of stroke survivors experiencing fatigue at any given
point in time) vary. Reliable reports of incidence are not available in
the literature. One of the earliest studies on PSF estimated the
incidence to be 75%.6
This study, however, did not provide a definition of fatigue and
evaluated only 44 individuals who were 3 to 24 months after stroke and
thus likely gives a better estimate of prevalence than incidence. In
reviews, prevalence estimates for PSF range from 23% to 77%.7–11
Because of the varying definitions and scales used, meta-analyses are
limited. One systematic review of individuals with transient ischemic
attack and minor stroke estimated the pooled prevalence of PSF to be
between 23% and 34%.7 Another systematic review that included 49 studies reported prevalence rates between 25% and 85%.12
Although no data were reported on stroke severity, with >3000
subjects represented in the review, it can be assumed that more than
transient ischemic attacks and minor strokes were represented, which
could be one possible explanation of the wide prevalence.
Lynch and colleagues13
created case definitions of PSF based on interviews with stroke
survivors in the initial and recovery stages. These definitions are as
follows:
For hospital patients: Since their stroke, the patient has experienced fatigue, a lack of energy, or an increased need to rest every day or nearly every day. And this fatigue has led to difficulty taking part in everyday activities (for inpatients this may include therapy and may include the need to terminate an activity early because of fatigue).... For community-dwelling patients: Over the past month, there has been at least a 2 week period when patient has experienced fatigue, a lack of energy, or an increased need to rest every day or nearly every day. And this fatigue has led to difficulty taking part in everyday activities.13
With this definition, the prevalence of PSF was estimated to be 40% after stroke.13 PSF was associated with female sex and emotional distress.13
In
summary, there is no consensus among clinicians or researchers on one
best definition of PSF. A consensus definition would lead to more
accurate estimates of incidence and prevalence.
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