RESEARCH ARTICLE
Fatigue in Stroke Rehabilitation Patients: A Pilot Study† Thomas John Chestnut* Institute of Psychiatry, King‘s College London
Abstract Background and Purpose. Stroke is the leading cause of adult disability. Rehabilitation is a vital component of post-stroke care with two-thirds of survivors requiring rehabilitation. Fatigue is a common issue affecting stroke patients and is a barrier to rehabilitation causing inefficient care provision and potential limitation to patient recovery. No study to date has investigated whether the experience of fatigue is different between the two main causes of ischemic stroke: small-vessel (SVD) and large-vessel disease (LVD). The aim of the present study is to complete a pilot study to inform the feasibility, design, magnitude of difference in experience of fatigue, and sample size for a definitive study to evaluate differences in fatigue between these two groups of stroke patients. The experimental hypothesis is that participants with LVD experience a significantly greater level of fatigue than those with SVD as assessed by the Fatigue Severity Scale (FSS). Methods. The study used a cohort observational design. Thirteen participants were recruited over a two-month period from King’s College Hospital. Participants were visited on average at the start of the second week of rehabilitation to complete the FSS. An independent t-test and ANCOVA were performed. For all statistical analyses, a significance level of p < 0.05 was used. Results. The study demonstrated a trend towards LVD participants reporting higher fatigue scores than SVD participants, even when controlling for age, with gender having no confounding effect. Conclusions. Fatigue is common amongst ischemic stroke rehabilitation participants with 85% of the combined sample experiencing fatigue at the start of the second week. The results demonstrate a trend towards LVD participants experiencing greater fatigue. While the results were non-significant, the study demonstrates a feasible methodology which could help lay the groundwork for future research. Copyright © 2010 John Wiley & Sons, Ltd. Received 28 January 2010; Revised 24 March 2010; Accepted 1 April 2010 Keywords fatigue; fatigue severity scale; rehabilitation; stroke *Correspondence Thomas John Chestnut, MSc, BSc, School of Physiotherapy, Faculty of Health and Social Care Science, St. George’s University of London and Kingston University, 2nd Floor Grosvenor Wing, Cranmer Terrace, London SW17 0RE. Email: [email protected] Published online 18 May 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.476
Introduction Stroke is the leading cause of adult disability with the greatest range and impact of disability in comparison †
This article was published online on May 18, 2010. Errors were
subsequently identified on Figure 2. This notice is included in the online and print versions to indicate that both have been corrected on June 4, 2010
Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
to other chronic diseases (Adamson et al., 2004). Rehabilitation is a vital component of post-stroke care with two-thirds of stroke survivors requiring rehabilitation (Tyrrell and Smithard, 2005). Stroke patients occupy roughly 25% of long-term beds and receive a programme of rehabilitation aimed at enablement following functional loss (Department of Health, 2005). There is an increased incidence of stroke as a result of the ageing British population in addition to 151
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an increased prevalence of stroke survivors with disability placing an increased demand on stroke rehabilitation (Bagg et al., 2002; Bhalla et al., 2004). Due to a changing economic climate within the National Health Service (NHS), there is a growing need on the part of the multidisciplinary team (MDT) to deliver the most efficient care possible (Wentworth and Atkinson, 1996; Murray and Lopez, 1997; Bagg et al., 2002; Maulden et al., 2005). With the growing strain on stroke rehabilitation, the identification and investigation of barriers to an efficient rehabilitation service is of major importance. Fatigue is a common issue affecting patients following stroke though limited information is known on its effect on inpatient rehabilitation (Ingles et al., 1999; Van de Werf et al., 2001; Glader et al., 2002). Recovery post-stroke depends largely on the type of stroke suffered. Over two-thirds of strokes are of the ischemic type. Ischemic strokes are subdivided according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification into large-vessel (LVD), smallvessel (SVD), and cardioembolic disease. The TOAST classification provides an unambiguous, practical and easily applicable system of subdividing ischemic strokes (Adams et al., 1993). The two most common causes of ischemic stroke are SVD and LVD (Bogousslavsky et al., 1988; Mohr et al., 1978; Sacco et al., 1989). SVD presenting as small-artery occlusion causes lacunar infarcts that results in specific clinical syndromes (Boiten and Lodder, 1991). LVD presenting as large-artery atherosclerosis results in a wider area of cerebral cortical impairment (Adams et al., 1993). Patients with SVD infarcts have better functional status and prognosis post-stroke compared with LVD patients (Adams et al., 1993; Petty et al., 2000; Ng et al., 2007). Lacunar infarcts account for roughly 25% (Lodder and Boiten, 1993) and large-artery atherosclerosis account for roughly 50% of all ischemic strokes (Ng et al., 2007; Lindley, 2008). Results from existing studies are inconclusive as to an association between fatigue and stroke subtype with further research suggested. To the author’s knowledge, no study has investigated whether the experience of fatigue is different between the two main causes of ischemic stroke. This information could potentially aid MDT treatment planning and timescales in the rehabilitation setting to improve efficiency of care. Physiologically, the second week after a stroke involves softening of the infarct, subsiding edema and 152
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vascular growth around the infarct (Meier-Ruge, 1990). Animal studies show an increased potential for cortical plasticity between days seven and eighteen post-stroke (Jones and Shallert, 1992; Hagemann et al., 1998). In addition, the second week brings a level of acceptance by the patient and a familiarity with the stroke unit (O’Kelly, 2005). Few studies investigate the acute stage at the start of the rehabilitation process during which the literature suggests patient recovery is greatest. Fatigue has an adverse effect on the physical and psychological recovery after stroke and thus the patients’ quality of life. It interferes with stroke rehabilitation thus affecting the patients’ overall recovery post-stroke (Glader et al., 2002; Morley et al., 2005). Research into fatigue after stroke show fatigue prevalence ranging from 31 to 70% at a range of between 2 and 36 months post-stroke. Investigation into fatigue is often complicated by the ambiguity and lack of clear definition of the term in addition to a lack of validated fatigue scales for stroke. It is largely believed that fatigue is a subjective experience best quantified using self-report questionnaires that focus on ‘experienced fatigue’ (Krupp et al., 1989; LaChapelle and Finlayson, 1998; Taylor et al., 2000; Comi et al., 2001; Dittner et al., 2004; Stulemeijer et al., 2005). An appropriate self-report questionnaire should measure the desired component to quantify ‘experienced fatigue’ using either unidimensional or multidimensional scales (Taylor et al., 2000). Though not validated for stroke, the Fatigue Severity Scale (FSS) is the most commonly used fatigue scale in post-stroke fatigue (PSF) papers and has strong reliability and validity data for use in chronic central neurological conditions such as multiple sclerosis (MS), Parkinson’s disease and brain injury. The FSS is a unidimensional scale that assesses intensity of disabilityrelated fatigue (Taylor et al., 2000).
Method Design The study applied a cohort observational design and was used as a pilot study to assess the feasibility of using the FSS to measure PSF in two groups of rehabilitation inpatients with different stroke subtypes as classified using TOAST. Staub’s (2007) definition of subjective fatigue was used: ‘a feeling of early exhaustion, weariness and aversion to effort’ (Staub, 2007, p. 572). Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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Subjects Participants were recruited over a two-month period from the Friends Stroke Unit, King’s College Hospital. Friends Stroke Unit is an integrated inpatient stroke unit comprising eight acute beds and twelve rehabilitation beds. King’s College Hospital is a large teaching hospital providing care to over 700,000 residents in south east London. The two experimental groups were actively participating in stroke rehabilitation delivered by the MDT with emphasis on early mobilization. The study included male and female participants between 60 and 80 years of age suffering an acute ischemic stroke confirmed by brain imaging and recorded in the medical notes by the medical team. Participants provided written informed consent. Exclusion criteria consisted of patients who presented with both SVD and LVD as confirmed by brain imaging, were unable to speak English or who had reduced cognitive functioning, were aphasic, had a disabling co-morbidity prior to stroke, and had a previous history of diagnosed depression documented in the medical notes. Reduced cognitive functioning and disabling co-morbidity prior to stroke were assessed by a score of less than or equal to 23 on the Mini-mental State Examination and a score of less than 18 on the Barthel Index, respectively. Materials At the start of the second week after admission following stroke, the researcher completed a single faceto-face visit with the participant lasting an average of 10 minutes. The FSS was originally devised to determine the experience of fatigue by patients with MS (Krupp et al., 1989). It contains nine statements assessing the impact of fatigue over the past week on a Likert scale from one to seven (one indicating strong disagreement and seven indicating strong agreement). The FSS score is calculated as the mean of the total from the nine statements (Krupp et al., 1989). Participants with average scores of four or more are considered fatigued with higher scores indicating greater fatigue (Krupp et al., 1989; LaChapelle and Finlayson, 1998; Mathiowetz et al., 2001). In studies of patients with MS, the FSS had high internal consistency measured by a Cronbach’s alpha level of 0.89 (Schepers et al., 2006), good test–retest reliability, good concurrent validity and distinguished patients with different diagnoses (Krupp et al., 1989; Dittner et al., 2004). Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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User views of the FSS and participant information sheet were sought prior to use with recruited participants. Procedure The researcher visited the stroke unit twice weekly between June and August 2009 during which all of the ward medical notes were reviewed to identify potential participants. Triggers to fatigue were noted and recorded including medication and pre-existing comorbidities such as hypertension, diabetes mellitus, smoking, hypercholesterolemia and physical dependence prior to stroke. Ineligible patients were not approached; however, reasons for exclusion were recorded. Patient conditions were then discussed with the nursing staff covering the individual patient bays. The patient was approached and the study was explained using the participant information sheet as a guide. The same researcher gained informed consent from each participant and carried out all of the FSS assessments. Participants who had visual disturbances or were unable to handle a pen were read the statements and asked to respond using the Likert scale of one to seven. The study gained ethical approval from the London-Surrey Borders Research Ethics Committee and King’s College Hospital Research and Development Department. Statistics Analyses were completed with the t-test and analysis of covariance (ANCOVA) using the raw scores from the questionnaire as it had the highest power with the small sample size. A t-test for independent samples was conducted to test for differences between the two groups followed by an ANCOVA with gender and group as between group factors and age as a covariate.
Results Participant characteristics Seventy-one patients admitted to the stroke unit with a diagnosis of stroke were screened. Of the 71 patients screened, 57 were excluded, one patient refused consent to participate due to reporting ‘excessive tiredness’, and 13 participants were included in analyses. Figure 1 presents the study profile for participant inclusion. Table 1 presents a summary of the reasons for exclusion. 153
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Table 2. Summary of participant characteristics
Figure 1 CONSORT flow diagram for participant inclusion
Table 1. Summary of reasons for exclusion Reasons for Exclusion Age Hemorrhage Comorbidities Aphasia Total
Total
Percentage
29 13 8 7 57
50.9 22.8 14.0 12.3 100
Participant age (Average years ± SD) Average Days Post-admission following Stroke for FSS Completion % Fatigued Average FSS score % Male % Hypertensive % Diabetic % Smokers % Independently mobile pre-stroke % Hypercholesterolemic
Data analyses Statistical analyses were completed using SPSS Version 15.0 (IBM, Chicago, Illinois, USA). A KolmogorovSmirnov test for normality was performed showing a normal distribution; therefore, a parametric independent t-test was used. For all statistical analyses, a significance level of p < 0.05 was used. Results were non-significant (p = 0.056) but showed a trend towards LVD participants reporting higher fatigue scores than SVD participants. Figure 2 presents a scatterplot of FSS score against age with gender indicated. Equal variances were not assumed as the standard deviation of mean fatigue scores for SVD participants was nearly three times that for LVD participants 154
Large-vessel disease (n = 4)
68.2 ± 6.8 7.7
74.8 ± 3.4 8.5
77.8 4.7 22.2 66.7 44.4 44.4 100.0 44.4
100.0 6.0 25.0 75.0 25.0 25.0 100.0 75.0
Table 3. Group statistics Group
The study demonstrated that fatigue is a common post-stroke symptom with all of the LVD participants and over three-quarters of the SVD participants (77.8%) achieving scores indicating fatigue. The average FSS scores for each group were over four indicating fatigue. Table 2 presents a summary of participant characteristics. Further analyses of the participants’ responses to the FSS show that the SVD participants scored statement nine highest with an average score of 5.7. Statement nine reads: Fatigue interferes with my work, family or social life. LVD participants scored statement eight highest with an average score of 6.8. Statement eight reads: Fatigue is amongst my three most disabling symptoms.
Small-vessel disease (n = 9)
Small-vessel disease Large-vessel disease
Participants
Mean total FSS score
Standard deviation
9 4
42.2 54.3
15.0 5.1
(Table 3). Further analyses were completed assuming normality to determine whether participant age and gender affected the fatigue scores. A Pearson’s correlation of 0.621 was found for variables FSS score and age demonstrating a significant effect (p = 0.023) of age on FSS score. A pearson’s χ2 test found no significant association between gender and group (p = 0.913). A two-sample t-test, assuming unequal variances, found no significant FSS mean score differences across gender groups (p = 0.560). Lastly, a two-sample t-test, assuming unequal variances, found that while females were older than males (71.1 vs. 67.3 years), the difference was not significant (p = 0.436). The three tests involving gender justify not considering gender as a covariate in subsequent analyses as it does not have a confounding effect on FSS scores. An ANCOVA was performed to identify potential confounding effects of the covariate age. In order to control for age, an adjustment was made to use the average participant age of 70.2 years. A trend towards LVD participants reporting higher fatigue scores than SVD participants remains (p = 0.074).
Discussion Analysis of the data shows a trend towards participants with LVD experiencing a greater level of fatigue than Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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Figure 2 Scatterplot of FSS score against age with gender indicated
participants with SVD. This trend is consistent with the experimental hypothesis but a definitive difference remains to be proven. Based on the results, a larger sample using the same methodology developed in this pilot study could be used to further test the experimental hypothesis. A sample size calculation indicates that 48 participants would be required for a definitive study using the same methodology to achieve statistical significance at an 80% power level and a 0.05 p-value. Eighty-five per cent of participants were fatigued from both ischemic stroke groups. This result is larger than fatigue levels reported in the five existing studies using FSS. Schepers et al. (2006) assessed fatigue levels at an average of six weeks after admission, which was the earliest of the five studies. While the percentage of participant reported fatigue in their study is less (52%), the results agree with the present study in regards to effect of age on fatigue as it was shown to have a greater impact in older participants. Morley et al. (2005) completed a pilot study of 20 participants of similar median age (78 vs. 72 years) in a similar British hospital rehabilitation setting to the present study with 40% of participants reporting fatigue; however, the authors used an average score of five on the FSS to indicate fatigue. By implementing the same cutoff, 62% of participants in the present study reported fatigue. Choi-Kwon et al. (2005) completed the study with the highest percentage Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
of ischemic stroke participants (91%). The authors briefly report that 77% of participants were fatigued within the first week post-stroke, which is comparable to the result of the present study (77% vs. 85%) at a similar time frame post-stroke. However, there are various problems with this report as the study stated exclusion of patients seen less than three months poststroke in addition to reporting a mean FSS score of 2.9 that does not indicate fatigue. Analyses of the participants’ responses to the FSS show that the SVD participants scored statement nine highest and LVD participants scored statement eight highest. The SVD result agrees with Ingles et al. (1999) as the participants with the less severe physical and cognitive disability post-stroke reported a greater impact of fatigue on issues relating to returning to everyday life. While statement nine does not seem appropriate for inpatients, the very fact that SVD participants scored it the highest demonstrates the particular nature of fatigue on these patients’ lives. The LVD result demonstrates the overall impact of fatigue for LVD participants reflecting the trend in the present study. In the present study, the percentage of SVD participants was higher than the literature, which is likely due to the faster turnover of patients in the stroke unit with better functional status and better prognosis. 155
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The present study had numerous strengths in developing and demonstrating the feasibility of the methodology; however, there were also limitations. The strengths of the present study were: 1) use of a clear definition of fatigue, 2) assessment of fatigue with the most appropriate fatigue scale for stroke patients, 3) notation of covariate information prospectively and 4) division of stroke subtypes using standardized classification. The use of the subjective definition of fatigue as defined by Staub (2007) was clearly stated in the methods of the present study. As a result of clearly defining the aspect of fatigue under investigation, the present study concludes that the results show a trend towards LVD participants experiencing a greater feeling of early exhaustion, weariness and aversion to effort as compared to SVD participants. The FSS is the most commonly used fatigue scale in existing PSF studies with proven validity and reliability for use with neurological patients and as such was the most appropriate choice of fatigue scale. Covariate participant information including age and gender was reported prospectively in the present study. This is a strength as existing studies report such information retrospectively. Lastly, the present study is the first to investigate experience of fatigue between two ischemic stroke subtypes using the TOAST classification. The major limitation of studies investigating stroke subtypes involves a lack of standardized classification use (Adams et al., 1993; van Port et al., 2007). The limitations of the present study were: 1) small sample size, 2) lack of a longitudinal view of the behaviour of fatigue over time, 3) various potential confounders to fatigue and 4) sources of possible bias. An obvious limitation of the present study is the small sample size in each group with the potential for Type II error as a result of being pilot research. A study over a longer period with more resources would permit recruitment of a larger sample. A limitation of the present study was the lack of investigation of the behaviour of fatigue over time. A longitudinal view of fatigue by multiple fatigue assessments throughout the duration of rehabilitation would enable investigation of the behaviour of fatigue. Additionally, the time of day at which the FSS was completed was not the same for each participant that may have led to participants being influenced by recent activity, even though the scale instructs participants to consider fatigue experience over the previous week. A longitudinal 156
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view of fatigue would enable investigation of fatigue experience throughout the day. Of the five existing studies using the FSS, results from Schepers et al. (2006) showed that fatigue had a significant effect of time poststroke (p < 0.05). Another limitation of the present study was the various potential confounders to fatigue and FSS scores. Firstly, there was the potential confounding effect of post-stroke depression (PSD) on fatigue scores. In a summary of the literature on fatigue after stroke, Staub and Bogousslavsky (2001) highlight the prevalence of PSD ranging from less than 25% to more than 75%. PSD has been extensively studied and is closely related to post-stroke fatigue as it is a criterion for depression. Of the five studies that used the FSS to investigate fatigue, only one (Schepers et al., 2006) assessed PSD and found that 29.3% of participants reporting PSF were also depressed. While the present study excluded patients with a previous diagnosis of depression, PSD is acknowledged as a separate medical issue that warrants assessment alongside PSF in future studies. Secondly, patient institutionalization was a potential confounder to fatigue during hospital admission as patients adopt a completely new routine to daily life. Future studies would benefit from investigation of fatigue levels between different patient settings including the community. Thirdly, while an inclusion criterion for the present study was involvement in rehabilitation, the study did not investigate the amount of rehabilitation received that may have been a confounder to fatigue levels. However, Winward et al. (2009) showed that fatigue is of a cortical origin instead of a result of increased physical effort in post-stroke rehabilitation. Recording the amount of rehabilitation received would enable future studies to further investigate this possible confounder to fatigue. Fourthly, participant medication post-stroke was recorded and acknowledged as a potential confounder to FSS scores; however, the effect of medication was not analyzed. The present study had various sources of possible bias. The possibility of researcher bias was reduced by involvement of the same researcher throughout and by use of a simple and commonly used outcome measure that was reported by participants themselves. Participants were largely unaware of the type of ischemic stroke suffered simply understanding that they had suffered a stroke. Future studies would benefit from blinding the researcher from group allocation to avoid Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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possible bias. While family members were not involved in completion of the FSS, their presence may have biased the participant’s response. Self-report scales require recall over a long duration and are therefore subject to recall bias. This source of bias is unavoidable due to the topic under investigation; however, the FSS requires only a short period of recall of experience of fatigue over the previous week.
Implications The present study was the first to investigate experience of fatigue in two groups of ischemic stroke inpatients allocated using standardized classification. The study highlighted that fatigue is common amongst ischemic stroke rehabilitation participants with 85% of the combined sample experiencing fatigue at the start of the second week. The FSS was used to assess fatigue level as it was the most appropriate scale for use with stroke patients. The methodology applied in the present pilot study enabled a detailed approach to the issue of fatigue after stroke. The results demonstrated the magnitude of difference in fatigue between two groups of stroke patients with a trend towards LVD participants experiencing greater fatigue. While the results were nonsignificant, the study demonstrated a feasible methodology which could help lay the groundwork for future research with a larger sample size to achieve statistically significant results. The effect of fatigue on rehabilitation warrants further investigation to devise fatigue management strategies. The recent Healthcare for London Stroke Rehabilitation Guide outlines a performance standard that rehabilitation inpatients receive ‘five 45-minute face-to-face sessions per week each of occupational therapy, speech and language therapy and physiotherapy as necessary’ (2009, p. 23). This standard places a high demand on MDT timetabling for the treatment of numerous stroke patients especially when 85% report fatigue. An awareness of the possible differences in the experience of fatigue between stroke subtypes could aid MDT treatment planning and timescales to best work with patient fatigue. Future studies into fatigue management would be beneficial for the MDT to enable patients to work with their fatigue and make it a surmountable barrier to rehabilitation. REFERENCES Adams H, Bendixen B, Kappelle L, Biller J, Love B, Gordon D, Marsh E. Classification of subtype of acute ischemic Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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stroke: definitions for use in a multicenter clinical trial. Stroke 1993; 24: 35–41. Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? Journal of Stroke and Cerebrovascular Diseases 2004; 13 (4): 171–177. Bagg S, Paris Pombo A, Hopman W. Effect of age on functional outcomes after stroke rehabilitation. Stroke 2002; 33: 179–185. Bhalla A, Grieve R, Tilling K, Rudd A, Wolfe C. Older stroke patients in Europe: stroke care and determinants of outcome. Age and Ageing 2004; 33: 618–624. Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: analysis of 1000 consecutive patients with first stroke. Stroke 1988; 19: 1083–1092. Boiten J, Lodder J. Lacunar infarcts: pathogenesis and validity of the clinical syndromes. Stroke 1991; 22: 1374–1378. Choi-Kwon S, Han S, Kwon S, Kim J. Post-stroke fatigue: characteristics and related factors. Cerebrovascular Diseases 2005; 19: 84–90. Comi G, Leocani L, Rossi P, Colombo B. Physiopathology and treatment of fatigue in multiple sclerosis. Journal of Neurology 2001; 248: 174–179. Department of Health. Reducing Brain Damage: Faster Access to Better Stroke Care. London: National Audit Office, 2005. Dittner A, Wessely S, Brown R. The assessment of fatigue: a practical guide for clinicians and researchers. Journal of Psychosomatic Research 2004; 56: 157–170. Glader E, Stegmayr B, Asplund K. Poststroke fatigue: a 2-year follow-up study of stroke patients in Sweden. Stroke 2002; 33: 1327–1333. Hagemann G, Redecker C, Neumann-Haefelin T, Freund H, Witte O. Increased long-term potentiation in the surround of experimentally induced focal cortical infarction. Annals of Neurology 1998; 44: 255–258. Healthcare for London. Stroke Rehabilitation Guide: Supporting London Commissioners to Commission Quality Services in 2010/11. London: HFL, 2009. Ingles J, Eskes G, Phillips S. Fatigue after stroke. Archives of Physical Medicine and Rehabilitation 1999; 80 (February): 173–178. Jones T, Shallert T. Overgrowth and pruning of dendrites in adult rats recovering from neocortical damage. Brain Research 1992; 581: 156–160. Krupp L, LaRocca N, Muir-Nash J, Steinberg A. The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology 1989; 46: 1121–1123. LaChapelle D, Finlayson M. An evaluation of subjective and objective measures of fatigue in patients with brain injury and healthy controls. Brain Injury 1998; 12: 649–659. 157
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Lindley R. Stroke: The Facts. Oxford: Oxford University Press, 2008. Lodder J, Boiten J. Incidence, natural history, and risk factors in Lacunar Infarction. In: Pullicino P, Caplan L, Hommel M (eds), Advances in Neurology: Volume 62: Cerebral Small Artery Disease. New York: Raven Press, 1993; 213–229. Mathiowetz V, Matuska K, Murphy E. Efficacy of an energy conservation course for persons with multiple sclerosis. Archives of Physical Medicine and Rehabilitation 2001; 82: 449–456. Maulden S, Gassaway J, Horn S, Smout R, DeJong G. Timing of initiation of rehabilitation after stroke. Archives of Physical Medicine and Rehabilitation 2005; 86 (2): S34–S40. Meier-Ruge W. Vascular Disease in Old Age. Basel: Karger, 1990. Mohr J, Caplan L, Melski J, Goldstein R, Duncan G, Kistler J, Pessin M, Bleich H. The Harvard cooperative stroke registry: a prospective registry. Neurology 1978; 28: 754–762. Morley W, Jackson K, Mead GE. Post-stroke Fatigue: an important yet neglected symptom. Age and Ageing 2005; 34 (3): 313. Murray C, Lopez A. Alternative projections of mortality and disability by cause 1990–2020: Global burden of disease study. Lancet 1997; 349: 1498–1504. Ng Y, Stein J, Ning M, Black-Schaffer R. Comparison of clinical characteristics and functional outcomes of ischemic stroke in different vascular territories. Stroke 2007; 38: 2309–2314. O’Kelly D. A patient’s perspective. In: Barnes M, Dobkin B, Bogousslavsky J (eds), Recovery after Stroke. Cambridge: Cambridge University Press, 2005; 637–646. Petty G, Brown R, Whisnant J, Sicks J, O’Fallon W, Wiebers D. Ischemic stroke subtypes: a population based study of functional outcome, survival, and recurrence. Stroke 2000; 31: 1062–1068.
158
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Sacco R, Ellenberg J, Mohr J, Tatemichi T, Hier D, Price T, Wolf P. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Annals of Neurology 1989; 25: 382–390. Schepers V, Visser-Meily A, Ketelaar M, Lindeman E. Poststroke fatigue: course and its relation to personal and stroke-related factors. Archives of Physical Medicine and Rehabilitation 2006; 87: 184–188. Staub F. Fatigue. In: Godefroy O, Bogousslavsky J (eds), The Behavioural and Cognitive Neurology of Stroke. Cambridge: Cambridge University Press, 2007; 571–586. Staub F, Bogousslavsky J. Fatigue after stroke: a major but neglected issue. Cerebrovascular Disease 2001; 12: 75–81. Stulemeijer M, Fasotti L, Bleijenberg G. Fatigue after stroke. In: DeLuca, J (ed.), Fatigue as a Window to the Brain. Cambridge: MIT Press, 2005; 73–87. Taylor R, Jason L, Torres A. Fatigue rating scales: an empirical comparison. Psychological Medicine 2000; 30: 849–856. Tyrrell P, Smithard D. Fatigue after stroke. Therapy 2005; 2 (6): 865–869. van Port I, Kwakkel G, Schepers V, Heinemmans C, Lindeman E. Is Fatigue an Independent Factor Associated with Activities of Daily Living, Instrumental Activities of Daily Living, and Health-related Quality of Life in Chronic Stroke? Cerebrovascular Diseases 2007; 23 (1): 40–45. Van de Werf S, Van de Broek H, Anten H. Experience of severe fatigue long after stroke and its relationship to depressive symptons and disease characteristics. European Neurology 2001; 45: 28–33. Wentworth D, Atkinson R. Implementation of an acute stroke program decreases hospitalisation costs and length of stay. Stroke 1996; 27: 1040–1043. Winward C, Sackley C, Metha Z. A population-based study of the prevalence of fatigue after transient ischemic attack and minor stroke. Stroke 2009; 40: 757–761.
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Fatigue in Stroke Rehabilitation Patients: A Pilot Study† Thomas John Chestnut* Institute of Psychiatry, King‘s College London
Abstract Background and Purpose. Stroke is the leading cause of adult disability. Rehabilitation is a vital component of post-stroke care with two-thirds of survivors requiring rehabilitation. Fatigue is a common issue affecting stroke patients and is a barrier to rehabilitation causing inefficient care provision and potential limitation to patient recovery. No study to date has investigated whether the experience of fatigue is different between the two main causes of ischemic stroke: small-vessel (SVD) and large-vessel disease (LVD). The aim of the present study is to complete a pilot study to inform the feasibility, design, magnitude of difference in experience of fatigue, and sample size for a definitive study to evaluate differences in fatigue between these two groups of stroke patients. The experimental hypothesis is that participants with LVD experience a significantly greater level of fatigue than those with SVD as assessed by the Fatigue Severity Scale (FSS). Methods. The study used a cohort observational design. Thirteen participants were recruited over a two-month period from King’s College Hospital. Participants were visited on average at the start of the second week of rehabilitation to complete the FSS. An independent t-test and ANCOVA were performed. For all statistical analyses, a significance level of p < 0.05 was used. Results. The study demonstrated a trend towards LVD participants reporting higher fatigue scores than SVD participants, even when controlling for age, with gender having no confounding effect. Conclusions. Fatigue is common amongst ischemic stroke rehabilitation participants with 85% of the combined sample experiencing fatigue at the start of the second week. The results demonstrate a trend towards LVD participants experiencing greater fatigue. While the results were non-significant, the study demonstrates a feasible methodology which could help lay the groundwork for future research. Copyright © 2010 John Wiley & Sons, Ltd. Received 28 January 2010; Revised 24 March 2010; Accepted 1 April 2010 Keywords fatigue; fatigue severity scale; rehabilitation; stroke *Correspondence Thomas John Chestnut, MSc, BSc, School of Physiotherapy, Faculty of Health and Social Care Science, St. George’s University of London and Kingston University, 2nd Floor Grosvenor Wing, Cranmer Terrace, London SW17 0RE. Email: [email protected] Published online 18 May 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.476
Introduction Stroke is the leading cause of adult disability with the greatest range and impact of disability in comparison †
This article was published online on May 18, 2010. Errors were
subsequently identified on Figure 2. This notice is included in the online and print versions to indicate that both have been corrected on June 4, 2010
Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
to other chronic diseases (Adamson et al., 2004). Rehabilitation is a vital component of post-stroke care with two-thirds of stroke survivors requiring rehabilitation (Tyrrell and Smithard, 2005). Stroke patients occupy roughly 25% of long-term beds and receive a programme of rehabilitation aimed at enablement following functional loss (Department of Health, 2005). There is an increased incidence of stroke as a result of the ageing British population in addition to 151
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an increased prevalence of stroke survivors with disability placing an increased demand on stroke rehabilitation (Bagg et al., 2002; Bhalla et al., 2004). Due to a changing economic climate within the National Health Service (NHS), there is a growing need on the part of the multidisciplinary team (MDT) to deliver the most efficient care possible (Wentworth and Atkinson, 1996; Murray and Lopez, 1997; Bagg et al., 2002; Maulden et al., 2005). With the growing strain on stroke rehabilitation, the identification and investigation of barriers to an efficient rehabilitation service is of major importance. Fatigue is a common issue affecting patients following stroke though limited information is known on its effect on inpatient rehabilitation (Ingles et al., 1999; Van de Werf et al., 2001; Glader et al., 2002). Recovery post-stroke depends largely on the type of stroke suffered. Over two-thirds of strokes are of the ischemic type. Ischemic strokes are subdivided according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification into large-vessel (LVD), smallvessel (SVD), and cardioembolic disease. The TOAST classification provides an unambiguous, practical and easily applicable system of subdividing ischemic strokes (Adams et al., 1993). The two most common causes of ischemic stroke are SVD and LVD (Bogousslavsky et al., 1988; Mohr et al., 1978; Sacco et al., 1989). SVD presenting as small-artery occlusion causes lacunar infarcts that results in specific clinical syndromes (Boiten and Lodder, 1991). LVD presenting as large-artery atherosclerosis results in a wider area of cerebral cortical impairment (Adams et al., 1993). Patients with SVD infarcts have better functional status and prognosis post-stroke compared with LVD patients (Adams et al., 1993; Petty et al., 2000; Ng et al., 2007). Lacunar infarcts account for roughly 25% (Lodder and Boiten, 1993) and large-artery atherosclerosis account for roughly 50% of all ischemic strokes (Ng et al., 2007; Lindley, 2008). Results from existing studies are inconclusive as to an association between fatigue and stroke subtype with further research suggested. To the author’s knowledge, no study has investigated whether the experience of fatigue is different between the two main causes of ischemic stroke. This information could potentially aid MDT treatment planning and timescales in the rehabilitation setting to improve efficiency of care. Physiologically, the second week after a stroke involves softening of the infarct, subsiding edema and 152
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vascular growth around the infarct (Meier-Ruge, 1990). Animal studies show an increased potential for cortical plasticity between days seven and eighteen post-stroke (Jones and Shallert, 1992; Hagemann et al., 1998). In addition, the second week brings a level of acceptance by the patient and a familiarity with the stroke unit (O’Kelly, 2005). Few studies investigate the acute stage at the start of the rehabilitation process during which the literature suggests patient recovery is greatest. Fatigue has an adverse effect on the physical and psychological recovery after stroke and thus the patients’ quality of life. It interferes with stroke rehabilitation thus affecting the patients’ overall recovery post-stroke (Glader et al., 2002; Morley et al., 2005). Research into fatigue after stroke show fatigue prevalence ranging from 31 to 70% at a range of between 2 and 36 months post-stroke. Investigation into fatigue is often complicated by the ambiguity and lack of clear definition of the term in addition to a lack of validated fatigue scales for stroke. It is largely believed that fatigue is a subjective experience best quantified using self-report questionnaires that focus on ‘experienced fatigue’ (Krupp et al., 1989; LaChapelle and Finlayson, 1998; Taylor et al., 2000; Comi et al., 2001; Dittner et al., 2004; Stulemeijer et al., 2005). An appropriate self-report questionnaire should measure the desired component to quantify ‘experienced fatigue’ using either unidimensional or multidimensional scales (Taylor et al., 2000). Though not validated for stroke, the Fatigue Severity Scale (FSS) is the most commonly used fatigue scale in post-stroke fatigue (PSF) papers and has strong reliability and validity data for use in chronic central neurological conditions such as multiple sclerosis (MS), Parkinson’s disease and brain injury. The FSS is a unidimensional scale that assesses intensity of disabilityrelated fatigue (Taylor et al., 2000).
Method Design The study applied a cohort observational design and was used as a pilot study to assess the feasibility of using the FSS to measure PSF in two groups of rehabilitation inpatients with different stroke subtypes as classified using TOAST. Staub’s (2007) definition of subjective fatigue was used: ‘a feeling of early exhaustion, weariness and aversion to effort’ (Staub, 2007, p. 572). Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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Subjects Participants were recruited over a two-month period from the Friends Stroke Unit, King’s College Hospital. Friends Stroke Unit is an integrated inpatient stroke unit comprising eight acute beds and twelve rehabilitation beds. King’s College Hospital is a large teaching hospital providing care to over 700,000 residents in south east London. The two experimental groups were actively participating in stroke rehabilitation delivered by the MDT with emphasis on early mobilization. The study included male and female participants between 60 and 80 years of age suffering an acute ischemic stroke confirmed by brain imaging and recorded in the medical notes by the medical team. Participants provided written informed consent. Exclusion criteria consisted of patients who presented with both SVD and LVD as confirmed by brain imaging, were unable to speak English or who had reduced cognitive functioning, were aphasic, had a disabling co-morbidity prior to stroke, and had a previous history of diagnosed depression documented in the medical notes. Reduced cognitive functioning and disabling co-morbidity prior to stroke were assessed by a score of less than or equal to 23 on the Mini-mental State Examination and a score of less than 18 on the Barthel Index, respectively. Materials At the start of the second week after admission following stroke, the researcher completed a single faceto-face visit with the participant lasting an average of 10 minutes. The FSS was originally devised to determine the experience of fatigue by patients with MS (Krupp et al., 1989). It contains nine statements assessing the impact of fatigue over the past week on a Likert scale from one to seven (one indicating strong disagreement and seven indicating strong agreement). The FSS score is calculated as the mean of the total from the nine statements (Krupp et al., 1989). Participants with average scores of four or more are considered fatigued with higher scores indicating greater fatigue (Krupp et al., 1989; LaChapelle and Finlayson, 1998; Mathiowetz et al., 2001). In studies of patients with MS, the FSS had high internal consistency measured by a Cronbach’s alpha level of 0.89 (Schepers et al., 2006), good test–retest reliability, good concurrent validity and distinguished patients with different diagnoses (Krupp et al., 1989; Dittner et al., 2004). Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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User views of the FSS and participant information sheet were sought prior to use with recruited participants. Procedure The researcher visited the stroke unit twice weekly between June and August 2009 during which all of the ward medical notes were reviewed to identify potential participants. Triggers to fatigue were noted and recorded including medication and pre-existing comorbidities such as hypertension, diabetes mellitus, smoking, hypercholesterolemia and physical dependence prior to stroke. Ineligible patients were not approached; however, reasons for exclusion were recorded. Patient conditions were then discussed with the nursing staff covering the individual patient bays. The patient was approached and the study was explained using the participant information sheet as a guide. The same researcher gained informed consent from each participant and carried out all of the FSS assessments. Participants who had visual disturbances or were unable to handle a pen were read the statements and asked to respond using the Likert scale of one to seven. The study gained ethical approval from the London-Surrey Borders Research Ethics Committee and King’s College Hospital Research and Development Department. Statistics Analyses were completed with the t-test and analysis of covariance (ANCOVA) using the raw scores from the questionnaire as it had the highest power with the small sample size. A t-test for independent samples was conducted to test for differences between the two groups followed by an ANCOVA with gender and group as between group factors and age as a covariate.
Results Participant characteristics Seventy-one patients admitted to the stroke unit with a diagnosis of stroke were screened. Of the 71 patients screened, 57 were excluded, one patient refused consent to participate due to reporting ‘excessive tiredness’, and 13 participants were included in analyses. Figure 1 presents the study profile for participant inclusion. Table 1 presents a summary of the reasons for exclusion. 153
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Table 2. Summary of participant characteristics
Figure 1 CONSORT flow diagram for participant inclusion
Table 1. Summary of reasons for exclusion Reasons for Exclusion Age Hemorrhage Comorbidities Aphasia Total
Total
Percentage
29 13 8 7 57
50.9 22.8 14.0 12.3 100
Participant age (Average years ± SD) Average Days Post-admission following Stroke for FSS Completion % Fatigued Average FSS score % Male % Hypertensive % Diabetic % Smokers % Independently mobile pre-stroke % Hypercholesterolemic
Data analyses Statistical analyses were completed using SPSS Version 15.0 (IBM, Chicago, Illinois, USA). A KolmogorovSmirnov test for normality was performed showing a normal distribution; therefore, a parametric independent t-test was used. For all statistical analyses, a significance level of p < 0.05 was used. Results were non-significant (p = 0.056) but showed a trend towards LVD participants reporting higher fatigue scores than SVD participants. Figure 2 presents a scatterplot of FSS score against age with gender indicated. Equal variances were not assumed as the standard deviation of mean fatigue scores for SVD participants was nearly three times that for LVD participants 154
Large-vessel disease (n = 4)
68.2 ± 6.8 7.7
74.8 ± 3.4 8.5
77.8 4.7 22.2 66.7 44.4 44.4 100.0 44.4
100.0 6.0 25.0 75.0 25.0 25.0 100.0 75.0
Table 3. Group statistics Group
The study demonstrated that fatigue is a common post-stroke symptom with all of the LVD participants and over three-quarters of the SVD participants (77.8%) achieving scores indicating fatigue. The average FSS scores for each group were over four indicating fatigue. Table 2 presents a summary of participant characteristics. Further analyses of the participants’ responses to the FSS show that the SVD participants scored statement nine highest with an average score of 5.7. Statement nine reads: Fatigue interferes with my work, family or social life. LVD participants scored statement eight highest with an average score of 6.8. Statement eight reads: Fatigue is amongst my three most disabling symptoms.
Small-vessel disease (n = 9)
Small-vessel disease Large-vessel disease
Participants
Mean total FSS score
Standard deviation
9 4
42.2 54.3
15.0 5.1
(Table 3). Further analyses were completed assuming normality to determine whether participant age and gender affected the fatigue scores. A Pearson’s correlation of 0.621 was found for variables FSS score and age demonstrating a significant effect (p = 0.023) of age on FSS score. A pearson’s χ2 test found no significant association between gender and group (p = 0.913). A two-sample t-test, assuming unequal variances, found no significant FSS mean score differences across gender groups (p = 0.560). Lastly, a two-sample t-test, assuming unequal variances, found that while females were older than males (71.1 vs. 67.3 years), the difference was not significant (p = 0.436). The three tests involving gender justify not considering gender as a covariate in subsequent analyses as it does not have a confounding effect on FSS scores. An ANCOVA was performed to identify potential confounding effects of the covariate age. In order to control for age, an adjustment was made to use the average participant age of 70.2 years. A trend towards LVD participants reporting higher fatigue scores than SVD participants remains (p = 0.074).
Discussion Analysis of the data shows a trend towards participants with LVD experiencing a greater level of fatigue than Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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Figure 2 Scatterplot of FSS score against age with gender indicated
participants with SVD. This trend is consistent with the experimental hypothesis but a definitive difference remains to be proven. Based on the results, a larger sample using the same methodology developed in this pilot study could be used to further test the experimental hypothesis. A sample size calculation indicates that 48 participants would be required for a definitive study using the same methodology to achieve statistical significance at an 80% power level and a 0.05 p-value. Eighty-five per cent of participants were fatigued from both ischemic stroke groups. This result is larger than fatigue levels reported in the five existing studies using FSS. Schepers et al. (2006) assessed fatigue levels at an average of six weeks after admission, which was the earliest of the five studies. While the percentage of participant reported fatigue in their study is less (52%), the results agree with the present study in regards to effect of age on fatigue as it was shown to have a greater impact in older participants. Morley et al. (2005) completed a pilot study of 20 participants of similar median age (78 vs. 72 years) in a similar British hospital rehabilitation setting to the present study with 40% of participants reporting fatigue; however, the authors used an average score of five on the FSS to indicate fatigue. By implementing the same cutoff, 62% of participants in the present study reported fatigue. Choi-Kwon et al. (2005) completed the study with the highest percentage Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
of ischemic stroke participants (91%). The authors briefly report that 77% of participants were fatigued within the first week post-stroke, which is comparable to the result of the present study (77% vs. 85%) at a similar time frame post-stroke. However, there are various problems with this report as the study stated exclusion of patients seen less than three months poststroke in addition to reporting a mean FSS score of 2.9 that does not indicate fatigue. Analyses of the participants’ responses to the FSS show that the SVD participants scored statement nine highest and LVD participants scored statement eight highest. The SVD result agrees with Ingles et al. (1999) as the participants with the less severe physical and cognitive disability post-stroke reported a greater impact of fatigue on issues relating to returning to everyday life. While statement nine does not seem appropriate for inpatients, the very fact that SVD participants scored it the highest demonstrates the particular nature of fatigue on these patients’ lives. The LVD result demonstrates the overall impact of fatigue for LVD participants reflecting the trend in the present study. In the present study, the percentage of SVD participants was higher than the literature, which is likely due to the faster turnover of patients in the stroke unit with better functional status and better prognosis. 155
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The present study had numerous strengths in developing and demonstrating the feasibility of the methodology; however, there were also limitations. The strengths of the present study were: 1) use of a clear definition of fatigue, 2) assessment of fatigue with the most appropriate fatigue scale for stroke patients, 3) notation of covariate information prospectively and 4) division of stroke subtypes using standardized classification. The use of the subjective definition of fatigue as defined by Staub (2007) was clearly stated in the methods of the present study. As a result of clearly defining the aspect of fatigue under investigation, the present study concludes that the results show a trend towards LVD participants experiencing a greater feeling of early exhaustion, weariness and aversion to effort as compared to SVD participants. The FSS is the most commonly used fatigue scale in existing PSF studies with proven validity and reliability for use with neurological patients and as such was the most appropriate choice of fatigue scale. Covariate participant information including age and gender was reported prospectively in the present study. This is a strength as existing studies report such information retrospectively. Lastly, the present study is the first to investigate experience of fatigue between two ischemic stroke subtypes using the TOAST classification. The major limitation of studies investigating stroke subtypes involves a lack of standardized classification use (Adams et al., 1993; van Port et al., 2007). The limitations of the present study were: 1) small sample size, 2) lack of a longitudinal view of the behaviour of fatigue over time, 3) various potential confounders to fatigue and 4) sources of possible bias. An obvious limitation of the present study is the small sample size in each group with the potential for Type II error as a result of being pilot research. A study over a longer period with more resources would permit recruitment of a larger sample. A limitation of the present study was the lack of investigation of the behaviour of fatigue over time. A longitudinal view of fatigue by multiple fatigue assessments throughout the duration of rehabilitation would enable investigation of the behaviour of fatigue. Additionally, the time of day at which the FSS was completed was not the same for each participant that may have led to participants being influenced by recent activity, even though the scale instructs participants to consider fatigue experience over the previous week. A longitudinal 156
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view of fatigue would enable investigation of fatigue experience throughout the day. Of the five existing studies using the FSS, results from Schepers et al. (2006) showed that fatigue had a significant effect of time poststroke (p < 0.05). Another limitation of the present study was the various potential confounders to fatigue and FSS scores. Firstly, there was the potential confounding effect of post-stroke depression (PSD) on fatigue scores. In a summary of the literature on fatigue after stroke, Staub and Bogousslavsky (2001) highlight the prevalence of PSD ranging from less than 25% to more than 75%. PSD has been extensively studied and is closely related to post-stroke fatigue as it is a criterion for depression. Of the five studies that used the FSS to investigate fatigue, only one (Schepers et al., 2006) assessed PSD and found that 29.3% of participants reporting PSF were also depressed. While the present study excluded patients with a previous diagnosis of depression, PSD is acknowledged as a separate medical issue that warrants assessment alongside PSF in future studies. Secondly, patient institutionalization was a potential confounder to fatigue during hospital admission as patients adopt a completely new routine to daily life. Future studies would benefit from investigation of fatigue levels between different patient settings including the community. Thirdly, while an inclusion criterion for the present study was involvement in rehabilitation, the study did not investigate the amount of rehabilitation received that may have been a confounder to fatigue levels. However, Winward et al. (2009) showed that fatigue is of a cortical origin instead of a result of increased physical effort in post-stroke rehabilitation. Recording the amount of rehabilitation received would enable future studies to further investigate this possible confounder to fatigue. Fourthly, participant medication post-stroke was recorded and acknowledged as a potential confounder to FSS scores; however, the effect of medication was not analyzed. The present study had various sources of possible bias. The possibility of researcher bias was reduced by involvement of the same researcher throughout and by use of a simple and commonly used outcome measure that was reported by participants themselves. Participants were largely unaware of the type of ischemic stroke suffered simply understanding that they had suffered a stroke. Future studies would benefit from blinding the researcher from group allocation to avoid Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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possible bias. While family members were not involved in completion of the FSS, their presence may have biased the participant’s response. Self-report scales require recall over a long duration and are therefore subject to recall bias. This source of bias is unavoidable due to the topic under investigation; however, the FSS requires only a short period of recall of experience of fatigue over the previous week.
Implications The present study was the first to investigate experience of fatigue in two groups of ischemic stroke inpatients allocated using standardized classification. The study highlighted that fatigue is common amongst ischemic stroke rehabilitation participants with 85% of the combined sample experiencing fatigue at the start of the second week. The FSS was used to assess fatigue level as it was the most appropriate scale for use with stroke patients. The methodology applied in the present pilot study enabled a detailed approach to the issue of fatigue after stroke. The results demonstrated the magnitude of difference in fatigue between two groups of stroke patients with a trend towards LVD participants experiencing greater fatigue. While the results were nonsignificant, the study demonstrated a feasible methodology which could help lay the groundwork for future research with a larger sample size to achieve statistically significant results. The effect of fatigue on rehabilitation warrants further investigation to devise fatigue management strategies. The recent Healthcare for London Stroke Rehabilitation Guide outlines a performance standard that rehabilitation inpatients receive ‘five 45-minute face-to-face sessions per week each of occupational therapy, speech and language therapy and physiotherapy as necessary’ (2009, p. 23). This standard places a high demand on MDT timetabling for the treatment of numerous stroke patients especially when 85% report fatigue. An awareness of the possible differences in the experience of fatigue between stroke subtypes could aid MDT treatment planning and timescales to best work with patient fatigue. Future studies into fatigue management would be beneficial for the MDT to enable patients to work with their fatigue and make it a surmountable barrier to rehabilitation. REFERENCES Adams H, Bendixen B, Kappelle L, Biller J, Love B, Gordon D, Marsh E. Classification of subtype of acute ischemic Physiother. Res. Int. 16 (2011) 151–158 © 2010 John Wiley & Sons, Ltd.
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stroke: definitions for use in a multicenter clinical trial. Stroke 1993; 24: 35–41. Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? Journal of Stroke and Cerebrovascular Diseases 2004; 13 (4): 171–177. Bagg S, Paris Pombo A, Hopman W. Effect of age on functional outcomes after stroke rehabilitation. Stroke 2002; 33: 179–185. Bhalla A, Grieve R, Tilling K, Rudd A, Wolfe C. Older stroke patients in Europe: stroke care and determinants of outcome. Age and Ageing 2004; 33: 618–624. Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: analysis of 1000 consecutive patients with first stroke. Stroke 1988; 19: 1083–1092. Boiten J, Lodder J. Lacunar infarcts: pathogenesis and validity of the clinical syndromes. Stroke 1991; 22: 1374–1378. Choi-Kwon S, Han S, Kwon S, Kim J. Post-stroke fatigue: characteristics and related factors. Cerebrovascular Diseases 2005; 19: 84–90. Comi G, Leocani L, Rossi P, Colombo B. Physiopathology and treatment of fatigue in multiple sclerosis. Journal of Neurology 2001; 248: 174–179. Department of Health. Reducing Brain Damage: Faster Access to Better Stroke Care. London: National Audit Office, 2005. Dittner A, Wessely S, Brown R. The assessment of fatigue: a practical guide for clinicians and researchers. Journal of Psychosomatic Research 2004; 56: 157–170. Glader E, Stegmayr B, Asplund K. Poststroke fatigue: a 2-year follow-up study of stroke patients in Sweden. Stroke 2002; 33: 1327–1333. Hagemann G, Redecker C, Neumann-Haefelin T, Freund H, Witte O. Increased long-term potentiation in the surround of experimentally induced focal cortical infarction. Annals of Neurology 1998; 44: 255–258. Healthcare for London. Stroke Rehabilitation Guide: Supporting London Commissioners to Commission Quality Services in 2010/11. London: HFL, 2009. Ingles J, Eskes G, Phillips S. Fatigue after stroke. Archives of Physical Medicine and Rehabilitation 1999; 80 (February): 173–178. Jones T, Shallert T. Overgrowth and pruning of dendrites in adult rats recovering from neocortical damage. Brain Research 1992; 581: 156–160. Krupp L, LaRocca N, Muir-Nash J, Steinberg A. The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology 1989; 46: 1121–1123. LaChapelle D, Finlayson M. An evaluation of subjective and objective measures of fatigue in patients with brain injury and healthy controls. Brain Injury 1998; 12: 649–659. 157
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Lindley R. Stroke: The Facts. Oxford: Oxford University Press, 2008. Lodder J, Boiten J. Incidence, natural history, and risk factors in Lacunar Infarction. In: Pullicino P, Caplan L, Hommel M (eds), Advances in Neurology: Volume 62: Cerebral Small Artery Disease. New York: Raven Press, 1993; 213–229. Mathiowetz V, Matuska K, Murphy E. Efficacy of an energy conservation course for persons with multiple sclerosis. Archives of Physical Medicine and Rehabilitation 2001; 82: 449–456. Maulden S, Gassaway J, Horn S, Smout R, DeJong G. Timing of initiation of rehabilitation after stroke. Archives of Physical Medicine and Rehabilitation 2005; 86 (2): S34–S40. Meier-Ruge W. Vascular Disease in Old Age. Basel: Karger, 1990. Mohr J, Caplan L, Melski J, Goldstein R, Duncan G, Kistler J, Pessin M, Bleich H. The Harvard cooperative stroke registry: a prospective registry. Neurology 1978; 28: 754–762. Morley W, Jackson K, Mead GE. Post-stroke Fatigue: an important yet neglected symptom. Age and Ageing 2005; 34 (3): 313. Murray C, Lopez A. Alternative projections of mortality and disability by cause 1990–2020: Global burden of disease study. Lancet 1997; 349: 1498–1504. Ng Y, Stein J, Ning M, Black-Schaffer R. Comparison of clinical characteristics and functional outcomes of ischemic stroke in different vascular territories. Stroke 2007; 38: 2309–2314. O’Kelly D. A patient’s perspective. In: Barnes M, Dobkin B, Bogousslavsky J (eds), Recovery after Stroke. Cambridge: Cambridge University Press, 2005; 637–646. Petty G, Brown R, Whisnant J, Sicks J, O’Fallon W, Wiebers D. Ischemic stroke subtypes: a population based study of functional outcome, survival, and recurrence. Stroke 2000; 31: 1062–1068.
158
T. J. Chestnut
Sacco R, Ellenberg J, Mohr J, Tatemichi T, Hier D, Price T, Wolf P. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Annals of Neurology 1989; 25: 382–390. Schepers V, Visser-Meily A, Ketelaar M, Lindeman E. Poststroke fatigue: course and its relation to personal and stroke-related factors. Archives of Physical Medicine and Rehabilitation 2006; 87: 184–188. Staub F. Fatigue. In: Godefroy O, Bogousslavsky J (eds), The Behavioural and Cognitive Neurology of Stroke. Cambridge: Cambridge University Press, 2007; 571–586. Staub F, Bogousslavsky J. Fatigue after stroke: a major but neglected issue. Cerebrovascular Disease 2001; 12: 75–81. Stulemeijer M, Fasotti L, Bleijenberg G. Fatigue after stroke. In: DeLuca, J (ed.), Fatigue as a Window to the Brain. Cambridge: MIT Press, 2005; 73–87. Taylor R, Jason L, Torres A. Fatigue rating scales: an empirical comparison. Psychological Medicine 2000; 30: 849–856. Tyrrell P, Smithard D. Fatigue after stroke. Therapy 2005; 2 (6): 865–869. van Port I, Kwakkel G, Schepers V, Heinemmans C, Lindeman E. Is Fatigue an Independent Factor Associated with Activities of Daily Living, Instrumental Activities of Daily Living, and Health-related Quality of Life in Chronic Stroke? Cerebrovascular Diseases 2007; 23 (1): 40–45. Van de Werf S, Van de Broek H, Anten H. Experience of severe fatigue long after stroke and its relationship to depressive symptons and disease characteristics. European Neurology 2001; 45: 28–33. Wentworth D, Atkinson R. Implementation of an acute stroke program decreases hospitalisation costs and length of stay. Stroke 1996; 27: 1040–1043. Winward C, Sackley C, Metha Z. A population-based study of the prevalence of fatigue after transient ischemic attack and minor stroke. Stroke 2009; 40: 757–761.
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