ReviewFrequency and natural history of fatigue after stroke: A systematic review of longitudinal studies☆
Introduction
Fatigue can be defined as a chronic subjective “feeling of lack of energy, weariness and aversion to effort” [1]. After stroke, fatigue is common and distressing to patients, for example, a recent study reported that 43% of stroke survivors felt they were not receiving enough help for fatigue [2]. Fatigue is an independent predictor of institutionalisation [3], [4] and, for stroke survivors under the age of 60 years, an independent predictor of being unable to return to paid work [5].
It is crucial to understand the natural history of fatigue after stroke. Stroke survivors need to know whether their fatigue is likely to improve over time, stay the same or progressively get worse so they can plan their future e.g. returning to work or resumption of previous leisure activities. Health care professionals need to know how many stroke survivors are likely to be fatigued at different time points so services can be planned accordingly. Researchers need to know whether fatigue starts immediately after stroke and how long it lasts, in order to decide how soon after stroke an intervention for fatigue should be delivered (if one could be developed).
Longitudinal studies have major advantages over cross sectional studies when studying the natural history of a condition or symptom because they report changes within individuals as well as the proportion of patients at a particular time point who have a symptom. Therefore longitudinal studies of post-stroke fatigue could tell us if fatigue is a stable symptom or whether it fluctuates over time. Longitudinal studies can also provide information about whether fatigue affects all patients for a short period of time or a small number of patients over an extended period; cross-sectional studies are unable to provide this information [6].
Several cross-sectional papers have demonstrated an association between fatigue and depression after stroke. [7], [8], [9], [10] leading to the suggestion that fatigue is a symptom of post-stroke depression [11], [12]. However, identifying an association between these two symptoms at a particular time point does not necessarily mean that one symptom causes the other, or vice versa; it is equally plausible that a third factor might cause both symptoms [13]. Longitudinal studies can potentially provide evidence regarding the direction of any observed association between fatigue and mood disorders i.e. whether depression precedes fatigue or vice versa [14]. Understanding the direction of causality is important because if depression precedes fatigue then identifying and treating depression might prevent or reduce the risk of developing post-stroke fatigue.
There are several published non systematic narrative reviews of fatigue after stroke [1], [15], [16], [17], [18], [19]. Systematic reviews are scientifically more robust and are consequently considered to be more objective sources of information and less prone to bias and error than traditional narrative reviews [20], [21]. The single previous systematic review used narrow search terms and so may have missed studies. Furthermore, the searches were performed in 2009, and we know of other studies on post-stroke fatigue that have been published since then [22].
The aim of this systematic review was to identify all longitudinal observational studies of fatigue after stroke to determine the frequency of fatigue, its natural history and the temporal relationship between fatigue and mood disorders.
Section snippets
Searches
Searches were conducted in MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1937) and PsychInfo (from 1806) on 7th April 2011 using keywords “fatigue” and “stroke” and their associated terms or synonyms. The same search terms were used in this review as in the published Cochrane systematic review [23] of interventions for post-stroke fatigue (Appendix 1).
Definition of stroke
Stroke was defined as “a clinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal, and at times
Results
The electronic search identified 7046 citations before duplicates were removed. The full texts of 101 potentially relevant papers were retrieved. A further seven papers were retrieved following scrutiny of the reference lists of papers (reviews, qualitative, cross-sectional and longitudinal studies) where the main topic was fatigue after stroke (Fig. 1).
Of these 108 papers, 99 were excluded. The main reasons for excluding a study were a) it was a review and contained no original research b) it
Discussion
This systematic review of longitudinal studies of post-stroke fatigue has demonstrated that the frequency of fatigue varied substantially between studies, with estimates ranging from 35% to 92% at first time point, probably reflecting the heterogeneity between the studies regarding the methods of recruitment and their methods of assessing fatigue.
Fatigue appears to be a persistent symptom after stroke at least for the first 36 months. The proportion of patients with fatigue at the beginning and
Conclusion
Fatigue is a common symptom post-stroke and is likely to persist in the long term for patients who develop it. This review explored the possibility of depression being a cause of fatigue but found insufficient evidence in the literature. Therefore it is vital for preventative and management strategies to be developed for those suffering from fatigue. For these interventions to be made possible potential causes of post-stroke fatigue must be further investigated.
Conflicts of interest
None.
References (50)
- et al.
Fatigue associated with stroke and other neurologic conditions: implications for stroke rehabilitation
Arch Phys Med Rehabil
(2003) - et al.
Fatigue after stroke
Ann Readapt Med Phys
(2006) - et al.
Post-stroke fatigue—a review
J Pain Symptom Manage
(2009) - et al.
Quality assessment of observational studies is not commonplace in systematic reviews
J Clin Epidemiol
(2006) - et al.
Poststroke fatigue: course and its relation to personal and stroke related factors
Arch Phys Med Rehabil
(2006) - et al.
Cancer-related fatigue and its associations with depression and anxiety: a systematic review
Psychosomatics
(2009) - et al.
Fatigue in Parkinson disease, stroke and traumatic brain injury
Phys Med Rehabil Clin N Am
(2009) - et al.
Fatigue after stroke
Ann Readapt Med Phys
(2006) - et al.
Patient factors associated with return to driving post-stroke: findings from a multi-center cohort study
Arch Phys Med Rehabil
(2010) - et al.
UK stroke survivor needs survey
(2010)
Poststroke fatigue: a 2-year follow up study of stroke patients in Sweden
Stroke
Effect of modafinil on subjective fatigue in multiple sclerosis and stroke patients
Eur Neurol
Post-stroke fatigue and return to work: a 2-year follow-up
Acta Neurol Scand
Advantages and disadvantages: longitudinal vs repeated cross sectional surveys. A discussion paper
Project Battelle
Fatigue at long-term follow up in young adults with cerebral infarction
Cerebrovasc Dis
Poststroke fatigue: characteristics and related factors
Cerebrovasc Dis
Clinical and psychological correlates of poststroke fatigue. Preliminary results
Neurol Neurochir Pol
Functional outcome in poststroke patients with or without fatigue
Am J Phys Med Rehabil
An investigation into fatigue post-stroke and its multidimensional nature
Adv Physiother
Consequences of mild stroke in persons < 75 years—a 1 year follow up
Cerebrovasc Dis
Correlations genuine and spurious in Pearson and Yule
Stat Sci
A systematic review of longitudinal studies on the association between depression and smoking in adolescents
BMC Public Health
Fatigue after stroke: a major but neglected issue
Cerebrovasc Dis
Post-stroke fatigue—where is the evidence to guide practice?
N Z Med J
Frequency, characterisation and therapies of fatigue after stroke
Neurol Sci
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This work was supported by a Chief Scientist Office of the Scottish Government grant.
- 1
Centre of Clinical Brain Sciences, Bramwell Dott Building, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, United Kingdom.
- 2
Geriatric Medicine, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom. Tel.: + 44 131 242 6369/6481; fax: + 44 131 242 6370.