FATIGUE

• Feeling of tiredness & lack of

strength due to physical / mental
strain or illness , which can be
ameliorated through additional
rest

09/19/09 2
 MUSCLE FATIGUE

• Any exercise induced reduction in the

ability of muscle to generate force or
power regardless of whether or not
the task can be sustained

SC
Gandevia , 2001
09/19/09 3
 NORMAL FATIGUE

• A state of general tiredness which

is the result of overexertion & can
be reversed by rest

09/19/09 4
 PATHOLOGICAL FATIGUE

• A state characterized by weariness

unrelated to previous exertion
levels & is usually not reversible by
rest

09/19/09 5
• Normal fatigue • Pathological
fatigue
• Rapid onset • Gradual onset

• Short duration • Long duration

• Single identifiable • Multiple unknown

cause causes

• Protective • Abnormal
09/19/09 6
CHRONIC FATIGUE SYNDROME

• Abnormally excessive

• Unexplained

• Persistent for six months or more

09/19/09 7
 NEUROLOGICAL FATIGUE

• Subjective lack of physical or mental

energy which is perceived by the
individual or caregiver to interfere with
usual & desired activities

MS council clinical practice

guidelines

,1998
09/19/09 8
Types of fatigue

09/19/09 9
2 types :

3.Physical fatigue

5.Mental fatigue

09/19/09 10
 PHYSICAL FATIGUE

• Inability to exert force within one’s

muscles to the degree that would
be expected given the individual’s
general physical fitness

09/19/09 11
 Muscle weakness

True weakness
Perceived weakness

09/19/09 12
 Objective weakness

A condition where the instantaneus

force exerted by the muscle is less
than that would be expected

09/19/09 13
 Subjective weakness

A condition where it seems to the

patient that more than normal effort
is required to exert a given amount
of force

09/19/09 14
 Enhanced perception of limited
endurance of sustained mental
activities

 Manifests
as somnolence or just
decrease of attention

09/19/09 15
 Mental stress

 Lack of sleep

 Depression

 Chemical causes
09/19/09 16
 17
09/19/09
09/19/09 18
 Reductionin the ability of muscle to
perform work because of impairment
anywhere along the command from
neuromuscular transmission to the
actin – myosin cross bridging

09/19/09 19
 Peripheral
model assumes fatigue at
one or more sites which initiates
muscle contraction

 Thereforedependent on the localized

chemical conditions of the muscles

09/19/09 20
 Depletion
of energy substrates
Aerobic metabolism
Anaerobic
metabolism

 Change in intracellular ion levels

leak of calcium
09/19/09 21
09/19/09 22
 Declinein force output due to
reduction in the neural drive or
nerve based motor commands to the
working muscles

09/19/09 23
 Protective phenomenon

 Worksto preserve the integrity of

system by initiating muscle fatigue
through muscle decruitment

09/19/09 24
 Failure in integration of limbic input
& the motor functions within basal
ganglia

09/19/09 25
 TNF-ALPHA
 INTERLEUKIN –6

Metabolic abnormalities of frontal

cortex & basal ganglia

09/19/09 26
 Hypofunctioning

 Reduced Cortisol secretion

09/19/09 27
 Increased level of serotonin in brain
during exercise , peak at fatigue

 Effectson arousal , lethargy ,

sleepiness & mood
09/19/09 28
 29
09/19/09
 30
09/19/09
 Change in the force response to
electric stimulation during rest
following exercise relative to pre
stimulation force

 Reveals any loss of force in the muscle

tissue after constant activation

 Decline in force reflects the severity of

fatigue 09/19/09 31
 Rest twitches before & after MVC

 Attenuationof post stimulation

twitches indicate peripheral fatigue

 Dominant slowing of the relaxation

phase
09/19/09 32
 Changes in sarcolemma

Variables :
 Amplitude
 Frequency
 Muscle fiber conduction velocity

09/19/09 33
 Amplitude
increases during
submaximal exercise

 Duringhigh contraction , amplitude

declines

 Change in frequency spectrum & MFCV

09/19/09 34
 35
09/19/09
 MVC + Electrical stimulation to motor
end plate

 Increased exertion of force demonstrates

Central Activation Failure

 The technique allows quantification of CAF

 Can’t differentiate between various

central causes
09/19/09 36
 Magnetic & electrical stimulation of
motor cortex

 Artificially activates CNS

 Response is measured at output site

 Studies reported diminished output

after fatiguing contraction
09/19/09 37
 Responses following magnetic
stimulation are often submaximal

 Any change in motor output is

interpreted as change in excitability of
motor cortex as induced by stimulus

 Notthe actual diminished voluntary

drive
09/19/09 38
 Negative movement related cortical
EMG potential over the scalp 1 sec
before a self paced motor act

 Generatedby supplementary motor

area & primary motor cortex

09/19/09 39
 Duringhigh force voluntary
contraction , RP increases

 Providesmeasure to determine
changes at the motor cortex level
instead at the output site

 Does not require artificial stimulation

 Prominent tool to study central

changes during natural repetitive
contractions
09/19/09 40
 41
09/19/09
 70 % of patients with MS

 Present even at rest

 Both
physical & cognitive
components

09/19/09 42
 Worsenedby stress & increase in
temperature

 Nocorrelation with age, neurological

impairment , sleep disturbance

09/19/09 43
 25 % - 92 % of stroke survivors

 Persistsdespite excellent
neurological recovery

09/19/09 44
 Tends to decrease with time

 Independent of stroke severity,

localization or functional impairment

 Correlation with brainstem or thalamic

stroke

09/19/09 45
 Incidence – 40%

 Related to Dopamine deficiency

 Levodopanormalizes cortical motor

neuron excitability

09/19/09 46
 47
09/19/09
 Muscle weakness – the commonest
symptom

 Metabolic / mitochondrial disorders :

Fatigue

 Exercise intolerance

 Weak atrophic muscles functioning at

their limits metabolically

 Energy supply fails because of

metabolic compromise
09/19/09 48
 Abnormal rise in sEMG potential

09/19/09 49
 Reported by 25- 40 %

 Post encephalitic damage

 Reticular Activating System

 Dopaminergic neurons in Substantia

Nigra
09/19/09 50
 Manifests at the onset

 Persistsfor months regardless of full

recovery of PNS

 Central fatigue component

09/19/09 51
 52
09/19/09
 To
ascertain whether normal or
pathological

 Toidentify possible predisposing

factors

09/19/09 53
 Onset

 Duration

 Severity

 Daily pattern

 Aggravating / Relieving factors

 Impact on daily living

09/19/09 54
 55
09/19/09
9 item measure

7 point likert scale format

 Ranges from :
1 ( strongly disagree)
7 ( strongly agree)

09/19/09 56
1. My motivation is lower when I am fatigued.
2. Exercise brings on my fatigue.
3. I am easily fatigued.
4. Fatigue interferes with my physical functioning.
5. Fatigue causes frequent problems for me.
6. My fatigue prevents sustained physical
functioning.
7. Fatigue interferes with carrying out certain duties
and responsibilities.
8. Fatigue is among my three most disabling
symptoms.
9. Fatigue interferes with my work, family or social
life
 
09/19/09 57
 Totalscore - Mean score across the
9 statements

 FSS score > 4 : Severe fatigue

 Most widely used measure in

neurological conditions

 Able to differentiate between

patients & healthy subjects
09/19/09 58
 High validity

 Internal consistency ( cronbach alpha =

0.81 – 0.95 )

 Test retest reliability ( 0.8 ) in patients

with MS & Polyneuropathies

09/19/09 59
 Modification of VAS for pain

 Scores range from : 0 (no fatigue)

to
10
( worst fatigue )

 VAS score > 4.4 : Severe

fatigue
09/19/09 60
 Simple, practical , reproducible & fast
to apply

 Used to measure fatigue changes over

time intervals (minutes, hours )

 Toclosely estimate average intensity

changes over longer time period
( weeks , months )
09/19/09 61
 4 statements

 7 point likert scale

 Total score = mean score of the 4

statements

 Able to differentiate between patients

& healthy subjects

 Internal consistency ( cronbech alpha

= 0.81) 09/19/09 62
 Developed for patients with MS

 40 independent symptom based

questions

 Scale of : “ 0 (no problem )”

to
“ 4 ( extreme problem)”

 Total score = Sum of responses to all 40

09/19/09 63
 Minimum score = 0 ( No fatigue)

 Maximum score = 160 ( Extreme

fatigue)

 FISscore of 80 or higher correlates

with moderate to severe fatigue

09/19/09 64
 Energy category - one of the 6
categories of NHP

 Consists of 3 yes / no questions

 Totalscore =
no. of questions answered with yes *
100
total no. of questions
09/19/09 65
 0 ( No complaints )
 100 ( Answered yes to all
complaints )

 Internal consistency ( Cronbach α =

0.71)

 Test retest reliability (Spearman ρ =

0.77 – 0.86) in patients with stroke
09/19/09 66
 Fatigue scores are not interchangeable

 Structure& attributes of questionnaire

differ remarkably

 Weight of individual components of

fatigue contribute to significant
interscale score deviation

09/19/09 67
 FSS : Asseses neuromuscular
fatigue

 VAS : No identifiable domains

 FIS: Less emphasis on physical

fatigue
More on emotional, cognitive
09/19/09 68
 69
09/19/09
 70
09/19/09
 Identification
& optimum
management of potential factors

 Nutrition counselling

 Drugs : Antidepressants
Amantadine
Modafinil

09/19/09 71
 72
09/19/09
 Combination of cognitive &
behaviour therapy approaches

 Identification
of unhelpful, anxiety
provoking thoughts & challenges

09/19/09 73
Stress management techniques : -

 Relaxation
 Hypnosis
 Guided imagery
 Distraction

09/19/09 74
 Moderate intensity :

Aerobic training

Strength training

Flexibility training

 Group therapy

 Level II evidence
09/19/09 75
 Fatigue dairy

 Restricting timing of daily activities

 Prioritizing tasks

09/19/09 76
 Imp to make the patient aware that
fatigue is real

 Recognition
by patients, caregivers
& family members

09/19/09 77
Goals :

 To improve understanding in patients

care giving

 To involve patient, caregivers in setting

goals, directing & evaluating the
intervention

09/19/09 78
 Relaxation training

09/19/09 79
 Chinesetechnique of inserting
needles into the body

 Strengthen
the vital essence of
human body

 Removes the blockage of channels

09/19/09 80
 S C Gandevia : Spinal and Supraspinal Factors in
Human Muscle Fatigue .Physiological Reviews ,
2001 ; 81 : 4

 Abhijit Chaudhuri, Peter O Behan :Fatigue in

neurological disorders ; The Lancet ; 2004 ; 363,
20

 Marloon groot et al : Fatigue associated with

stroke and other neurologic conditions:
implications for stroke rehabilitation Arc
hives of Physical Medicine and Rehabilitation
Volume 84, Issue 11, November 2003, Pages
1714-1720
09/19/09 81
M J Zwartz : Clinical neurophysiology of
fatigue ; Clinical neurology , 119 ,
(2008), 2-10

 William s, B Krupp : Multiple sclerosis

related fatigue ; Phys Med Rehab Clin N
Am , 16 (2005) , 483

 Physiolological Basis Of Movement :

Latash 09/19/09 82
 83
09/19/09