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HomeMembersAssemblies and SectionsAssembliesPulmonary RehabilitationQuarterly Bite ▶ Fatigue as a relevant outcome in patients with COPD
Fatigue as a relevant outcome in patients with COPD

Authors: Yvonne M.J. Goërtz1, Zjala Ebadi2, Maarten Van Herck3.

1 Department of Research and Education, Ciro, Centre of Expertise for Chronic Organ Failure, Horn, NM 6085, The Netherlands.

2 Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 GA Nijmegen, The Netherlands.

3 REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium.

 

People diagnosed with chronic conditions, including chronic obstructive pulmonary disease (COPD), experience a myriad of symptoms. Fatigue, defined as “a subjective, unpleasant symptom which incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition which interferes with individuals’ ability to function to their normal capacity” (Ream & Richardson, 1997), is ranked by people with moderate to severe COPD as the second most prominent and disabling symptom, and it significantly and adversely affects quality of life (Blinderman, Homel, Billings, Tennstedt, & Portenoy, 2009; Goertz et al., 2018). In contrast with a prevalence rate of 10% in elderly people without COPD, severe and clinically relevant fatigue (which is defined as a score 36 points on the subscale subjective fatigue of the Checklist Individual Strength) is experienced by half of stable outpatients with COPD (Goertz et al., 2019). Despite being a predictor of poorer health outcomes and highly prevalent, fatigue remains to date often under-reported by people with COPD. A reason for this might be that patients believe it to be a natural consequence of their disease (Stridsman, Skar, Hedman, Ronmark, & Lindberg, 2015). Moreover, fatigue is also under-diagnosed and under-treated by healthcare professionals (Janssen, Spruit, Uszko-Lencer, Schols, & Wouters, 2011). This might be due to the underrepresentation of fatigue questions in commonly used health status assessment tools (Stridsman et al., 2018). Another reason may be that fatigue is a poorly understood symptom, and the previously mentioned definition of fatigue, although broad, does not reflect the complexity of this symptom. Not to mention, the underlying causes of fatigue in COPD remain elusive. Consequently, therapeutic approaches aimed at reducing fatigue in COPD are lacking. Of note, management of COPD is still rather focused on relieving respiratory symptoms.

 

A longitudinal study on the course of fatigue in 77 stable outpatients with moderate to severe COPD found that the prevalence of severe fatigue doubled after four years follow-up despite standard COPD care (cfr. treatment as usual: education, smoking cessation, optimal medication prescription, counselling regarding exercise and physical activity; Figure 1). Of note, lung function parameters did not significantly differ between baseline and follow-up (Peters et al., 2011).

 image 1

 

Treatment strategies such as exercise training (Arslan & Oztunc, 2016), self-management programs (Mitchell et al., 2014) and cognitive behaviour therapy (Luk, Gorelik, Irving, & Khan, 2017) etc., have been shown to reduce fatigue in people with COPD, but on their own, these strategies only benefit a limited number of people. This is probably due to the multifactorial nature of fatigue (Spruit, Vercoulen, Sprangers, & Wouters, 2017). Therefore, a holistic approach, such as a comprehensive pulmonary rehabilitation (PR) program (Spruit et al., 2013), seems the most appropriate choice to reduce fatigue. A Cochrane review on the effectiveness of PR in people with COPD (McCarthy et al., 2015) demonstrated a clinically relevant moderate-certainty evidence that PR relieves fatigue (mean difference [95% CI] in the fatigue subscale of the Chronic Respiratory Disease Questionnaire 0.68 [0.45 to 0.92]; 19 trials on 1291 participants). Similar results were found in a recent published paper of the FAntasTIGUE consortium. A multidisciplinary inpatient PR program, that included 446 participants with moderate-to-very severe COPD, was able to decrease the prevalence of severe fatigue from 75% to 33% after PR (Figure 2). But although PR is an effective strategy to reduce fatigue in patients with COPD on group level, not everyone reports a minimal clinical improvement following PR despite room to improvement (Van Herck et al., 2019). This emphasizes the need for personalized medicine based upon a comprehensive assessment of possible contributing factors of fatigue.

 image 2

 

Up to now only few studies investigated possible factors that contribute to increased fatigue (Al-shair et al., 2011; Baghai-Ravary et al., 2009; Breukink et al., 1998; Gift & Shepard, 1999; Goertz et al., 2019; Kapella, Larson, Patel, Covey, & Berry, 2006; Kentson et al., 2016; Lewko, Bidgood, & Garrod, 2009; Matura, Malone, Jaime-Lara, & Riegel, 2018; Woo, 2000). Although it is expected that multiple factors play a role in the cause of fatigue in people with COPD, these few studies did not include all possible factors that contribute to increased fatigue (Spruit et al., 2017). Currently, a large multicentre, longitudinal, observational (FAntasTIGUE) study in patients with COPD is investigating all physical, psychological, behavioural, and systemic factors that contribute to fatigue in people with COPD (Goertz et al., 2018). This study is likely to identify underlying factors and empower health professionals to prescribe the optimal treatment, at the optimal time, for each individual. We look forward to, in the near future, informing you about the findings of this study.

References

Al-shair, K., Kolsum, U., Dockry, R., Morris, J., Singh, D., & Vestbo, J. (2011). Biomarkers of systemic inflammation and depression and fatigue in moderate clinically stable COPD. Respir Res, 12, 3. doi:10.1186/1465-9921-12-3

Arslan, S., & Oztunc, G. (2016). The Effects of a Walking Exercise Program on Fatigue in the Person with COPD. Rehabil Nurs, 41(6), 303-312. doi:10.1002/rnj.206

Baghai-Ravary, R., Quint, J. K., Goldring, J. J., Hurst, J. R., Donaldson, G. C., & Wedzicha, J. A. (2009). Determinants and impact of fatigue in patients with chronic obstructive pulmonary disease. Respir Med, 103(2), 216-223. doi:10.1016/j.rmed.2008.09.022

Blinderman, C. D., Homel, P., Billings, J. A., Tennstedt, S., & Portenoy, R. K. (2009). Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease. J Pain Symptom Manage, 38(1), 115-123. doi:10.1016/j.jpainsymman.2008.07.006

Breukink, S. O., Strijbos, J. H., Koorn, M., Koeter, G. H., Breslin, E. H., & van der Schans, C. P. (1998). Relationship between subjective fatigue and physiological variables in patients with chronic obstructive pulmonary disease. Respir Med, 92(4), 676-682. doi:10.1016/s0954-6111(98)90517-0

Gift, A. G., & Shepard, C. E. (1999). Fatigue and other symptoms in patients with chronic obstructive pulmonary disease: do women and men differ? J Obstet Gynecol Neonatal Nurs, 28(2), 201-208. doi:10.1111/j.1552-6909.1999.tb01985.x

Goertz, Y. M. J., Looijmans, M., Prins, J. B., Janssen, D. J. A., Thong, M. S. Y., Peters, J. B., . . . Spruit, M. A. (2018). Fatigue in patients with chronic obstructive pulmonary disease: protocol of the Dutch multicentre, longitudinal, observational FAntasTIGUE study. BMJ Open, 8(4), e021745. doi:10.1136/bmjopen-2018-021745

Goertz, Y. M. J., Spruit, M. A., Van 't Hul, A. J., Peters, J. B., Van Herck, M., Nakken, N., . . . Vercoulen, J. H. (2019). Fatigue is highly prevalent in patients with COPD and correlates poorly with the degree of airflow limitation. Ther Adv Respir Dis, 13, 1753466619878128. doi:10.1177/1753466619878128

Janssen, D. J., Spruit, M. A., Uszko-Lencer, N. H., Schols, J. M., & Wouters, E. F. (2011). Symptoms, comorbidities, and health care in advanced chronic obstructive pulmonary disease or chronic heart failure. J Palliat Med, 14(6), 735-743. doi:10.1089/jpm.2010.0479

Kapella, M. C., Larson, J. L., Patel, M. K., Covey, M. K., & Berry, J. K. (2006). Subjective fatigue, influencing variables, and consequences in chronic obstructive pulmonary disease. Nurs Res, 55(1), 10-17.

Kentson, M., Todt, K., Skargren, E., Jakobsson, P., Ernerudh, J., Unosson, M., & Theander, K. (2016). Factors associated with experience of fatigue, and functional limitations due to fatigue in patients with stable COPD. Ther Adv Respir Dis, 10(5), 410-424. doi:10.1177/1753465816661930

Lewko, A., Bidgood, P. L., & Garrod, R. (2009). Evaluation of psychological and physiological predictors of fatigue in patients with COPD. BMC Pulm Med, 9, 47. doi:10.1186/1471-2466-9-47

Luk, E. K., Gorelik, A., Irving, L., & Khan, F. (2017). Effectiveness of cognitive behavioural therapy in a community-based pulmonary rehabilitation programme: A controlled clinical trial. J Rehabil Med, 49(3), 264-269. doi:10.2340/16501977-2189

Matura, L. A., Malone, S., Jaime-Lara, R., & Riegel, B. (2018). A Systematic Review of Biological Mechanisms of Fatigue in Chronic Illness. Biol Res Nurs, 20(4), 410-421. doi:10.1177/1099800418764326

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev(2), Cd003793. doi:10.1002/14651858.CD003793.pub3

Mitchell, K. E., Johnson-Warrington, V., Apps, L. D., Bankart, J., Sewell, L., Williams, J. E., . . . Singh, S. J. (2014). A self-management programme for COPD: a randomised controlled trial. Eur Respir J, 44(6), 1538-1547. doi:10.1183/09031936.00047814

Peters, J. B., Heijdra, Y. F., Daudey, L., Boer, L. M., Molema, J., Dekhuijzen, P. N., . . . Vercoulen, J. H. (2011). Course of normal and abnormal fatigue in patients with chronic obstructive pulmonary disease, and its relationship with domains of health status. Patient Educ Couns, 85(2), 281-285. doi:10.1016/j.pec.2010.08.021

Ream, E., & Richardson, A. (1997). Fatigue in patients with cancer and chronic obstructive airways disease: a phenomenological enquiry. Int J Nurs Stud, 34(1), 44-53. doi:10.1016/s0020-7489(96)00032-6

Spruit, M. A., Singh, S. J., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., . . . Wouters, E. F. M. (2013). An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. Am J Respir Crit Care Med, 188(8), E13-E64. doi:10.1164/rccm.201309-1634ST

Spruit, M. A., Vercoulen, J. H., Sprangers, M. A. G., & Wouters, E. F. M. (2017). Fatigue in COPD: an important yet ignored symptom. The Lancet Respiratory Medicine, 5(7), 542-544. doi:10.1016/S2213-2600(17)30158-3

Stridsman, C., Skar, L., Hedman, L., Ronmark, E., & Lindberg, A. (2015). Fatigue Affects Health Status and Predicts Mortality Among Subjects with COPD: Report from the Population-Based OLIN COPD Study. Copd, 12(2), 199-206. doi:10.3109/15412555.2014.922176

Stridsman, C., Svensson, M., Johansson Strandkvist, V., Hedman, L., Backman, H., & Lindberg, A. (2018). The COPD Assessment Test (CAT) can screen for fatigue among patients with COPD. Ther Adv Respir Dis, 12, 1753466618787380. doi:10.1177/1753466618787380

Van Herck, M., Antons, J., Vercoulen, J. H., Goertz, Y. M. J., Ebadi, Z., Burtin, C., . . . Peters, J. B. (2019). Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis. J Clin Med, 8(8), 1264. doi:10.3390/jcm8081264

Woo, K. (2000). A pilot study to examine the relationships of dyspnoea, physical activity and fatigue in patients with chronic obstructive pulmonary disease. J Clin Nurs, 9(4), 526-533.