(1)
Neurorehabilitation Centre at CNA, Breda, Noord-Brabant, The Netherlands
Summary
Fatigue is a frequently occurring symptom in CNS disorders. It has also been shown to be a major limiting factor in general functioning and to have a negative influence on any neuropsychological function impairments that may be present. Fatigue is easy to treat from the biopsychosocial perspective. Providing insight into burden and resilience and offering the patient tools for rediscovering the balance are all part of physiotherapy care. From the same holistic vision, it is also possible to influence the limbic system in such a way that the subjective perception of fatigue is reduced. The goal is to reduce the influence of the stressors (negative emotion, negative cognition, and negative coping behavior) as much as possible in such a way that desensitization of the limbic system occurs. Positive reformulation and redefining of negative ideas contribute to the reduction of experienced fatigue. Coaching and helping the patient to learn positive coping behavior can contribute to achieve structural changes. Desensitization of the limbic system also leads to less sensitization of the paralimbic regions of the brain, resulting to a positive influence on the functions that are regulated from those areas, such as memory, sleep, and mood.
8.1 Introduction
Fatigue is a frequently occurring symptom in CNS disorders. It has also been shown to be a major limiting factor in general functioning and to have a negative influence on any neuropsychological function impairments that may exist. For this reason, it is worth taking a closer look at fatigue and knowing which options exist for influencing this symptom.
This chapter firstly states what fatigue is and looks at the hypothetical causes of it. Then, two options are proposed from the biopsychosocial perspective that could be implemented in the physiotherapy care of the patient with a CNS disorder. Fatigue is easy to treat from the biopsychosocial perspective. Providing insight into burden and resilience and offering the patient tools for rediscovering the balance are all part of physiotherapy care. From the same holistic vision, it is also possible to influence the limbic system in such a way that the subjective perception of fatigue is reduced. The aim is to reduce the influence of the stressors (negative emotion, negative cognition, and negative coping behavior) as much as possible, which then results in desensitization of the limbic system occurring. Positive reformulation and redefinition of negative ideas contribute to the reduction of the fatigue experienced.
Coaching and helping the patient to learn positive coping behavior can contribute to achieving structural changes. Desensitization of the limbic system also leads to less sensitization of the paralimbic regions of the brain, resulting to a positive influence on the functions that are regulated from those areas, such as memory, sleep, and mood.
It is known that fatigue occurs very frequently in CNS disorders. Given the impact of this symptom on the entire functioning and the other existing impairments, treatment of fatigue will contribute to better general well-being. Because of this, the patient will function better in his immediate surroundings. This chapter does not claim to be complete, but aims to make influencing fatigue a structural component of physiotherapy care (◘ Figs. 8.1, 8.2, 8.3, and 8.4).
Fig. 8.1
The limbic system and its connections
Fig. 8.2
Graded activity A
Fig. 8.3
Graded activity B
Fig. 8.4
Graded activity C
8.2 Fatigue
Fatigue is a major problem for people with a CNS disorder. Firstly, it is not pleasant for them to feel constantly tired. Secondly, it creates problems through the impact that fatigue has on the other impairments that exist as a result of the CNS disorder.
The chronic fatigue experienced by people with a CNS disorder means their ability to adapt is small. This can lead to the cascade breakdown phenomenon; this means that a relatively small disruption can upset the fragile balance resulting in a speedy decline.
Example from Practice 8.1
Mrs. J. has Parkinson’s disease and is classified as stage 3 according to the Hoehn and Yahr classification. She lives in a service flat and is independent in her ADL. She has a slight cold. Because of her kyphotic posture, she has less power to cough. After 2 weeks, she is still being bothered by the same cold.
In the end it turns into an upper respiratory infection because of her inability to cough up sputum. It costs her a lot of energy. She thus now also needs daily help, because she is no longer able to run her household. She needs to rest a lot more, and this leads to a reduction in her stamina. Eventually the home care has become an essential part of her daily functioning as a consequence of this slight cold. She is now classified as stage 4.
The literature does not reveal any unequivocal definitions of the term «fatigue.» The definitions of normal and pathological fatigue are:
- 1.
Normal fatigue: state of general tiredness that occurs after effort and that improves with rest
- 2.
Pathological fatigue: a state that is characterized by fatigue that is not been related to preceding effort and that does not recover with rest
Research has shown that fatigue occurs a lot with CNS disorders. In one study conducted 9 months after the CVA, both the partners (83%, n = 143) and the patients concerned (74%, n = 172) indicated that this symptom is present and forms a major limiting factor for general functioning. This also applies to the other CNS disorders.
8.3 Hypothetical Causes of Fatigue
We talk about hypothetical causes, because there are no perceptible abnormalities that can explain the occurrence of fatigue. They are also called idiopathic symptoms, but that does not mean that the complaints are not real. Thus, for example, it has been shown in terms of experiencing pain that someone who is rejected or left in the lurch actually feels pain (Eisenberger et al. 2003). It produces disruption in the limbic regions.
As a result of which, the adaptive interactions between the mental activity and the visceral situation become disrupted, and psychosomatic phenomena can arise. This is a confirmation that idiopathic symptoms, such as fatigue, can lead to subjectively experienced symptoms.
With specific events, it is good to remember that this can have an influence on the limbic system. The next example illustrates that.
Example from Practice 8.2
A woman was robbed of her handbag and indecently assaulted in Paris 6 years ago. She thought that she had dealt with it well in the meantime. She lives in Amsterdam and the same sort of things can happen there after all. In spite of that, she had no problems being alone on the street, also at night.
Until she went back to Paris again. It was the middle of the day. She walked through the alleyway where the attack had happened. She started walking faster, her heart was racing, she felt hot, and she was constantly looking around.
In the literature, the following are given as possible hypothetical causes of fatigue:
Physical changes, such a change in nutritional status, biochemical abnormalities, systemic diseases, and a reduced mobility.
A combination of the CNS disorder and the psychosocial stress that is associated with this: learning to deal with the sudden health threat, the loss of functional abilities, and an intensive and long-term rehabilitation process.
Sleep disorders, such as insomnia, hypersomnia (pathological sleepiness and an increased inclination to go to sleep), and apnea (temporary cessation in breathing during sleep).
Diminished cognitive functioning, such as memory and concentration.
Overdemanding (internally or externally) and, as a result, the feeling of always having to perform on the limit of the ability to function.
Compensation of impairments: this takes a lot of energy.
Fatigue can also be an indirect consequence of other factors that are present, for example:
Medication.
Reduced energy level and an disrupted balance of burden versus resilience.
A feeling of having not much grip on one’s own situation (external locus of control).
Gloominess/depression. From a previously mentioned study (Hochstenbach and Mulder 1997), it was apparent that depression is a frequent problem for CVA patients. Nine months after the CVA, both the partners (50%; n = 143) and the patients concerned indicated (45%; n = 172) that there are depressive moods. This is also known to be the case with the other CNS disorders.
The presence of depression in patients with CNS disorders can have an organic cause or be a response to the pathology. This is relevant for the treatment intervention. Organically defined depressive moods can easily be influenced, as it happens, by medication.
Fatigue and depression are closely related with each other, but can also occur independently of each other:
Fatigue and the presence of depression: 39%
Fatigue and the absence of depression: 38%
Through this close relation, treatment of the depression can contribute to reducing the fatigue experienced. The identification of depression in a patient with a CNS disorder should therefore be part of the multidisciplinary care plan during rehabilitation.
8.4 Biopsychosocial Model
Models are often used within the (para)medical world. The purpose of this is to make the complexities of the human body more transparent. The biopsychosocial model is one of those models.
In medical research, symptoms are often explained according to the biomedical model: that is to say that a disease or disorder is or can be explained medically. Example: an abnormality in the pancreas results in the blood sugar level becoming abnormal.
In addition to this biomedical model, the psychosocial model is also used: the disease or disorder is explained by a disruption in psychosocial functioning. Example: someone is too busy at work and is forced to work in the evenings. He can consequently not keep up with his social contacts, and after 3 weeks, he finds himself with headaches.
If these models are viewed independently of each other – psyche and somatic are separated – then these are called dualistic models. If the models are, by contrast, regarded as inextricably bound together, this is known as a holistic model. The person is thereby considered as a biopsychosocial entity. «Bio» stands for organic level (e.g., the pancreas), «psycho» for the person level, and «social» for the person and his surroundings, placed within the social and cultural context.
From this model, it is assumed that several factors are present that maintain the problems that have arisen.
Example from Practice 8.3
Mr. W. has a pancreatic disorder, and as a result, his blood sugar level is not regulated (biomedical). It is noteworthy that the deregulation of his blood sugar level always occurs out of the blue, despite his structured daily routine. This makes it all somewhat uncertain, because when he has a hypo he loses consciousness.
For a number of years, the frequency of the number of hypos has not been so high, and generally they occur at night. When this happens, his neighbor comes to his aid. In the last year, on the contrary, he has found himself having a hypo in the middle of the day. Mr W. has decided to no longer drive for that reason, and the result is that he is less able to get out and about (social). He is really fed up with this, and to add to his misery, things are not going well at work. He works for a large bank and there have been a succession of reorganizations. He is afraid that it will be his turn, at some time, to be made redundant.
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