Ideal Fatigue Interventions for People With SCI Based on What We Know
Because of the limited literature on interventions and the multifactorial nature of global fatigue, it is difficult to recommend one ideal treatment protocol for fatigue in people with SCI; however, some previous research has highlighted certain things that would be useful to address.
Having a better understanding of which factors are most strongly associated with fatigue is key to establishing preventive and therapeutic interventions. Onate-Figuérez et al. (2023) conducted a systematic review including 29 studies, and a meta-analysis including 23 studies, investigating the association between fatigue and clinical and demographic variables in people with SCI. A direct association was found between fatigue and 9 factors: self-efficacy (r=-0.63; 95% CI, 0.81 to 0.35), anxiety (r=0.57; 95% CI, 0.29-0.75), stress (r=0.54; 95% CI, 0.26-0.74), depression (r=0.47; 95% CI, 0.44-0.50), pain (r=0.34; 95% CI, 0.16-0.50), participation (r=-0.32; 95% CI, 0.58 to 0.001), analgesic medication (r=0.32; 95% CI, 0.28-0.36), assistive devices (r=0.23; 95% CI, 0.17-0.29), physical activity (r=-0.17; 95% CI, 0.28 to 0.05), lesion level (r=0.15; 95% CI, 0.07-0.23), incomplete SCI (r=0.13; 95% CI, 0.05-0.22), and medication (r=0.12; 95% CI, 0.01-0.23) (Onate-Figuérez et al. 2023). No association was found with age, sex, educational level, time since injury, or spasticity (Onate-Figuérez et al. 2023). These results should be considered when designing intervention approaches to improve fatigue in people with SCI.
It has been suggested that the management of fatigue in people with neurological disorders like SCI and multiple sclerosis requires a multidisciplinary team and approach (Hourihan, 2015; Smith et al. 2016). A physiatrist or family doctor can conduct a thorough physical and medical history to determine potential causes of fatigue (such as pain, sleep, or medications). Physicians should review whether medications that may contribute to fatigue can safely be replaced, decreased, or discontinued (Rosenthal et al. 2008; Dukes et al. 2021). It is important to ask about and address pain, as it is one of the most common co-occurrences with fatigue in people with SCI (Onate-Figuérez et al. 2023). Laboratory testing may also uncover any contributing factors to fatigue like anemia or thyroid disorders (Hourihan 2015). Sleep quality should be reviewed to ensure that treatable secondary causes of sleep dysfunction—such as obstructive or central sleep apnea—are not contributing to fatigue. Structured physical activity and/or exercise is indicated to treat fatigue in people with SCI, multiple sclerosis, and in the general population; physical therapists or other professionals prescribing exercise should be aware of the person’s fatigue status and levels of exercise should be moderate and increased gradually (Rosenthal et al. 2008; Hourihan 2015; Heine et al. 2015). To ensure that any regimens that are put into place to manage fatigue, it has been suggested that follow-up visits are regularly scheduled (Rosenthal et al. 2008).
Previous research has identified that psychological factors like stress, anxiety, and depression contribute substantially to fatigue in people with SCI, suggesting that an evidence-based mental health therapy such as cognitive-behavioral therapy or the prescription of selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline, could be considered as part of any fatigue treatment in appropriate patients (Craig et al. 2013; Onate-Figuérez et al. 2023; Rosenthal et al. 2008). Researchers have posited that cognitive-behavioral therapy could be useful in helping people lessen the effects of chronic pain on depressive moods, and might help in establishing more attributions of self-efficacy, in that the person with SCI has some control over their body and their health (Craig et al. 2012; Craig et al. 2013). In an interview study with people with SCI, family members, care assistants, and occupational therapists, Hammell et al. (2009) found that interviewees suggested an ideal fatigue management program would address achieving greater participation in their everyday lives; providing a sense of enhanced control, reduced pain and helplessness; and enhancing relationships strained by fatigue. Notably, these goals align with the intended achievements of cognitive-behavioral therapy as well as with the self-management interventions found in two of the RCTs included in this review.
