An intervention for cardiac arrest survivors with chronic fatigue: A feasibility study with preliminary outcomes

doi:10.1016/j.resuscitation.2016.05.020

Resuscitation

Volume 105, August 2016, Pages 109-115

https://doi.org/10.1016/j.resuscitation.2016.05.020 Get rights and content

Abstract

Aim

The primary aim was to examine the feasibility of recruiting and retaining participants for an Energy Conservation + Problem Solving Therapy (EC + PST) intervention delivered over the telephone, to evaluate the acceptability of the intervention, and to assess the appropriateness of the outcome measures. The secondary aim was to evaluate the preliminary intervention effect on fatigue impact, activity performance, and participation in daily activities in post-cardiac arrest (CA) adults with chronic fatigue.

Methods

This feasibility study used a prospective, pre-post experimental design. Individuals who were at least 3 months post-CA with moderate-to-severe fatigue were eligible to participate. By participating in EC + PST intervention sessions, participants learned how to apply EC strategies to solve their fatigue-related problems. Participants were assessed before and after completing the intervention using outcome measures assessing fatigue, activity performance, and participation in daily activities.

Results

Eighteen CA survivors with chronic fatigue successfully completed the intervention and the assessments with high satisfaction. We observed a 15% recruitment rate and ceiling effects on two outcome measures of perceived-performance in daily activities. Significant decreases in the impact of physical (p = .001) and cognitive (p = .006) fatigue of CA survivors were observed with small to moderate effect sizes of r = 0.23–0.25 after receiving the EC + PST intervention.

Conclusion

The delivery of EC + PST intervention over the telephone is feasible, and the intervention is highly acceptable to CA survivors with chronic fatigue. Also, the EC + PST intervention seems promising in reducing the impact of physical and cognitive fatigue of CA survivors.

Introduction

Cardiac arrest (CA) is common and often deadly, resulting in approximately 325,000 deaths annually in North America,¹ and only 10% of those who experience an out-of-hospital CA survive.² Survivors often experience problems with memory, attention, mood, physical ability, fatigue, participation, and quality of life.3, 4, 5, 6 Prolonged complaints of fatigue are common in post-CA adults, with more than half experiencing moderate-to-severe fatigue 3 years post CA.⁶ Chronic fatigue is a general and sustained feeling of exhaustion or difficulty performing physical and mental activities for days to weeks, which is not resolved by rest.⁷ Chronic fatigue negatively affects cognitive, physical, and emotional functions, activities of daily living, participation, and quality of life.8, 9, 10 Despite its prevalence and the known negative impact of chronic fatigue,6, 8 no pharmacological or non-pharmacological interventions are recommended for managing fatigue or improving daily activities in people with post-CA chronic fatigue. Therefore, an intervention to improve daily activities, by means of fatigue management in post-CA adults, is urgently needed.

Prior to a clinical trial of any therapy, it is necessary to evaluate the feasibility of delivering interventions and of measuring relevant outcomes.¹¹ The primary aims of this feasibility study were to determine (1) the feasibility of recruiting and retaining participants, (2) the feasibility of delivering an Energy Conservation + Problem Solving Therapy (EC + PST) intervention over the telephone, (3) the acceptability of the intervention to individuals who experience chronic fatigue, and (4) the appropriate outcome measures to capture fatigue impact, activity performance, and participation level in this population. The secondary aim was to evaluate the preliminary intervention effect on outcome measures of fatigue impact, activity performance, and participation level in post-CA adults.

Section snippets

Design

A prospective, pre-post cohort design was used for this study. After the pretest, participants received the EC + PST intervention for up to 4 weeks. The posttest occurred at Week 5.

Participants

Individuals who were at least 3 months post-CA and had chronic fatigue were eligible to participate in the study (Table 1).

EC + PST intervention

Energy Conservation (EC) education promotes fatigue management and improvement in daily activity performance in individuals with chronic fatigue.¹² EC incorporates strategies, such as taking rest

Sample characteristics

The mean age for the 18 participants was 53.2 years (SD = 11.3), and the majority were white males (56%). All participants except one had at least a high school education. Most of the participants experienced a shockable (94%), out-of-hospital (67%) CA and were witnessed (61%). A half of the participants received bystander cardiopulmonary resuscitation. CAMCI scores indicated that all but three participants were at low risk for mild cognitive impairment: one had a moderate risk, a second a

Discussion

Recruiting participants for this study was feasible, albeit challenging. We recruited 15% of potential participants referred mostly by physicians in the Post-CA Care Service of a tertiary care hospital. Of those referred, 60% declined participation because they were not interested, insufficiently fatigued, or not able to be contacted. Many potential participants who were in the acute stage of post-CA recovery and experienced severe acute fatigue showed interest when the study was described to

Conclusions

The EC + PST intervention was shown to be highly feasible and acceptable to CA survivors with chronic fatigue, and the effectiveness seems promising for reducing the physical and cognitive impact of fatigue in CA survivors. Although all participants successfully completed the study, the use of a standardized cognitive assessment for screening will ensure the inclusion of participants with appropriate cognitive levels. MFIS demonstrated superior performance in measuring the impact of fatigue in

Conflict of interest statement

The authors have no conflicts of interest.

Acknowledgements

This study was funded by American Occupational Therapy Foundation Dissertation Research Grant and University of Pittsburgh School of Health and Rehabilitation Sciences Development Fund. The study sponsors had no involvement during the study. The authors would like to thank the Post-CA Service at UPMC Presbyterian for the excellent care they provide to these patients.

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Though we did show a small effect for MFI-20 general fatigue the lack of effect on the MFIS could be due to some participants having low initial fatigue scores. An earlier study testing EC + PST22 with CA survivors found the MFIS improved significantly, but only included participants with chronic fatigue with a baseline mean MFIS total score of 50.4 (scale 0–84) compared to 29.4 in our study. Further, the MFIS result could have been affected by the poor completion of final outcomes, with the non-completers reporting a significantly higher baseline MFIS score (39.6) than the completers (24.3) (Table S11, supplementary).
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SCARF was found to be a feasible intervention with high participant/clinician satisfaction, high participant retention and the possible potential to improve self-reported and physical capacity outcomes. Procedures for study recruitment and collection of final outcomes should be modified before a fully powered randomised controlled trial is conducted.
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Participants were 19 adults who had a CA at least three months prior to the study, reported moderate-to-severe fatigue (4 or greater out of a possible range of 1–7) according to the Fatigue Severity Scale (FSS), 17 had access to a phone, lived within 150 miles of the research center, could comprehend and speak English, demonstrated intact cognition,16 and lived in the community. The rationale for the study eligibility criteria is available elsewhere.16 The median FSS score of 19 participants was 5.56 with IQR of 4.67−6.67.
This study aimed to examine the associations between participation in physical activities and objective and subjective factors modifiable by rehabilitation in cardiac arrest survivors with fatigue.
Participants in a clinical feasibility study (N = 19) completed several subjective (patient-reported) and objective outcome measures on one occasion only. The associations between an individual's level of participation in physical activities (Participation Objective Participation Subjective) and their levels of cognition (Computer Assessment of Mild Cognitive Impairment), body movement (Keitel Functional Test), depressive symptoms (Center for Epidemiologic Studies Depression Scale), ambulation and pain (Health Utilities Index Mark 3), and fatigue impact (Modified Fatigue Impact Scale) were explored. Pearson’s correlation coefficientr was calculated for all associations, except for body movement (Spearman’s correlation coefficient r_s).
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The moderate, negative and positive associations between participation in physical activities and subjective factors suggest that subjective complaints of depressive symptoms, ambulation ability, pain, and fatigue impact may be important factors when seeking to improve participation in physical activities. In particular, addressing physical and cognitive endurance as well as perceptions of fatigue may hold the key to increasing physical activity in cardiac arrest survivors with fatigue.
Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation
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More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.
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Clinical paperAn intervention for cardiac arrest survivors with chronic fatigue: A feasibility study with preliminary outcomes

Abstract

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Design

Participants

EC + PST intervention

Sample characteristics

Discussion

Conclusions

Conflict of interest statement

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Behav Therapy

Resuscitation

Lancet

Eval Program Plann

Arch Phys Med Rehabil

Regional variation in out-of-hospital cardiac arrest incidence and outcome

JAMA

Heart disease and stroke statistics-2014 update: a report from the American Heart Association

Circulation

Quality of survival after cardiopulmonary resuscitation

Arch Intern Med

Physical and mental fatigue in Parkinson's disease: epidemiology, pathophysiology and treatment

Drugs Aging

Correlates of fatigue in patients with heart failure

Prog Cardiovasc Nurs

Activities of daily living for old persons in primary health care with chronic heart failure

Scad J Caring Sci

Recommendations for planning pilot studies in clinical and translational research

Clin Trans Sci

One-year follow-up to a randomized controlled trial of an energy conservation course for persons with multiple sclerosis

IJRR

A randomized clinical trial of energy conservation for patients with cancer-related fatigue

Cancer

Optimizing access to home, community, and work environments

Computer assessment of mild cognitive impairment

Postgrad Med

Clinical paper
An intervention for cardiac arrest survivors with chronic fatigue: A feasibility study with preliminary outcomes