Development of a psychological intervention for post-stroke fatigue

Abstract

Background Post-stroke fatigue (PSF) is a common and distressing problem after stroke. It impedes patients’ participation in daily activities and is associated with higher risks of institutionalisation and death following stroke. Despite its high prevalence and detrimental consequences, little research has been conducted to develop effective treatments for PSF. Psychological interventions are effective in treating fatigue in other conditions such as cancer and chronic fatigue syndrome. This thesis described the development of a psychological intervention for PSF. Methods This thesis was based on the theoretical, modelling and part of the piloting phases of the Medical Research Council (MRC) framework for designing and evaluating complex interventions. This intervention was developed in collaboration with a multidisciplinary group of stroke clinicians, clinical psychologists, a psychotherapist, and stroke survivors. Both qualitative and quantitative methods were used. Systematic reviews were conducted to explore the natural history of PSF and to identify potential targets for a psychological intervention for PSF. The format of the intervention was adapted from existing psychological interventions for cancer-related fatigue and chronic fatigue syndrome. The intervention was delivered by a clinical psychologist (i.e. the therapist) to 12 patients with PSF (i.e. the participants) to test its acceptability and feasibility in the local health system. After the feasibility study, the intervention was refined according to the feedback from the participants and the therapist. A Cochrane review of interventions for PSF was updated to identify any new evidence that could inform future studies. Results Systematic reviews suggested that PSF often occurred early after stroke and persisted over time (which justified the need for interventions for PSF) and that PSF was associated with distressed mood, lower self-efficacy, reduced physical activity and sleeping problems (which were potential targets for the treatment of PSF). Based on interventions that have been used to treat fatigue in other conditions, these psychological and behavioural factors could be addressed by psychological interventions that challenge patients’ thoughts and behaviours (i.e. the cognitive behavioural therapy, CBT). Thus a manualised CBT was developed for PSF. This CBT was delivered to each participant individually, through six face-to-face treatment sessions over a period of 12 weeks, followed by a telephone-delivered review session one month later. Both the participants and the therapist gave favourable opinions on the acceptability of the intervention. The recruitment and follow-up procedures were feasible in the local health system. Following the feedback from participants and therapist, the intervention manual was refined for future use, where the last two treatment sessions will be combined to a single session and the review session will be delivered in person by the therapist. There were statistically significant improvements in fatigue, mood, mobility, and participation in social activity from baseline to three months after the end of treatment. The updated Cochrane review concluded that there was insufficient evidence to recommend any specific intervention for PSF; psychological interventions are one type of interventions worth being investigated in future trials. Conclusions PSF is associated with distressed mood, lower self-efficacy, reduced physical activity and sleeping problems, which are potential targets for the treatment of PSF. Although there was insufficient evidence to recommend any intervention for the treatment of PSF, psychological interventions are one type of promising interventions worth future investigation. The promising results from this uncontrolled feasibility study support the need for a subsequent exploratory randomised controlled trial (RCT) of this brief psychological intervention.