fatigue and exercise after a subarachnoid haemorrhage€¦ · all the benefits of exercise are...
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Fatigue and exercise after a subarachnoid
haemorrhage
Laura O’Flaherty Matt Wingfield
Occupational Therapist Physiotherapist
16th September 2017
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Outline
What is fatigue?
How to manage fatigue
Why is exercise important after my SAH?
Is it safe to exercise after SAH?
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Fatigue
“A subjective lack of physical and/or mental energy that is
perceived by the individual or caregiver to interfere with usual or
desired activities” MS council
Fatigue can be defined as an overwhelming sense of tiredness,
lack of energy and feeling of exhaustion (Krupp,1996)
Can persist post a SAH even when good outcomes experienced
in other domains
(Buunk et al., 2015 and Boerham et al., 2016)
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Fatigue
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Experienced by many people with neurological disorders, experience
is unique to each person
30-90% of people post SAH experience fatigue
(Kutlubaev, 2012)
Fatigue can come on suddenly and can foil a
person’s most doable to-do list
Unlike usual tiredness, fatigue doesn’t always improve with rest
and it isn’t related to how busy or active you’ve been
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“I feel mentally tired,
like my brain is totally
fried and find it really
difficult to concentrate.
Also I make mistakes
or garble my words”
“I get so tired during the day that I can't
concentrate and feel like I have to sleep
right there and then. Everything just feels
really heavy as well, especially my arms”
“Fatigue feels like being weighed
down, as if you are trying to walk
up to your neck in a deep, muddy
river in heavy, wet clothes
carrying shopping bags full of
rocks”
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“I find the biggest problem
about fatigue is that others
don’t understand it. I think it
would be easier for people to
understand if you were
wearing a plaster cast” “I still sometimes feel guilty
that I should do more, and
sometimes slip back into old
ways of taking on too much,
not taking a break, but I soon
pay the price with a
worsening of symptoms”
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Secondary
Primary
-Directly related to SAH
-Underlying cause not known
Environment Depression
and stress
Medication
Deconditioning
Other medical
conditions
Sleep
disturbance
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Fatigue management
IS
A coordinated approach involving your active
participation and also the involvement of family
and health professionals
AIMS TO
• Help you to understand more about fatigue and
factors contributing to your individual
experience of fatigue
• Improve your ability to manage all aspects of
your life within the context of fatigue
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How can I manage my fatigue?
Analyse your
fatigue
Minimise your
fatigue
Manage any fatigue
that remains
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ACTIVITY DIARY
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Activity diary
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Time F V S Activity Comments
8.00am 7 9 5 Made breakfast standing up
10mins
Blurred vision while
standing, eased off
when sat down to eat
9.00am 9 1 4 Hovered the bedroom floor
for 30mins
By end of activity felt
completely drained,
had to go back to bed
1-10 (1 = very low; 10 = very high)
F = Fatigue level
V = Value of activity
S = Satisfaction you feel with your performance
Date: 10/08/2017
Sleep: Slept well, felt rested, woke one time for bathroom, went back to
sleep immediately
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Using your diary as an ‘energy bank’
Overall fatigue levels
How your fatigue fluctuates during the day and week
How fatigue is related to activities
Possible factors that may contribute to your fatigue
Where and how you are spending your energy
Possible changes in behaviour, equipment or
environment that may help reduce fatigue 12
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Feeling that you have to ‘push through’
your fatigue (even if its 10/10)
Doing too little and feeling lethargic
Having no energy left for activities that you enjoy
Not matching your activities to your energy level
Not planning ahead
Not asking others for help to do things
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Example of poor fatigue management!
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Example of poor fatigue management!
‘Boom and bust’
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Activity
Rest
Rest
Re
st
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Rest and relaxation
Rest is most effective when used in conjunction
with relaxation techniques
You need a quiet environment and the
willingness to rest
Examples:
Deep breathing, muscle relaxation, meditation (headspace
app), yoga, Tai Chi, exercise
Music or sounds, such as the sea or birdsong.
Aromatherapy
Imagery/visualisation
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Activity
‘Any task that requires energy to perform it’
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Physical
Cognitive
Emotional
Social
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Grading
Prioritisation
Pacing
Organisation
Delegation
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Remember the 4 D’s….
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Do Delay Delegate Ditch
Is the activity
something you
enjoy or has to
be done? – try
to get a balance
Can it wait? Can someone
else do it/share
the task?
Can you
eliminate it
altogether
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Summary
Fatigue is common following SAH
It is subjective and it is important to educate friends and family
about your fatigue
Keeping a diary is a good what of identifying your fatigue patterns
Avoid ‘bust and bust’
Create and energy bank and balance rest and activity
Use your toolbox – prioritisation, delegation, pacing, organisation
and grading.
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What else can help?
Healthy lifestyle
Exercise
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Why do exercise
Prevent complications from prolonged inactivity
Decrease recurrent cardiovascular and neurovascular
events
Increase aerobic fitness
All this not withstanding functional limitations
Journal of Stroke April 22, 2004
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Why do exercise
Complications from inactivity - high blood pressure - Weight gain and obesity - Heart disease - Osteoporosis - Stroke - Diabetes - Breast and colon cancer - Depression and Anxiety
- Fatigue
Reduced recurrent cardiovascular
and neurovascular events - Lowers risk of strokes - Lowers risk of heart attack - Lowers risk of heart failure
Increases aerobic fitness - Lowers risk of strokes - Lowers risk of heart attack - Lowers risk of heart failure - Lowers blood pressure - Easier control and prevention of diabetes - Elevates mood - Improves sleep cycle
World Health Organization - 2017
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Why don’t we do enough exercise?
SAH severity and functional limits as a result
Comorbidities
Support to facilitate exercise
Depression
Fatigue
Social integration issues
Cultural issues
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Is it safe?
Quick google search
*images
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Fears of exercise
What if it happens again?
Incidences of spontaneous SAH as a result of
exercise are few and far between
Any cases you can find are in people completing
Valsalva maneuvers (power lifting) and/or have
underlying undiagnosed pathology
There is an overall “re-bleeding rate” of less than 2%
worldwide – Lancet 2007
You have all had your brains scanned at some
point
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Is it safe
Exercise post neurovascular event is recommended and
considered safe by the following groups’ or counties’ clinical
guidelines
Europe
Australia
Canada
United States of America
Brazil
Japan
Information from the respective entities clinical practice guidelines
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What kind of exercise
Walking
It is the single BEST thing you can do for your
health
Swimming
Cycling
Jogging (if you are able)
Lifting weights
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How long and how strenuous
GOOD NEWS!
All the benefits of exercise are available to people who
exercise at a level where you can maintain a
conversation and speak in full sentences
If you wanted to wear a heart rate monitor it would be
60 – 70% of your ‘maximum heart rate’
Aim for 30 minutes a day
As long as you exercise for 10 minutes or more it can
count towards your daily total
3 sessions of 10 minutes of walking will get all of the
improvements we have discussed
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23 ½ hours
Can you limit your sitting, resting, TV watching, sleeping
and eating to just 23 ½ hours per day? – Dr Mike Evans
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Strategies
Find a walking partner
Get off a stop early on the tube or bus
Walk the long way home from the closest station
Keep a diary
Leave yourself notes around the house as reminders
Phone apps
REWARD YOURSELF
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The Truth…
The safety considerations for exercise all are the same
for you, as they are for any person.
We can acknowledge the extra difficulties that you will
have in returning to exercise
BUT
There is no medical reason that you, with a treated
aneurysm, cannot go about a normal healthy level of
exercise.
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Questions?
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References
Kluger, B. M., Krupp, L. B., & Enoka, R. M. (2013).
Fatigue and fatigability in neurologic illnesses: Proposal
for a unified taxonomy. Neurology, 80(4), 409–416.
http://doi.org/10.1212/WNL.0b013e31827f07be
Lush and Hourihan 2005
Krupp, L, Pollina, D, (1996) Mechanisms and
management of fatigue in progressive neurological
disorders, Trauma and rehabilitation, p456-459
Kutlubaev M, Barugh AJ and Mead GE, (2012), ‘Fatigue
after subarachnoid haemorrhage: a systematic review’. J
Psychosom Res. 72(4):305-10
Living with fatigue Ms society
https://support.mstrust.org.uk/shop?prodid=204 34