Osteoarthritis (OA) is a disease of the skeletal muscles that is associated with the development of the significant mortality and morbidity. The following literature will focus on the correlation of fatigue in OA. The search of the literary papers was done from the electronic databases by the use of the keywords and through the use of the Boolean operators. The analysis of the selected papers leads to the identification of the three significant themes. The review of the themes identified that fatigue in OA leads to the development of sleep deprivation; depression and inability of perform physical activity and thereby increase the severity of the fatigue further.
Osteoarthritis (OA) is one of the most prevalent types of arthritis that is significantly correlated with high risk of mobility disability. People suffering from the condition generally require help to climb stairs or during walking since their knees get affected in this condition. OA has also been identified to be a multifactorial condition that is predominantly characterized by alterations in the function and structure of the joint (Perrot, 2015). OA can be defined as the pathological and clinical outcome of a plethora of disorders that eventually leads to a functional and structural failure of the synovial joints.Conventionally, OA has also been regarded as a disorder of articular cartilage. The contemporary notion considers that OAcreates an impact on thecomplete joint organ, together with the subchondral bone, ligaments, menisci,capsule, periarticular muscle, and synovium (Palazzo et al., 2016).
Some common pathological changes that occur during OA comprise of destruction and progressive loss of the articular cartilage, development of osteophytes, subchondral bone thickening, degeneration of menisciand ligaments, inflammation of the synovium, and hypertrophy of joint capsule.Some of the common systemic factors that result in an increase in susceptibility of the joints to OA comprise of an increase in age, nutritional deficiencies, and female gender. Amid individuals who are identified to be at risk, a range of local mechanical factors facilitate the disease progress. Some of these factors are weakness in muscles, misalignment, and modifications in the structural integrity of the joints. According to Fukutani et al. (2016) people suffering from OA often have to put in extra physical effort, with the aim of conducting the activities of daily living.
This commonly results in fatigue. Moreover, inflammation in the joints that is brought about by cytokines, the chemical mediators also results in fatigue. This fatigue is commonly described as a form of exhaustion and tiredness and creates a substantial negative impact on their physical functioning. In other words, fatigue is one of the most prevalent and non-specific sign that is commonly experienced by people suffering from OA at one point in their lives (Fawole et al., 2018). It relates to the subjective and enduring sensation of exhaustion and generalised tiredness and is typically conceptualised as weakness, weariness, and decreased energy. Hence, often fatigue has been identified as categorised as a secondary or primary compliant of the disease. Owing to the high prevalence of fatigue related symptom in OA, there is a need to conduct a literature review for correlates of fatigue in OA. With the aim of extracting articles, search terms were fed in the two electronic databases CINAHL and MEDLINE. The table given below highlights the keywords and search terms used, limitations, databases searched, and the inclusion and exclusion criteria. Literature review topic Correlates of fatigue in osteoarthritis Search terms and boolean operators OsteoarthritisOR OA AND ExhaustionOR weakness AND CorrelatesORfactors Databases searched CINAHL PubMed Inclusion criteria Published in English Peer reviewed Published on or after 2010 Full text availability Exclusion criteria Unpublished articles Manuscripts Clinical guidelines Published in foreign language.
Table 1- Search strategy
Initially 212 articles were obtained from the two databases, 76 articles were obtained after removal of the duplicates. These articles were then screened, following which 52 were excluded. The remaining 24 articles were assessed for full-text eligibility and eventually 11 articles were included in the literature review (refer to appendix for PRISMA).
Murphy et al. (2013) tried to assess the association between momentary fatigue and subsequent physical activity amid OA patients and adopted a quantitative approach for the same. The researchers recruited participants though advertisements and flyers and subjected them to questionnaires, performance assessment and home monitoring. The findings suggested that fatigue was the most significant marker of decreased physical activity amid OA patients and only functional mobility weakened the association between fatigue and activity. Moreover, the association was found to be strongest for people having high functional activity. The research is particularly important to the research question since it helped in establishing momentary fatigue as an important and robust variable, associated with reduced physical functioning of the OA patients. However, the findings could be generalised only to OA patients who suffer from mild to moderate fatigue symptoms. Moreover, there might have been errors in physical activity measurement. Another study had been conducted by Murphy et al. (2016) for determining the impact of self-reported fatigue and pain on physical activity of hip and knee OA patients. Conduction of a cross-sectional study was a correct approach since multiple variables could be analysed at a particular time and the process is beneficial in disproving or approving assumptions. Following the recruitment of 154 patients with OA, having pain for at least 3 months or more, the researchers used the Brief Pain Inventory and Brief Fatigue Inventory. It was found that pain-associated activity interference exerted a significant impact on theconnotation between physical activity and momentary pain in OA, but only during the initial part of a day. However, they failed to find any significant impact of fatigue-related activity on the correlation between physical activity and fatigue reported by the OA patients. Hence, the researchers argued that fatigue did not create any major impact on physical activity of people diagnosed with OA.
Likewise, Novaes et al. (2011) also argued that fatigue in OA patients is significantly correlated with disability of the patients. The researchers elaborated on the fact that fatigue is generally identified as alow vitality, subjective symptom reported by patients as exhaustion, weakness, weariness, tiredness, and depleted energy,which results in areduced capacity for mental and physical work. The researchers tried to evaluate the association of fatigue with disability in OA patients and pain in rheumatoid arthritis (RA) patients. Following the recruitment of 20 patients each suffering from the two diseases, they were assessed using the Patient Global Assessment, visual analogue scale, and Health Assessment Questionnaire. It was found that there fatigue was substantially more amid OA patients, compared to the other disease. Additionally, there was a correlation between Health Assessment Questionnaire with fatigue visual analogue scale amid OA patients (r = 0.54; P < 0.05). Importance of the findings can be accredited to the fact that it helped in identification of the different correlates of fatigue in OA and RA.
Castrejon et al. (2016) tried to characterise the correlation of fatigue with different variables amid patients suffering from rheumatic diseases. All patients had been subjected to the MDHAQ, VAS, RheuMetric checklist, and a routine assessment of patient index data (RAPID3). The researchers found that there existed significant positive correlation between fatigue and depression amid OA patients. However, joint pain, a common symptom of OA was found to affect the relation between depression and fatigue. The major strength of this study was that it established depression as a correlate of fatigue in OA.
This was in accordance to the findings presented by Hawker et al. (2011) who conducted a longitudinal research for explaining the pain-depression association in older adults diagnosed with OA. Adoption of a longitudinal approach was correct since they are generally effective in assessing inconstant patterns over time and are known to have greater power, in comparison to cross-sectional studies, in relation to exclusion of individual differences and time variants. The researchers conducted telephonic interviews at the community cohort and found that OA pain acted as a strong predictor of disability and fatigue, both of which anticipated imminent depressed mood. The significance of the research was that it identified the interrelation between depressed mood and fatigue. Thus, it was found that fatigue exacerbated depressed mood and vice versa.
Sambamoorthi, Shah and Zhao (2017) conducted a review in order to establish the relationship between the osteoarthritis (OA) and depression. The review revealed that prevalence of depression varies depending upon the type of arthritis and the severity of arthritis. The authors reported that the severity of depression varies in between the 4.1% to 5%. Increase in the rate of depression increases the overall rate of morbidity and mortality among the older adults with OA. More precisely, it has been stated that depression not only increases the overall rate of morbidity but also contribute the increase in the overall mortality risk among the OA patients. Moreover, increase in the rate of depressive symptoms hampers the overall quality of life of the patients suffering from OA. Increase in the rate of the depressive symptoms increase the rate of disabilities among the OA patients. Disability is used in order to measure the overall disease burden. Increase in the rate of disability increases the overall disease burden further. One of the significant information that has been highlighted this study is, the study helped in understanding the relationship between the OA, depression and how it increases the subsequent rate of mortality and morbidity.
One of the limitation of the study is, the study failed to highlight the detailed methodology that it used for the selection of the articles that were included in the review. Another limitation of the study is, the study failed to establish how the development of depression lead to the development of fatigue among the patients suffering from OA. Lee and Giuliani (2019) stated that the development of the depression arising out of the OA has a strong relationship towards the development of fatigue. Lee and Giuliani (2019) argued that in case of depression that is arising from inflammation, there is a strong association behind the development fatigue out of depression. OA is an inflammatory disease and the development of OA leads to the development of depression. Under the increase sense of depression, the individuals suffering the OA suffer from poor mental health condition and lack of quality sleep and thereby promoting the development of fatigue. The similar results were reported in the systematic review conducted by the Hackney et al. (2019). Hackney et al. (2019) further helped in understading how the fatigue arising out of OA is associated with depression, anxiety, lack of physical activity and thus leading to poor health-related quality of life.
Taylor‐Gjevre et al. (2011) identified the impact of poor sleep on quality of life, mortality, morbidity and pain perception. With the purpose of assessing the elements of sleep quality and sleep fragmentation, the researchers invited OA and RA participants to fill a self-administered questionnaire. It was found that SF‐36 mental component summary and mHAQ were the most significant predictors for increased PSQI scores amid OA patients. In addition, responses collected from the OA patients also manifested abnormalities in subjective sleep assessment, sleep duration, sleep latency, daytime dysfunction, sleep efficiency, and augmented usage of sleep‐aid medication. 49% OA patients considered the need for using washroom as the most common reason behind sleep disturbance that resulted in awakening and subsequent fatigue. Similarly 45% OA patients also considered pain as a significant contributor to awakening and led to fatigue. The findings are important since fatigue was correlated with abnormality in sleep quality.
Parmelee, Tighe and Dautovich (2015) conducted a cross-sectional and longitudinal association of the osteoarthritis (OA)-related pain or disability along with sleep disturbances and development of the depressive symptoms. The authors surveyed 367 individuals who are diagnosed with OA by the physicians and are complaining about disturbances in sleep, pain in joint, depressive symptoms along with poor functional outcome in the quality of life. The same test was again conducted after one year over 288 samples in order to produce a comparative analysis. The baseline data indicated that OA leads to disturbance in sleep attributed to pain. The lacks of quality sleep at night increase the level of fatigue and depression. However, no significant relationship was establish between the developed of disability and OA. Lack of sleep and pain is the main mediator of the development of the depressive symptoms among the OA individuals (Parmelee, Tighe & Dautovich, 2015). The authors thus confirmed that there is strong relationship of OA and lack of quality sleep at night (sleep apnoea) and thus leading to the development of the depressive symptoms and fatigue. One of the limitations of the study that has been selected for this review, the study assessed the quality sleep, severity of depression and pain with the help of the self-reported questionnaire. Parmelee, Tighe and Dautovich (2015) stated that self-reported questionnaire is biased and thus might lead to the development of the biased results. Moreover, during the follow-up session, the after one year, the sample size got reduced and thus further limiting the chances of the generalised results and increasing the probability of biased results. One of the significance of the results is it helped in understanding the association between the OA ain followed by sleep disturbances and development of fatigue and depression.
The review of the articles helped in a detailed understanding of the mechanism of the development of fatigue from osteoarthritis. The current evidences showed that the there is a potential correlated between the fatigue and OA. Development of the OA is associated with severe pain in the joints. Increase in the joint pain hampers the course of the activities of daily living, increase the sense of depression and hampers the overall sleep at night. Depressive mind along with sleep apnoea increase the sense of fatigue further. However, the severity of fatigue varies with the type of osteoarthritis and age of the individuals.
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Castrejon, I., Nikiphorou, E., Jain, R., Huang, A., Block, J. A., &Pincus, T. (2016). Assessment of fatigue in routine care on a Multidimensional Health Assessment Questionnaire (MDHAQ): a cross-sectional study of associations with RAPID3 and other variables in different rheumatic diseases. Clinical and experimental rheumatology, 34(5), 901-909.
Fawole, H. O., Riskowski, J. L., Dell'Isola, A., Steultjens, M. P., Chastin, S. F., Nevitt, M. C., ...&Felson, D. T. (2018). Prevalence and factors associated with self-reported fatigue in individuals with symptomatic knee osteoarthritis: the most study. Osteoarthritis and Cartilage, 26, S217.
Fukutani, N., Iijima, H., Aoyama, T., Yamamoto, Y., Hiraoka, M., Miyanobu, K., ...& Matsuda, S. (2016). Knee pain during activities of daily living and its relationship with physical activity in patients with early and severe knee osteoarthritis. Clinical rheumatology, 35(9), 2307-2316.
Hackney, A. J., Klinedinst, N. J., Resnick, B., Renn, C., & Fiskum, G. (2019). A review and synthesis of correlates of fatigue in osteoarthritis. International journal of orthopaedic and trauma nursing.
Hawker, G. A., Gignac, M. A., Badley, E., Davis, A. M., French, M. R., Li, Y., ...& Lou, W. (2011). A longitudinal study to explain the pain‐depression link in older adults with osteoarthritis. Arthritis care & research, 63(10), 1382-1390.
Lee, C. H., & Giuliani, F. (2019). The Role of Inflammation in Depression and Fatigue. Frontiers in immunology, 10, 1696.
Murphy, S. L., Alexander, N. B., Levoska, M., & Smith, D. M. (2013). Relationship between fatigue and subsequent physical activity among older adults with symptomatic osteoarthritis. Arthritis care & research, 65(10), 1617-1624.
Murphy, S. L., Niemiec, S. S., Lyden, A. K., &Kratz, A. L. (2016). Pain, fatigue, and physical activity in osteoarthritis: the moderating effects of pain-and fatigue-related activity interference. Archives of physical medicine and rehabilitation, 97(9), S201-S209.
Novaes, G. S., Perez, M. O., Beraldo, M. B., Pinto, C. R., &Gianini, R. J. (2011). Correlation of fatigue with pain and disability in rheumatoid arthritis and osteoarthritis, respectively. Rev Bras Reumatol, 51(5), 451-5.
Palazzo, C., Nguyen, C., Lefevre-Colau, M. M., Rannou, F., &Poiraudeau, S. (2016). Risk factors and burden of osteoarthritis. Annals of physical and rehabilitation medicine, 59(3), 134-138.
Parmelee, P. A., Tighe, C. A., & Dautovich, N. D. (2015). Sleep disturbance in osteoarthritis: linkages with pain, disability, and depressive symptoms. Arthritis care & research, 67(3), 358-365.
Perrot, S. (2015). Osteoarthritis pain. Best practice & research Clinical rheumatology, 29(1), 90-97.
Sambamoorthi, U., Shah, D., & Zhao, X. (2017). Healthcare burden of depression in adults with arthritis. Expert review of pharmacoeconomics & outcomes research, 17(1), 53-65.
Taylor‐Gjevre, R. M., Gjevre, J. A., Nair, B., Skomro, R., & Lim, H. J. (2011). Components of sleep quality and sleep fragmentation in rheumatoid arthritis and osteoarthritis. Musculoskeletal care, 9(3), 152-159.
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