Fatigue is a complex state characterized by a reduced mental and physical performance and lack of alertness, Lack of energy, difficulty in concentration . Which directly affects on performance of an individual - this document discuss about the fatigue its Definition, Introduction, Types, Causes, Assessment, Different scales to measure, and its Management and physiotherapy management and its prevention.

1. BY- DR. ANJALI RAI
JUNIOR RESIDENT
Ravi Nair Physiotherapy College
FATIGUE
IT’S CAUSES, ASSESMENT, SCALES & MANAGEMENT

2. AT THE END OF THE SESION LEARNERS SHOULD BE ABLE TO KNOW-
1. What is fatigue
2. It’s types, causes & symptoms
3. Fatigue assesment
4. Multidimensional scales used for fatigue
5. fatigue management or recovery strategies
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3. • FATIGUE
Is defined as an:-
• "A multi-dimensional phenomenon in which the biophysiological,
cognitive, motivational emotional and physical state of the body is
affected resulting in significant impairment of the individual's ability to
function in their normal capacity“
It is described as:-
• a state of tiredness (which is not sleepiness) or exhaustion. Difficulty or
inability in initiating activity( perception of generalized weakness)
reduced capacity maintaining activity and difficulty with concentration,
memory and emotional stability
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Davies K, Dures E, Ng W (January 15, 2021). "Fatigue in
inflammatory rheumatic diseases:

4. • COMPARISON WITH OTHER TERMS
• Classification
By type -
TIREDNESS SLEEPINESS
Uni-
dimensional
multi-
dimensional

5. Physical
BY TIMESCALE
MUSCLE
FATIGUE
NEURO-
MUSCULAR
JUNCTION
CENTRAL
NERVOUS
SYSTEM
ACUTE PROLONGED CHRONIC

6. Mental- Mental fatigue is a temporary inability to maintain optimal cognitive
performance. The onset of mental fatigue during any cognitive activity is gradual, and
depends upon an individual's cognitive ability, and also upon other factors, such as
sleep deprivation and overall health.
A loss of energy may be related to mental health problems such as:_
• Depression
• Anxiety
• Grief
These conditions exhaust the body physically and emotionally and cause severe fatigue
to set in.
NEUROLOGICAL FATIGUE- People with Multiple sclerosis experience a form of
overwhelming tiredness that can occur at any time of the day, for any duration, and
that does not necessarily recur in a recognizable pattern for any given patient,
referred to as "neurological fatigue”.
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7. CAUSES
1) MEDICAL
There are numerous potential causes of fatigue. For the majority of medical illness, fatigue is a
possible symptom.
• The medical causes of fatigue can be classified under broad disease categories. Some of
these disease categories include:
• Metabolic/Endocrine: Conditions such as anemia, diabetes, hormonal imbalances, or liver
or kidney disease
• Infections: Influenza, tuberculosis, or malaria
• Cardiac (heart) and pulmonary (lungs): Congestive heart failure, chronic obstructive
pulmonary disease (COPD), arrhythmias, and asthma
• Sleep problems: Sleep apnea, insomnia, and restless leg syndrome
• Vitamin deficiencies: Vitamin D deficiency, vitamin B12 deficiency, or iron deficiency
• Other conditions: Cancers and rheumatic/autoimmune diseases
• Medications you are taking to treat other health conditions may also cause fatigue. This can
include anti-depressants and anti-anxiety medications, sedative medication, some blood
pressure medications, chemotherapy, radiation therapy, and steroids.
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8. 2) LIFESTYLES
Lifestyle causes include:
• Sleep disturbances: If you are not getting enough sleep, too much sleep, or waking up during the night, you may
experience daytime fatigue.
• Diet: If you are eating a lot of high-carb, high-fat, or quick-fix foods, sugary foods and drinks, or caffeinated
drinks, you are not providing your body enough fuel or nutrients to function at its best. Moreover, these foods
may cause you to experience energy boosts that quickly wear off, leading to a "crash" and worsening fatigue.
• Alcohol and drugs: Alcohol is a depressant that will slow down the nervous system and disturb sleep. Cigarettes
and caffeine will stimulate the nervous system and cause you trouble with falling asleep and staying asleep.
• Lack of regular activity: Physical activity is known for improving your health and well-being, reducing stress, and
improving your energy levels. It will also help you sleep better and reduce daytime fatigue.
• Individual factors: Personal or family illness or injury, having too many commitments, and financial problems can
cause a person to feel fatigued.
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9. WORKPLACE RELATED FATIGUE
People who work night shifts may experience daytime fatigue. This is because the human body is
designed to sleep at night, and a person who works the night shift confuses the body’s circadian clock.
Poor workplace practices that can also contribute to fatigue include:
• Irregular working hours
• Physical labor
• Long hours
• Noisy workplaces
• Fixed concentration
• Repetitive tasks
Fatigue may also be caused by the following workplace stressors:
• Heavy workload
• Conflict with bosses or coworkers
• Workplace bullying
• Threats to job security
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10. SIGNS AND SYMPTOMS
1) forgetfulness
2) poor communication
3) impaired decision- making skills
4) lack of alertness
5) slow reaction time
6) quick of anger
7) no sense of humor
8) lack of intrest
9) always tired

11. •FATIGUE ASSESMENT
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12. HISTORY
 ID :- age, gender, nationality, occupation
 Chief complain
ONSET- abrupt or gradual, related to event or illness
 COURSE- stable improving or worsening
 Factors that alleviate or exacerbrate symptoms
 Impact on daily life- ability to work.
Medical history: to ask about recent stressful (good and bad) events in your life, such as the birth of a child, surgery,
work stress and family problems, or other symptoms you have experienced in addition to fatigue.
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13. PHYSICAL EXAMINATION
- A physical exam will help your practitioner check for signs of disease. Your medical
professional may also ask about your current diet and lifestyle.
General appearance
Posture
Patients walking
Trouble breathing or loss of muscle strength
Palpation
SPECIFIC CLINICAL SIGNS OF ORGANIC DISEASE ASSOCIATED WITH FATIGUE .

15. LOCAL ASSESMENT
Assessment procedure which indicate a fall in the strength or firing ability of the muscle fiber
can be used to determine fatigue.
-Muscular fatigue
-Fall strength or firing ability of the muscle fiber to determine fatigue
Commonly used technique are:-
• Electrophysiological
• Decremental studies
• EMG
• MMT
• Endurance testing

16. • SYSTEMIC ASSESSMENT
a) Anaerobic Assesment
b) Measurement of blood lactate level
c) Measurement of aerobic capacity
d) Measurement of energy expenditure
A) ANAEROBIC FATIGUE:- Assessment of the fatigue during
anaerobic power performance when vigorous exercises
continues for more than few seconds.
Anaerobic Fatigue is the percentage decline in the power output
during the test.
The various test which are used for anaerobic fatigue are
following:-

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18. WINGATE CYCLE ERGOMETER TEST:-
It is capable of identifying two primary measures-
1) Anaerobic capacity
2) Anaerobic power outputs
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19. • The presence of lactate in the muscle and blood indicates the contribution
from anaerobic metabolism to give energy to the work performed.
• Measurement of lactate in blood can give an idea regarding the extent of
fatigue.
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B) MEASUREMENT OF BLOOD LACTATE LEVEL

20. LACTATE THRESHOLD TEST
• These tests are typically called step tests and rely on stepping up the intensity of the
exercise effort over 2, 3 or more steps.In order to track your lactate threshold
• A simple step test would look like this:
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21. C) MEASUREMENT OF AEROBIC CAPACITY
It gives an information regarding fatigue that occurs due to lack of oxygen supply to the
exercising structures. This type of aerobic fatigue occurs during a prolonged exercise
program when the energy producing sources are the aerobic system.
The aerobic capacity of an individual can be measured by calculating his maximal oxygen
consumption which is given VO2 Max.
It is given with flick’s equation:-
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VO2 Max = cardiac output x arteriovenous O2 difference
= Q x a-VO2
Cardiac output(Q) = heart rate x stroke volume
Arteriovenous O2 difference = arterial O2 – venous O2

22. D) MEASUREMENT OF ENERGY EXPENDITURE
Energy expenditure can also be determined easily by open circuit portable
spirometry and also by telemetry.
1) Spirometer
2) Telemetry
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MULTIDIMENSIONAL FATIGUE SCALES
1) Modified fatigue impact scale
2) fatigue severity scale
3) Multidimensional fatigue inventory
4) Brief fatigue inventory
5) Chalder fatigue scale
6) Piper fatigue scale
7) BORG rating of perceived exertion(RPE)

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1) MODIFIED FATIGUE IMPACT SCALE (MFIS)
•The MFIS is a modified form of the Fatigue Impact Scale, This instrument provides an
assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial
functioning. The full-length MFIS consists of 21 items while the abbreviated version has
5 items.
•The MFIS is a structured, self-report questionnaire that the patient can generally
complete with little or no intervention from an interviewer.
• Scoring- The total score for the MFIS is the sum of the scores for the 21 items.
Individual subscale scores for physical, cognitive, and psychosocial functioning can also
be generated by calculating the sum of specific sets of items.

25. • For example some questions are:-
• RESULTS- A higher score means fatigue is more significantly affecting your life. For
example, someone with a score of 70 is affected by fatigue more than someone with a
score of 30. The three subscales provide additional insight into how fatigue affects your
day-to-day activities.

26. 2) FATIGUE SEVERITY SCALE
•The Fatigue Severity Scale (FSS) is a 9-item scale which measures the severity
of fatigue and its effect on a person's activities and lifestyle in patients with a
variety of disorders. It was originally devised for people with Multiple
Sclerosis (MS) or Systemic lupus erythematosus.
Method of Use
• A self-report scale of nine items about fatigue, its severity and how it affects
certain activities. Answers are scored on a seven point scale where 1 =
strongly disagree and 7 = strongly agree. This means the minimum score
possible is nine and the highest is 63. The higher the score, the more severe
the fatigue is and the more it affects the person's activities.
Test-retest Reliability
• The study reported excellent test-retest reliability (ICC = 0.91)

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28. 3) BRIEF FATIGUE INVENTORY
Consists of nine items that look at fatigue in the past that are rated on a 0 -10
numeric rating scale where 0 is no fatigue or does not interfere and 10 is
bad fatigue or completely interferes with activity/work.
• Reliability: Cronbach alpha
reliability ranges from 0.82 to 0.97

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4) MULTIDIMENSIONAL FATIGUE INVENTORY
•The Multidimensional Fatigue Inventory (MFI) is a 20-item self-report instrument
designed to measure fatigue. It covers the following dimensions: General Fatigue, Physical
Fatigue, Mental Fatigue, Reduced Motivation and Reduced Activity.
•This new instrument was tested for its psychometric properties in cancer patients
receiving radiotherapy, patients with the chronic fatigue syndrome, psychology students,
medical students, army recruits and junior physicians.
•Reliability and Validity In an initial psychometric evaluation, developers reported an
internal consistency ranging from .53 to .93

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5) CHALDER FATIGUE SCALE
• The Chalder fatigue scale is widely used to
measure physical and mental fatigue in
chronic fatigue syndrome patients.
• The constructs of the 14-item fatigue scale.

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WHAT IS RECOVERY ?
The recovery that might reduce fatigue to restore a status of
performance readiness (eg- physiological & psychological).
FATIGUE MANAGEMENT
SLEEP NUTRITION
ACTIVE
REST
HYDRO-
RECOVERYE
NT
PSYCHOLOGICAL
SKILLS
PHYSICAL
THERAPY

33. • Overcoming or reversal of fatigue
• Body systems repair and damaged tissues & replenish energy stores.
• Insufficient recovery can lead to overtraining or long term(chronic) fatigue.
• Includes number of different processes.

35. SLEEP
-Sleep is the most important recovery modality
Night sleep: adults 7 – 9 hr; kids 9-10 hr
Day nap: 15-20 min
-However, too much or too little sleep can affect performance Not only quantity but
also quality of sleep is important
Deep sleep (75-80%): growth and repair
REM sleep (20-25%): neural function
SLEEPING TIPS: THINGS TO DO
-Practice relaxation techniques before going to bed (eg soft music and muscle
relaxation)
-Lie down to sleep ONLY when you are sleepy

36. -If you don't fall asleep within 30 min after turning out the light, get up
and do some relaxation again
-If you wake up in the night and can't get back to sleep, get up and do
some relaxation again Get up at the same time every day
SLEEPING TIPS: THING NOT TO DO
Caffenine eg (coffee, tea, and coke)
Nicotine (Alcohol leads to disturb sleep patterns)
High protein and large meal

37. REPLENISH ENERGY STORES NUTRITION
-Replenish glycogen stores (CHO) (65% diet) -Should be replenished in first 15-30 mins with
high Gl foods
Fluid: continue re-hydrating until urine colour is clear Sports drink
Oxygenated water eg:- OxyShot
Chocolate milk: carbohydrate + protein
Fuel: immediately after (30 min to 2 hr)
Carbohydrate: 1 g/kg/hr
Glycemic index (GI): glucose and insulin ↑
perhaps consumed every 15-30 min
REHYDRATION
Be hydrated before exercise 400-600mL in
2 hours prior
200-300mL every 15-20 mins during exercise

38. PSYCHOLOGICAL SKILLS
• Emotional recovery
mood-lifting activities (eg music, movie)
→ should be individualized
• Relaxation techniques
Meditation, Visualization, Flotation
HYDROTHERAPY or HYDRO-RECOVERY
- External application of water (liquid, ice, hot, cold or warm ) to heal and recover
• Pool recovery (aqua exercise): 15 - 40 min
• Spa (water jet massage) : 20 min
helps muscle recovery,
• Shower: within 5 – 10 min after training or competition
• Bath -hot bath: can improve quality of sleep
-

39. CRYOTHERAPY
• Ice packs, pool sessions, ice baths and ice vests.
• Reduced blood flow to reduce swelling and fluid retention around joints
• Important for damaged or injured sites
• Causes vasoconstriction of blood vessels & removal of waste products.
• Maintains core body temprature.
HOT AND COLD CONTRAST BATH
• Alternate between hot & cold shower.
• EFFECTS- relaxes muscles
assists neurological recovery
removal of waste products &
deliver nutrients

40. PHYSICAL THERAPY
• STRETCHING- gentle, prolonged or brisk stretching According to condition.
- for performance enhancement
- 50% fewer injury rate
• STRENGTHNING- of specific muscle group muscles (for increasing power & muscle
endurance)
• MODALITIES – for releaving pain(TENS,IFT) FOR Tissue healing(ultrasound)
• COMPRESSSION GARMENTS
- increased blood flow
- increase venous return & reduce blood pooling
- increase lactate clearance(decreasing blood lactate levels
- enhance proprioception
- decrease DOMS

41. 3 LEVELS OF RECOVERY
LEVEL - 3 : ENHANCE RECOVERY THROUGH TRAINING
LEVEL – 2 : ACTIVE RECOVERY
LEVEL – 1 : PASSIVE RECOVERY

43. TAPERING
• TAPERING, refers to a progressive reduction in training load prior to
athletic competition aiming to reduce fatigue while
maintaining/enhancing training adaptations.
• This reduction in fatigue and maintenance/enhancement of training
adaptions has a substantial impact on athletic performance, normally
leading to improvements of 2–3%.
• Maintaning training intensity, reduce volume by 60-90%, maintain
frequency at more than 80%.

45. 4 RESPONSES TO RECOVRY ARE:-
• 1. PHYSICAL
• 2. PHYSIOLOGICAL
• 3. PSYCHOLOGOCAL
• 4. MEDICAL

46. REFRENCES
1. McArdle 8th edition exercise physiology
2. Willmore 7th edition- physiology of sports & exercise
3. Brukner & khan’s clinical sports medicine: the medicine of exercise
4. ACSM guidelines

47. THANK YOU