susan murphy scd, otr 1,2,4 neil alexander md 1,2,3,4
DESCRIPTION
Self-reported Fatigue: Relationships with Physical Function and Oxygen Uptake in Leg Osteoarthritis and Type 2 Diabetes. Susan Murphy ScD, OTR 1,2,4 Neil Alexander MD 1,2,3,4. - PowerPoint PPT PresentationTRANSCRIPT
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Self-reported Fatigue: Relationships with Physical Function and Oxygen Uptake in Leg Osteoarthritis and Type 2 Diabetes
Mobility Research Center (MRC)1; Department of Physical Medicine and Rehabilitation, University of Michigan2 ; Geriatrics Center and Division of Geriatric Medicine3 University of Michigan Hospitals;
VA Ann Arbor Health Care System Geriatric Research Education and Clinical Center (GRECC)4
Acknowledgments: National Institute on Aging; National Center for Medical Rehabilitation Research; American College of Rheumatology Research and Education
Foundation; VA Office of Research and Development (Rehab R&D and Medical Research Services)
Susan Murphy ScD, OTR1,2,4
Neil Alexander MD1,2,3,4
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Presentation
Part I: Older women with leg osteoarthritisA. Daily pain and fatigue, in relation to
physical activityB. Behavioral intervention to reduce barriers
to PA and increase symptom controlPart II: Task-specific oxygen uptake and self-
reported fatigue in older adultsA. As predictors of mobility performanceB. In Type 2 diabetes mellitus
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Symptoms and Physical Activity in Women with OA
• 60 women (40 with knee or hip OA, 20 controls)
• Mean age 64 + 8 years• 5 day home assessment
– Watch measured physical activity; recorded symptoms 6 times/day
– Pain/fatigue measured on scale of (0- none to 4-extremely severe)
– Fatigue defined as “tiredness or weariness”
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Part I A: Clinical Research Questions
• How do pain and fatigue symptoms manifest in daily routines?
• How do pain and fatigue symptoms impact physical activity?
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Pain in Women with OA and Controls (data depicted as means + SE)
0
0.5
1
1.5
2
2.5
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
All Timepoints over 5 days
Pain
0-4
controlOA
Day 1 Day 2 Day 3 Day 4 Day 5
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Fatigue in Women with OA and Controls (data depicted as means + SE)
0
0.5
1
1.5
2
2.5
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
All Timepoints over 5 days
Fatig
ue 0
-4
controlOA
Day 1 Day 2 Day 3 Day 4 Day 5
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Momentary Within-Day Symptoms by WOMAC Physical Disability
0
0.5
1
1.5
2
2.5
Low WOMAC Physical Disability High WOMAC Physical Disability
Sym
ptom
Sev
erity
PainFatigue
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Dependent Variable: Physical Activityβ
estimateStandard
Error P valueFatigue -30.08 6.21 <.0001
Pain -16.86 8.36 .04
Age -2.43 1.79 .18
Geriatric Depression Scale -7.52 5.40 .17
Daily Medication Use -2.07 14.50 .89
Timed Up and Go Test -14.30 6.00 .02
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Summary and Conclusions • For women with mildly painful OA, momentary
fatigue may increase more disproportionately through the day than pain, particularly in those with higher disability (more pain)
• In addition to pain, increased momentary fatigue is associated with decreased physical activity
• Interventions to increase physical activity and manage symptoms in leg osteoarthritis may need a better emphasis on fatigue
Murphy SL et al. Arthritis Rheum 2008
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Part 1 B: Behavioral Intervention• Current exercise programs for OA limited in their
link to activity or environmental context, nor are they designed to reduce individual barriers to PA and improve symptom control
• Hypothesis: Compared to those randomized to group exercise
and health education, can group exercise plus activity strategy training (AST, an OT approach) more effectively improve pain, fatigue, and physical activity?
• Design:– 1 month intervention with 2 and 4 month boosters– 6 month follow-up
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Baseline Characteristics
EX + ED(n=26)
EX + AST (n=28)
P value
Age (years) 74.8 (7.3) 75.8 (7.1) .65
No. of women (%) 22 (85) 26 (93) .33
BMI (kg/m2) 30.0 (4.8) 30.1 (6.5) .98
No. of chronic conditions 1 (1.2) 1.5 (1.4) .17
No. of painful joints 4.6 (2.1) 4.4 (2.1) .79
(Murphy SL et al, Arthritis Rheum, in press)
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EX+ED EX+AST
Pain and Fatigue Symptoms in OA PatientsPre and Post Intervention
0
2
4
6
8
PRE POST
fatigue
pain
Fatigue - Brief Fatigue Inventory, severity subscale; Pain – WOMAC pain subscale
Pain (time) p<0.005
Fatigue (time x group) p<0.05
Trend for fatigue to decrease in AST and increase in ED
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Daily Peak Activity
600
640
680
720
760
Pre-Intervention Post-Intervention
Activ
ity C
ount
s
EX+ED EX+AST
Activity counts – collected via wrist-worn accelerometry (Actiwatch, MiniMitter-Respironics)
Trend for peak activity to increase in AST and decrease in ED
(time x group) p<0.05
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Summary and Conclusions
• Compared to controls. participants in a group exercise plus activity strategy training designed to reduce individual barriers to PA and improve symptom control had:– Reductions in pain– Reductions in fatigue– Improvements in peak physical activity
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Part II: Task-specific oxygen uptake and self-reported fatigue in older adults
• Global question: How does aerobic function relate to: – mobility performance?– symptoms of exertion and fatigue?
• A: Analysis of peak V02 versus submaximal oxygen kinetics in predicting mobility performance.
• B: In Type 2 diabetics, analysis of VO2 during peak GXT, submax, and six minute walk (6MW) in predicting perceived exertion (RPE) and fatigue
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Background and Significance
• Age- and disease-associated declines in aerobic capacity (VO2 Max) contribute to functional disability in older adults.
• Standard VO2 measures may be limited– Max VO2 (e.g. max treadmill) is difficult to
achieve in older adults– Peak VO2 is frequently reported
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Background and Significance (2)
• The aerobic demands of many ADL’s are submaximal
• Measures of submaximal (vs maximal or peak) aerobic fitness might:– Be easier and safer to perform, especially
for frail older adults– Better predict functional ability
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Oxygen Kinetics in Healthy and Mobility Impaired Older Women
0 180 360 540 720 900
Time (seconds)
Healthy Woman
RestWalking (1.0 mph) Recovery
(63.7 mL)
(944.1 mL)
0
200
400
600
800
1000
Oxy
gen
Upt
ake
(mL/
min
)
O2 Deficit
O2 Debt
0 180 360 540 720 900
Time (seconds)
Mobility Impaired Woman
RestWalking (1.0 mph) Recovery
(873.0 mL)
(1734.4 mL)
0
200
400
600
800
1000
Oxy
gen
Upt
ake
(mL/
min
)
O2 Deficit
O2 Debt
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Mean (SEM) Comparisons: Aerobic Unimpaired (n=21) vs Impaired (n=20)
Unimpaired Impaired
Age (yrs) 76 (1) 82 (1)*
Peak VO2 (ml/kg/min) 24 (1) 14 (1)*
TCdeficit (s) 23 (3) 58 (9)*
TCepoc (s) 40 (7) 57 (7)
Get up + Go (s) 12 (1) 20 (2)*
6-min-walk (m) 415 (17) 286 (27)*
*p<0.05
(Alexander, J Gerontol, 2003)
Tcdeficit => Initial oxygen deficitTcepoc => Excess post-exercise oxygen
consumption
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Peak VO2 and Oxygen Kinetics versus Functional Performance: Unimpaired Old
Task Peak VO2 tcdeficit tcEPOC Peak VO2 0.62** 0.29
GUG 0.48* 0.58* 0.06
GUG x 3 0.55* 0.60** 0.13
Bag Carry 0.29 0.22 0.59**
Six Min Wk 0.45* 0.31 0.15
** p<0.01; * p<0.05 (Alexander, J Gerontol, 2003)
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Peak VO2 and Oxygen Kinetics versus Functional Performance: Impaired Old
Task Peak VO2 tcdeficit tcEPOC Peak VO2 0.11 0.49*
GUG 0.21 0.10 0.42
GUG x 3 0.41 0.02 0.33
Bag Carry 0.35 0.07 0.53*
Six Min Wk 0.62** 0.18 0.64**
** p<0.01; * p<0.05 (Alexander, J Gerontol, 2003)
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Summary and Conclusions• Older adults with aerobic impairment have:
– Slowed submaximal oxygen kinetics– Poor functional mobility performance
• Measures of submaximal oxygen kinetics correlate as highly with functional mobility performance as Peak VO2 measures, particularly for impaired old during post-exercise recovery.
• Submaximal VO2 kinetics may be more useful than Peak VO2 in estimating the contribution of aerobic function to mobility impairment.
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Type 2 Diabetics[Enrolled in RCT ex program, age >60, n=56 [27 female]
Mean (SD) Range
Age (years) 70.4 (5.7) 60-83
BMI 33.6 (5.9) 24-50
EPESE total 1.0 (1.2) 0-6.0
BFI (global) 2.0 (1.8) 0-7.3
BFI (severity) 2.9 (2.2) 0-8.3
6MW dist (feet) 1264.5 (229.6) 660-1960
Comf Gait Sp (m/s) 1.2 (0.2) 0.8-1.5
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Oxygen Uptake (VO2) Measurements
Three tasks:Graduated treadmill
(traditional peak)Submaximal treadmill
(1 MPH)Six minute walk
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Self Report Measurements
During exercise task:• Rated Perceived Exertion (RPE): How hard
you worked– Range 6-20; 11=fairly light; 13=somewhat
hard; 15=hard; 17=very hard• Fatigue: How much fatigue you had
– 0=No fatigue; 10=Fatigue as bad as could be
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0
5
10
15
20
25
Peak VO2 During TaskSubmax6MWGXT
Mean(SD)
OxygenUptake
(ml/kg/min)
*
*
*
0
5
10
15
20
Post-Task Rate of Perceived Exertion (RPE) Submax6MWGXT
Mean(SD)RPE
Score
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0
5
10
15
20
25
Peak VO2 During TaskSubmax6MWGXT
Mean(SD)
OxygenUptake
(ml/kg/min)
*
*
*
0
1
2
3
4
5
6
7
8
Fatigue Post-TaskSubmax6MWGXT
Mean(SD)
FatigueScore
*
*
*
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Self-reported task-specific fatigue is not related to general fatigue
Fatigue during task GXT Submax 6MW BFI global 0.12 0.18 -0.04 BFI severity 0.12 0.07 -0.11 Submax fatigue 0.52* 0.50* 6MW fatigue 0.39* 0.50* GXT fatigue 0.52* 0.39*
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Non-GXT task-related fatigue may better relate to usual mobility function
Fatigue during task GXT Submax 6MW BFI global 0.12 0.18 -0.04 BFI severity 0.12 0.07 -0.11 EPESE 0.14 0.32* 0.16 TUG 0.28* 0.31* 0.16 Comf Gait Sp -0.25 -0.32* -0.22 6MW dist -0.14 -0.47* -0.32*
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Task specific self-reported fatigue relates more to VO2 kinetics than peak VO2
Fatigue during task GXT Submax 6MW Peak GXT VO2 -0.12 Peak Submax VO2 -0.04 Peak 6MW VO2 -0.05 Submax Tc deficit 0.15 Submax Tc EPOC 0.34* 6MW Tc deficit 0.33* 6MW EPOC 0.39*
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Summary and ConclusionsIn this group of relatively functional older adult
Type 2 diabetics:• Peak VO2 and post-task fatigue increase with
task demand• Self-reported task-specific fatigue is not
related to general fatigue• Non-GXT task-related fatigue may better
relate to usual mobility function• Task specific self-reported fatigue relates
more to VO2 kinetics than peak VO2
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Discussion• Measures acquired during submaximal exercise
tests, including 6MW, as opposed to peak GXT, are better indicators of physical function, and likely fatigue.
• Future studies should consider:– Whether these relationships hold true for
other models of disability and fatigue (such as in non-cardiac disease, high baseline fatigue)
– What the underlying physiological link is between subjective fatigue and objective measures of oxygen utilization