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Focus on Guillain–Barré Syndrome and Pompe Disease Cell. Mol. Life Sci. (2010) 67:701–713 DOI 10.1007/s00018-009-0184-2 Cellular and Molecular Life Sciences REVIEW Fatigue in neuromuscular disorders: focus on Guillain–Barre´ syndrome and Pompe disease J. M. de Vries • M. L. C. Hagemans • J. B. J. Bussmann • A. T. van der Ploeg • P. A. van Doorn Received: 30 June 2009 / Revised: 12 October 2009 / Accepted: 13 October 2009 / Published online: 16 November 2009 Ó The Author(s) 2009. This article is published with open access at Springerlink.com Abstract Fatigue accounts for an important part of the persist, non-pharmacological interventions, such as exer- burden experienced by patients with neuromuscular disor- cise and cognitive behavioral therapy, can be initiated. ders. Substantial high prevalence rates of fatigue are reported in a wide range of neuromuscular disorders, such Keywords Fatigue Á Neuromuscular disease Á as Guillain–Barre´ syndrome and Pompe disease. Fatigue Experienced fatigue Á Physiological fatigue Á can be subdivided into experienced fatigue and physio- Guillain–Barre´ syndrome Á Pompe disease logical fatigue. Physiological fatigue in turn can be of central or peripheral origin. Peripheral fatigue is an important contributor to fatigue in neuromuscular disor- Introduction ders, but in reaction to neuromuscular disease fatigue of central origin can be an important protective mechanism to Everybody experiences periods of fatigue, but these usually restrict further damage. In most cases, severity of fatigue can be mended by taking a rest or enjoying a good night’s seems to be related with disease severity, possibly with the sleep. In a wide range of diseases, however, fatigue is a well- exception of fatigue occurring in a monophasic disorder known chronic symptom. In patients without demonstrable like Guillain–Barre´ syndrome. Treatment of fatigue in somatic disease chronic fatigue may occur and may lead to neuromuscular disease starts with symptomatic treatment the diagnosis of chronic fatigue syndrome [31]. Severe of the underlying disease. When symptoms of fatigue fatigue as a chronic symptom and its impact on daily living are starting to receive more and more attention as patient- reported outcome measures in clinical trials in patients with somatic disease. Several studies have demonstrated that & J. M. de Vries ( ) fatigue is a disabling symptom in chronic diseases such as Department of Neurology, Erasmus MC, University Medical Centre, Room Number EE 22-30, Dr. Molenwaterplein 50-60, cancer, but also in a variety of neurological disorders and Postbus 2040, 3000 CA Rotterdam, The Netherlands conditions (Table 1)[14]. Severe fatigue can also occur as a e-mail: [email protected] side effect of drugs like beta-blockers, proton-pump inhib- itors, anxiolytic drugs and antipsychotics [2]. J. M. de Vries Á M. L. C. Hagemans Á A. T. van der Ploeg Division of Metabolic Diseases and Genetics, The first studies on fatigue in neurological diseases Department of Paediatrics, Erasmus MC, focused on diseases of the central nervous system (CNS), Sophia Children’s Hospital, Rotterdam, The Netherlands such as cerebrovascular disease, multiple sclerosis and Parkinson’s disease [29, 30, 44, 54, 88, 106]. Nowadays, it J. B. J. Bussmann Department of Rehabilitation Medicine, Erasmus MC, is recognized that fatigue is also an important and fre- University Medical Centre, Rotterdam, The Netherlands quently occurring symptom in disorders of the peripheral nervous system (PNS) with a high impact on physical P. A. van Doorn abilities and perceived health status in these patients [104]. Department of Neurology, Erasmus MC, University Medical Centre, Room Number BA 450,0s Gravendijkwal 230, This review focuses on fatigue in neuromuscular disor- Postbus 2040, 3000 CA Rotterdam, The Netherlands ders, with emphasis on fatigue in Guillain–Barre´ syndrome 702 J. M. de Vries et al. Table 1 Neurological diseases and conditions associated with 29, 51, 53, 57, 107]. In basic neurosciences, it is defined as fatigue a time-related force decline [32, 102]. Considering the Neurological diseases and disorders associated with fatigue different aspects of fatigue it is best regarded as a multi- dimensional concept in which the level of experienced Cerebral vasculitis and cerebrovascular diseases fatigue and the ability to perform activities are influenced Channelopathies by the type of disease, the health status of the patient and Charcot-Marie-Tooth disease type 1 (CMT type 1) several aspects of patient functioning. A distinction is made Chronic inflammatory demyelinating polyneuropathy (CIDP) between experienced fatigue and physiological fatigue, Developmental disorders (cerebral palsy, Arnold-Chiari which can both be influenced by psycho-sociological fac- malformations) tors [101]. The multidimensional concept of fatigue is Dysautonomic states depicted in Fig. 1. In this figure fatigue is integrated in the Encephalitis World Health Organization’s International Classification of Facioscapulohumural dystrophy (FSHD) Functioning, Disability and Health (WHO-ICF). The Granulomatous disorders (neurosarcoidosis, Wegener’s WHO-ICF represents the effect of disease on body function granulomatosis) and structure and the level of activities and participation of Hypothalamic and pituitary diseases the patient [1]. Intracranial infections (meningitis and encephalitis) Metabolic encephalopathy and mitochondrial diseases Migraine Physiology of fatigue Motor neuron disease Multiple sclerosis With electrophysiological testing, fatigue can be measured Multiple system atrophy as a loss of voluntary force-producing capacity of the Myotonic dystrophy muscles during exercise [8, 72]. To understand this reduced Narcolepsy and related sleep disorders capacity of the muscle it is important to know how fatigue Paraneoplastic (limbic encephalitis, opsoclonus-myoclonus) arises. The central governor model clarifies in a logical Parkinson’s disease and other parkinsonian disorders way how fatigue arises during mental or physical effort and Pompe disease and other metabolic myopathies how fatigue is essential for protecting the body against Cerebral commotion damage due to excessive exercise [69]. During performed Guillain-Barre´ syndrome (GBS) effort the CNS is continuously informed about the level of Post-infection fatigue states (poliomyelitis, Lyme disease, Q-fever, perceived exertion by feedback from muscles, joints, body and viral infections) temperature, the cardiorespiratory system and cognitive Postoperative (posterior fossa) surgery domains (afferent pathways). This feedback is processed at Adapted from Ref. [14] the primary somatic sensory cortex, subsequently sensory motor integration takes place and the activation by the (GBS), an immune-mediated polyradiculoneuropathy, and primary motor cortex of the brainstem motor nuclei and Pompe disease, a metabolic muscle disorder. Various anterior horn cells in the spinal cord (efferent pathway) is aspects of fatigue will be discussed, including differences adjusted if needed to maintain body homeostasis. This between experienced and physiological fatigue and differ- continuous feed forward and feedback control mechanisms ent methods available for assessment of fatigue. GBS and regulate the work rate and determines when rest is needed Pompe disease are taken as examples to discuss possible [14, 69]. pathological mechanisms of fatigue, treatment strategies With this model it is not fully explained how severe and options for future research. fatigue can be present in chronic disease or how fatigue can be present in a resting situation. In patients with severe fatigue the sense of normal fatigue is amplified due to Different types of fatigue and their definitions pathological changes in the motor system, disruption of feedback to the primary somatic sensory cortex and/or Fatigue covers a broad spectrum of symptoms and com- change in patients’ motivation [14, 69]. In a resting situa- plaints, and has no uniform definition. In clinical research, tion an estimation is made whether the body can cope with commonly used definitions of fatigue are an overwhelming an increase in effort. Up-regulation of metabolism occurs and persistent feeling of tiredness and diminished ability to during exercise; however, in case of disease, the capacity to sustain voluntary mental and physical activities. In addi- increase the metabolic rate is limited. This is perceived at tion, weakness, lethargy and lack of energy that interfere the level of the CNS as fatigue and the patient will avoid with daily activities are used as definitions [9, 13, 22, 23, excessive effort and requires rest. Fatigue in neuromuscular disorders 703 Health status and disease I + III Body function Activity, Participation & structure Capacity & II + III II Performance II Physiological Experienced fatigue fatigue Fatigue Psychological factors IV Fig. 1 Fatigue as a multidimensional concept implemented in the physiological fatigue have an effect on activity and participation World Health Organization’s Classification of Functioning, Disabil- and are in most diseases related to health status and disease severity. ity, and Health. The multidimensional concept of fatigue is integrated Psychosocial factors have an influence on fatigue and on activity and in the World Health Organization’s International Classification of participation. The numbers indicate at which level the different Functioning, Disability and Health (WHO-ICF), representing the treatment strategies have an effect on fatigue: I treatment of effect of disease on body function
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