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 State of the Science

Defining and Measuring Fatigue

Lauren S. Aaronson, Cynthia S. Teel, Virginia Cassmeyer, Geri B. Neuberger, Leonie
Pallikkathayil, Janet Pierce, Allan N. Press, Phoebe D. Williams, Anita Wingate

In response to a long history of problems with defining and measuring fatigue, the University
of Kansas School of Nursing established a Center for Biobehavioral Studies of Fatigue
Management to facilitate the study of fatigue in diverse populations. Thepurpose of this article
is to review past efforts to define and measure fatigue and the conceptual problems relevant to
currently used measures of fatigue. Several distinct characteristics and corresponding measures
of fatigue are identified and a definition and framework for the study of fatigue are discussed.
Future research on fatigue must attend to the conceptual distinctions among various measures
and the measures of fatigue most appropriate to the goals of a study.

IMAGE: SCHOLARSHIP, 1999; 31 :1, 45-50.01999 SIGMA

JOURNAL OF NURSING INTERNATIONAL.
THETATAU

[Key words: fatigue; measurement; health concepts]

* * *

n’ atigue is a universal symptom not only associated with

most acute and chronic illnesses, but also with normal,
depletion of hormones, neurotransmitters or essential substrates
of physiological function. Physiological fatigue has been
healthy functioning and everyday life. It is one of the most associated with fever, infection, anemia, sleep disturbances, and
common complaints of people seen in primary health care. pregnancy. Some investigators also distinguish between central
Fatigue is prevalent and distressing to those with and peripheral models of fatigue (Gibson & Edwards, 1985).
rheumatoid arthritis, diabetes, multiple sclerosis,AIDS, and those Central models involve malfunction of the central nervous system
undergoing radiation or chemotherapy, to name a few. It also is (CNS), such as impaired transmission between the CNS and the
the primary disturbance in those with chronic fatigue syndrome, peripheral nervous system or dysfunction of selected areas of the
a poorly understood condition characterized by unremitting and CNS such as the hypothalamic region. Peripheral models involve
debilitating fatigue. Indeed, the ubiquitous nature of fatigue has
Lauren S. Aaronson, RN, PhD, Delta, Professor and Associate Dean for
made understanding it fully all the more challenging for Research; Cynthia S. Teel, RN, PhD, Delta, Assistant Professor; Virginia
researchers and clinicians. Cassmeyer, RN, PhD, Associate Professor; Ceri B. Neuberger, RN, EdD,
In 1992, we established the Center for Biobehavioral Studies Delta, Associate Professor; Leonie Pallikkathayil, RN, DNS, Delta, Assistant
of Fatigue Management at the University of Kansas School of Professor; and Janet Pierce, RN, DSN, Delta, Assistant Professor; School
of Nursing. Allan N. Press, PhD, Associate Professor, School of Social
Nursing to systematically study fatigue in diverse populations. It Welfare. Phoebe D. Williams, RN, PhD, Professor, and Anita Wingate,
was, and is, our hope that multiple studies of fatigue under different RN, PhD, Delta, Associate Professor, School of Nursing. All are at the
circumstances and among people with different clinical conditions University of Kansas, Kansas City, KS.This project was supported by NIH
will help shed more light on this perplexing and distressing grant P20 NR03270, Center for Biobehavioral Studies of Fatigue
Management, L. Aaronson, director. The individual studies are: Fatigue
problem. The purpose of this article is to review what we found and metabolic control in patients with non-insulin-dependent diabetes
as we embarked on this endeavor to define and measure fatigue mellitus, V. Cassmeyer, PI; Correlates of fatigue in rheumatoid arthritis
to study it, understand it, and ultimately develop interventions to clients, G. Neuberger, Pi; Contractile and biochemical changes i n
prevent and relieve fatigue. diaphragm fatigue, J. Pierce, Pi; Caregiver fatigue and at-risk infants at
home, P. Williams, PI; Elder fatigue in caregiving and non-caregiving roles,
C. Teel, PI; Experience of fatigue in healthy individuals, L. Pallikkathayil,
Defining Fatigue PI; and Daily variations in chronic fatigue syndrome immune signs and
Not surprisingly, defining fatigue-given the complex symptoms, L. Aaronson, PI. We wish to acknowledge the contributions of
interaction of the biological processes, psychosocial phenomena, Cheryl Cahill (associate director during our first year) and jenean Sears
concerning early discussions about the center and its development, as
and behavioral manifestations involved-has challenged scientists well as the center’s advisory committee (Kathleen O’Connell, joan Shaver,
for many years. While some distinguish normal fatigue from Sue K. Donaldson, Edna Hamera, Frederick E. Samson Jr., David Ekerdt,
pathological and psychological fatigue, others simply view normal and A. L . Chapman) for their critical reviews and support. Correspondence
fatigue as acute and pathological fatigue as chronic. to Dr. Aaronson, University of Kansas School of Nursing, 3901 Rainbow
Blvd., Kansas City, KS 661 60. E-mail: [email protected]
From a purely physiological perspective, fatigue is defined as
functional organ failure (Berger, McCutcheon, Soust, Walker, & Sidebar: Frances Crighton, RN, MS, AOCN, Delta, Genitourinary
Wilkinson, 1991). Such organ failure generally is attributed to Oncology Coodinator, University Hospital, Denver, CO.
excessive energy consumption and can be characterized by the Accepted for publication December 3, 1997.

Volume 31, Number 1, First Quarter 1999 1mage:journal of Nursing Schofarship 45

dysfunction of the peripheral nervous system, such as impaired unknown function or purpose, as primarily affecting ill clinical
neuromuscular transmission at the motor-end-plate. Others, populations, as having multiple, additive, or unknown causes, and
however, have used the term peripheral to refer to a physical is often experienced with no relation to activity or exertion.
etiology of fatigue while using central to refer to a psychological Chronic fatigue also is perceived as abnormal, unusual, or
etiology (O’Dell, Meighen, & Riggs, 1996). Some nurses also excessive, has an insidious onset, persists over time, is not
dichotomize physical and mental fatigue (e.g., Milligan, Lenz, generally relieved by usual restorative techniques, and has a major
Parks, Pugh, & Kitzman, 1996). Nonetheless, most research on effect on the individual’s activities of daily living and quality of
fatigue from a physiological perspective has been with muscles life. This dual approach, however, does not capture all the
and muscle fatigue. This work differentiates fatigue-a state in complexities of the fatigue experience.
which function can be restored with rest and support for the Because we were concerned that a definition or conceptual
mechanisms of restoration-from exhaustion, a condition in which framework for studying fatigue be clearly biobehavioral to
recovery of function does not occur (MacLaren, Gibson, Parry- recognize the contributions of physiological and psychological
Billings, & Edwards, 1989). functioning as well as social and cultural factors on the experience
Stuifbergen and Rogers (1997) suggest the fatigue of multiple of fatigue, none of these definitions was wholly satisfactory.After
sclerosis is different from tiredness because it is abnormal and considerable discussion, we now view fatigue as: “The awareness
unrelated to exertion or activity. Still others seek to distinguish of a decreased capacity for physical and/or mental activity due to
among exertional fatigue (such as that experienced with an imbalance in the availability, utilization, andor restoration of
Parkinson’s disease), pain-related fatigue (such as with arthritis), resources needed to perform activity.”This definition is consistent
and fatigue caused by weakness from illness or treatment (such with a self-monitoringand self-regulation framework and captures
as in terminal cancer) (Barofsky & Legro, 1991). Distinguishing the critical elements needed to study fatigue in our center’s studies.
fatigue in these ways introduces psychosocial phenomena into The inherently subjective nature of any symptom requires
the experience of fatigue. awareness of the phenomenon. Moreover, resources can range
From a psychological perspective, fatigue has been defined as from biochemical properties and other physiological capacities
a state of weariness related to reduced motivation (Lee, Hicks, & to social and cultural factors that also may affect how one
Nino-Murcia, 1991). Stone and colleagues (1997) recently interprets, or reacts to, the experience of fatigue. Thus, within
conceptualized fatigue as one of 13 mood states. Psychological this conceptualization, utilization and restoration are processes
fatigue has been associated with stress and other intense emotional whereby resources are continually employed and replenished to
experiences and may accompany depression and anxiety. As with support all activity. Fatigue occurs when this system is out of
physiological fatigue, fatigue within a psychological framework balance-that is, when there are insufficient resources either
can be viewed as a response to internal or external demands because the demand or need is too great or because mechanisms
exceeding available resources. of utilization and restoration are disturbed.
Nurses have attempted to integrate the psychological and
physiological aspects of fatigue. The North American Nursing Measuring Fatigue
Diagnosis Association definition of fatigue is: “The self- Defining fatigue or identifying a framework within which to
recognized state in which an individual experiences an study fatigue is a start but it is not enough. Valid and reliable
overwhelming sustained sense of exhaustion and decreased measures also are need. However, given the general lack of
capacity for physical and mental work that is not relieved by rest” consensus in the literature on a definition of fatigue, it is not
(Carpenito, 1995, p. 379). Following an analysis of the concept surprising that measuring (and, therefore, studying) fatigue has
of fatigue, Ream and Richardson (1997) defined fatigue as: “A challenged scientists for decades. Often a measure of fatigue is
subjective, unpleasant symptom which incorporates total body tailored to the situation in which fatigue is studied,further limiting
feelings ranging from tiredness to exhaustion creating an generalization of findings. Measuring fatigue has been hindered
unrelenting overall condition which interferes with individuals’ not only by its ubiquitous nature but also because fatigue is a
ability to function to their normal capacity” (p. 45). Kellum (1985) symptom and, as such, its subjectivity presents additional
proposed that nurses categorize fatigue as normal, pathologic, measurement difficulties.
situational, or psychological depending on assumptions about the Thus, definitional difficulties and an absence of a gold standard
origins of the fatigue. More recently, Carpenito (1995) categorized measure of fatigue have seriously limited efforts to synthesize
factors that caused fatigue as pathophysiologic,treatment-related, common knowledge about fatigue. In fact, Muscio (1921) was so
situational,or maturational. However, the origin of fatigue is often convinced of the futility of ever measuring fatigue adequately
unclear. that he recommended abandoning its study. Nearly 60 years later,
Piper (1989) proposed that the most useful classification Eidelman (1979) stated, “The absence of an overall definition of
distinguishes acute and chronic fatigue. According to Piper, acute fatigue preempts any scientific basis for measuring the condition,
fatigue is characterized as protective, is identifiably linked to a because logically, that which cannot be defined cannot be
single cause, generally occurs in healthy individuals, is perceived measured, and is not understood” (p. 340).
as normal, has a rapid onset and short duration,is usually alleviated Despite these concerns, however, several efforts to measure
by rest, diet, exercise, and stress management, and has minor or fatigue have appeared in the literature. Early work focused on
minimal effect on activities of daily living and quality of life. fatigue in the work place and was conducted by industrial
Chronic fatigue, on the other hand, is characterized as having an psychologists,hygienists, and military researchers. These studies,

46 frnage:Journal of Nursing Scholarship Volume 3 1 , Number 1 , First Quarter 1999

 Fatigue

and the measures of fatigue developed for these studies, generally fatigue in their studies must consider what it is about fatigue that
focused on healthy populations and fatigue at the specific time of is relevant to each study when selecting a specific measure. Given
measurement. Yoshitake’s (1971) Fatigue Scale and Pearson and that our center was interested in studying all aspects of fatigue,
Byars’ (1956, 1957) Fatigue Feeling Tone Checklist are two of we identified a measurement for each of these important
the more popular and widely cited examples of these efforts. Both characteristics.By determining the conceptual distinctions among
were rigorously developed using the best available principles of various measures of fatigue and by selecting multiple measures
instrument development at the time. However, they are less useful to address each distinct aspect, we hoped to better identify possible
and less satisfactory for general use with clinical populations and causes and consequences of fatigue, free of artifact.
are further compromised by outdated language of the items. We believe that the challenge in studying fatigue is to integrate
Recently, concern about the debilitating and distressing health its various aspects in order to advance knowledge about the
effects of fatigue among clinical populations has revitalized efforts biobehavioral interface of fatigue. Doing so requires a broad
to measure fatigue. While some populations and conditions are conception of fatigue such as we have proposed, separate measures
well-suited to contemporaneous measures (e.g., fatigue before of the different aspects of fatigue, and clarity about what each
and after sleep in patients with sleep disorders), other clinical actually measures. Moreover, by using the same set of different
populations require more comprehensive, general measures of measures of fatigue across multiple studies, possible discrepant
what Piper calls chronic fatigue (e.g., fatigue in patients with findings among studies attributable to the use of different measures
multiple sclerosis, rheumatoid arthritis, those undergoing is reduced. This is how we approach studying and measuring
chemotherapy or radiation therapy). fatigue in our Center for Biobehavioral Studies of Fatigue
Among more recent measures are: McCorkle and Young’s Management.
(1978) Symptom Distress Scale, Rhoten’s (1982) Fatigue Scale
and Fatigue Observation Checklist, Piper’s Fatigue Self-Report Characteristics and Corresponding Measures of Fatigue
Scale (Piper et al., 1989), Lee’s Visual Analog Scale for Fatigue Subjectivequantijication of fatigue can be determined with the
(Lee et al., 1991), Krupp, LaRocca, Muir-Nash, and Steinberg’s Lee and colleagues (1991) Visual Analog Scale for Fatigue (VAS-
(1989) Fatigue Seventy Scale, the Multidimensional Assessment F). The VAS-F is an 18-item scale (5 items measure an energy
of Fatigue (Tack, 1991), and Pugh’s work (1993). These subscale and 13 items measure a fatigue subscale) that anchors
instruments address different aspects of fatigue; some address the measure of fatigue to the current measurement time. It has
more than one aspect. Thus, descriptions or characterizations of multiple items to characterize fatigue as it is presently being
fatigue, subjective feelings of distress associated with fatigue, experienced-for example, sleepy, fatigued, worn out, energetic,
presumed causes of fatigue, and consequences attributed to fatigue, lively, etc. Six of the 13 fatigue subscale items address behavioral
all appear in one or more of these instruments. With the exception manifestations of fatigue--e.g., moving my body is no effort at
of Rhoten’s Observation Checklist, all of these measures require all versus a tremendous chore. Lee reports Cronbach alphas for
self-assessment and self-reports. Piper’s measure assesses more the VAS-F ranged from .91-.96 in samples of 75 healthy subjects
than one aspect of fatigue through the identification of subscales and 57 sleep disorder individuals measured both before and after
and is exceptionally lengthy. Another scale actually combines, a night’s sleep. The fatigue and energy subscales correlated -.54
and perhaps confuses, descriptions (e.g., I am easily fatigued), among the normal sample and -.73 among the sleep disorder
causes (e.g., exercise brings on fatigue), and effects (e.g., fatigue sample. Concurrent validity was demonstrated by high correlations
interferes with my physical functioning) of fatigue in a single between the VAS-F subscales and the Stanford Sleepiness Scale
nine-item scale (Krupp et al., 1989). and the fatigue and vigor subscales of the POMS. The absolute
Each of these measures has advantages and disadvantages- values for most of these ranged from approximately .6 to just
largely tied to the purpose for which it was developed. over .8. All correlations carried the appropriate, expected sign.
Unfortunately, those who use these scales and sometimes scale Paired t-tests also suggested good sensitivity of this measure to
developers as well do not always carefully identify what it is about discriminate within subject changes (Lee et al., 1991). Others
fatigue they wish to measure: Its character? Its precursors and also have found this measure to discriminate within subject
causes? The effects of fatigue? Each can be addressed from a changes (Elek, Hudson, & Fleck, 1997). Lee reported plans to
physiological, psychosocial, cultural, or behavioral perspective. convert the visual analog format to a numeric rating scale (K. A.
Doing so in isolation, however, is both limiting and incomplete. Lee, personal communication, 1992) and this modification was
Proposing to study one aspect of fatigue, but using a measure that used in our studies. Numeric rating scales are less influenced by
taps a different aspect of fatigue, is even more problematic. eye-hand coordination problems and hand deformities, require
Thus, in view of the concerns about defining and measuring less time to complete, are easier to score for computer analyses,
fatigue, our center’s group discussions led us to identify salient and generally yield similar information to visual analog scales-
characteristics to assess when measuring fatigue. These are: (a) that is, quantified, increasing, monotonic function.
subjective quantification of fatigue, (b) subjective distress because Subjective quantification of fatigue also can be measured with
of fatigue, (c) subjective assessment of the impact of fatigue on the two-item subscale of the Multidimensional Assessment of
activities of daily living, (d) certain widely recognized correlates Fatigue (MAF) (Tack, 1991). These items ask for a rating of the
of fatigue, and (e) key biological parameters. No single measure degree to which a person has experienced fatigue in the past week
of fatigue adequately captures the complexity of the phenomenon. and how severe that fatigue was. Both questions address the notion
Rather, investigators interested in including a measurement of of quantifying fatigue from a global subjective perspective.

Volume 31, Number 1, First Quarter 1999 Image: journal of Nursing Scholarship 41
Fatigue

The MAF is brief and clearly distinguishes the characteristics the respondent’s ability to engage in a number of routine
of subjective quantification, distress, and effect. It is a revision activities. Indeed, a report of activity interferencemay be a more
of the longer and more detailed Piper Fatigue Scale. In addition sensitive measure for assessing changes in fatigue, or evaluating
to the two items that measure severity or subjective quantification, the success of an intervention, than the more abstract concept of
one item measures distress, 11 items measure interference with numerically assigning a “degree” of fatigue.
activities of daily living, and two focus on the timing of fatigue. Correlates offatigue, such as sleep and depression, constitute
Cronbach’s alpha was .93 when this measure was tested on a the fourth identified characteristic to assess when measuring
group of 133 individuals with rheumatoid arthritis (Belza, Henke, fatigue. Obtaining a measure of sleep proximate to the time that
Yelin, Epstein, & Gilliss, 1993). Unfortunately, this reliability fatigue measures are taken is important for factoring in, or
assessment appears to have been calculated using all 16 items, controlling, the effect of sleep disturbance and quality on
rather than assessing each conceptually distinct subscale measures of fatigue. Assessment of the previous night’s sleep
separately. This approach gives undue weight to the subscale may be measured with the VerradSnyder-Halpem (VSH) Sleep
with the most items and fails to acknowledge the importance of Scale (Snyder-Halpern & Verran, 1987; Verran & Snyder-
the conceptual distinctions among the subscales. We recommend Halpern, 1988). It is a 15-item instrument, originally designed
that investigators either use the subscales, rather than individual in a visual analog format. A 16th item is created by summing
items, in calculating an overall reliability of this measure; or two other items. The scale specifically refers to the previous
calculate reliablilities of the subscales separately. night’s sleep and contains three separate scales measuring sleep
Belza and colleagues (1993) report correlations of the MAF disturbance (seven items), effectiveness (five items) and
with the fatigue subscale of the Profile of Mood States (POMS) supplementation (four items). According to the scales’ authors,
that established convergent validity, and with the POMS vigor empirical testing does not support using a single total score. The
subscale that established divergent validity. The MAF uses a 1- VSH Sleep Scale has been tested in several populations including
week time referent for its ratings. This allows for a period long healthy adults, adults with insomnia, and hospitalized patients
enough to capture the respondent’s usual and persistent level of in the United States and Taiwan. Theta coefficients across
fatigue, yet is short enough to not be overly compromised by samples indicate adequate reliability of the disturbance scale
recall problems. Belza (formerly Tack) reported plans to convert (32-.86), moderate reliability for the effectiveness scale (.72-
the visual analog scales of the MAF to 10-point numeric rating .81), and some inconsistency for the supplementationscale (.68-
scales (B. Belza, personal communication, 1992) and this .84 for the ill adult samples, .45 for the healthy adult sample).
modification was adopted for our studies. We obtained permission to convert the VSH Sleep Scale to a
The single distress item of the MAF may be used to measure numeric rating scale consistent with our other measures and for
subjective distress, the second characteristicof fatigue. This item the other advantages of numeric rating scales identified above.
simply asks the rater to report to what degree fatigue has caused Depression is the other critically important correlate requiring
distress. Youngblut and Casper (1993) offer compelling some assessment in any study of fatigue. Because fatigue is a
arguments for the validity of single-itemmeasures of phenomena well-recognized symptom of depression (American Psychiatric
such as symptom intensity or distress. Association, 1994), it is important that studies have a standard
Subjective distress because of fatigue also may be measured measure of mood disturbance in order to factor in, or control,
with the Symptom Distress Scale (SDS) (McCorkle & Young, the effect of depression on measures of fatigue. The Profile of
1978).The SDS consists of 13 items about symptoms (e.g., pain, Mood States (POMS) is a well-established measure of mood
nausea, tiredness) that are rated on a five point scale reflecting disturbance consisting of six subscales: depression, tension,
degrees of distress ranging from the symptom being absent to anger, confusion, fatigue, and vigor. The Short Form of the Profile
the symptom being at its worst. It has been used with many of Mood States (POMS-SF) (McNair,Lorr & Droppleman, 1992)
different clinical populations and in various settings. Reliability consists of 30 of the 65 items in the original POMS-five items
coefficient alphas are reported between .79 and .89 (McCorkle, for each of the six subscales. The authors report alpha reliablities
1987).Convergent validity of the SDS has been demonstratedby a for the POMS-SF subscales from three samples (reported
high correlation (.90) with Ware’s Health Perception Questionnaire. separately for men and women) are as follows: Depression (31-
The SDS has discriminated between patients and controls and .91), Tension (.73-.93), Anger (34-.91), Confusion (.67-.83),
demonstrated sensitivityto changes in patients (McCorkle, 1987). Fatigue (.86-.95), and Vigor (.87-.93), (McNair, Lorr, &
Kukull, McCorkle, and Driever (1986) also found the SDS Droppleman, 1992). The reduced time needed to complete the
discriminates among types of patients and demonstrates stability POMS-SF, and the comparably high measures of internal
in patients whose conditions remain stable. The high correlations consistency were the primary reasons we selected this version
between fatigue and several of the other symptoms (mood, appetite, over the original 65 item POMS for our studies.
insomnia), and the potential for confounding fatigue with other Another important consideration for our center in selecting
symptomsexperiencedby different clinical populations, made this the POMS-SF over other measures of depression or mood
a desirable tool to use with all participants in our center’s studies. disturbance is that the fatigue and vigor subscales of the POMS
The effect offatigue on activities of daily living is the third are the standards that most developers of new measures of fatigue
important characteristic that investigators may be interested in use to establish criterion or concurrent validity of their scales.
measuring.As described above, the MAF has an 11-itemsubscale Because it seemed important to obtain the one measure of fatigue
that specifically asks to what degree fatigue has interfered with used to validate other measures, selecting the POMS-SF provided

48 Image:Journa/ of Nursing Scholarship Volume 31, Number 1, First Quarter 1999

 Fatigue

dual advantage. However, this subsequently raised an interesting furthering knowledge about fatigue. This presents important
issue. Because the POMS is primarily a measure of mood considerations for the study of fatigue.
disturbance, it is likely that the fatigue and vigor subscales may Distinctions about fatigue and its various measures are all the
more closely approximate mood disturbance, or depression, more important given the subjective nature of fatigue. As with
aspects of fatigue than the other salient characteristics discussed any subjective phenomenon, individual differences on such things
here. Given our arguments about the distinct salient as response biases and expectations about how one does feel,
characteristics of fatigue, the POMS fatigue and vigor subscales, versus how one should feel, may significantly influence reports
as part of a clear measure of mood disturbance, may not be the of fatigue. Further, little has been done to investigate the role that
best choices for criterion or concurrent validity of other measures potential discrepancies in expectations-between how one does
of fatigue. Moreover, when designing specific studies, feel and how one thinks one should feel-play in self-reports of
investigators should consider the extent to which fatigue is fatigue. It may be that examining expectation discrepancies will
confounded in the measure of depression, or the extent to which be more fruitful than pursuing absolute measures of fatigue.
depression is confounded in measures of fatigue. Conceptualizing fatigue as we have-as an awareness of a
The fifth and last characteristic necessary for assessing and decreased capacity for physical or mental activity because of an
measuring fatigue is comprised of key biological parameters. imbalance in the availability, utilization, or restoration of resources
Because no clear biological markers for fatigue have been needed to perform activity in the context of a self-monitoring,
identified, we chose to obtain common blood tests in our studies. self-regulating framework-supports a focus on such expectation
At the very least, these tests could serve a ‘rule out’ function, discrepancies. Not only would expectations affect the awareness
helping to identify suspected pathological states associated with of a decreased capacity for activity, but expectations also would
fatigue such as hypothyroidism, renal failure, or anemia. A blood affect the perception of a resource imbalance. For example, with
chemistry profile provides information about fluid and increased age or in chronic health conditions, people may alter
electrolyte status, renal function, liver function, and metabolic their expectations about how they should feel or may adapt and
status. Hemoglobin and hematocrit values, as part of a complete adjust to different expectations. From the perspective of our
blood count, reflect the adequacy of oxygen-carrying capacity. framework, these people may learn how to better monitor and
Because fatigue has been associated with activation of the regulate the use and restoration of their resources such that they
immune system in infections as well as in chronic fatigue do not perceive as much imbalance and consequently may report
syndrome, white cell counts with differential are additional less fatigue than younger or otherwise healthier persons.
useful data to obtain. Normal thyroid function is essential for The historical uncertainties with defining and measuring fatigue
normal metabolic functioning and because thyroid pathology is may be, in part, because of inattention to the differing
associated with fatigue, obtaining measures of thyroid function characteristics or aspects of fatigue. Future studies of fatigue must
also should be considered. Specific clinical populations under be more sensitive to how fatigue is defined and measured. Our
study may dictate measurement of other specific biological researchers in the Center for Biobehavioral Studies of Fatigue
parameters. For example, interleukin 6 and C-reactive protein Management have begun an exploration of fatigue in several
may be obtained in a study of people with rheumatoid arthritis, populations using common instrumentation and multiple measures
and glycosylated hemoglobin and fibrinogen might be obtained of fatigue-both self-report and biological measures-to
in a study of people with diabetes. investigate more fully the different characteristics of fatigue. The
We anticipate that obtaining data on possible biological development of such a data base is particularly important for the
correlates of fatigue will contribute to a better understanding study of fatigue and to characterize and understand fatigue as a
and diagnosis of fatigue by providing empirical measures that truly biobehavioral human experience. More studies using this
may vary with the severity and etiology of fatigue across clinical strategy are needed to advance knowledge about fatigue and,
populations. Also, if biological correlates of fatigue can be ultimately, its management.
identified, they would be useful in monitoring the effectiveness
of interventions to relieve or attenuate fatigue.
References
Implications of Fatigue Characteristics
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mental disorders (4th ed.). Washington, DC:Author.
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and yet may all be valid. For example, an intervention may have Belza, B., Henke, C., Yelin, E., Epstein, W., & GiUiss, C. (1993). Correlates of
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Volume 31, Number 1, First Quarter 1999 Image: journal of Nursing Scholarship 49
 ~

Elek, S.M., Hudson, D.B., & Fleck, M.O. (1997). Expectant parents’experience
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or friends. Clinicians can assist patients in scheduling rest periods so of rheumatoid arthritis pain and fatigue: Examining momentary reports and
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Nursing Research, 16,459-465.

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