1 Introduction

Background Dengue is the widely spreading mosquito borne arboviral illness caused by four different types of dengue viruses ( DENV1, DENV2, DENV3,DENV4 ) owned by Flavivirdae family found in tropical and sub-tropical areas during monsoon.

Infection is caused by infected Aedes aegypti and Aedes albopictus that are female mosquito generally feed on indoor and outdoor during daytime only. On average an individual has tendency of four times to get infected by four different DENV.

Incubation period is about 3-7 days on average one week depends upon individual’s immunity system. Patient present with flu-like illness accompanied by severe headache, high graded fever (103-104 degree), skin eczema that leads to itching and irritation. These symptoms gradually combined by joints stiffness, extreme muscle ache. In other word’s dengue is also known as “BREAKBONE FEVER”.

In more severe cases symptoms progress to DENGUE GEMORRHAGIC FEVER (DHF) which include high blood pressure, vomiting, diarrhea, abdominal pain and low cognitive level contribute to dengue shock.  For treatment of this infection no efficacious antiviral drugs are available. Treatment is given according to the hematological monitoring.

Other fevers come, stay and recover but dengue leaves it footprints that will spook for long. Post dengue fatigue syndrome, neuritis, myalgia/myositis, polyarthralgia, hypokalemia paralysis, excessive weight loss, these all are the common post dengue complications people dealing with.

1.1  POST INFECTIOUS FATIGUE SYNDROME- PIFS

The postinfectious fatigue syndrome is defined as umbrella for group of symptoms, mostly associated from muscular and neurological characteristics.

Spectrum of neurological symptoms available in literatures compose of neuritis, weakness in limbs as paresthesia, acute- macular neuropathies and severe headache. Various muscular symptoms involved such as myositis, myalgia, hypokalemic paralysis and general body weakness may include activity limitation without or with pain. Although pain is more evident when patient do daily living activity.

In post dengue fatigue syndrome infections that are caused bacteria, viruses and parasites more often give rise to severe and prolonged fatigue which invited the muscular and neurological symptoms interfere with functional activity. Sudden on set of flu like illness may resolve within 2-3 weeks but develops chronic illness which takes months to year to resolve.

Progression of the illness varies from patient to patient as a consequence 50% of decline in ADL’s for more than 6 months termed as PIFS.

1.2  MECHANISM OF FATIGUE

The exact evident base mechanism for PDFS is unknown.

The PIFS is outcome arise from decline in systemic immune system (induced by dengue virus). Patient feel tiredness, uneasy with low cognitive abilities may be result of certain toxin chemicals released from body accumulated in brain causing fatigue. In several researches it is assumed that production lactic acid is only cause of fatigue syndrome. Although in recent articles it was stated that lactic acid act as fatigue preventing medium. It has been suggested that interplay of the neurological, musculoskeletal, endocrinal and immunological system act through the hypothalamic-pituitary-adrenal axis give rise to clinical presentation of fatigue in dengue infected patient.

1.3  Myositis-

skeletal inflammation is known as myositis which is outcome of viral infectious disease. Clinical presentation of myositis is asymmetrical motor weakness of upper and lower limb from sudden to progressive in nature leads to trunk weakness and sometimes lung failure but the exact cause of myositis is unknown. Decrease metabolic rate, muscle edema and change in endothelial tissues are tends to be responsible for muscle dysfunction in myositis. Release of cytokines from viremia causes extreme inflammation and later destruction to muscle fibers.

1.4  Myalgia

Myalgia refers to stiffness, muscle swelling, pain. Disseminate myalgia is one of the major symptoms of fever associated with dengue recorded during initial phase of illness. Most of the muscle ache most frequently affects the lower back region, pain in arm and leg muscles. Muscle Contraction can be felt by the patient and feel difficulty to walk per square distance because of severe muscle ache. Exact cause or mechanism of myalgia is still not known but it is assumed that it is because of inflammatory changes within muscle fibers tends to caused muscle pain.

1.5  Need of the Study  

 There are very less number of studies conducted on post dengue fatigue syndrome. Studies are need to conduct to know better rehabilitation protocol for PDFS

2 Review of Literature

Post-dengue fatigue syndrome (PDFS) is not atypical phenomenon of dengue viral infection. The PDFS has wide spectrum of Musculo-skeletal and neurological features. It was observed in most of the hospitalized patients with dengue.

The exact pathogenesis is not known, but this complex interaction of immune, endocrine, musculoskeletal and neurological system act through the hypothalamic-pituitary-adrenal axis causing clinical features of fatigue in dengue.

The database, Google scholar was searched using the term of „dengue fatigue‟ or „Post dengue fatigue‟, or „post viral fatigue‟ and „post infectious fatigue‟ in any field or after dengue with no data limits. After exclusion of double entries, I assessed all publications.

In 2006 author D. Maquet published Chronic fatigue syndrome: a systematic review article in which he concluded that graded exercises were appear to be greater factor for relieving the fatigue syndrome.

In 2012, Deborah Van Cauwenbergh published article Based on the available evidence, exercise therapy for people with CFS should be aerobic and must comprise of 10–11 sessions. A time-contingent approach is preferred over a symptom-contingent way of exercising. In addition, people with CFS can perform home exercises five times a week with an initial duration  of 5–15 min per exercise session. The exercise duration can be gradually increased up to 30 min.

Aug, 2017, Umakanth M, published article about Post dengue fatigue syndrome He advice about graded exercise is essential. “Start low and go slow” is the correct advice for activities and exercise. The exercises need to be followed by a rest period at a 1:3 ratio (i.e., 10 minutes of exercise: 30 minutes of rest).

In August 22, 2018, author  Maheswaran Umakanth published his in which he concluded that In future, more studies about PDFS manifestations, evaluation, and management are needed to better understand this post infectious fatigue in dengue infection.

 08 Oct. 2019, World Journal of Pharmaceutical Research Dr. R. Ganesan write about  EXPANDED DENGUE SYNDROME: A CASE REPORT in which he observed that the supported antibiotic treatment and physiotherapy improved overall condition of the patient

2.1 Justification

Dengue fever has wide spread clinical presentations. Symptoms associated with musculoskeletal are difficult to manage. Patient feel inactive, disturbed sleep pattern, giddiness although exact known cause of PDFS is not known. It is assumed to be it is because of accumulation of  cytokines in brains which causes affects mental abilities and poor judgement. Dengue severity is not depend upon age or gender. In future several studies need to be conducted to know the best rehabilitation protocol to improve the overall condition of the patients.

2.5 Research Gap Identified

Researches has been conducted but still the exact physical therapy rehabilitation protocol for the post dengue fatigue syndrome has noy yet been clarified. In this work we will address the subjects with post dengue fatigue syndrome with effective rehabilitation programme. Therefore, the purpose of the study is to determine the effects of combination of graded exercises, Jacobson exercises and aerobic exercises in post dengue fatigue syndrome.

2.6 Conceptual Framework   

Current rehabilitation programs focus not only on strengthening exercises but also on improving patient’s dependent level.

: The conceptual framework for evaluating the effects of  graded exercises, Jacobson exercises, and aerobic exercise on individual health

2.7 Objective

Ø   Overall objective

To Evaluate and management chronic fatigue syndrome in patent with post dengue fatigue syndrome.   

Ø  Specific objective:

Ø  To assess clinical effectiveness of physiotherapeutic management in improving fatigue syndrome

Ø  To evaluate the clinical effectiveness of physiotherapeutic management in improving health related quality of life

2.8  Research Question

Ø  Whether graded exercises, Jacobson exercises and aerobic exercises improves the post dengue chronic fatigue syndrome.

2.9  Hypothesis

2.9.1 Alternate hypothesis

·         There will be statistically more significant effect of graded exercises, Jacobson exercises and aerobic exercises in combination  in improving post dengue fatigue syndrome.

·       There will be statistically more significant effect of graded exercises in improving the post dengue fatigue syndrome

2.9.2 Null Hypothesis

·         Graded exercises, Jacobson exercises and aerobic exercises in combination a are less statistically effective than graded exercises on post dengue chronic fatigue syndrome.

Objective outcome measures: the main aim of this study is to see the effect of the combination of three exercises (graded exercise, Jacobson exercise and aerobic exercise)  in post dengue chronic fatigue

3. Methodology

3.1 Adapted Research Paradigm

The present research work adopts positivistic paradigm in backing up the quantitative research. Here, the data is assembled through understanding and observation and it is totally measured by using the systems for quantitative techniques like the quantifiable examination, tests and reviews and so on. The positivism help in promoting continuation reality of the world and its significance is based on the measurement of correlating factors associated in order to promote the insight on reality. More over positivism is recognized to be as quantitative stratagem and so it is promisingly suitable for the proposed study topic

3.2 Research Approach

This research work is amended with deductive approach for the verbalization of hypothesis and provision of verdicts accordingly.

3.2.1 Research Design

This study comprises of interventional experimental design under the randomized controlled trial.

3.2.2 Sampling Design

A simple random sampling method will be adopted for collection of samples.

3.2.3 Recruitment Source

All the data will be recruited from lovely professional university  

3.2.4 Sampling method

A simple random sampling method will be adopted

3.2.5     Sample size calculation

The sample size will be calculated on the basis of the formula for comparison of mean of one group using functional activity as the primary outcome variable  and the final sample size is 120.

3.2.6 Study Duration- 1 years

3.2.7 Treatment Duration- 4 weeks

3.3 Selection Criteria- 

3.3.1 Inclusion Criteria

Ø  Participants diagnosed with dengue by physician

Ø  Patients who having age between 20- 60 year age male and female both.

Ø  Participants those will be agreed with the purpose of this study and agree to sign in the consent form.

3.3.2 Exclusion Criteria       

Ø  Participants those who will not sign the consent form. 

Ø  Patients with severe illness like cardiac, renal, neurological.

Ø  Patients who are not affected with dengue or least affected with dengue syndrome.

Ø  Patients who have already took physiotherapy rehabilitation for dengue.

Ø  Patients who are above age of 65 years.

3.3      Study Procedure

3.3.1 Group allocation

The entire participant will be randomly divided into two groups by using lottery method namely group A and Group B. Group A will receive conventional rehabilitation Protocol and group B will receive graded relaxation exercises, Jacobson exercises and aerobic exercises.

3.3.2 Outcome Measures

1.      Subjective Outcome Measure

2.      syndrome

3.3.3 Intervention  

3.3.3.1 Graded Exercise Therapy

The main objectives of GET are to improve a patient’s functional ability to approach physical activity by counteracting/switching the overall physical inactivity of patient and exercise fluctuation associated to prolonged immobility. The baseline foundation of the GET is to improve the all daily living activities of an individual facing chronic fatigue syndrome to make them independent to perform ADL’s by there own.

Main indications for GET are as follow- myalgia(muscle ache), pain in joints (more than 2 joints), Headache or to improve concentration level, improve sleep pattern.

3.3.3.2 Jacobson Relaxation Exercise

 it is a therapy which emphasis on contracting and relaxing the specific muscle groups of body in a particular sequence. By engaging the specific muscle group patient participate more actively and it help in promoting good mental health and relieving the stress. It improves sleep as well and reduces blood pressure in patient with hypertension. It involves specifically feet, abdomen, shoulder and neck muscle group.

3.3.3.3Aerobic exercises

 It involves exercises from low intensity to high intensity to improve overall ability of individual to make them independent. It generally involves large muscle groups like arm, forearm, leg rom exercises. Aerobic exercises are also very helpful to increase stamina and strength. it is very helpful in making patient independent as well active.

3.4 Ethical Approval

The entire participant will be obtained from the institutional ethical approval committee as well from lovely professional university. 

 3.5 CTRI registration

The study will be register under clinical trial registration of India after Ethical Approval  

 3.6 Statistical analysis

Statistical analysis will be carried out through SPSS 21 and all the data will be saved in the Microsoft Excel 2010. Paired and un-paired t-test will be used to compare variables.

REFERENCES

References -

1.      Umakanth, M. (2017). Post dengue fatigue syndrome. International Journal of Current Medical and Pharmaceutical, 3, 2230-2231.

2.      Garg, R. K., Malhotra, H. S., Jain, A., & Malhotra, K. P. (2015). Dengue-associated neuromuscular complications. Neurology India, 63(4), 497.

3.      Mallhi, T. H., Khan, Y. H., Adnan, A. S., Tanveer, N., & Aftab, R. A. (2021). Dengue-Induced Musculoskeletal Complications. In Expanded Dengue Syndrome (pp. 97-114). Springer, Singapore.

4.      Wilder-Smith, A., & Rupali, P. (2019). Estimating the dengue burden in India. The Lancet Global Health, 7(8), e988-e989.

5.      Li, G. H., Ning, Z. J., Liu, Y. M., & Li, X. H. (2017). Neurological manifestations of dengue infection. Frontiers in cellular and infection microbiology, 7, 449.

6.      Maquet, D., Demoulin, C., & Crielaard, J. M. (2006, July). Chronic fatigue syndrome: a systematic review. In Annales de réadaptation et de médecine physique (Vol. 49, No. 6, pp. 418-427). Elsevier Masson.

7.      Van Cauwenbergh, D., De Kooning, M., Ickmans, K., & Nijs, J. (2012). How to exercise people with chronic fatigue syndrome: evidence‐based practice guidelines. European journal of clinical investigation, 42(10), 1136-1144.

8.      Umakanth, M. (2017). Post dengue fatigue syndrome. International Journal of Current Medical and Pharmaceutical, 3, 2230-2231.

9.      Umakanth, M. (2018). Post dengue fatigue syndrome (PDFS) among dengue IgM-antibody positive patients at Batticaloa Teaching Hospital, Sri Lanka. Open Access Library Journal, 5(8), 1-6.

10.  Ganesan, R., Lakshmi, S., & Riya Raju, G. (2019). EXPANDED DENGUE SYNDROME: A CASE REPORT

11.  Fulcher, K. Y., & White, P. D. (1997). Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. Bmj, 314(7095), 1647.