Fatigue is a common subjective experience of having reduced capacity to a common physiologic phenomenon as the result of mental or physical exertion 1. It describes reduced capacity to sustain force or power output, reduced capacity to perform multiple tasks over time and simply a subjective experience of feeling exhausted, tired, weak or having lack of energy 2. It can occur without preceding exercise and without associations with known illnesses or diseases, as the fatigue is a disease in itself 3. Fatigue is expressed in related concepts such as 'overwhelmingly tired', 'exhausted', 'weakness', 'lassitude', 'feeble lethargy', 'lack of energy', 'wrung out' and 'mentally tired' 3. Persistent fatigue can cause a lack of mental clarity, difficulty in concentrating and in some cases, it causes memory loss. It is the body's way of signalling need for rest and sleep 4.

Fatigue is characterized by a profound lack of energy, feelings of muscle weakness and slowed movements or central nervous system reactions 4. It is triggered by stress, medication, overwork, or mental and physical illness or disease 4. It might be the result of a health undermining way of living, characterized by too much burdening, too less rest, insufficient food, the use of substances, or family dynamics 3.

On the basis of principles of cellular nutrition and metabolic-control logic there are 5 metabolic causes of fatigue. Those are; depletion of the phosphor-creatine concentration in muscle, accumulation of proteins in muscle, depletion of glycogen in muscle, a decrease in the blood glucose concentration, an increase in the plasma concentration ratio of free tryptophan to branched-chain amino acids 5.

Fatigue is a multifaceted. Many studies are done about the factors that causing fatigue .That includes; Physical inactivity, mental disturbances, sleep disturbances, improper diet, underlying disease, heavy exertion. Fatigue is also a nonspecific symptom in many medical conditions such as chronic inflammatory conditions, bacterial or viral infections, or autoimmune illnesses; and Psychiatric disorders such as major depression, anxiety disorders, and Somatoform disorders 4.

Physical inactivity is a major contributing factor to the increased fatigability. De-conditioning as a result of restricted Physical activity results in large decreases in muscle mass and strength, as well as increased fatigability due to changes in muscle metabolism. Physical activity potentially could be related to a reduced risk of feelings of low energy and fatigue in the general population. Individuals increase physical activity; they also increase the frequency of feelings of energy and decrease the frequency of feelings of fatigue 1.

Although Physical activity is effective in reducing fatigue, too much physical exhaustion can also lead to fatigue. Exhaustion can be defined as extreme fatigue, a state in which an individual may exceed his/her physiological limits and then experience a ‘‘catastrophic’’ failure of homeostasis 6.

Mental disturbance which includes; stress, anxiety, depression and other psychological factors are also one of the leading causes of fatigue. High levels of stress and fatigue are associated with depression and anxiety, decreased Psychological and Physical well-being and a reduced quality of life. Both stress and fatigue as factors that together create negative effects, they are distinct psychological entities 7.

Adequate sleep is important for better cognitive performance and also to avoid health problems and psychiatric disorders 8. Sleep problems are highly prevalent in many populations. Subjective sleep quality can account for fatigue more than quantitative sleep measures, such as sleep latency, nocturnal awakenings and early morning arousals 9.

The determinant factors for fatigue will depend on nutrition also. A number of studies have documented the adverse impact of hunger on the academic, behavioural, physical and mental health of students. Hungry adolescents suffer from two to four times as many health problems, such as fatigue, headaches, irritability, inability to concentrate etc. Hunger is a common experience reported by adolescents. It affects health and academic performance 10.

Pain is also found to one of the main causes of fatigue. There is a close relationship that exists between muscle pain and fatigue. Pain and fatigue may occur together during sustained exhausting muscle contractions, particularly as the limit of endurance is approached. Both can play a significant role in reducing muscle performance during exercise 11.

Based on studies, majority of these factors are found to be present in student population. Numerous studies have examined how students experience stress in professional health education. Medical, nursing, dental, pharmacy, occupational therapy, and physical therapy students have reported high levels of perceived stress 7.

Physiotherapy being one of the flourishing courses in India as well as globally, it is both physically and mentally demanding when compared to many other medical and paramedical courses. Typical Physiotherapy practices involve repeated lifting, bending, twisting, reaching, and performing manual therapy. The manual procedures often involve forward flexion, lateral flexion, and rotation. Work‑ related physical stresses to the hand, wrist, neck, and shoulder lead to injuries and have been identified through a number of cross-sectional epidemiologic studies 12. Considering all this, course evaluation instruments administered within universities indicate that students describe their undergraduate education as demanding and academic requirements as stressful 13.

The available evidence indicates high levels of academic stress among Physiotherapy students 13. All students reported that academic issues were the greatest sources of stress, and this was significantly greater than personal and financial sources of stress. Student stress often stems from academic load, classroom environment, faculty interaction, illness, and emotional concerns outside of the classroom or clinic 7.

Zhang et al. showed that students experience high levels of stress while performing an objective clinical examination, and these stress levels negatively impact their performance and eventually lead to fatigue. This in turn negatively impacted academic experience and professional development. This continues as a vicious cycle 7.

A study done in 2016, assessed to find the sleep habits and disorders in the adolescent and adult paramedical personnel among which were Physiotherapy students. On analysis of the data on the basis of quality of sleep, it was found that 76% of BPT students used to feel sleepy and unrefreshed on awakening. 18% of BPT students felt chronically sleepy 8.

As students progress through medical courses, they are faced with multiple challenges such as examination pressures, fear of failure, intense competition among peers, lack of leisure time, and perceived mistreatment ; all of which may subject medical students to academic, personal and social challenges. Students suffering from depressive and anxiety symptoms often have “empathy fatigue” and feel emotionally detached from their patients with professional and ethical consequences that may compromise patient safety and care. This is also true for Physiotherapy students 14.

Medical education is intended to prepare graduates for a career that is personally, professionally, and intellectually rewarding. But this growth gets obstructed when students are mentally and physically drawn to fatigue level. As these students will become future health care providers, it is important for institutions to know the fatigue level of their students so that proper strategies can be developed to overcome it 14. Fatigue is subjective feeling and its ill effect are frequently seen in many ways. It leads to task performance decrement, cognitive impairment, sleep problem, and emotional disturbance. In students it leads to decline attention deficit, academic performance, negative health outcome and refusal to attend the class. Medical, nursing, dental, pharmacy, occupational therapy and physiotherapy students reported high level of stress that leads to fatigue. And till date no studies have been done to know the prevalence of fatigue among physiotherapy students.

Table 1 shows descriptive statistics for demographic data

Table 2 Inferential statistics

Table 3 Inferential statistics

Data were collected using online forms . A total of 207 data were collected. Among them 37 students were excluded on the basis of selection criteria. A total of 160 subjects (44 males, 116 females) with mean age of (21.54 ± 1.741) were recruited in our study. The data including demographic and for all parameters were recorded on online data collection form and then converted it into tabular form. The data was entered into the software SPSS 16(Statistical Package for Social Sciences) in windows. To examine the baseline characteristics of the subjects, we analyzed the frequency and descriptive statistics and then it was subjected for finding of normality. Inferential analysis was carried out by using Chi- Square test for the outcomes of VAS- F. The result of the present study showed that the demographic data were not statistically significant (p>0.05). Gender and batch were not significant (p>0.05). The prevalence of fatigue was; mild 27.3%,moderate 34.2% and severe 37.9% .

Fatigue is a universal symptom not only associated with most acute and chronic illnesses, but also with normal healthy functioning in everyday life 21, 22. It impacts negatively on work performance, daily functioning, family and social life and other relationship 23. It affects all kind of occupation and in our study, we focused on physiotherapy student 24, 25.

Nowadays, we can observe an increasing demand for physiotherapist services, as the number of patients and working hours is increasing 26, 27. As a result, physiotherapists experience growing work-related load and fatigue so assessment of fatigue in physiotherapists is important both in managing the negative consequences of fatigue, as well as to prevent chronic fatigue 28, 29.

Literature revealed the physical fatigue, cognitive weariness and global burnout scores were higher in physiotherapists with higher workload and this is reinforced by the significant association between daily working hours and number of patients treated 30. Another literature stated that physiotherapists spent largest amount of time with the patient, compared to doctors and nurses 28 36

Literature attributed that there was direct relationship between the presence of musculoskeletal discomfort/pain and fatigue. It stated that holding a static and awkward posture for long periods during the work could lead to discomfort/pain and chronic fatigue [37] and the therapist are mostly involved in many discomfort position.

Work like Performing manual orthopaedic techniques, lifting or transferring dependent patients, assisting patients during gait activities, carrying, lifting, or moving heavy materials or equipment, unanticipated sudden movements or falls by patient, applying modalities, performing repetitive tasks, responding to an unanticipated or sudden movement by patient and working in the same position for long periods are factors prone to cause fatigue 29, 31.

Some work related issues like Performing the same task over and over, treating a large number of patients in one day, working scheduling, not enough rest breaks during the day, personal work factors like working at or near your physical limits, continuing to work when injured or hurt, inadequate training in injury prevention and working when physically fatigued are lead to cause more fatigue. Some repeated activities like performing overhead activities, bending/twisting, reaching, climbing stairs and squatting also cause fatigue 29, 31. A therapist needs to be sufficiently focused, engaged and motivated at work. It is same for a student 28. They have to focus on their study, clinical classes and also in treating patient. Literature stated university students are often faced with study stress, resulting from high study demands, and concern about academic grades. The prevalence of study-related fatigue, and its negative impact on health and on academic performance. Both psychological and physiological working mechanisms may underlie potential positive effects of exercise on study-related fatigue [38].

Some associated factors are responsible for causing fatigue; as physical activity, stress, depression, anxiety, sleep disturbance, inadequate nutrition, underlying disease & heavy exertion. Based on studies, majority of these factors are found to be present in student population also. Several literatures has been published on this statement. In current study we described these factors 1, 4, 6, 7, 9, 10, 11.

On gender basis fatigue affects on both group. In our study we took both male and female student, however the proportion of females was much higher in our study comparative to male as per table 2. It’s because of many causative factors like thyroid problems, heart disease, vitamin D deficiency, Iron deficiency, sleep apnea, emotional exhaustion and lack of sleep. W.Wang et al stated that excessive fatigue and iron deficiency are common complications in young women 32.

Numerous studies have identified prevalence of fatigue among different professional like drivers, foresters, pilots, air traffic controllers and marine traffic controllers. Another group studied included medicine-related jobs, with studies on both doctors and nurses. The available literature lacked a study on physiotherapists and there was no study among physiotherapy student population 28. Current study focused on prevalence of fatigue among physiotherapy students in Mangalore and the prevalence of fatigue in the last year was; mild - 27.3 %, moderate - 34.2 % & sever- 37.9 % per 160 physiotherapy students in college of Mangalore.

Literature reveals assessment of subjective fatigue with the Japanese questionnaire in Polish Physiotherapists and found highest level of fatigue with decrease in activity (47%) after work, the decrease in motivation was 42%, physical fatigue was 38% and general fatigue was 42% 28.