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FATIGUE

By Rosamund Vallings MB BS

The dictionary definition of fatigue describes weariness from mental or bodily exertion. This defines “normal” fatigue, but in medical practice we frequently see patients who are fatigued as a result of illness. In fact fatigue in a routine day in general practice is reported by 70% of people of all ages. We could therefore consider fatigue as along a continuum from healthy fatigue through to disease-related fatigue. Healthy fatigue resolves with nutrition, rest and sleep.

Chemical changes occur in the cells throughout the body during physical or mental activity and the cells will correct their imbalances at a variable rate according to how we treat them. Sometimes however, such as during illness, there may be a “blockage” or “sluggishness” of the natural healing processes involved in overcoming fatigue. Any cellular activity needs energy and nourishment to function properly. No cell lies idle and even in deep sleep, cellular activity is ticking over keeping the system functioning and restoring itself. Every cell needs oxygen, glucose and a cocktail of chemicals to maintain efficiency. Good clean air and correct breathing patterns, ensure an oxygen supply, glucose and other minerals, vitamins etc will be obtained through nutrition and metabolism. Some of the essential chemicals are self manufactured, others are absorbed and utilised directly.

During any illness a lot of energy is needed for combat and healing. The circulation may therefore be channelled to the parts of the body most in need, leaving other areas compromised. It is easy to observe this activity if you think of a simple boil under the skin. The area becomes red and swollen as the circulation pumps white combat cells and other immune chemicals to the site of infection. Toxins also need removal and a good circulation is therefore required to take away this waste.

Our cells thrive on use, and if we do not use our bodies for the activities for which they are destined, or if we abuse them, we quickly notice that we become unfit, sluggish and unhealthy. Nourishing the body correctly, keeping a good circulation established and having adequate rest is the surest way of maintaining good health.

Fatigue will be associated with most illnesses, and the more severe the illness the greater the fatigue is likely to be. Unhealthy fatigue will also occur due to inadequate sleep, poor diet, stress, poor ventilation, boredom etc. It is really a matter of trying to maintain a healthy balance. The cells are constantly trying to correct their own imbalances with chemical interchange, and we need to do all we can to make these processes easier.

Fatigue associated with illness can be classified as acute (sudden onset) or chronic (prolonged). Acute fatigue is experienced very obviously in viral infections (eg influenza) or following injury (eg concussion). Chronic fatigue however will occur in association with many illnesses both mental and physical. Fatigue is a major component of diseases such as SLE (lupus), rheumatoid arthritis, MS, emphysema, depression and cancer, to name just a few. Endocrine (glandular) imbalances also frequently account for chronic fatigue, examples being thyroid deficiency, diabetes, adrenal insufficiency etc.

Many people who are chronically fatigued do wonder if they are suffering from Chronic Fatigue Syndrome (CFS), which is a separate disease entity. CFS, which usually follows a viral illness, can only be diagnosed according to very strict criteria once other causes of chronic fatigue have been eliminated. A diagnosis cannot be made until the illness has lasted 6 months, at which time the fatigue (often very severe) can now be classified as chronic. A number of other associated symptoms have to be present. One of the particular characteristics of this illness, is that the fatigue following exercise is not alleviated by rest. The person has to go through an exhaustive battery of tests to establish this diagnosis. Tests may involve checks of the blood, urine, endocrine, rheumatological, neurological and psychological systems. Most with this condition also suffer from a non-restorative sleep pattern and chronic pain, both of which worsen the fatigue.

So how do we best manage fatigue. Understanding the cause is obviously the most important aspect of any management strategy. Attention to lifestyle change will improve many of the causes of fatigue due to issues such as stress, poor nutrition, lack of exercise etc. Some of the disease related causes can be corrected (eg anaemia, hormonal deficiency, depression). Many of the underlying causes of fatigue however have no specific cure and need to be treated efficiently, alleviating as many symptoms as possible to enhance the chance of a better quality of life. Both patient and doctor need to work together as a team often with other health professionals and family members.

There are 7 main strategies forming a kind of “package deal” to help overcome fatigue.

1. Stress management.

   Stress is part of our lives and is implicated to some extent in aggravating every illness. Even recovery from the common cold can be more prolonged in stressed individuals, so developing good stress management approaches will be beneficial to everyone. It is the bottled up stress which is so damaging, so finding a person to talk to or trying to somehow work the stress out of the system is vital. Cognitive behavioural therapy has been shown to help most people with chronic health problems. Stress leads to anxiety, depression, poor sleep and many physical symptoms, and will be worsened by pain and isolation. Those with a support person or network always do better. Learning some good relaxation approaches such as meditation, self hypnosis or visualization, and allowing yourself plenty of leisure are all part of the plan. Chronic illness can be perceived as a good opportunity to rethink your whole life, and a new career or interest may result.

2. Exercise and breathing

   The body was designed to be used, and we now know that a lot of lying around is not a good thing. In days gone by women rested for 3 weeks following childbirth, and weeks were often spent in bed following surgery. Apart from risks of thrombosis (clots in veins) the body quickly becomes deconditioned and rehabilitation takes a long time. On the other hand extreme fatigue/burnout can occur from over-exercise. Again it’s a matter of getting the balance right, by doing enough not to deteriorate and to keep the muscle chemistry ticking over, without overdoing things to the level of relapse or even collapse. Correct exercise will improve circulation and the better breathing associated with exercise means more oxygen getting to the tissues. Emphasis needs to be placed on good breathing and fresh air when possible. Many people who are unwell are inside for much of the time and the air maybe stale, and also breathing may become inefficient with a tendency to hyperventilation syndrome and worsening fatigue.

3. Diet.

   The body needs fuel just like any other machine, and unless it is fuelled correctly, it will not work properly and will tire easily. There is no magic diet to fix fatigue, and many people have become worse due to extreme elimination or restricted diets. The best approach is “good balanced nutrition” with plenty of variety and frequent eating. Often during illness, the stomach cannot tolerate large amounts and the “little and often”: approach works best. It is sensible to avoid rich foods (which may take a lot of energy to digest), alcohol and caffeine, both of which may aggravate fatigue by interfering with sleep. Fluids should be plentiful to maintain fluid balance and keep the kidneys working well to help eliminate toxins.

4. Supplements.

   There are many supplements on sale with promises of energy and cure for just about everything. But in reality you only needs supplements if your diet is lacking some essentials (such as iron if vegetarian) or if there is a proven deficiency on blood testing. Some with chronic illness do become deficient in Vitamin D due to lack of exposure to sunlight. Occasionally a particular supplement may be shown in research to have a specific benefit in a specific condition. (eg omega 3 fish oil in some brain disorders). On the whole though, it is wisest to save the money spent on supplements and concentrate on better nutrition, as vitamins and minerals are better absorbed from food than pills.

5. Hormones.

   As mentioned earlier, hormonal disturbances can lead to fatigue, and this may be a specific disease. But sometimes these imbalances may occur as a result of another illness and need to be watched for. Poor sleep for example can result in some lowered hormonal output. Supplementation of hormones should however only ever be undertaken with medical advice and surveillance, as the endocrine system is closely linked and under control of the pituitary gland and meddling with the system can lead to serious consequences.

6. Sleep management.

   This is probably the most important strategy in the overall management of fatigue. We all know the effects of even just one broken night, and there is plenty of evidence that those on shift work or who have a poor sleep pattern are at risk to themselves and others. Deep restful sleep is the time when the body heals itself and many hormones and chemicals are released during the various stages of sleep to restore and repair. During illness it is not unusual to never feel properly refreshed on waking, and tired aching bodies, which should have been relieved by sleep, just go on hurting. There are a number of diagnosable sleep disorders which require specific treatment, and issues such as pain and stress also need attention. Many with chronic health problems will however require medication to retrain the sleep/wake cycle which maybe seriously out of kilter. Avoidance of medication with addictive potential is generally recommended, although occasionally short term mild sedation (benzodiazepines) to help with mental or physical relaxation maybe necessary. It is preferable however to consider low dose tricyclics, which usually help restore the architecture of sleep and are non addictive. Occasionally melatonin (a natural sleep hormone) maybe helpful and some herbal preparations do have a mildly sedating effect. These should however be used with caution as may not always mix with other medication, so the doctor needs to know what you are taking.

7. Medication.

   There are some drugs which can be used to reduce fatigue and promote feelings of wellbeing and energy. The SSRI group of antidepressants can work in this way in small doses. Methylphenindate and the amphetamines are stimulants and although they may help with fatigue, they may give a false sense of wellbeing, and lead to a tendency to overdo it. There is also risk of addiction. A newer drug called Modafinil holds some promise.

Other causes of fatigue must not be forgotten. Adolescence is a time when much energy goes into growth and development and the young person may seem to want to lie around a lot and “sleep in”. This is a normal part of growing up but parents should always be on the lookout for depression, drug abuse and anorexia. Many people will tend to feel more tired as they get older, but this is generally not so for those who remain mentally and physically active. Sometimes medication will lead to fatigue and from time to time this should be reviewed.

It is important to note however that fatigue alone is not usually indicative of serious disease, though many do worry that they are developing a life threatening illness and the worry alone can create the stress/insomnia/fatigue merry-go-round. If ever you are worried about any aspect of health, it is always wise to discuss this openly with the doctor, who can initiate the necessary investigations to put your mind at rest and give you professional advice about alleviation of your fatigue.

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