How To Beat Fatigue

Fatigue is a mysterious and persistent foe, but you can beat fatigue and feel more energetic than ever

Everyone gets tired. That is how the body signals it needs to rest and recharge. Overwork yourself physically and you feel it in your muscles or joints. Overwork yourself mentally and you need a break. But when your need for rest seems excessive or becomes disruptive – thwarting your productivity, making everyday tasks seem daunting, robbing you of enjoyment and interaction with others – what once may have been tiredness has become fatigue. But rest assured: There are viable fatigue treatments and means to beat fatigue.

Fatigue often means something sinister is lurking. The symptom accounts for 10 million doctor office visits each year, many of who are by people with arthritis-related conditions. Up to 98 percent of people with rheumatoid arthritis (RA) report fatigue, as do 50 percent or more of those with lupus or Sjögren’s syndrome. The percentage grows higher when obesity, depression, fibromyalgia, congestive heart failure, lung problems or chronic headaches are present, too.

Because so many people with so many different medical problems experience fatigue, doctors have a tough time sorting out causes. Here we take a look at what could be behind your zapped energy and help you learn how to beat fatigue.

The challenge of fatigue

Fatigue is hard to describe and harder to diagnose. If you find yourself with no energy even after a full night’s rest, it may be fatigue. But understanding fatigue requires more than understanding the body’s normal need for rest.

Martha Grant, 53, of Berkeley, California, knows fatigue all too well. Except for a brief respite in her early 20s, she’s struggled with it since her diagnosis with juvenile rheumatoid arthritis (JRA) at age 11. “Most people feel well as the norm and then get the flu for a few days. For me, living with fatigue is like having the flu every single day,” she says.

In a study of how people with RA perceive fatigue, Sarah Hewlett, PhD, senior lecturer in Rheumatology Health Professions at the University of Bristol in England, found patients described fatigue as “severe weariness and dramatic and overwhelming exhaustion attributed to inflammation, working the joints harder and getting unrefreshing sleep.” Patients with various chronic diseases experience fatigue as an occasional come-and-go symptom, but many RA patients experience long-lasting fatigue, says Ken Pischel, MD, head of the rheumatology division at Scripps Clinic in La Jolla, California. Their bouts of fatigue sometimes seem unwarranted because they usually aren’t preceded by excess activity and may even occur when their joints are feeling good.

As such, patients have a hard time telling their doctors what may have led to the fatigue. In Hewlett’s study, the few RA patients who felt comfortable discussing fatigue with their doctors still reported inadequate care for it, perhaps because of the emphasis on more measurable physical problems, or perhaps because pain is usually eased with medication, whereas a fatigue treatment isn’t that straightforward. In often-rushed appointments, doctors may only be able to confirm fatigue’s existence, but Hewlett says this offers little help to patients.

Grant agrees. She knows the “Oh dear, here we go again” look from doctors when she brings up her fatigue. “Doctors don’t want to hear how tired patients feel – I think it makes them feel uncomfortable because they can’t fix it,” she says.

Untangling causes

Finding the cause of fatigue means ruling out the many possible culprits. Dr. Pischel explains that fatigue has many contributing factors. “Not only is joint inflammation a major factor but also chronic pain, hormonal changes, anemia, poor sleep, depression and stress.” But one in five people with RA also has fibromyalgia, and the majority of those with fibromyalgia also experience chronic fatigue. Some people with inflammatory diseases also have celiac disease, cardiovascular problems or lung problems associated with inflammation, and all of those conditions make the body’s systems work harder and may lead to fatigue. Figuring out the trigger is like unraveling dozens of tangled strings of lights to find the few burned-out bulbs.

Sleep problems are usually the first line of investigation. But even if insomnia or restless sleep is an issue, the search is not over. Maybe multiple factors are at work.

Sleep and pain

For many people with arthritis, fatigue often is triggered by insomnia and unrefreshing sleep due to unrelieved pain. Getting into a position comfortable enough to allow solid slumber is a challenge when joints are swollen and sore. And quality of sleep tends to be more important than quantity. Getting six or seven hours of deep, restorative sleep makes you feel better than spending eight or nine hours in bed tossing, turning and waking up repeatedly.

People with obstructive sleep apnea may wake briefly hundreds of times per night as they gasp for air. Weakened muscles or excess tissue in the throat can block the airway and lower the amount of oxygen in the blood. Sensing the low oxygen level, the body arouses itself. Waking up briefly to allow the airway to open interrupts normal, restorative sleep. Studies show that disrupted sleep or too little sleep may heighten pain.

Depression

Chronic pain can cause fatigue directly, or it can lead to depression, which can increase fatigue. Depression is the most common cause of fatigue among all patients who visit doctors. While fatigue occurs most often with depression, it also accompanies other mood disorders, including anxiety, bipolar disorder and seasonal affective disorder. Grant has struggled with depression despite having a generally positive attitude about life. She attributes some of her depression to medication side effects. The prednisone she took for 12 years created mood swings, and she required two years to stabilize after stopping it. In addition to mood-swings, other corticosteroids like prednisone also contribute to depression and insomnia.

Grant attributes the rest of her depression to the draining effects of dealing with the chronic pain of her disease. A 2003 study from Stanford University showed that people with depression were more than twice as likely to have chronic pain than people without symptoms of depression. And the stress of dealing with a chronic illness affects the brain, causing fluctuations in hormone levels and neurotransmitters like serotonin, which can lead to depression. Those chemical changes combined with the release of immune system cells and substances that cause inflammation predisposes people to anxiety and depression, according to a recent study in Ireland.

Medication side effects

If depression is a fatigue-causing factor, a wide variety of antidepressants are available to help relieve it. In fact, low doses of antidepressants often are used to treat symptoms of fibromyalgia and as fatigue treatments. But up to 20 percent of patients taking selective serotonin-reuptake inhibitor (SSRI) antidepressants, including Paxil, Prozac, or Zoloft, report drowsiness as a side effect. While you might think drowsiness would help fatigued people get the sleep they crave, daytime drowsiness related to oversedation can be a source of fatigue.

Many other medications list drowsiness as a common side effect: pain medications such as oxycodone (OxyContin); some prescription nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac (Voltaren) or naproxen (Naprosyn); tricyclic antidepressants such as amitriptyline hydrochloride (Endep); disease-modifying antirheumatic drugs (DMARDs) such as azathioprine (Imuran); antihistamines such as diphenhydramine (Benadryl) and some blood pressure medications.

If drowsiness or insomnia is a side effect of your medication, do not stop taking it without talking to your doctor first. Abruptly stopping medications, especially SSRIs, or missing several doses can lead to discontinuation syndrome, which causes flu-like symptoms.

Inflammation

The body’s immune system normally helps keep people healthy, fighting off illness-causing invaders. But in those with autoimmune diseases, the system targets the person’s own tissues. Researchers have found the foremost fatigue inducers to be higher-than-normal levels of cytokines – chemical messengers that regulate the intensity and duration of immune responses.

Researchers in Australia recently studied symptoms related to “acute sickness behavior.” These consisted of fatigue, malaise, listlessness, inability to concentrate, poor memory, fever and decreased appetite. The researchers interviewed 69 people with infections to learn which symptoms of acute sickness behavior they had. The researchers then measured the amount of cytokines in the patients’ blood samples and cell cultures. Results showed that fatigue consistently correlated with levels of interleukin-1 (IL-1) and IL-6, both of which are connected with inflammatory forms of arthritis. The higher the levels, the more unwell the study participants felt.

Anemia

Anemia affects up to two-thirds of RA patients and is most common in those with severe joint disease. Fortunately, if the anemia can be successfully treated, the joint pain, swelling and tenderness respond better to treatment, and improving those symptoms helps beat fatigue, according to a 2004 review of a dozen studies focusing on anemia in people with RA.

In Grant’s case, Dr. Pischel determined that one reason she felt fatigued was anemia of inflammation, formerly called anemia of chronic disease. This type of anemia occurs when chronic illnesses cause a drop in the longevity of red blood cells. Her hematocrit, a measure of the number and size of red blood cells, is 30 (normal is between 36 and 44). With too few or too-small blood cells, her body has too little iron. And too little iron means less energy, because iron is what holds onto oxygen in the red blood cells, and oxygen is vital for energy production.

“Because Grant’s hematocrit is 20 percent lower than normal, her body has to work an extra 20 percent harder whenever she moves,” says Dr. Pischel. When performing normal daily physical activities, the muscles are taxed closer to their maximum capacity – similar to a healthy person working out intensely. Overtaxed muscles result in fatigue after even a short burst of activity.

Loss of muscle mass

The loss of muscle tissue means the loss of cells that produce energy. More than half of people with severe RA, according to one study, are affected by a condition called cachexia, in which muscle mass decreases and fatigue increases. Cachexia is linked with overactive immune system cytokines; in fact, tumor necrosis factor-alpha – the cytokine targeted by the biologic medications adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) – is sometimes called ‘cachectin’ because of its connection with cachexia.

Looking deeper

What happens when major issues have been sorted through but the source of fatigue cannot be pinpointed? Doctors may order a series of lab tests that can provide clues or uncover an as-yet-undiagnosed condition.

White blood cell (WBC) count. A high level of WBCs, which are the immune system cells that fight bacteria and viruses, usually indicates an underlying infection that may be causing the body to use extra energy in attempts to fight off bacteria or a virus.

The Chem-20 panel. This standard blood test of 20 chemicals measures electrolytes like calcium, potassium and sodium, which help cells produce energy. Abnormal levels of the proteins, enzymes or chemicals, including glucose or carbon dioxide, may indicate problems with metabolism, the liver or kidneys, or it may indicate other chronic conditions, like hypoglycemia, which may reduce energy levels.

Thyroid-stimulating hormone (TSH) test. A TSH level that is too high indicates the pituitary gland is working overtime in an attempt to get the thyroid to pump out enough of the hormones that keep metabolism and energy production at a normal level. If the thyroid gland is not producing enough, the condition is called hypothyroidism. Fatigue is a major symptom of hypothyroidism, sometimes an autoimmune disease in its own right, which occurs at a higher frequency among people with autoimmune diseases like RA.

Urinalysis. Urine can be tested to see if bacteria, excess protein or blood is present. Abnormal results may indicate the presence of a urinary tract infection, kidney problems or metabolic disorders such as anemia or diabetes.

Pulse oximetry test. This simple test measures oxygen levels in the blood. Blood that is not well saturated with oxygen can be a reason for fatigue. Oxygen levels may be lower than normal in people with lung problems or obstructive sleep apnea.

Sleep study. This overnight test looks for sleep problems that might affect the amount of restorative sleep a person gets, such as obstructive sleep apnea.

Treating symptoms

Once a doctor has sifted through possible causes for fatigue, he then takes cues from the body, treating each symptom individually instead of searching for a blanket fatigue treatment. “If there’s inflammation, I treat that. If depression, I try to make that better. If a certain activity or task is draining, occupational or physical therapy may help. And if sleep or medications are to blame, I’ll make adjustments,” says Dr. Pischel.

Your doctor can help relieve your most troublesome symptoms – prescribing nsaids, dmards, biologic agents or corticosteroids to reduce inflammation or prescribing iron treatments or the hormone epoietin (Epogen, Procrit) to reduce anemia. But there are several other tactics that will help you beat fatigue and prevent it from returning.

What your doctor can do:

Stimulant medications. “People who say their unrelenting fatigue is more of a problem than their pain may need ‘activating’ medications that increase energy,” says Daniel Clauw, MD, rheumatologist and director of the Chronic Fatigue and Pain Research Center at the University of Michigan.

Some antidepressants, such as buproprion (Wellbutrin), are used as activating medications, as is the psychostimulant medication modafinil (Provigil), which reduces the excessive sleepiness brought on by sleep disorders such as narcolepsy or sleep apnea. “The combination of drugs such as activating agents and non-drug therapies such as exercise and cognitive behavior therapy reduces fatigue and increases energy in many cases,” he says.

Sleep medications. For people who have trouble falling asleep or staying asleep at night due to anxiety or insomnia, a host of newer sleeping pills promote restorative sleep while reducing or preventing next-day grogginess. These newer medications, including eszopiclone (Lunesta), lorazepam (Ativan), zaleplon (Sonata) and zolpidem (Ambien) may be less likely to trigger low-dose dependence than older sleep medications or mild tranquilizers, including alprazolam (Xanax), clonazepam (Klonopin) and diazepam (Valium).

While these newer medications are not free of side effects – headaches and daytime sleepiness still occurred in some of the people studied – you may find relief by working with your doctor to find the right dose or fatigue treatment combination.

What you can do:

Exercise. Want more energy? Get moving. It may seem counterintuitive, but movement generates energy.

Exercise combats fatigue in several ways, says Miriam Nelson, PhD, associate professor with the Freeman School of Nutrition at Tufts University. “The gain in muscle mass and strength makes movement easier, and the increased blood circulation and flexibility also reduces pain. In addition, exercise generates endorphins, which are brain chemicals that produce a sense of well-being and more energy,” she says.

Nelson recommends gradually working up to two or three days per week of strength training, with aerobic activity on most of the other days. Exercise is especially important for those with cachexia, who are losing muscle mass. But strength training is not the only way to improve your fitness. Walking, cycling and swimming increase your endurance and strength, and flexibility exercises such as yoga or tai chi not only increase your range of motion but also reduce stress and energize you. A recent study showed that attending two 90-minute yoga classes per week for 12 weeks generated significant reductions in anxiety, depression and fatigue and significant improvements in well-being and vigor.

Eat right. Eating is a pleasure with purpose: to nourish your cells and create energy. Adopt the habit of always choosing healthy foods as your energy source. Reaching for nuts, fruits and vegetables, fortified cereals and whole grains will help provide omega-3 fatty acids and the “workhorse” B vitamins that make the energy in food usable by the body. Always start your day with breakfast. This jump-start meal increases energy levels and attention spans. Make sure to include some protein, like an egg or yogurt, along with carbohydrates such as whole-grain bread or oatmeal.

Support your joints. Wearing a brace or using a cane when necessary can help take stress off your joints and the muscles surrounding them, which can help beat fatigue.

Develop good sleep habits. Consistency is key when it comes to sleep. Go to bed and get up about the same time every day. Each night, follow the same bedtime ritual as a signal to your body that it’s time to sleep. Whether it’s taking a warm bath, reading a book, listening to music or doing a crossword puzzle, the ritual is right if it works for you.

Be judicious with rest. Learn your body’s cues so you know when to counter activity with rest. Rest allows muscle tissues to repair themselves and refuel for more activity. But rest shouldn’t exceed activity, most days, unless a fever or infection is present. You can beat fatigue. Stay positive when working to identify and eliminate your fatigue triggers. Remember that each person is unique in what causes their fatigue; likewise each person is unique in what fatigue treatments work for them. Keep trying to feel your best and know that, in the meantime, doctors and researchers will continue to study how and why most people with inflammatory diseases experience fatigue, with the hope of creating more and better treatment options.