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Fighting Fatigue

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By Bruce Campbell


(Note: From the series Treating CFS and Fibromylgia.)

Fatigue is the central symptom in CFS and a significant problem for most people with fibromyalgia. The word fatigue may be a misleading way to refer to the physical and mental exhaustion common in both CFS and FM. Manifesting as listlessness, sleepiness and a reduced tolerance for exercise, it can be brought on by low levels of activity or for no apparent reason. Fatigue is often disproportional to the energy expended and lasts far longer than it would in a healthy person ("post-exertional malaise").


Causes of Fatigue

The fatigue associated with CFS and FM can have many causes. One is the illness itself, which uses energy in attempting to heal. Others include:

Pain Ongoing discomfort brings muscle tension, leading to fatigue
Poor Sleep Sleep is often not restorative, compounding sense of tiredness
Activity Level Overexertion intensifies symptoms (push and crash syndrome)
Deconditioning Lower activity level makes activity more tiring
Stress/Emotions Stress leads to muscle tension. Worry and anger dissipate energy
Poor Nutrition Tiredness from insufficient food or poor digestion
Medications Drugs can cause fatigue as a side effect

Treating Fatigue

Perhaps the single most important key to controlling fatigue (and other symptoms of CFS and FM) is to adjust your activity level to fit the limits imposed by illness. This is often called "living within the energy envelope" or pacing. Rather than fighting the body, with repeated cycles of push and crash, you seek to understand your body's new requirements and to live within them.


Living successfully with CFS or fibromyalgia requires many practical adaptations, as you develop a detailed understanding of your new limits and then gradually adjust your life to them. Each person's limits will be different, depending mainly on the severity of their illness. Dr. Paul Cheney summarizes this approach well when he says, "Proper limit-setting, which is always individualized, is the key to improvement." See Chapter 9 in our course text for instructions on how to define your energy envelope and Chapter 10 for pacing strategies.


While adjusting to limits means making many changes to daily habits and routines, another part of the challenge of adjustment is psychological: accepting that life has changed and learning to see your life in a new way. This acceptance is not resignation, but rather an acknowledgment of the need to live a different kind of life, one which honors the limits imposed by illness.


This acknowledgment requires you to develop a new relationship to your body. In the words of one person in our program, "Getting well requires a shift from trying to override your body's signals to paying attention when your body tells you to stop or slow down." This process of accepting limits and learning to live a different kind of life usually takes several years and requires coming to terms with loss. For ideas on how to move through loss to a new life, see Chapter 16.


Strategies for Treating Fatigue Due to...

The rest of the article describes treatments, organized by causes of fatigue.

Pain and Poor Sleep: Pain and poor sleep can intensify fatigue. Pain is inherently tiring and also tends to produce muscle tension, which, in turn, creates fatigue. Non-restorative sleep leaves you as tired in the morning as you were before going to bed. Treating pain and sleep using the strategies described in the next two articles in this series produces the bonus of reducing fatigue at the same time.

The relationship between fatigue on the one hand, and pain and sleep on the other, works in the other direction as well. Just as treating poor sleep and pain can reduce fatigue, treating fatigue can have a positive impact on sleep and pain. For example, since feeling tired increases the experience of pain, reducing fatigue lessens pain. In sum, fatigue, pain and sleep interact with one another. An improvement in one symptom can have a positive effect on the other two. Probably the most common symptom to attack first is sleep.


Activity Level: If overexertion is your problem, the most effective response is pacing, as described earlier. Pacing begins with defining your limits. You can do this in a general way by rating yourself on the CFS & Fibromyalgia Rating Scale. Your self-assessment suggests a safe daily activity level. If you wish to understand your limits in detail, for example how much exercise you can do or how much time you can spend with others, you can fill out the Energy Envelope form.


Once you have understood your limits, you can learn to live within them using pacing strategies, such as priority setting, rest breaks, short activity periods, living by a schedule, and managing special events, such as vacations and holidays. For more on pacing, see the articles in the Pacing archive. The archive includes both how to articles and patient success stories.


Deconditioning: If being ill reduces your activity level and leads to deconditioning, you may be able to start a spiral in the other direction with exercise . Exercise produces a higher level of fitness, thus reducing the fatigue caused by inactivity. It also helps combat pain, lessens stress and improves mood. Exercise is usually recommended for fibromyalgia patients and may also be helpful for CFS as well.


Stress and Emotions: You can combat the fatigue coming from stress by using relaxation and other stress management strategies. Because stress is so pervasive in chronic illness and because it intensifies symptoms such as pain and poor sleep as well as fatigue, many patients use a variety of strategies to combat it. Like other self-management strategies, stress management techniques improve multiple symptoms.


Powerful emotions are part of chronic illness, a response to the disruption, losses and uncertainty it brings. Emotions can be treated using a combination of self-management strategies, professional help and medications.


Nutrition: CFS and fibromyalgia patients often experience several different kinds of problems getting good nutrition. First, because of energy limitations, lack of appetite or severity of symptoms, some people may not spend enough time to prepare and eat balanced meals. Getting help, freezing meals ahead of time and using prepared foods can help.


Second, most patients experience an intolerance of alcohol and many are sensitive to caffeine and/or sweeteners. Cutting down or eliminating these substances may reduce symptoms and mood swings and also improve sleep.


Lastly, about one third of CFS patients, and a comparable portion of fibromyalgia patients, experience sensitivities to various foods or have difficulty absorbing nutrients. The most effective strategy for controlling food allergies is an elimination diet, in which foods are taken out of the diet and then reintroduced one by one.


Medications: Many medications , including some anti-depressants and drugs prescribed for pain, create fatigue as a side effect. To combat this source of tiredness, ask your doctor about fatigue when reviewing medications. A change of medication or a lower dosage may help.