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Fighting Fatigue

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By Bruce Campbell


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

Fatigue is the central symptom in CFS and a significant problem for most people with fibromyalgia.

The term ‘fatigue' may be a misleading way to refer to refer to the physical and mental exhaustion experienced by people with the two conditions. Manifesting as listlessness, sleepiness and a reduced tolerance for exercise, fatigue can be brought on by low levels of activity or for no apparent reason. Fatigue is often much greater than and lasts far longer than it would in a healthy person ("post-exertional malaise").

For people with CFS and/or FM, fatigue can have many causes. One is the conditions themselves, which leave people with less energy for daily activities. Other causes include: 

Overexertion Being too active, living "outside energy envelope"
Pain Ongoing pain produces muscle tension, which is tiring
Poor Sleep Feel tired if sleep is not restorative
Deconditioning Lower activity level makes activity more tiring
Stress/Emotions Stress leads to muscle tension. Depression produces listlessness.
Poor Nutrition Lack energty if don't eat well or have poor digestion
Medications Drugs can cause fatigue as a side effect

You can address fatigue by matching the strategies below to the causes you experience.

  • Pacing
  • Treating pain and poor sleep
  • Exercise
  • Reducing stress
  • Addressing depression and other emotions
  • Improving nutrition
  • Considering medication changes

Pacing

Probably the single most important key to controlling fatigue and other symptoms of CFS and FM is to adjust activity level to fit the limits imposed by the two conditions. We call this "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: developing through trial and error a detailed understanding of your new limits, and then gradually adjusting your daily habits and routines to honor those limits. Each person's limits will be different, depending mainly on the severity of their illness.

Other artilces on this site explain how to define your envelope and describe many practical strategies for living within it, such as scheduled rest breaks, short activity periods, switching between high and low intensity tasks and using a schedule. (See the Pacing archive.)

Pacing also includes mental adaptation: accepting that life has changed. Acceptance is not resignation, but rather an acknowledgment of the need to live a different kind of life. 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." 

Treating Pain and Poor Sleep

Fatigue is intensified by pain and poor sleep. Pain is inherently tiring and also tends to produce muscle tension, which in turn intensifies 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 artilces in this series produces the bonus of reducing fatigue at the same time.

Reciprocally, treating fatigue can have a positive impact on sleep and pain. 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. 

Exercise

Exercise counteracts the part of fatigue caused by a lower activity level and the resulting loss of fitness. Exercise improves fitness, thus reducing the fatigue caused by deconditioning. It also helps combat pain, lessens stress and improves mood. For ideas on how to exercise safely, see the article Exercise.

Reducing Stress

Because stress is so pervasive in chronic illness and because it intensifies symptoms such as pain and poor sleep as well as fatigue, many people with CFS and FM use relaxation and other stress management strategies to combat it. See articles in the Stress Management archive for our ideas on both stress reduction and stress avoidance. Like other self-management strategies, stress management techniques improve multiple symptoms.

Addressing Depression and Other Emotions

Powerful emotions such as depression, frustration, anxiety, guilt and grief are a frequent consequence of chronic illness, a response to the disruption, losses and uncertainty it brings. One symptom of depression is fatigue, so treating depression can reduce fatigue.

As with pacing and stress management, addressing depression and other feelings triggered by illness can improve several symptoms. For ideas on managing emotions, see articles in the Emotions archive.

Improving Nutrition

People with CFS and fibromyalgia often experience several kinds of problems getting good nutrition. Lack of appetite or severity of symptoms may make it difficult to spend enough time to prepare and eat balanced meals.

Some possible strategies include preparing meals in ways that respect the body's needs (e.g. taking rest breaks, using a stool, limiting repetitive motions), buying food online or by phone, preparing and freezing meals when feeling better, and getting help.

Second, most people with CFS and FM experience an intolerance of alcohol
 and many are sensitive to caffeine and other stimulants, sweeteners (such as sugar, corn syrup, fructose, aspartame and saccharin), food additives (such as MSG, preservatives, artificial colors and artificial flavors) and tobacco. Cutting down or eliminating these substances may reduce symptoms and mood swings, and also improve sleep

Third, a substantial number of people with CFS and fibromyalgia experience food sensitivities or food allergies or have difficulty absorbing nutrients. Negative reactions include gastrointestinal symptoms (such as heartburn, gas, nausea, diarrhea and constipation), headaches, muscle pain, changes in pulse and fatigue.

Some common sources of food allergy for people with CFS and FM include dairy products, eggs, soy, wheat and corn. Other sources include tomatoes and potatoes; fruits; spicy foods; gas-producing vegetables, such as onions, cabbage and broccoli; raw foods; and nuts.


There are two major treatments for food sensitivities and allergies: avoidance and the rotation diet. The first step in both treatments is the same: identifying foods that trigger allergic reactions. To do this, eliminate foods you think might cause problems, then reintroduce them one by one. If foods produce strong reactions, such as diarrhea, nausea, headaches or hives, you will probably have to eliminate them from your diet entirely.

Often, the elimination of just a few foods can improve symptoms dramatically. Alternatively, you may find you can tolerate a food if you eat it only occasionally. This is usually called the rotation diet. After eating a food, you wait a period of four to seven days before eating it again.


If you have food sensitivities, they may be caused by other conditions such as irritable bowel syndrome (IBS); yeast infections, like candida; celiac disease, which causes a strong allergic reaction to wheat and other grains; and lactose intolerance, which is the inability to digest the sugar in milk.
 

Considering Medication Changes

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 change in dosage may help. 

You might also consider certain stimulant medications as a treatment for fatigue. Drugs such as Nuvigil, Provigil, Adderall and Ritalin can help those who are somnolent during the day, as opposed to just tired. (Somnolent individuals fall asleep watching TV, reading, riding in the car, etc.) 

Note on Super Strategies

As you read through the next three articles, you will find pacing, stress management and exercise discussed repeatedly, just as they were in this article on fatigue. They are “super strategies.” Using them will help you reduce multiple symptoms.