Fatigue can be a problematic symptom and the reasons are often multifactorial. These can include:
- a prodromal symptom of increased inflammation;
- a direct result from pain and/or poorly restorative sleep
- systemic effects from some arthritides (eg related to elevation of cytokines such as TNFa)
- a co-existent diagnosis such anaemia, autoimmune hypothyroidism or affective disorder (eg depressive illness)
Fatigue alters the patient's perception of pain, prevents him or her from being able to cope with the task of living with pain on a daily basis and drains his or her ability to cope with the accompanying symptoms of anxiety, increased muscle tension and autonomic nervous system arousal.
- learning to pace activities;
- taking frequent, short rests;
- stopping activities before the pain becomes severe.
Relatively simple instructions which can be monitored with the help of a daily diary, have been shown to produce beneficial effects, with improvements in levels of pain, anxiety, depression (Lorig et al 1985) and energy and physical activities (, ).
Although depression is not specific to arthritis, it is another phenomenon that can occur and co-existent depression is certainly under-diagnosed. There is a wide range of incidences of depression reported in the literature; from 10% to 83% (, , , , ). It is possible that it is associated with sleep disturbance, fatigue, lack of mobility, increasing dependence on others, potential loss of body image due to joint disfigurement and a decrease in activity. The patient's world becomes smaller and smaller and can end up being limited to the patient's own body and mind, when pain management becomes almost impossible.
Strategies for treating depression can encompass psychological therapies, pharmacological treatments and alternative therapies. However, depression should be assessed in conjunction with pain and treated accordingly.
An effective treatment for most rheumatic conditions is rest. Prolonged immobilisation, however, is counter-productive. In part this may be due to loss of muscle strength, loss of descending endogenous pain control mechanisms, and establishment of pattern-generating mechanisms, involving circuits which retain a pattern (or memory) for pain. Indeed this problem of complete rest sensitising the pain perception mechanism is well exemplified by reflex sympathetic dystrophy and chronic low back disability. Stress causes sympathetic over activity, which seems to trigger flares of RA. Benefits of rest therefore are direct - from resting the joints, and indirect - from decreasing stress.
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