How to deal with the fatigue elephant (in the room)


It may sound counterintuitive but exercise is the most effective treatment for fatigue associated with rheumatological diseases, a world renowned expert has told congress.

Speaking to the limbic following his presentation to ACR 2017 delegates on ‘fitness with fatigue and persistent pain’ Daniel J Clauw MD, Professor of anaesthesiology and rheumatology at the University of Michigan said fatigue was under-recognised across the spectrum of rheumatological diseases.

Fatigue tended to be the elephant in the consulting room because it was hard for physicians to find the underlying cause and then deal with it.

“There are so many reasons that someone can have fatigue that physicians just don’t ask about – it could be from anaemia, innate fibromyalgia or chronic fatigue which are very common co-morbidities in any rheumatic disease,” said Professor Clauw who is the Director of the Chronic Pain and Fatigue Research Center in Michigan.

Because of this physicians tended to focus on the signs and symptoms of the disease that they were most comfortable treating.

“Rheumatologists look for inflammation, they measure inflammation,  and we have all these drugs to reduce inflammation. They’re very comfortable in that paradigm because that’s how they’ve been trained,” he said.

How to frame a conversation around fatigue with your patients

The data suggests that even with biologics up to 70 percent of people with rheumatoid arthritis still experience fatigue that is more functionally limiting for them than their pain.

“If you have pain in a couple of areas of the body you could just not use that area of the body, but with fatigue you can’t do anything,” Professor Clauw explained.

Evidence has shown time and time again that exercise is the best intervention for combatting fatigue but Dr Clauw stresses that it is important for physicians to take care how they frame this in a conversation with their patient.

He says the word ‘exercise’ can scare a lot of patients so a better word to use is ‘activity’.

“The best way is to talk to patients about becoming more active, they don’t have to increase their activity very much for their fatigue to get better.”

“If you do too much exercise it’s like over dosing on a drug. If you start low and go slow you tend not to have any side effects”.

Professor Clauw is a fan of analogies. One he likes to bring out when he talks to patients about fatigue centres around his twice yearly trip to Kenya.

By the time he gets off the 20-hour flight he says he feels like someone with fibromyalgia.

“When I get off that plane, I’m tired, I ache all over, I feel terrible. I say to patients ‘you’ve been on  that plane for twenty years and if you don’t get off that plane you’re going to keep feeling terrible – you have to have a certain amount of activity just to feel okay,’” he explains.

Another tip is to get patients to do activities that they enjoy, perhaps before they developed their disease.

“It’s better to let the patient tell you what their specific barriers to physical activity are and then help them work through those,” he advises.

“It’s better to say I know that you are fatigued and that really bothers you,  I get why you can’t do exercise so let’s just start with what you can do and let’s talk about what you do right now”.

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