Understanding and Managing Chronic fatigue

FATIGUE OR TIREDNESS

We all experience days of immense fatigue, where the body and mind can’t push themselves any longer. Sometimes we may feel like this for a day or two, and maybe even days, but with adequate rest and sleep, along with some relaxing or pleasurable activities, we spring back to our work schedules and daily routines.

But what is seen increasingly today is a feeling of long term tiredness and drop in energy levels which lasts for many months. This is Chronic Fatigue and is seen commonly in the 40-50 years age group, and slightly more common in women.

SYMPTOMS OF CHRONIC FATIGUE

Chronic Fatigue Syndrome (CFS) refers to a profound and severe feeling of exhaustion or tiredness lasting for 6 months or more, and presents with the symptoms below:

• Fatigue worsened by exertion (called PEM- Post Exertional Malaise) or exercise (physical or mental), not relieved by rest, and lasting > 24 hours after the exertion/exercise
• Feeling unrefreshed and fatigued even after a night’s sleep
• Reduction in cognitive functions like memory or concentration
• Feeling low and irritable more often than not
• Generalized body aches or muscle pains
• Joint pains (without any redness, swelling or restriction in movement)
• Recurrent headaches
• Symptoms of palpitation, dizziness, weakness, anxiety, sweating along with fatigue which come on or worsen while standing and reduce by lying down/reclining (Orthostatic intolerance).
• Sore throat episodes, or enlarged nodes in neck/armpits

Other symptoms may include nausea, lack of appetite, recurrent colds, allergies or sinus problems, and reaction/intolerance to alcohol or medicines. Depression can develop in patients with CFS or be the underlying cause of the manifestation of CFS symptoms. The most important factor for establishing Chronic Fatigue Syndrome is the absence of any underlying medical condition.

POSSIBLE TRIGGERS

Chronic fatigue commonly sets in after an episode of illness especially viral infections with flu-like symptoms (fever, body aches, and weakness) as has been seen post-recovery from COVID. Other triggers may include injury (physical trauma), a psychologically disturbing event, or having undergone hospitalization or surgery. Sometimes no trigger may be identifiable and chronic fatigue may develop gradually over many months or years due to possible chronic physical or mental stress.

The theories so far put forward for developing chronic fatigue include abnormalities of the immune system and/or the nervous system, decreased energy metabolism in body cells, and hormonal imbalance, but none substantiated convincingly, and no specific diagnostic tests developed yet.

Chronic widespread body pain with fatigue is seen in a condition called fibromyalgia.

WHAT TO TEST

Often an underlying medical condition can be the cause, and this needs to be meticulously investigated and treated. First thing, a general physical examination by a physician including a blood pressure check and calculation of Body Mass Index (BMI) is recommended.

Lab investigations should include a Complete Blood Count (CBC), Blood Sugar, Tests for Thyroid, Liver and Kidney function, Lipid profile, Vitamin D, and Vitamin B12. Additionally, an ECG with a Stress test (TMT- Treadmill test) is also advisable.

Testing for sleep disorders would be helpful as it may reveal abnormal sleep rhythms or sleep apnea which may be making sleep less refreshing and contributing to chronic fatigue. The history of snoring is a valuable clue.

Psychological evaluation and counseling are also important as the symptoms may be a manifestation of an underlying mental illness (like depression, bipolar disorder, schizophrenia, delusional disorders, eating disorders like anorexia nervosa and bulimia, drug/alcohol abuse or dementia). Chronic fatigue is not considered to be a psychological or psychiatric illness even though such patients can develop depression over time.

In women, chronic fatigue can be part of menopause symptoms or Pre-Menstrual Syndrome (PMS).

Rarely undiagnosed cancer in the body can cause chronic fatigue with or without weight loss.

HEALTH SOLUTIONS FOR CHRONIC FATIGUE

Tests help to rule out conditions like anemia, hypothyroidism, diabetes, or other medical conditions present which can be appropriately treated.

However, if these are ruled out and no underlying health disorder is found, the diagnosis of Chronic Fatigue Syndrome is usually made. The solutions lie in taking a holistic approach and working on multiple aspects of daily life and routine-

• Slowing down and prioritizing activities along with a reduction in hectic work schedules and multitasking is the first and important step.
• Physical activity, exertion and exercise should be gradually graded up. A physical therapist should be consulted to design and monitor a plan of aerobic exercises. Yoga should focus more on stretching, de-stressing, and breathing and then graded up to more complex postures.
• Incorporating a daily relaxation time with pleasurable hobbies which may be as a structured class or a self-allotted time (music, craft, reading, games, entertainment, etc) is helpful.
• Diet followed should be well-structured. A healthy diet not only helps improve energy levels but also decreases BMI and cuts the risk of other chronic diseases. Obesity or being overweight has been linked to a greater risk of developing chronic fatigue.
• Sleep should be adequate in both duration and quality. Improving sleep should be a central part of managing Chronic fatigue.
• Psychological counseling can help in managing stress as well as the impact on mental health or the presence of depression. Counseling can also help in cognitive training and improvement.
• Medicines: Antidepressants are often prescribed to improve low moods, body pains, and lack of sleep in chronic fatigue, but have a supportive role only. Similarly, pain-relieving medicines may be given for short periods for addressing body pain, headache, muscle, and joint pains.
• Vitamins and Minerals have been studied to play a role in improving symptoms and energy levels in chronic fatigue, however, there may be considerable variability in individual treatment responses.

Vitamin B12 plays an important role in our body along with Folic acid (Vitamin B9) in producing energy from cellular metabolism, production of Red blood cells that carry oxygen, and for effective nerve functioning. B12 therapy can be tried in chronic fatigue, especially if there is lab evidence of B12 deficiency and can be given in large oral doses or as injections. For effective and surer results, (as oral absorption of Vitamin B12 is dependent on many factors and individual variations), injectable B12 is more commonly used. It is available in dosing regimens ranging from 1mg daily to 3mg alternate days or 5 mg thrice weekly. Though improvement may be felt after the first few doses itself, at least a 6-8 week period with a gradual reduction in injection frequency is required for maintaining a satisfactory level of improvement.

Folic acid is combined with Vitamin B12 treatment in an oral dose ranging from 1-5 mg/day, and there are combination injections of B12/folic acid available.

B3 (Niacinamide) and B6 (Pyridoxine) are 2 other B-group vitamins available in combination with Vitamin B12, which are known to participate in energy production and improve fatigue symptoms and cognitive functions.

Vitamin C is also often co-prescribed orally, or as a combined pack injection in a separate ampoule to be given in the same sitting as Vitamin B12 injection. Apart from improving immunity and iron utilization in our body, Vitamin C helps to synthesize a substance called L-carnitine in our body which helps in energy production in our cells.

L-carnitine itself is also available as injections and oral supplements and may be prescribed for chronic fatigue.

There is still a need for more robust clinical evidence on these treatments for Chronic fatigue, and there is a likelihood of variation in the benefit and response not only in different patients but also in the same patient over the years.

Vitamin D is still being studied further for its role in chronic fatigue. Current evidence suggests that if there is documented Vitamin D deficiency from Lab tests in patients suffering from Chronic fatigue, Vitamin D supplementation, and normalizing its blood levels, can help in improving symptoms. The dose prescribed depends on the amount of deficiency, and can be as single injections (1 to 3 lakh IU), or as oral weekly sachets/liquid shots of 60,000 IU (usually for 8-12 weeks), or as daily oral doses of 1000-2000IU over 3-6 months. However, there are several people who have low Vitamin D levels with no symptoms, therefore there is still more understanding and studies required on the effect and benefit of Vitamin D in Chronic fatigue.

Lifestyle modification is the cornerstone of managing Chronic Fatigue along with periodic support with medicines and supplements.

Chronic Fatigue is different from Fibromyalgia which is a disorder of altered processing and amplification of pain sensations and signals. It is characterized by widespread and severe pain in muscles and joints along with fatigue, sleep disturbance, and effects on memory and mood. Though some of the symptoms and treatment aspects are common, the symptomatology and management of fibromyalgia are centered around pain relief.

Further reading-

Not getting enough sleep can be detrimental to health: Tackling Insomnia

10-point approach to stress management

5 Factors affecting Immunity

For any query, additional information or to discuss any case, write to info@drvarsha.com, and be assured of a response soon.

References

IACFS, NIH, Mayo CFS http://www.iacfsme.org

B12 factsheet NIH

Effect of Correction of Low Vitamin D in Fatigue Study (EViDiF Study): 2014