How to advise patients in terms of managing fatigue

Fatigue is a common problem in many health conditions, whether those are related to respiratory or long COVID.^[1][2]

Fatigue is associated with reduced quality of life, increased rates of hospitalisation, reduced physical activity levels, and exercise intolerance, and it may even be life-changing: when fatigue among employees becomes severe and persistent, it may lead to long term sick leave and work disability. ^[3][4]

Even so, fatigue in itself rarely gets much attention by health professionals, and few get any training on how to advise patients.

Here I will explore two areas which I find are particularly useful when considering practical advice to give to patients: pacing and sleep.

The basic idea of pacing is to avoid both prolonged activity and prolonged rest. Instead, we are aiming for gentle activity interspersed with plenty of breaks.

Firstly, I advise patients who suffer from fatigue to pace their activities. This means spreading activities out evenly throughout the day, avoiding any ‘boom and bust’ in activity.

Patients are often tempted to squeeze in all their commitments whilst they have a good day, but this leads to overdoing things, what we call a ‘boom’ in activity and which is unhelpful.

In my experience, if a patient overdoes their activity, it usually leads to a crash where there will be excessive resting, which can further exacerbate the fatigue.

In order to avoid boom and bust, I advise patients should aim to do a similar amount each day and make sure that activities are kept to a manageable level. This means aiming for their baseline: this is the halfway point between the activity that can be achieved on a good day and the activity that can be achieved on a bad day.

For example, if a patient can go for a 20-minute walk on a good day, and 0 minutes on a bad day, the midpoint between these two is 10 minutes. This is the baseline. I therefore advise the patient to have a 10-minute walk every day. This means that on good days, the patient will have to stop while they still have lots of energy left and on bad days, they will have to push themselves slightly. If a patient is acutely unwell, they should, of course, rest.

It can be hard to find the correct baseline to begin with and a certain amount of trial and error should be expected. The patient will know that they have found an appropriate level of activity when they are able to undertake activities without experiencing crashes afterwards. A crash is where a person has to have extended rest because of exhaustion and they may feel unwell and experience an increase in their symptoms of fatigue.

If a patient is able to follow their baseline activity for a week or two without crashes, they can then increase their activity. For example, when the person that we mentioned in the previous example has been able to do their 10-minute walk for a whole week, she could then increase her walks to 12 minutes a day.

Any increase in activity should be done in very small steps, to avoid the risk of overdoing things. Reducing fatigue can be a lengthy process but it is important not to rush things.

When it comes to sleep, I find that patients with fatigue often sleep for lengthy periods of time because they are so exhausted. It is also likely that over-sleeping may exacerbate the symptoms of fatigue.

I’ve found that patients who sleep significantly more than eight hours per day and who are also fatigued are likely to benefit from reducing their sleep, not increasing it. Over-sleeping and day-time napping could cause disruptions to night-time sleep which will then cause further fatigue.

Reducing fatigue is likely to be a lengthy journey but by keeping to this advice improvements will be had, although both patient and healthcare professional will have to be patient and willing to work with setbacks that happen during the way.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi). All content in this article is for informational and educational purposes only. Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within. No advice in this article is intended to be a substitute for your own professional judgment in the clinical management of your patients.

[1] Paddison J, Effing T, Quinn S et al. Fatigue in COPD: association with functional status and hospitalisations. European Respiratory Journal 2013;41:565-570.

[2] Townsend L, Dyer A, Jones K et al. Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection. PLoS ONE 2020;15(11): e0240784.

[3] Mathieu, G. Fatigue in Chronic Respiratory Diseases: Theoretical Framework and Implications For Real-Life Performance and Rehabilitation. Frontiers in Physiology 2018;9:1285

[4] Huibers M, Beurskens A, Prins J, et al. Fatigue, burnout, and chronic fatigue syndrome among employees on sick leave: do attributions make the difference? Occupational and Environmental Medicine 2003;60:i26-i31