by Dr. Mark J Pellegrino, MD
Excerpted from the book, Fibromyalgia: Up Close and Personal
In CFS support groups and fibromyalgia support groups I have attended, both pain and fatigue are frequent topics of discussion... I think one person describing her fatigue said it best. She said her eyelids felt like cement weights and she felt like she was wearing cement shoes. Fatigue can be an overwhelming problem in fibromyalgia, and unfortunately, many people get the double curse – both severe pain and severe fatigue.
Why do patients with fibromyalgia (and CFS) have such a problem with fatigue?
There are multiple factors involved. These factors include:
1. Non-restorative Sleep Disorder
Restoration that should be occurring during the deep stage of sleep is not happening. Manufacture of proteins, replenishment of energy stores, and repair of tissues are incomplete. Poor sleep leads to increased fatigue.
2. Deconditioned Muscles
Deconditioned muscles in fibromyalgia have lost their ability to make the body’s energy molecules called ATP (adenosine triphosphate). This energy molecule is stored in our tissues, particularly muscles, and is used as fuel to enable the body to perform all of its functions, including muscle contractions.
The less ATP around, the less energy available, and once the stored supplies are used up, fatigue occurs. If this process occurs quickly, one may feel a sudden, unpredictable energy crash. In fibromyalgia, our chronically low ATP contributes to chronic fatigue.
3. Constant Pain
The body’s process of monitoring pain, recording pain, and expressing pain isenergy consuming and involves nerves, neurotransmitters, and other enzymes and hormones. The patient in constant pain will use up more energy and have less stored energy than normal. (See “Fibromyalgia – Ultimately a Disease of Amplified Pain.”)
4. Decreased Oxygen Use by the Muscles
Studies have shown that muscles with fibromyalgia do not use oxygen as well as normal muscles. This may reflect a problem with the muscle mitochondria, the small organelles that use oxygen and manufacture ATP. A biochemical problem may prevent the available oxygen from being used efficiently and adequately to create ATP.
5. Associated Clinical Depression
Depression is seen in nearly half of patients with fibromyalgia and can cause extreme mental fatigue.
6. Associated Chronic Conditions
Such as arthritis, hypothyroidism, or other disease. People with fibromyalgia may have other conditions that consume a lot of energy and contribute to excessive fatigue.
7. Cognitive Factors
Fibromyalgia causes difficulty with concentration and attention, increased anxiety, increased sensitivity to depression, and absentmindedness. This is our fibrofog.
8. Dysfunctional Autonomic Nervous System
We are more prone to anxiety and panic attacks, Raynaud’s phenomenon, fast heart rate (especially in response to stress), rashes on the skin (especially in response to touch), throat tightness, irritable bowel syndrome, irritable bladder and other symptoms that are all consequences of an over-sensitized autonomic nervous system. Fatigue can also be a consequence of our dysfunctional autonomic nerves. (The autonomic nervous system maintains the "automatic" bodily functions performed by many organs, muscles and glands, and drives responses to physical or emotional stress - fight or flight.)
9. Visual Overload
I use this term to describe the overwhelming information our eyes receive and have difficulty interpreting. (Reviewed in Chapter 4 of Fibromyalgia: Up Close & Personal.)
We try to spot a particular object but are confronted with a variety of shapes, sizes, colors, and lines in different directions that literally overwhelm our visual senses and at times cause a feeling of dizziness, light-headedness and increased anxiety. I believe this contributes to fatigue by demanding so much energy to sort out this information.
10. Decreased Respiratory Endurance
Many patients with fibromyalgia complain about their shortness of breath with short bursts of activity such as climbing steps, running or walking swiftly. They may actually have difficulty catching their breath. This respiratory complaint may be from sudden exercise-induced fatigue of the respiratory muscles that disrupts the breathing rhythm.
The complaint seems to be independent of whether or not the person is out of condition or living a sedentary lifestyle. Since an efficient breathing process is necessary to deliver oxygen to the bloodstream, any problem in this area will certainly create potential for fatigue.
11. Constant Muscle Movements
People with fibromyalgia are frequently shifting their bodies to find more comfortable positions. Habitual movements such as tapping fingers on the table, tapping or bouncing the feet on the ground, frequent crossing of the legs, and kicking out a leg are probably subconscious movements to relieve muscle stress, keep the blood flowing, and readjust the muscles and posture to try to decrease the pain. However, the side effect of these movement patterns is increased energy consumption.
12. Hormonal Problems
Decreased supply of hormones or inefficient use of available hormones may factor into fatigue. Low growth hormone and low thyroid levels are common in fibromyalgia and can decrease energy metabolism and hence increase fatigue. Altered stress mechanisms in our bodies will increase energy consumption and interfere with efficient use of energy, hence fatigue is worsened. Other hormones that can cause fatigue when in short supply are estrogen and serotonin.
13. Hypoglycemia/Insulin Hypersensitivity
Our brains require a steady dose of glucose (blood sugar) and if our nutritional dysfunctions lead to hypoglycemia, our brains will react by signaling: “You’ll feel lousy until I get more glucose!” (See discussion of hypoglycemia in “Why weight gain is a problem with fibro, and what to do about it.”)
14. Low Magnesium
Magnesium levels in the cells are low in most fibromyalgia patients. Magnesium is a key mineral in the formation of ATP/energy molecules in the muscles. Low magnesium means low ATP, which means more fatigue. (See “Nutritional Approaches in Fibromyalgia: Deficiencies, Symptoms, Supplement Strategies.”)
15. Candidiasis (Yeast Infection)
Candida albicans is a yeast normally found in healthy intestines. In fibromyalgia, Candida can overgrow in the intestines and become “unfriendly.” This can lead to systemic symptoms including fatigue. (See “Candidiasis – Yeast Infection and Nutritional Repair.”)
Fatigue creates problems in our daily activities, regardless of the cause or causes. A major negative effect of fatigue is increased pain which in turn consumes more energy and causes further fatigue – a self-perpetuating cycle of pain and fatigue. Fatigue interferes with our ability and motivation to socialize, carry out daily routine chores, and perform our jobs properly.
There are many strategies for treating fatigue. Fatigue will probably never be completely eliminated, but many things can be done to control its consequences and minimize its impact on everyday life.
Your doctor may first want to investigate for underlying diseases such as hypothyroidism, sleep disorders, anemia, and connective tissue disease – which involve different treatment approaches. If there are no significant underlying diseases present, the fatigue may be attributed to the fibromyalgia syndrome (or chronic fatigue syndrome).
Some specific labs that I frequently order in fibromyalgia patients with significant fatigue include:
- Complete blood count (to evaluate for anemia or blood disorders)
- Sedimentation rate (to evaluate for any underlying inflammation)
- T4, TSH levels (to evaluate for any thyroid abnormalities)
- Insulin-like growth factor 1 level (to measure for growth hormone deficiencies)
- Magnesium RBC (to measure for any intracellular magnesium deficiency).
If labs are in the normal range but low/normal, I may interpret these to be “abnormal” for an individual patient. That is, the patient’s level is still too low for what the patient needs, even though the level may be within the normal range.
What steps can be taken to minimize the potential debilitating effects of fatigue?
Below is a list of strategies that I have found helpful.
1. Develop Good Sleep Habits
Quality sleep is necessary for the body to manufacture energy. Develop a good sleep routine. (Reviewed in Chapter 22 of Fibromyalgia: Up Close & Personal.)
2. Avoid Long Daytime Naps
Although fatigue may be compelling at times, it is best to try to avoid taking naps since this alters the body’s sleep rhythm. Naps are often non-refreshing and time-consuming. Upon awakening, many people feel even less energetic and have more difficulty getting going again. They may even have a period of increased confusion and mental fogginess.
In some people, however, a strategic nap (less than one hour) accomplishes its goal by refreshing and restoring the individual for more successful completion of the remainder of the day. As long as the primary nighttime sleep is not disturbed any more than usual, these naps are not to be discouraged.
However, it is my experience (and sleep studies show) that most people who try to overcome fatigue with a nap actually do not accomplish the refreshing and restoring mood that they are seeking, and the evening sleep pattern is disrupted.
3. Proper Nutrition
A higher protein/lower carbohydrate diet has helped many people improve their energy. Diets too rich in fat can put the body into a lazy mode, but if you reduce your fats at the expense of getting too little protein, you may have more fatigue, so find your balance. (For details, see “Why weight gain is a problem with fibro, and what to do about it.”)
4. Natural Supplements - and Prescription Medications
The dozens of natural supplements advertised to increase energy are successful for some people. However, many energy products contain the stimulants caffeine or ephedrine, which can long-term adverse effects on the body and can be dangerous if taken together. Before trying any natural energy product, I recommend first consulting with your doctor.
- I recommend a Magnesium and Malic Acid combination, and Colostrum as the top two supplements to try to improve energy levels. Magnesium and Malic Acid combinations work by increasing energy formed in the muscle. Colostrum promotes improved metabolism and energy by increasing growth hormone levels.
- If the B-12 level is low/normal, I may recommend vitamin B-12, in either lozenge, sublingual (under the tongue) or injection form. B-12 pills may not absorb well from the stomach, whereas the other forms of B-12 are absorbed differently (lozenges and sublingual forms are absorbed into the blood from the capillaries in the mouth and underneath the tongue, and injection B-12 is absorbed into the bloodstream from the muscle).
- If the thyroid is low or low/normal, I may prescribe Armour Thyroid in the morning. Co-enzymeQ10 (CoQ10) is another supplement that can help increase ATP/energy levels in the muscles.
- Prescribed medicines that increase serotonin levels can help improve energy as well. These include the selective-serotonin reuptake inhibitors (SSRI’s) such as Prozac, Zoloft, Paxil, Celexa, Lexapro and Effexor.
- Welbutrin is a different type of antidepressant that is reported to increase the norepinephrine level instead of the serotonin level. Norepinephrine is important in improving our focusing, concentration and energy levels.
- 5-HTP is a natural nutritional building block for serotonin which can help improve sleep and mood and decrease pain, all of which can help fatigue. St. John’s Wort and SAM-e are other natural herbal antidepressants that can help increase serotonin levels. If underlying depression is a problem, your physician may opt to prescribe an antidepressant medication because improving the depression will usually improve the fatigue as well.
- Certain prescription medicines known as central nervous system stimulants can be prescribed by your doctor in cases of extreme fatigue causing debilitating functional problems. These medicines are similar to the ones used for children with attention deficit disorders. They include Ritalin, Cylert and Provigil.
6. Plan Scheduled Activities, Especially in the Evening
The late afternoon and early evening are often the most difficult times for persons with fatigue. After supper can be an especially difficult time, especially if the person sits down to relax or lies down to read the paper. ‘Crashing’ and inability to do any useful activity for the rest of the evening may occur.
My advice is to routinely plan some activity, especially for after supper, that includes running errands, getting outside, visiting people, or just staying up on your feet. You will be surprised to learn how frequently a second wind will come. Many people have a natural rhythm that causes low energy in the late afternoon and early evening, but then the mood and energy level swings back up again.
If you are a night owl, you tend to feel better and more energetic around 9 PM and may have a few good hours where you feel alert and can accomplish a lot.
Recognize your own biorhythm and take advantage of it to:
- Plan your best work around your high points
- And try to stimulate yourself through the low points by involving yourself in an activity.
7. Divide Your Task into Smaller Projects Instead of One Big One
Do a little at a time and do more at your best time. For example, yard work can be divided into specific chores for different nights of the week. You may mow the front lawn one night, the back another, and trim on a third night, instead of doing all three in one day. If we are moving and decide to do our own packing, it is much easier to pack a box per day for the six weeks prior to the actual moving date, than to try to do all the packing in one or two days prior to the move. This type of self-discipline is also needed when vacationing and decorating for the holidays. (Actually, self discipline could help a lot of things!)
8. Perform Regular Exercise and Relaxation
Exercise increases endurance, cardiovascular conditioning, and a sense of well being. In fact, regular exercise is the best way to improve the ATP/energy manufacturing within our muscles. Relaxation decreases stress and reduces pain. A 30-minute brisk walk after supper provides exercise and mental relaxation and counteracts the low biorhythm point at the same time.
One does not have to sit perfectly still to physically and mentally relax; in fact, this often increases fatigue and the tendency to sleep. Remember to relax, not nap.
9. Make a Daily Schedule and Check Off Things as You Accomplish Them
Allow plenty of time to complete the task. By keeping a structured list, you have a better chance of motivating yourself to reach daily goals.
10. Delegate Chores to Others
One of the best energy-saving techniques known is to have someone else use his or her energy to do your task! While delegating responsibilities is difficult for many people, there are others who will gladly perform certain chores for you. It is best to be as independent as possible, but it is better to allow someone else to helpl if it means you will have energy for a longer portion of your day.
Hopefully, some of these weapons can help you combat fatigue. Remember that fatigue, like pain, is a relative problem. (No I don’t mean cousin Vito!) The problem is always there, but you try to achieve a lower, more functional state that, relative to the previous level, is considered a successful, manageable level.
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Dr. Pellegrino has seen more than 20,000 FM patients in his practice at the