Fatigue is a symptom rather than a condition, it is all too common in today’s demanding world. It affects people of all ages, at any stage of life, and can be associated with a lack of energy and motivation. Healthcare professionals sometimes find it difficult to distinguish fatigue from other common symptoms, such as tiredness, and often treatment does not commence until the situation has become chronic. 

Fatigue in spinal cord injury (SCI) is under-reported, under-researched and not sufficiently understood. Females tend to be more affected than males and the level of injury appears to be relevant too: people living with tetraplegia report more fatigue than people living with paraplegia. These findings come from a longitudinal study of 300 British SCI people who have been living with their injury for more than 23 years.

If your injury is incomplete or you are able to walk, you are just as likely to experience fatigue as people with complete injuries.  

Take fatigue seriously, it may be associated with how long you have been injured and it probably won't go away on its own.

What causes fatigue?

Fatigue can be caused by a combination of factors:

Medical conditions:

• anaemia
• respiratory problems
• diabetes
• metabolic disorders e.g. thyroid deficiency
• immune system disorders 
• pain – chronic/severe
• infections; bacterial or viral – e.g. urinary tract and respiratory tract
• high levels of spasticity
• low blood pressure (hypotension)
• depression and other psychological conditions
• people who experience frequent episodes of autonomic dysreflexia

Medications:

• certain painkillers and muscle relaxants
• alcohol and drug abuse 

Other causes:

• performing daily tasks
• transferring many times during the day
• pain
• mood swings / anxiety / boredom
• chronic headaches
• sleep disturbance – your sleep may be disturbed if you need to relieve pressure or empty your bladder

How can fatigue be treated?

Treating the symptoms

For example, if pain is keeping you awake at night you should seek treatment for your pain.

Counselling

Try to ensure that the person you see is registered with one of the professionally recognised bodies in your country, who has experience of working with SCI people. 

Cognitive Behavioural Therapy (CBT)

This therapy helps manage your problems by changing the way you think, and ultimately the way you behave.

Seeking medical advice

Try to seek specialist medical advice before fatigue affects your daily life. You may require bloods tests to eliminate conditions such as anaemia or an underactive thyroid. There may be a local specialist clinic or facility where you can get advice or treatment and have your fatigue level monitored.

Self Help

This doesn’t necessarily mean going it alone, you can still engage family and friends to help you. Also, there are self-help books including audio books which can be obtained.

Complimentary therapies

You may consider using complimentary (alternative) therapies on their own, or in conjunction with conventional treatments such as drug therapy.

Complimentary therapies include massage, relaxation techniques, acupuncture, hydrotherapy and mindfulness (meditation).

The therapies work for some people and not others and there is generally a cost implication.  Some therapies may be difficult to access in your area or country, so try to source therapists where you have a personal recommendation; it may be wise to check with your medical team that your chosen therapy is safe for you.

Cautionary effects of fatigue in SCI

• over time you may begin to feel that you don’t have the strength to transfer properly due to weakness or lack of strength, when you will be at risk of shearing injuries that can lead to pressure ulcers
• if you feel too tired to prepare proper meals and eat healthily, you may risk ill health
• years of walking with crutches or sticks can lead to fatigue as over time our muscle mass reduces and leads to increased weakness, which affects muscle function
• chronic fatigue may cause problems such as mood swings, memory and concentration lapses, and disruption to sleep patterns. You might need to alter work and leisure activities to make sure these issues don’t affect your relationships with family and friends. 

Coping strategies

• consider how you could reduce certain daily tasks without taking unnecessary risks
• current advice suggests that going to bed and getting up at the same time helps with sleep patterns; if you are reliant on a carer then strict timings may be difficult to stick to. 
• setting aside a time each day to rest and relax may be difficult to achieve but is worth trying - turn off mobile phones and avoid other distractions such as computers and TV
• look at reducing the number of car journeys you make, to cut down on the number of transfers you carry out in a day - if you lift your wheelchair into the car yourself you might consider introducing mechanical aids 
• working full time may be contributing to your fatigue so consider working part-time, or at home; particularly when heading towards retirement.
• bladder and bowel management may be taking longer and you may feel exhausted after performing these tasks - think about how you could change your regime, which may involve seeking outside assistance (from a physical point of view) or advice from a healthcare professional
• Try shopping online once a week instead of going to the supermarket.

Top tips

Lifestyle

• keeping a diary can be useful for reporting symptoms to your GP and Spinal Consultant, and for your own benefit to monitor progress - you can record how severe you feel your fatigue is by devising a scoring system using a scale of 1 to 10
  
  • you can record feelings of weakness and whether it is worse in the morning or evening? 
  • you may be aware that your fatigue is related to physical activity, or it may be related to your mood - it is important to record what makes it better.
• make small changes to your daily routine using evidence from your diary - if you can identify what makes you tired and at what time of the day this occurs, then you can start to make some adjustments
• try to plan something to look forward to each day, even something small like a favourite TV or radio programme; when you’re feeling happy and positive you will usually feel more energized
• it is important to pace yourself, getting the balance right between exercise, activity and rest

Health

• if you are experiencing increased levels of weakness, try to determine the underlying cause and ascertain whether this weakness is perceived or actual
• eating nutritious food and taking enough fluids will help your general feeling of wellbeing - try to eat smaller meals more regularly instead of large meals, which take of a lot of energy to digest

Physical

• exercise of the right type and quantity e.g. yoga or Pilates; a physiotherapist can help you 
• devise which type of exercise is best for you

Mental

• be honest about your situation with friends and family so they understand your limitations and don’t be afraid to say “no” on occasions
• talking to other SCI people about their experiences and how they cope can be motivating, and help prevent you feeling isolated
• experiment with relaxation techniques such as mindfulness - for some people just 10 minutes a day can help them re-energize

Equipment

• make changes to your equipment/aids e.g. using a hoist will save wear and tear on your joints and will also conserve energy - if you are a walker, using a wheelchair part-time will have the same effect
• consider using a power wheelchair or e-motion wheels, both of which are ideal for the preserving of energy and protection of your shoulder joints
• for walkers, consider using a wheelchair both for preserving energy and for your safety, especially in crowded places

Quality of life

Chronic fatigue, if left unchecked, can impact on many aspects of a persons’ life. Living with a spinal cord injury will alter the way you prioritise and set goals and cause you to reassess the things you value in life; you need to set realistic goals and learn how to pace yourself. Fatigue is one issue that you may have to deal with and adapt to, so that it has a minimal effect on the quality of your life.

Keeping in touch with extended family and meeting up with friends can be energising. Don’t be afraid to share your concerns with those closest to you, and don’t forget that your able-bodied friends will also experience fatigue and aches and pains, along with other effects of ageing.

Avoid the company of negative people as they can affect your mood; this may be unintentional but the effect is just the same.

Summary

The key aspects of managing fatigue in advancing years are recognising that it is a problem and then implementing the necessary changes/adaptations in order to minimise the impact on your life. Eating healthily, exercising within your capability, pacing yourself and making time for rest are all important. Equally, staying positive and involving family and friends, along with proper assessment by the appropriate healthcare professionals, will help in controlling levels of fatigue.