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Fatigue

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What is Fatigue?

Although the exact Definition of Fatigue is ill-defined, the generally accepted view of Fatigue is described as a "Persistent and Overwhelming" Feeling of Tiredness, Lack of Energy, Exhaustion, and/or Weakness. Fatigue can interfere with day-to-day tasks as it causes a Decreased Ability to Perform Physical or Mental Work. [6][7]
- Often occurs with other symptoms including: Depression, Anxiety, Impaired Coping, and Disordered Sleep.

Types of Fatigue

Acute vs. Chronic
Acute Fatigue
Acute Fatigue is a short duration type of Fatigue which is considered "Normal" and occurs in healthy persons.
- Usually caused by a single factor which is often resolved with appropriate rest, stress-reduction, diet and/or exercise.

Chronic Fatigue (CF)
- Often Associated with Illness or Pathology
- Cause can be Unknown (Ideopathic) or Multiple Causes
- Can Last for Months or More
- Can Affect Physical Function
- Can Affect Mental Function

Central Fatigue vs. Peripheral Fatigue
The complicated nature of the Immune System and its interactions with the Nervous System, Hormone Levels and Health in General makes separating "Peripheral Fatigue" from "Central Fatigue" a difficult one. Patients may display both types.
Peripheral Fatigue
Peripheral Fatigue is often seen in Inflammatory Diseases Affecting the Peripheral Body Systems (e.g., Muscles, Joints, Heart, Lungs).
- Does not often Affect Cognitive Functions (i.e., Mental Tasks, Thought, Attention, Memory, Problem-Solving, Attention, etc.)

Central Fatigue
Central Fatigue can also co-Associate with: Anxiety, Depression, and Sleep Disorders.

Measurement of Fatigue

Measurement of Fatigue is generally via questionnaire based tests that are often used to Quantify Fatigue for many different diseases and disorders, including Inflammatory Bowel Diseases (IBD). There are multiple types of these Questionnaires available, making comparison between different Research or Treatment studies difficult. [10]

Fatigue-based Questionnaires attempt to understand different facets of Fatigue Including[6]:
1. Affective Fatigue - Motivation reduced, Low Mood, Low Energy Levels.
2. Cognitive Fatigue - Difficulty with Concentration and/or Thinking Clearly, Memory Function is Impaired
3. Physical Fatigue - Weakness, Tiredness, Perception that they are Unable to Begin or Complete a Task, Measured Decrease in Physical Activity or Performance with Repeated or Prolonged Activity.

Fatigue Questionnaire (FQ)
The Fatigue Questionaire (FQ) is a Questionnaire-based measurement of Fatigue: [9]
- Physical Fatigue
- Mental Fatigue

Multidimensional Fatigue Inventory (MFI-20)
The Multidimentional Fatigue Inventory (MFI-20) quantifies Fatigue in 5 Areas:[7][8]
- Generalized Fatigue
- Physical Fatigue
- Mental Fatigue
- Reduced Activity
- Reduced Motivation

Causes of Fatigue

Anemia / Anaemia

- Particularly in patients that bleed, or in patients with Vitamin and Mineral Deficiencies, there may be anaemia. There are different types of anaemia, so a doctor would be able to advise if anaemia is present, and the best form of treatment.
- Female Ulcerative Colitis patients with Anemia had a greater likelihood for Fatigue than those that were non-Anemic.[7]

Dehydration

- Dehydration may cause symptoms. This is common in patients with chronic diarrhoea. Some patients may need to drink more than the recommended 2 litres of water a day (your doctor should be able to advise on this). Oral rehydration fluids can also be bought or made using this recipe http://rehydrate.org/solutions/homemade.htm#recipes.

Gender

Fatigue in general is found more often in Females than in Males.

Inflammatory Bowel Disease (IBD)

Fatigue is more common in patients with Inflammatory Bowel Disease (IBD) versus healthy persons,[11] and is most severe in patients with Active Disease. Even when not experiencing IBD-type symptoms, patients in Remission still report Fatigue (ranges between 29% - 44% of patients). [4][5][7]
Fatigued IBD Patients can also have Depression.

Fatigue in Crohn's Disease

In Patients with Crohn's Disease, Fatigue is correlated with:
- Active Disease (Flare)
- Anemia

Fatigue in Ulcerative Colitis

Fatigue in Ulcerative Colitis (UC) is correlated with Steroid/Prednisone Treatment.
Gender Differences:
- Females with Active UC Disease had a greater likelihood for Fatigue than those that were in Remission.[7]
- Males with UC had Fatigue correlating with Steroids or Biological therapies.[7] However in general Biological Therapies exhibit reduced Fatigue symptoms.[6]

Hypothalamus Pituitary Adrenal (HPA) Axis

A hypoactive cortisol response to stress has been shown to cause symptoms of fatigue and depression.

Immune System: Inflammatory Factors

Certain Pro-Inflammatory factors can cause symptoms of Fatigue. These Pro-Inflammatory factors can be released in an appropriate manner in response to an Infection, or in a nonproductive manner as in Autoimmune Disease, certain types of Cancer, or in a Dysregulated Immune Response such as in Crohn's Disease (CD)

Immune System Factors that can induce Fatigue:
Tumor Necrosis Factor - alpha (TNF-alpha)
Interleukin 1 - IL1[2]
Interleukin 1 Receptor A (IL1RA)[6]
Interleukin 6 - IL6[2]
Interferon
Neopterin[6]

Medication / Drug Treatments

Remicade (infliximab) And Fatigue

- Remicade Infliximab significantly reduces Fatigue Levels in patients who respond to treatment 7 Days after infusion.[4]
-- For more information on Remicade (infliximab) Please visit the Remicade Wiki HERE
- Remicade-Type Treatments may actually increase Fatigue in Males with Ulcerative Colitis. [7]

Oxidative Stress

Reactive Oxygen Intermediates (ROI) are produced in many biochemical pathways in the body, especially in the immune response. ROIs are very damaging products of these pathways and must be neutralized quickly. If this does not occur Oxidative Stress can result. Increased Oxidative Stress correlates with Fatigue in persons with chronic inflammatory diseases.

Resource Diversion

- A patient's body will be diverting resources to the immune system to fight off the perceived threat to the digestive system. This means less energy is available for the body as a whole. As the IBD is treated, fatigue should lessen.

Stress / Worry

Stress and/or Worry can have dramatic effects on fatigue. Especially when stress or worry situations are chronic.[3]

Vitamin and Mineral Deficiencies

- Particularly in patients with small bowel disease, there may be [wiki]Vitamin and Mineral Deficiencies[/siki]
Potassium or Sodium- A patient could be deficient in potassium or sodium (this can be a problem for patients with small bowel involvement, particularly if they are following a low salt diet). This can be checked during routine blood tests. Bananas are a rich source of potassium, and sodium can be obtained from salt.
Vitamin B12
Vitamin D

Underactive Thyroid

- Thyroid function should also be checked, particularly in female patients. Both over and underactive thyroid can lead to fatigue.

Tips for dealing with fatigue

One of the most effective ways of dealing with chronic fatigue is to pace yourself. This means dividing tasks into manageable chunks, allowing plenty of rest in between. If you have a good day, try not to do too much as this can lead to needing several days recouperating.

Increasing Energy Levels

Here are some tips for increasing energy levels: Yahoo Lifestyles article
(link originally posted by Astra101)

If you have a support network of family or friends who can take some of the pressure off you (e.g. by helping with household chores), let them help! If you don't have help available, prioritise which tasks are most important. Perhaps try online supermarket shopping to free up time and energy for other tasks.

Remember to allow time for leisure activities too!

If you are working, is there any way that you could do less hours, or delegate some jobs to take pressure off you?

It may seem counter intuitive, but exercise may help to increase energy levels. The key is to take it slow and steady, doing very small amounts to begin with and gradually building up. Remember, doing too much can set your energy levels back so don't push yourself to do too much too soon.

Finally, increasing Serotonin levels may help to reduce symptoms of fatigue.

References

1. Minderhoud IM, Samsom M and Oldenburg B. Crohn’s disease, fatigue, and infliximab: Is there a role for cytokines in the pathogenesis of fatigue? World J Gastroenterol. 2007; 13(14): 2089-2093.

2. Norheim KB, Jonsson G and Omdal R. Biological mechanisms of chronic fatigue. Rheumatology. 2011; 50(6): 1009-1018. http://rheumatology.oxfordjournals.o....full.pdf+html

3. Jelsness-Jorgensen L-P, Bernklev T, Henriksen M, et al. Chronic fatigue is associated with increased disease-related worries and concerns in inflammatory bowel disease. World J Gastroenterol. 2012; 18(5): 445–452. http://www.ncbi.nlm.nih.gov/pmc/arti...WJG-18-445.pdf

4. Minderhoud IM, Samsom M, Oldenburg B. Crohn's disease, fatigue, and infliximab: Is there a role for cytokines in the pathogenesis of fatigue? World J Gastroenterol. 2007; 13(14): 2089-2093. http://www.wjgnet.com/downpdf.asp?ur...7-9327/13/2089

5. Minderhoud IM, Oldenburg B, van Dam PS, van Berge Henegouwen GP. High prevalence of fatigue in quiescent inflammatory bowel disease is not related to adrenocortical insufficiency. The American Journal of Gastroenterology (2003) 98, 1088–1093; doi:10.1111/j.1572-0241.2003.07414.x http://www.nature.com/ajg/journal/v9...jg2003251a.pdf

6. van Langenberg DR. and Gibson PR. Systematic review: fatigue in inflammatory bowel disease. Aliment Pharmacol Ther. 2010; 32: 131-143. http://onlinelibrary.wiley.com/doi/1...10.04347.x/pdf

7. Bager P, Befrits R, Wikman O, Lindgren S, Moum B, Hjortswang H, Hjollund NH, and Dahlerup JF. Fatigue in out-patients with inflammatory bowel disease is common and multifactorial. Alimentary Pharmacology & Therapeutics. 2012; 35: 133–141. doi: 10.1111/j.1365-2036.2011.04914.x http://onlinelibrary.wiley.com/doi/1...11.04914.x/pdf

8. Smets EM, Garssen B, Bonke B, De Haes JC. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995; 39: 315–25.

9. Czuber-Dochan, W., Ream, E. and Norton, C. (2013), Review article: description and management of fatigue in inflammatory bowel disease. Alimentary Pharmacology & Therapeutics. doi: 10.1111/apt.12205 http://onlinelibrary.wiley.com/doi/1.../apt.12205/pdf

10. Hjollund NH, Andersen JH, Bech P. Assessment of fatigue in chronic disease: a bibliographic study of fatigue measurement scales. Health and Quality of Life Outcomes 2007; 5:12 doi:10.1186/1477-7525-5-12. http://www.hqlo.com/content/5/1/12

11. Jelsness-Jørgensen L-P, Bernklev T, Henriksen M, Torp R, Moum BA. Chronic Fatigue Is More Prevalent in Patients with Inflammatory Bowel Disease than in Healthy Controls. Inflamm Bowel Dis. 2011; 17: 1564-1572. http://onlinelibrary.wiley.com/doi/1.../ibd.21530/pdf

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