Self help strategies to help fight fatigue.
Chronic fatigue has profound effects on the physical, emotional and mental health [Thomas]. It can have a phenomenal impact on a patient’s quality of life, interfering with daily activities and also may potentially have devastating social and economic consequences [Thomas].
Cancer Related Fatigue (CRF) has overtaken nausea and pain as the most distressing symptom experienced by patients during and after their anticancer therapies. It is reported by 60-96% during chemotherapy, radiotherapy or after surgery and the post treatment fatigue syndrome can last for up to 12 months [Thomas]. It is also reported, in up to 40% of patients taking therapies which are taken for longer periods such common hormones and biological agents [Thomas]. It can even hinder a patient’s chance of remission or even cure, if it effects compliance with treatment [Wagner]. The precise aetiology of chronic or cancer related fatigue is not fully understood but researchers have linked it to excess oxidative stress [Logan].
Management of Chronic Fatigue:
Medical treatments: Associated aggravating medical conditions should be looked for and treated if possible. The most obvious include anaemia, electrolyte imbalance, liver and renal failure; drugs such as opiates, antihistamines, anti-sickness medication, steroid withdrawal or adrenal insufficiency and sedatives [Thomas]. Some symptoms can cause fatigue by disturbing sleep pattern, such as anxiety, depression, nocturia, pain, restless legs, night sweats and pruritus [Thomas].
Once this conditions have been excluded or treated medical treatment have been tried with limited success. Psycho-stimulants such as the amphetamine salts such as dextroamphetamine and levoamphetamine (Adderall) or methylphenidate (Ritalin) licensed for deficit hyperactivity disorder and narcolepsy, have been shown to improve fatigue and concentration in the short term and hence its popularity amoung students but can induce insomnia and agitation with long term use aggravating chronic fatigue syndromes [Yancey]. Caffeine is the most commonly used self administered drug but this only offers a short term fix, does not help chronic fatigue and in fact may make if worse by impairing sleep [Greenlee].
Integrative strategies (non-nutritional): Techniques aimed at reducing stress include relaxation classes, yoga and massage have some evidence for fatigue improvement by improving sleep patterns along side other sleep hygiene strategies [Bower, Garssen]. Caffeine in tea and coffee can help in the morning but can lead to dependency and can impairing sleep in sensitive individuals [Greenlee]. Regular Qigong, a Chinese system of breathing techniques, posture and stretching has been shown to help in management of fatigue [Chen, Deng] as well as therapist delivered acupuncture and Cognitive Behavior Therapy [molassiotis, Price].
Exercise: The most robust evidence for a benefit for CRF is seen with moderate, regular physical activity and the most notable RCT’s have been summarised in two meta-analysis. The first published in 2008 by Cochrane reviewed 28 RCT’s [Cramp] and the second in 2009 from the Netherlands reviewed 18 RCT’s [Velthuis]. Supervised exercise programmes, which involve Graduated Exercise Therapy (GET) had the best results as they improve motivation and progressively build up the regimen over several weeks. These avoid exercise which exceeds the anaerobic threshold or a level of exercise which requires an oxygen consumption of over 40-50% of the individuals VO2 max (ml/kg/min at peak exercise) depending on their level of fitness both of which require drawing on energy reserves and subsequent post-exertional malaise [Sisto]. It is often not practical to measure these within a typical exercise session so heart rate is often used as a surrogate measurement of the anaerobic threshold. It is usually around about 60% of a person’s maximum heart rate (220 minus current age), though each person is different and an individual’s threshold may vary from day to day or within a day [Wilmore]. In the UK, it is possible obtain a supervised exercise referral from the medical staff to a local exercise facility but, finances allowing, a personal trainer session three times a week may be money well spent. Above all, exercise should be regular, moderate to strenuous and enjoyable if it going to be sustained for the long term [Thomas].
In terms of timing, exercise interventions do not have to wait until initial treatments have finished. The PACES RCT reported significant reductions in fatigue is women started a supervised moderately intense exercise programme starting during chemotherapy [Van Waart].
Nutritional strategies: Identifying and corrected food intolerances such as lactose and gluten can improved fatigue as well as gut and associated systemic symptoms [Werbach, Manuel]. Correcting essential vitamin, mineral, fatty acids and amino acid deficiencies or excesses can been shown to help [Werbach, Manuel. Shunning high glycaemic rich foods such as sugar and refined carbohydrates, especially on an empty stomach, can help fatigue by avoiding cause sudden rises in blood sugar prompting inappropriate insulin release and subsequent hypoglacemia [Werbach]. It is often difficult for people to identify added sugar in foods and juices but numerous online recipes are now available which can guide a switch to slow release carbohydrates via whole fruits, green vegetables, vegetable oils and nut [blog.cancernet.co.uk].
Ginseng (Panax quinquefolius) has long been used in traditional Chinese medicine as a natural energy enhancer. These foods can be added to meals or drank in teas but, in terms of scientific investigation, most of the data stems from laboratory or clinical trials which have concentrated it into nutritional supplements: Ginseng’s active ingredients, called ginsenosides, have been shown in animal studies to reduce cytokines related to inflammation and to help regulate cortisol levels, two factors with contribute to the aetiology of fatigue [Greenlee]. Its potential benefits for cancer related fatigue in humans was investigated in a double-blind randomized trial which recruited 364 patients from 40 USA community Hospitals. Participants took either a capsule containing 2000mg of ginseng (standardised to 3% ginsenosides) or a placebo. By 8 weeks, a statistically significant difference change in fatigue was seen as measured by the Multidimensional Fatigue Symptom Inventory. Greater benefit was reported in patients receiving active cancer treatment [Barton D]. It must be noted that this study used a whole root product not ginseng methanolic extract commonly used in other over the counter supplements which has demonstrated estrogenic effects in breast cancer cell lines [king].
Probiotics: There have been a number of small but interesting studies evaluating the effect of probiotic bacteria on chronic fatigue. In one study Lactobacillus acidophilus and Bifidobacterium lactis were given to patients with high fatigue severity scores and high disability scores. By 4 weeks, health and physical activity improved using a Visual Analogue Scales and the SF-12 Health Survey [Sullivan A]. In another small randomised study involving people with fatigue and irritable bowel syndrome, bowel symptoms improved as well as emotional well being within the probiotic group [Roa]. Although further trials are required to confirm these findings, given the other benefits of probiotics the it would certainly worth giving them a two months trial. It is important to note they should be at least a 5 strain brand and of a trusted and reliable source.
Guarana (Paullinia cupana), is a plant in the maple family that grows along the Amazon and is common in Brazil. Guarana is commonly used as a stimulant and contains about twice the caffeine of the coffee bean. It also contains theobromine and theophylline, other stimulants that affect the central nervous system. Well conducted RCT have not been published evaluating Guarana. [da Greenlee, Costa Miranda, de Oliveira Campos].
Carnitine is essential for mitochondrial energy production. Disturbance in mitochondrial function may contribute to or cause the fatigue seen in Chronic Fatigue Syndrome (CFS) patients. Previous investigations have reported decreased carnitine levels in CFS. Acetyl-l- carnitine has been investigated in small studies the evidence of a benefit is not robust [Hershaman]. However a meta analysis of 12 of the best studies, published in 2017, did not support the use of carnitine supplementation for cancer-related fatigue.
Various vitamins and minerals are likely only to help if correcting a known deficiency [Greenlee] and the only way to find this out is via micronutrient test. Melatonin (0.5 to 3 mg, 5 to 8 hours before bedtime) has been shown to improve fatigue symptoms among people with Chronic Fatigue Syndrome with poor sleep patterns [van Heukelom] but has not ben investigated post cancer [Greenlee]. A small study of polyphenol rich, sugar free cocoa did demonstrate an improvement in the functional disability caused by fatigue but further confirmatory trials are required [Sathyapalan].
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