By Pam Clarke, Expert Hand & Rehabilitation Therapist, The OT Practice
Fatigue is a common feature of a client’s journey, whether that be one of rehabilitation and recovery or restoration and maintenance.
Despite its prevalence, however, fatigue remains poorly understood. There is little consensus as to which part of the brain is responsible for generating fatigue, while its impact upon function and quality of life continues to be either underestimated, or overlooked.
Fatigue can be broadly categorised into two groups: non-pathological (or ‘normal’) and pathological (or chronic) fatigue.
Normal fatigue is a signal from the body that a rest is required, usually triggered by an episode of physical or mental exertion. This type of fatigue is time-limited and alleviated by an appropriate period of rest and recovery, with little in the way of impact on functional ability.
Conversely, pathological fatigue is commonly associated with a pervasive sense of lassitude or lethargy, disproportionate to the prior activity, unresponsive to rest and can prevent engagement in usual and required daily activities.
That said, it is also important to remember that fatigue in itself is not a disease; rather an underlying symptom triggered by another illness or condition, such as:
Brain or spinal injury
Neurological conditions - such as Multiple Sclerosis, Parkinson’s Disease, Motor Neurone Disease, Stroke and Dementia
Mental health conditions
Endocrine and metabolic disorders
There are, however, occasions where the trigger or cause may remain unidentified - with fatigue being present, despite the lack of obvious illness or disability.
Signs and Symptoms
Fatigue is a subjective and uniquely personal experience that can make it difficult for the individual to both articulate and quantify their symptoms. However, in my experience, the following are commonly used words and phrases by individuals when attempting to describe how they feel:
Lacking in energy and motivation
Walking through glue
Feelings of uselessness and hopelessness
Word finding difficulties, or slurred speech
The role of the OT
Once fatigue has been identified as a barrier or challenge to the rehabilitation / maintenance journey, there are techniques and strategies that can be taught and implemented to support the client with managing or over coming this.
As part of the assessment process, the occupational therapist (OT) will work collaboratively with the client to determine the type and severity of the fatigue. While there is no specific test or objective assessment to do so, the OT will work with the individual, their family and others involved in their care to obtain as clear a picture as possible of the nature of their client’s problems. They will consider how they experience their fatigue on a day-to-day basis, its impact upon their illness or condition, their overall functional ability and the impact upon their quality of life.
Having established the type and severity of the fatigue, the OT will then work with the individual and their family/carers to develop a fatigue management programme. This may involve building a programme of graded achievable activities which seek to restore function, whilst managing the need for rest and recuperation and ensuring that the individual is supported and encouraged to stretch their capabilities.
Throughout this process, it is critical that ‘normal’ activity is encouraged. For example, the individual should be discouraged from either resting or sleeping for lengthy periods of time throughout the day. Equally, they should not be attempting to engage in vigorous activity or immediately resuming previous daily patterns, as this can exacerbate their symptoms.
The OT will also work with their client, assisting them to both prioritise and adopt pacing and energy conservation techniques, when completing activities of daily living. Breaking down tasks or activities, to ensure that they are completed in an efficient manner, which may include learning alternative techniques or strategies, in addition to considering the use of adaptations and equipment.
The overall effect of which should be to minimise an individual’s overall level of fatigue, whilst enabling them to move forward toward their goals.
Identifying Triggers and Managing Set Backs
The process of rehabilitation is rarely straightforward and inevitably an individual will encounter setbacks, the severity of which can be difficult to both foresee and to manage.
To obviate this as far as possible, the OT will work closely with their client to identify likely triggers, which may be physical, psychological or environmental. The OT will also work to develop strategies and techniques to manage these, whilst supporting the individual to work through the difficulties they are experiencing.
All this must be done with a view to providing their client with the necessary skills to navigate future problems and minimising the impact of further setbacks upon their functional ability.
Why is fatigue management important?
Fatigue can pose a significant barrier to function, its effect can pervade all areas of an individual’s existence and can often have a devastating impact upon their life and that of their family and friends - which can be difficult to overcome.
While there is little research to objectively demonstrate that fatigue management is effective, in my practice, successful management of fatigue has, without exception, had an enormous impact upon my client’s ability to engage in their activities of daily living - and has had an objective positive impact upon their quality of life.
Fatigue is experienced by everybody at one point or another and is frequently discussed within day-to-day life, often in a competitive way. It is therefore important to remember that pathological fatigue, which has many similar descriptors to non-pathological fatigue, is by nature - and the way that it is experienced - entirely different.
As such, the individual experiencing it frequently feels misunderstood, frustrated, a burden to their family and friends and distressed at the often utterly disproportionate level of fatigue that they feel, often many months or years after their injury or illness.
This must be acknowledged and respected by the therapist and not compared to other clients, whose injury or illness may objectively appear more or less severe.
Instead, the therapist must work in collaboration with their client and their family to promote understanding of the condition and to develop the tools with which to overcome it, in order to restore functionality. While working collaboratively, the therapist must also ensure that underpinning any intervention is the notion that fatigue management will for many be a life long approach, which must be adopted in all aspects of their day-to-day life.
It will not be overcome by the miracle of hands-on treatment; instead it will in all likelihood require a progressive approach. This will, over time, work with the individual to not only achieve their aims, but also to moderate and mediate the effects of set-backs and failures.
The key to fatigue management from an OT perspective revolves around providing your client with the resilience to persevere with the programme and thereby promoting confidence and independence in their daily life.
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