Dr. Aly Cohen Contributes to Creaky Joints Article on Fatigue from Inflammatory Arthritis

Credit: fizkes/istock Tatiana Ayazo for CreakyJoints

PUBLISHED 10/18/21 BY SUSAN JARA

From brain fog to irritability, here are some subtle signs that your inflammatory arthritis is causing fatigue.

Fatigue from inflammatory arthritis is, well, exhausting. But it’s different than just being super tired or feeling sleepy. “Fatigue is a debilitating physical and mental symptom that takes you out of your regular process of life,” says Aly Cohen, MD, a rheumatologist at Integrative Rheumatology Associates in Princeton, New Jersey, and founder of the social media platform TheSmartHuman.com.

Fatigue interferes with your ability to work, care for your family, do chores, run errands, and engage in social activities. For CreakyJoints member Ashley Z., fatigue makes basic things like using the bathroom or taking a shower “feel like a chore.”

Fatigue is a high-ranking issue for people with many types of inflammatory arthritis, including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis (axSpA). In fact, a study from the Global Health Living Foundation (GHLF) and CreakyJoints found that fatigue is one of the most important symptoms that people living with arthritis say they want to monitor, due in large part to how much it affects their day-to-day lives. (You can use our ArthritisPower app to track your symptoms and disease activity and share your results with your doctor.)

“Patients anecdotally report that fatigue is one of the worst parts of having a chronic inflammatory disease, and that their loved ones and even sometimes health care providers don’t fully understand the magnitude and impact it can have on their lives,” says study coauthor Kelly Gavigan, MPH, manager of research and data science at GHLF.

Unfortunately, there’s no quick fix for fatigue. Unlike when you’re tired, you can’t just drink a cup of coffee, take a power nap, or psych yourself up to push through your day.

Fatigue is a symptom that you can’t shake and shouldn’t ignore, as it may indicate an arthritis flare or could be a red flag for another underlying disease, says Dr. Cohen.

By understanding the symptoms of inflammatory arthritis-related fatigue — and how they differ from merely feeling tired — you can have an informed conversation with your health care providers so you can pinpoint the underlying causes and start feeling better. “You owe it to yourself to go through life with energy,” says Dr. Cohen.

Causes of Fatigue in Inflammatory Arthritis

There’s no one single cause of inflammatory arthritis fatigue — it’s “multifactorial,” or due to a number of causes, explains Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at Mount Sinai in New York City. And the causes are often interrelated, which can make you and your rheumatologist do some detective work to figure out what’s going on.

Dr. Cohen shows her patient a “fatigue wheel” with fatigue in the middle and the potential causes around it. “There is so much overlap, so it’s my job to be the detective and tease away all of the different things on the fatigue wheel that contribute to fatigue,” she says.

The following factors and comorbidities are all potential causes of inflammatory arthritis fatigue:

  • Anemia
  • Anxiety and depression
  • Cardiovascular disease
  • Chronic stress
  • Chronic pain that disrupts sleep
  • Diabetes
  • Fibromyalgia
  • High disease activity or inflammation
  • Certain inflammatory arthritis medications (including disease-modifying antirheumatic medications, or DMARDs)
  • Lack of exercise or de-conditioning
  • Low thyroid
  • Nutritional deficiencies

Symptoms of Fatigue in Inflammatory Arthritis

Just like there are many causes of fatigue, there are also many symptoms that may indicate what you have is inflammatory arthritis-related fatigue. It’s very “subjective and not quantifiable with a lab or measurable outcome, which is why fatigue can feel so frustrating and overwhelming,” says Dr. Cohen. “You can’t quantify it, but you know it’s not normal.”

Here’s a look at some of the key symptoms to discuss with your health care team:

Extreme tiredness

Dr. Khattri says that while symptoms of fatigue and feeling tired do overlap, fatigue is often at the extreme end. You feel like you have no control.

“With ‘normal tired’ you know sleep can fix it,” says CreakyJoints community member Lel. “Fatigue decides when it’s over; you’re just a helpless bystander.”

Change in energy levels

While some patients wake up feeling fatigue, others experience sudden, overwhelming changes in energy levels and simply “hit a wall.”

“RA fatigue stops me in my tracks. I feel myself fading out suddenly, then I have to rest (if I can). It feels like sandbags dropped on me,” says CreakyJoints community member Kristina H. “It hits me around the same time every day, or sometimes I wake up knowing it’s going to be a low energy day.”

Increase in flares

People who have their inflammatory arthritis under control can experience fatigue, but it’s also a symptom of high disease activity and inflammation. During an inflamed state, the body is fighting itself and it gets tired, explains Dr. Cohen. “If your overactive immune system, which is pointed to itself, doesn’t get quieted down, it zaps your energy.”

Poor sleep

Trouble sleeping is both a symptom and a cause of fatigue — and it can also make your fatigue worse. Despite the fact that inflammatory arthritis fatigue can make you feel extremely sleepy, you may have trouble falling asleep, staying asleep, and/or feeling refreshed after sleep.

Research shows that poor sleep can make the symptoms of fatigue worse, increasing sensitivity to pain, irritability, and making it that much harder to concentrate,” says Dr. Cohen.

Brain fog

“Brain fog” — or cognitive dysfunction — is often a difficult and embarrassing part of living with inflammatory arthritis. It can also be a symptom of fatigue. “If you don’t have restful sleep, you have brain fatigue, and it’s difficult to carry on cognitive functions,” says Vinicius Domingues, MD, a rheumatologist in Daytona Beach, Florida. When you have brain fog, you’re more forgetful and have a shorter attention span and less mental alertness.

The symptom of brain fog, or “fibrofog,” is also likely to occur when fibromyalgia is an underlying cause of your fatigue, says Dr. Domingues. Fibromyalgia is characterized by widespread muscle and joint pain and stiffness and fatigue.

Reduced quality of life

Another symptom that distinguishes inflammatory arthritis fatigue from being tired is a reduction in your quality of life. Fatigue can prevent you from visiting with family and friends, attending work and social events, and doing the things you love.

According to a 2019 CreakyJoints community poll, nearly 90 percent of respondents (almost 1,000 people) reported that fatigue stops them from participating in their usual activities/engagement.

Irritability

It’s not too surprising that being in a bad mood may be a symptom of fatigue. Irritability can result from two common causes of fatigue: not sleeping and greater sensitivity to pain. Studies have found that when you’re fatigued, you have higher perceptions of pain and a lower threshold for pain.

“If you have a painful rheumatic condition and you’re up with pain because it’s not being managed well enough, your perception is different than if you had a good night’s sleep,” says Dr. Cohen. “Chicken or the egg — but they both suck.”

Low motivation

This symptom is in the very definition of the word: Fatigue is “a lack of energy and motivation,” accompanied by both drowsiness and apathy (a feeling of not caring), according to MedLine Plus.

Low motivation and apathy also play a role in anxiety and depression, which is common among people with inflammatory arthritis, and is a major cause of fatigue.

Headache

When you’re tired, a cup of coffee may be sufficient to boost your energy and get you going. For someone with fatigue, however, caffeine won’t do the trick. They may find themselves overusing artificial stimulators like coffee, teas, soft drinks, and energy drinks, says Dr. Cohen, which can result in a throbbing headache.

“Instead of going to a practitioner and trying to figure out the cause of the fatigue, we end up trying to treat it ourselves by upping and downing artificially to survive,” says Dr. Cohen.

Head pain can also come from dehydration, which can also cause fatigue, Dr. Cohen adds.

It’s important to note that headaches can be a sign of many conditions, so be sure to consult your health care provider if you’re dealing with chronic or bothersome headaches.

Changes in appetite

You’re eating habits will likely change if you just don’t have the energy to get up and make yourself something to eat, explains Dr. Cohen.

But there’s another reason why fatigue is linked to appetite loss: Fatigue can lead to depression, anxiety, or decreased hopelessness that are all known to cause changes in your appetite, she says.

Slowed reflexes/reaction time

When fatigue is the result of poor sleep, both your reflexes and reaction time can be impacted. This is because sleep deprivation actually slows down neurons in your brain, leading to that “slow motion” feeling that many people experience with fatigue.

“There’s no question that reflexes go down when you’re sleep deprived — and your reflexes also go down when you’re in pain,” says Dr. Cohen.

Reducing Fatigue

Talking to your health care provider about your fatigue is crucial. Fatigue in inflammatory arthritis is rarely caused by only one issue, and you’ll need to work together to identify potential causes and solutions.

Treatment for fatigue will depend on what’s causing it. Recurring disease flares may need to be treated with a change to your arthritis medications, whereas you may need to take supplements to treat certain nutrition deficiencies. If depression or anxiety is playing a role in your fatigue, which is very common, getting mental health support is key.

No matter the cause, certain lifestyle changes can help, such as getting regular physical activity, managing stress and anxiety with go-to tactics that work for you (such as meditation, reading a book, listening to music), and trying to get better sleep (giving yourself a set bedtime and wake time, not using your phone or tablet too close to bedtime, etc.)

Check out more of these resources on managing fatigue in inflammatory arthritis.

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