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Managing Fatigue After
Transplant
by Lillian M. Nail, PhD, RN, FAAN, Associate Professor, University
of Utah School of Nursing and Carolyn W. Sutherland, MS, RN, OCN, Clinical
Instructor, Brigham Young University College of Nursing
Fatigue is a common side effect of cancer treatment, irrespective
of the type of treatment. The use of high dose chemotherapy, with or without
total body irradiation, followed by bone marrow or stem cell transplant exposes
patients to a variety of potential causes of fatigue. These include anemia,
muscle mass loss due to catabolic steroids, decreased physical activity,
medication side effects, disruptions of normal hormone function, nutritional
deficits, pain and sleep disruption. Research with relatively long-term bone
marrow transplant survivors reveals that persistent fatigue is a concern for
many survivors. Even though there is little published research on fatigue
during the acute phase of transplant, it is clear that the physiologic changes
and demands of care during this phase are similar to those that contribute to
fatigue with other forms of cancer treatment.
The recognition of fatigue as the most common side effect of
cancer treatment has generated interest in exploring the mechanisms underlying
this troublesome sensation, describing the pattern of fatigue one experiences
with various types of cancer treatment, and testing approaches to preventing
and managing fatigue.
One of the biggest challenges in fatigue management is addressing
misconceptions about cancer treatment-related fatigue (CRF) held by family
members, friends, and health care providers. These misconceptions include the
idea that you can tell how tired a person is by their appearance ("You don't
look tired!"), assuming that a complaint of fatigue is an indicator of
depression ("You're not tired—you're just depressed"), believing that
fatigue disappears the moment treatment is over or upon discharge from the
hospital ("You can't still be tired"), and thinking that sensations of fatigue
are always accompanied by decreased activity ("But you're going to work").
CRF appears to differ from the fatigue experienced by healthy
people in several ways. First, CRF is not necessarily tied to activity. A
person experiencing CRF can have overwhelming sensations of tiredness,
sometimes described as feeling paralyzed, during periods of rest. Second, CRF
is not completely relieved by sleep and rest. Cancer patients rate sleep and
rest as moderately, but not fully, effective in providing short-term relief
from CRF. Third, fatigue becomes a constant companion to the point that cancer
patients redefine the sensation of "not being tired" by substituting what they
used to think of as "being a little tired" and developing a new definition of
"extremely tired" that exceeds what they previously thought was possible. These
differences account for the puzzled expressions people with CRF exhibit when
they tell a healthy person that they feel really tired and the healthy person
responds "Oh, I know what you mean. I feel tired too."
What can be done about fatigue?
Most of the research on CRF is done with people who are receiving
radiation treatment or chemotherapy as outpatients, not with people undergoing
bone marrow or stem cell transplantation. The research specific to transplant
patients indicates that fatigue is an important quality-of-life issue and that
it persists in some bone marrow transplant survivors years after treatment.
Studies of BMT survivors indicate that the majority feel that their energy
level has not recovered to the level they recall prior to their cancer
diagnosis and indicate that fatigue is an ongoing quality-of-life concern.
The first step in managing fatigue is identifying any contributing
medical conditions. Problems such as infection, anemia and dehydration can
cause fatigue and effective treatment will help relieve feelings of
tiredness.
Exercise is being studied as a means of promoting recovery
following transplant. Exercise has been helpful in managing fatigue in women
with breast cancer and early indications are that it shows promise in
transplant patients as well.
Other suggestions for managing fatigue include: 1) promoting
effective sleep and rest by limiting interruptions, establishing a regular
sleep/rest schedule, and managing symptoms that interfere with sleep (e.g. hot
flashes, pain, and diarrhea); 2) recognizing the pattern of fatigue so that
high-priority activities are carried out at the time when energy level is
highest; 3) delegating activities that are tiring or not satisfying to someone
else if possible; 4) using energy conservation techniques such as sitting
rather than standing, keeping frequently used items within less than one arm's
length of reach, and clustering all the items needed for a single task close
together; 5) taking time to refresh your mind by listening to music,
appreciating nature, or playing a computer game without thinking about anything
else; and 6) recognizing that a sudden increase in fatigue should be discussed
with your health care provider because there may be a change in your body
(hormone shifts, infection, dehydration, etc.) that should be corrected.
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