Everyone has experienced fatigue or tiredness, but for people living with rheumatic conditions, this fatigue is often extreme and persistent. While normal fatigue typically improves with rest, for those with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), lupus, fibromyalgia, and/or sjögren’s syndrome, the tiredness is linked to deeper immune and inflammatory processes and often does not improve with sleep. Understanding and managing the underlying causes of fatigue is an important piece of treatment.
What Does Normal Fatigue Feel Like?
Normal fatigue typically results from activity, lack of sleep, or stress. It usually resolves with rest, sleep, or lifestyle changes. In chronic conditions, fatigue is often disproportionate to activity, persisting despite adequate rest. With normal fatigue, one often has a reason why they are tired, but the fatigue of autoimmune diseases can be variable and unpredictable.
Fatigue in RA, PsA, and AS: How Common and Severe Is It?
Fatigue is a common symptom in inflammatory arthritis (RA, PsA, AS). Research indicates that one in every 2 people with inflammatory arthritis experiences significant fatigue1. In all of these conditions, chronic inflammation is a key driver of exhaustion due to immune system overactivity. These are systemic diseases affecting many body systems, contributing to the common symptoms of fatigue.
- Rheumatoid arthritis fatigue is linked to inflammation, joint pain, and medication side effects. Many patients describe it as a "bone-deep exhaustion" that makes daily tasks challenging.
- Psoriatic arthritis fatigue is often worsened by skin inflammation and associated stress. The immune system’s overactivity contributes to persistent weariness.
- Ankylosing spondylitis fatigue stems from inflammation in the spine and joints, compounded by sleep disturbances due to pain.
Fatigue in Lupus, Fibromyalgia, and Sjögren’s: Unique Features and Prevalence
- Lupus fatigue affects up to 90% of patients, often triggered by inflammation, immune dysregulation, and medication side effects2. People with lupus frequently experience "crash days," where exhaustion makes even small activities feel impossible.
- Fibromyalgia fatigue Fibromyalgia involves widespread pain and sensory sensitivities. Fatigue in fibromyalgia is worsened by poor sleep quality and heightened nervous system activity.
- Sjögren’s syndrome fatigue is exacerbated by dryness, chronic pain, and immune dysfunction. Patients describe feeling "drained," with mental fog that makes concentration difficult.
How Do Sleep Interruptions Affect Fatigue in Rheumatic Conditions?
Sleep disturbances are a major contributor to fatigue in autoimmune diseases. Common issues include:
- Trouble falling asleep due to pain, anxiety, or restlessness.
- Frequent awakenings caused by discomfort, night sweats, or medication side effects.
- Non-restorative sleep, where patients wake up feeling unrefreshed despite adequate hours in bed.
- Sleep disorders such as insomnia, restless leg syndrome, and sleep apnea, which are more prevalent in people with rheumatic conditions3.
Physiological Basis of Fatigue in Chronic Illness
Unlike normal tiredness, fatigue in rheumatic diseases is driven by several physiological factors:
- Chronic inflammation disrupts energy metabolism and neurotransmitter function, leading to sustained exhaustion.
- Pain increases stress hormone levels and prevents deep, restorative sleep.
- Immobility from joint stiffness or discomfort reduces circulation and oxygen delivery to tissues, worsening fatigue.
- Medication side effects, including those from DMARDs and biologics, can contribute to tiredness in some patients.
Can Fatigue and Poor Sleep Worsen Other Symptoms?
Yes. Fatigue and disrupted sleep can amplify pain perception, increase cognitive dysfunction ("brain fog"), and contribute to depression and anxiety. In inflammatory arthritis, poor sleep is associated with higher disease activity and lower quality of life4.
When Does Fatigue Indicate a Sleep Disorder?
Fatigue can be a symptom or an independent diagnosis. If extreme tiredness persists despite controlling inflammation and improving sleep hygiene, it may indicate chronic fatigue syndrome (CFS) or another sleep disorder requiring specialist evaluation5 with a sleep specialist or neurologist.
How to Manage Fatigue in Rheumatic Conditions
Effective fatigue management involves treating underlying inflammation, improving sleep quality, and incorporating lifestyle modifications.
Medical Treatments
- DMARDs and biologics: Reducing inflammation with medications like methotrexate, TNF inhibitors, and IL-17 blockers can significantly improve fatigue levels.
- Cognitive Behavioral Therapy (CBT): Helps patients manage thoughts and behaviors that contribute to fatigue and poor sleep.
Lifestyle Strategies
- Pacing and planning: Structuring daily activities with built-in rest breaks prevents energy crashes.
- Diet and nutrition: Anti-inflammatory diets rich in omega-3s, antioxidants, and whole foods may improve fatigue.
- Exercise: Low-impact activities like yoga, swimming, and walking help boost energy and reduce stiffness.
- Sleep hygiene: Establishing a consistent sleep schedule, limiting screen time before bed, and using relaxation techniques improve sleep quality.
- Alcohol and smoking: Reducing alcohol and quitting smoking can enhance sleep and energy levels.
- Social connection and stress management: Engaging in supportive communities and practicing mindfulness can counteract fatigue.
Conclusion
Fatigue in rheumatic diseases is more than just being tired; it is a pervasive, life-altering symptom. Understanding the physiological basis of fatigue, recognizing its impact on disease progression, and implementing targeted treatment strategies can help patients regain a sense of control. Whether through medical interventions, cognitive therapy, or lifestyle changes, managing fatigue effectively can lead to significant improvements in daily functioning and quality of life.
To learn more about our Rheumission approach to care, please visit the Why Rheumission? section of our site or book a 15-minute intro call with one of our providers. The Rheumission Way helps you get back to being you, with more joy and less pain. We will listen to you and co-create a plan that works for where you are now and where you want to be. We are always here for you.
About the author
Jill Ryan is a seasoned Rheumatology Physician Assistant with over 30 years of experience and a strong commitment to patient care. She worked at Dartmouth Health System as a Rheumatology Physician Assistant for 24 years, and prior to that role, as an Internal Medicine Physician Assistant for 8 years. Jill is deeply passionate about caring for patients and guiding them on their wellness journeys. With training in integrative medicine, she focuses on holistic approaches that empower individuals to manage autoimmune diseases effectively, believing in the importance of patient education and developing personalized care plans that promote overall health and well-being.
Note: This information is for informational purposes only. No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.
References:
5. Cleveland Clinic. "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)". Jul 2023
