What should I do if I have fatigue and body aches?

Evaluation and Management of Fatigue and Body Aches

Start by assessing fatigue severity using a 0-10 scale, then conduct targeted evaluation for treatable causes including anemia, thyroid dysfunction, depression, sleep disorders, and medication effects, while simultaneously initiating physical activity and energy conservation strategies. 1, 2

Initial Assessment

Screen fatigue severity immediately:

• Use a 0-10 numeric scale (0 = no fatigue, 10 = worst imaginable) 3, 1
• Mild fatigue = 1-3; Moderate = 4-6; Severe = 7-10 3
• Scores ≥4 require comprehensive evaluation 1

For body aches, assess:

• Location, pattern, and severity using a pain scale 3
• Relationship to activity and time of day 4
• Associated symptoms (fever, weight loss, joint swelling) 3

Comprehensive Evaluation for Moderate-Severe Symptoms (Score ≥4)

Focused History - Ask specifically about:

• Onset timing: sudden vs. gradual, duration, and pattern throughout the day 1, 2
• Sleep quality: difficulty falling asleep, staying asleep, or early awakening (sleep disorders affect 30-75% of fatigued patients) 2
• Mood symptoms: anhedonia, hopelessness, anxiety (depression present in 18.5-33% of cases and represents the strongest association with persistent fatigue) 2, 5
• Current medications: review ALL prescriptions, over-the-counter drugs, and supplements for sedating effects (narcotics, antihistamines, β-blockers, antidepressants) 2, 4
• Physical activity level: deconditioning creates a self-perpetuating fatigue cycle 2
• Functional impact: ability to work, perform daily activities 1

Physical Examination - Focus on:

• Vital signs including heart rate (bradycardia from β-blockers) 2
• Thyroid examination for enlargement or nodules 2
• Lymph node assessment 6
• Cardiopulmonary examination (especially if history of cardiotoxic treatments) 3, 2
• Musculoskeletal examination for tender points, joint abnormalities 3

Essential Laboratory Testing:

• Complete blood count with differential (assess anemia) 1, 2
• Thyroid-stimulating hormone (TSH) 1, 2
• Comprehensive metabolic panel 1
• Consider: iron studies, vitamin B12, folate if anemia present 1

Do NOT order extensive testing without specific clinical indicators - previously undiagnosed cancer accounts for only 0.6% of fatigue cases, and organic causes are rare (4.3%) 5

Management Algorithm

Step 1: Treat Identified Contributing Factors

If anemia detected:

• Address underlying cause (iron deficiency, B12 deficiency, etc.) 3
• Consider erythropoietin for specific indications 3

If thyroid dysfunction:

• Initiate thyroid hormone replacement for hypothyroidism 3, 2

If depression/anxiety (present in 18.5-33%):

• Offer antidepressant therapy AND/OR cognitive behavioral therapy 3, 2
• Depression represents the most robust association with persistent fatigue 2

If sleep disturbance:

• Implement sleep hygiene measures 3, 7
• Limit daytime naps to <1 hour to preserve nighttime sleep 3, 4
• Consider sleep study if sleep apnea suspected 2

If medication-related:

• Adjust timing of doses to prevent afternoon crashes 4
• Consider splitting doses or changing administration schedule 4
• Discontinue or substitute sedating medications when possible 2, 4

Step 2: Implement Non-Pharmacologic Interventions (Category 1 Recommendation)

Physical Activity - ESSENTIAL intervention:

• Start regular exercise program combining aerobic (walking, swimming) and resistance training 3
• Begin with 10-15 minutes of walking and gradually increase 4
• Exercise during peak energy periods (typically morning) 4
• This is a Category 1 recommendation with robust evidence 3

Energy Conservation Strategies:

• Schedule important activities during peak energy times 3, 4
• Set priorities and delegate non-essential tasks 3
• Use labor-saving devices (reachers, rolling carts) 3, 4
• Pace activities and take breaks 3
• Attend to one task at a time rather than multitasking 3, 4

For Body Aches Specifically:

• Acetaminophen or NSAIDs for pain control 3
• Physical activity (reduces both fatigue and musculoskeletal pain) 3
• Consider acupuncture 3
• Refer to physical therapy if pain persists 3

Step 3: Consider Pharmacologic Interventions

Methylphenidate (psychostimulant):

• Consider ONLY after ruling out treatable causes 3, 4
• Starting dose: 5 mg twice daily 4
• Use cautiously; optimal dosing established for cancer-related fatigue 3
• Caution: Do not use with bone metastases, thrombocytopenia, severe anemia, fever, or active infection 3

Step 4: Referrals When Indicated

Refer to specialists if:

• Cognitive behavioral therapy needed for persistent symptoms 3
• Physical therapy for musculoskeletal pain or rehabilitation 3
• Occupational therapy for functional limitations 3
• Mental health professional for depression/anxiety 3
• Sleep specialist if sleep disorder suspected 2

Follow-Up and Monitoring

Reassess regularly:

• Repeat fatigue screening at each visit using same 0-10 scale 3, 1
• Adjust management based on response 1
• If moderate-severe fatigue persists 6-12 months without other symptoms, extensive workup may not be warranted 3
• If fatigue worsens or new symptoms develop (weight loss, pulmonary complaints), consider more extensive evaluation for metastatic disease or comorbidities 3

Critical Pitfalls to Avoid

Do not:

• Order extensive laboratory testing without clinical indicators (leads to overdiagnosis) 5
• Neglect physical activity interventions - this is the strongest evidence-based intervention 3, 1
• Assume fatigue always indicates serious disease - most cases are due to sleep disorders, depression, or psychosocial stress 2, 5
• Prescribe stimulants before addressing treatable causes 3, 4
• Recommend aggressive exercise for patients with postexertional malaise (suggests ME/CFS) 7

Do:

• Screen for depression systematically - it's the most common treatable cause 2, 5
• Review ALL medications for sedating effects 2, 4
• Emphasize that persistent fatigue after treatment does not necessarily indicate disease progression 3
• Provide patient education about realistic expectations for energy recovery 3