Sheila, a 55-year-old woman with Type 2 diabetes and peripheral neuropathy (PN) in her feet, lived with chronic pain every day, and she was always tired. When she started eating better and took some effective medication, her pain got better and everything changed. “I have so much more energy,” she told me. “I can do what I need to do! Pain was exhausting me, but I didn’t realize it.”
Sheila’s experience has been shared by millions of people. The Arthritis Foundation says, “The pain–fatigue connection can be a vicious circle. Dealing with pain for months at a time over many years can wear you down. It can affect your sleep habits, which adds to your exhaustion. Being fatigued, in turn, can worsen pain and make it more difficult to manage.”
Diabetes adds another layer to the pain–fatigue circle, because pain and fatigue interfere with self-management. A study by Rebecca Sudore, MD, and others at University of California San Francisco (UCSF) reported, “Patients with chronic pain had poorer diabetes self-management overall and more difficulty following a recommended exercise plan and eating plan.” Some also reported greater difficulty with taking diabetes medications.
How diabetes causes pain
Diabetes can hurt in several ways, most caused by nerve or blood vessel damage from high blood sugar levels. You may have heard of peripheral neuropathy, often experienced as burning in legs and feet, or peripheral artery disease (PAD), which causes sharp or cramping pain when walking. Back and neck pain also occur more often in people with diabetes. There are joint problems such as frozen shoulder and carpal tunnel syndrome, and abdominal pain can result from damaged nerves in the gut.
In various studies, chronic pain has been found to affect between 20 and 60 percent of people with diabetes, and fatigue is a major symptom of chronic pain. Diabetes has other ways of causing fatigue too, so pain can make daily life a struggle.
How pain causes fatigue
According to pain specialists at the Arthritis Foundation, “Lack of energy can be caused by inflammation” [present in many diseases including diabetes]. They advise that pain can also be caused by the side effects of pain medications.
The Foundation says “Fatigue may be triggered by insomnia and unrefreshing sleep,” and pain can make it harder to sleep. Pain can also cause a person to walk or move in unnatural ways, wearing themselves out to avoid the pain. Sleep apnea, a condition in which breathing stops during sleep, waking a person up, affects up to 48 percent of people with Type 2 diabetes, and contributes to pain, fatigue and poor glucose control.
Pain can also cause fatigue by keeping us physically inactive. People may lie around because moving hurts, but Arthritis Foundation scientists note that “The more you lay around, the more exhausted you feel. Unused muscles — including the heart muscle — can weaken, and you get tired more easily.”
Our mental state also makes a difference. Pain can be depressing, especially if it prevents us from living as we want to live, and doctors Steven Targum, MD, and Maurizio Fava, MD, at Massachusetts General Hospital write that fatigue is a major symptom of depression.
How fatigue contributes to pain
When people are tired, they may not move as well. Their posture may slump and slide. They may get depressed. Their blood sugar levels may go up from eating fast, easy food or from not exercising. All these changes can increase levels of pain.
Breaking the pain–fatigue cycle
Because pain and fatigue have so many causes, we have many choices to try for relief. You don’t have to do them all — just try one and see how it works, then try something else if needed.
Get better sleep
This is where recovery often starts. Be evaluated and treated for sleep apnea. Organize your life and physical environment to promote sleep using some of these tips. Eat foods that help you sleep, as Certified Diabetes Educator and Registered Dietitian Amy Campbell explains here.
Engage in gentle exercise
A study from the University of Georgia found that low-intensity exercise decreases fatigue by 65 percent. Subjects engaged in as little as 20 minutes of low-to-moderate aerobic exercise three days a week for six consecutive weeks and reported an increase in energy levels and feeling less fatigued. The Mayo Clinic suggests walking, yoga, tai chi or water exercise. Many exercises can be done while seated. Water exercise or riding a bike are low impact, so these approaches might be less painful.
Peripheral neuropathy, peripheral arterial disease, and most of the pain conditions in diabetes are worsened by smoking. Similarly, excessive alcohol use increases fatigue.
Have your medicines reviewed
Fatigue specialist Lawrence Probes, MD, says opiates, antiseizure medicines used for pain (such as pregabalin [brand name Lyrica] and gabapentin [Neurontin]) sleep medications, muscle relaxers, some blood pressure medications and antidepressants might be causing fatigue and should be evaluated.
Consider whether you might be depressed
This very short depression screen can help you determine if depression might be adding to your fatigue. If you test positive, you can take this slightly longer (3-minute) test. If you score as depressed, you can get help with that — speak with your health-care provider to determine the best course of action.
Evaluate your diet
Refined carbohydrates such as white bread and sweets make most people tired, after a short rush of energy. Generally, foods that are healthy for diabetes are good for energy levels too.
Consider whether the source of pain be treated
Ask your doctor, educator or support group. There may be a treatment or better ways to self-manage, or better glucose control might help.
The Mayo Clinic says stress is tiring. If you can let some things go, you will probably have less pain and fatigue.