How to Address Rheumatoid Arthritis Fatigue (RA Fatigue) Naturally

How to Manage Chronic RA Fatigue and What to Do During a Flare-Up

• What is RA Fatigue|
• Gut Health and Fatigue|
• Managing RA Fatigue|
• Addressing Fatigue During a Flare-Up|
• Resolve RA Fatigue Naturally|

Eighty percent of rheumatoid arthritis patients experience fatigue, yet it often seems to be swept under the rug and disregarded compared to more obvious physical symptoms like joint pain and swelling. What’s worse, many physicians have nothing to offer patients to address fatigue, which 50% of patients rate as severe [1].

Rheumatoid arthritis (RA) is an autoimmune disease of the joints, characterized by joint pain, stiffness, swelling, and difficult mobility, especially in the morning. But along with many other autoimmune diseases, fatigue is a real and frustrating symptom of RA that’s worthy of being addressed.

If you’re experiencing fatigue with RA, you can recover your energy and motivation using natural remedies like a personalized, anti-inflammatory diet, probiotics, cognitive behavioral therapy, and other natural therapeutic strategies. In this article, we’ll discuss what rheumatoid arthritis fatigue is and why it happens, the connection between gut health and fatigue, how to manage RA fatigue, and how to address fatigue during a rheumatoid arthritis flare-up.

How to Address RA Fatigue Naturally: A Snapshot

Here are the main points you need to know to address RA fatigue naturally. 

• Start with identifying the potential causes: 
  • Inflammation
  • Sleep disruption
  • Depression (and more)
  • Gut health imbalances
• Address the potential causes: 
  • Diet and exercise
  • Probiotics
  • Stress management
  • Cognitive behavioral therapy
• Develop strategies to handle RA flare ups (which can worsen fatigue):
  • Heat/cold therapy
  • Deep breathing/meditation
  • Gentle exercise

Here’s an encouraging statistic: RA patients with fatigue who participated in group therapy for 6 months had improvements in emotional and physical fatigue that lasted two years [2]! It’s absolutely possible to improve RA fatigue in a sustainable way. And group therapy isn’t the only option available. Let’s move on to finding the causes of fatigue in RA and then examine what you can do to manage it. 

What Is RA Fatigue, and What Causes It?  

Chronic fatigue in RA is described as having the following characteristics: 

• Extremely low physical and mental energy that may be difficult to explain to other people, more than just “tiredness” 
• Lack of motivation
• Feeling overwhelmed [1]

We don’t know the exact causes of fatigue in RA, but evidence from observational studies suggests RA fatigue may result from [1, 3, 4, 5, 6]: 

• Inflammation
• Gut health imbalances
• Impaired physical ability
• Obesity
• Low mood
• Pain
• Sleep disturbance
• Depression
• Anxiety

A 2015 systematic review of 29 observational studies involving 21,076 patients found that the symptom most consistently associated with fatigue was a low mood (lower moods were associated with more fatigue). Researchers concluded that interventions focusing on mental health and perceptions of RA may be helpful for those who experience fatigue [5]. 

One literature review explained that disease activity (inflammation, pain, and joint symptoms) is associated with RA fatigue. However, RA medications that reduce disease activity — such as methotrexate and biologic DMARDs (disease-modifying antirheumatic drugs) — have small impacts on fatigue [7]. This suggests that other factors — including obesity, physical inactivity, disrupted sleep (which can be caused by pain), and depression — may also contribute to fatigue in RA. 

One other interesting review of chronic pain and fatigue suggests that fatigue may be an adaptive evolutionary strategy that we’ve learned to help us rest and prevent further pain and nervous system stress [8]. While this knowledge doesn’t negate the powerful impact fatigue has on a person’s quality of life, it may be comforting to know that fatigue is, from the physical body’s perspective, a healing strategy meant to keep you alive and safe. 

Gut Health and Fatigue

The state of your gut health is directly related to how much energy you have each day, as well as your mental state. We know that a balanced microbiome with a diversity of beneficial bacteria is likely to improve energy levels and mood [9, 10, 11].

Chronic inflammation also often begins in the gut, and inflammation is another leading cause of fatigue, especially in autoimmune conditions [12]. Inflammation can also get worse over time as the gut lining weakens from causes like an inflammatory diet, emotional stress, and environmental pollutants. These inputs continue the cycle of inflammation and fill up your metaphorical stress bucket, until the bucket overflows and symptoms manifest. 

Managing RA Fatigue

A deep feeling of fatigue is one of the most difficult symptoms of any autoimmune disease, including rheumatoid arthritis, because it can prevent you from taking other actions that would help you feel better, like cooking healthy meals or exercising.

That’s why it’s important to take on changes slowly and stay the course with overall diet and lifestyle changes one step at a time. Cognitive behavioral therapy may also be helpful for maintaining these habits and reducing fatigue. Let’s investigate these strategies more in depth.

Follow an Anti-Inflammatory Diet 

There is no one “rheumatoid arthritis diet,” but any anti-inflammatory diet is likely to help with symptoms of rheumatoid arthritis and should always be your first treatment option. For example, a 2013 systematic review and meta-analysis of 24 randomized controlled trials (2,882 RA patients) found evidence that a Mediterranean diet (along with physical activity) improved fatigue in adults with RA [13]. A Mediterranean diet prioritizes a high intake of vegetables, legumes, fresh fruit, unrefined grains, and olive oil, with lower amounts of animal protein and very low sweets and processed foods. 

While the Mediterranean diet tends to be the most studied model, other anti-inflammatory diets like the Paleo diet are also likely to be helpful. The Paleo diet includes lean animal protein, vegetables, fresh fruits, nuts and seeds, and excludes dairy, grains, and processed foods and oils. 

If you haven’t found success with Paleo or Mediterranean style diets, the Autoimmune Paleo (AIP) diet may also be useful for improving fatigue in RA. A systematic review found that omega-3 fatty acids, vitamin D, turmeric, and a diet low in high-glycemic foods reduced inflammation and improved blood pressure and fatigue in patients with lupus, another autoimmune disease [14].

Note that, in spite of its name, the Autoimmune Paleo Diet is not necessarily the best option for everyone with an autoimmune disease. And because it’s a more challenging and restrictive diet, it should only be tried when less restrictive options have not worked. 

Add in Probiotics

So what else can you do to manage your gut health to reduce inflammation (and therefore fatigue) in RA or any other condition? Eating a therapeutic diet is foundational, but probiotics may be helpful too.

Two randomized clinical trials involving 60 RA patients each found that those who took probiotics had lower inflammatory markers, improved joint pain, and improved disease activity overall [15, 16].

Additional research found that incorporating probiotics with an anti-inflammatory diet was helpful for reducing disease activity in 50 Swedish RA patients [17].

Evaluate Your Sleep Quality

Getting a good night’s sleep is also extremely important for reducing fatigue and regaining energy throughout the day. Obstructive sleep apnea (OSA) may also be a contributing factor for some people with autoimmune and rheumatic diseases, possibly by creating a chronic inflammatory state that exacerbates these conditions [18].

Some people may have mild sleep apnea without realizing it, but a simple home sleep test like the WatchPAT One can help you to figure out what’s going on. We’ve been using these tests with our patients and have found them helpful. If you do have some sleep apnea or impaired breathing at night, simple techniques like myofunctional therapy (exercises for your tongue and facial muscles) can help to improve breathing and sleep [19, 20].

Develop a Consistent Exercise Routine

Exercise is one of the most important interventions for reducing chronic fatigue in rheumatoid arthritis.

RA fatigue improved with aerobic exercise, according to a 2019 umbrella review of eight systematic reviews involving 6,740 participants [21].

Another 2018 systematic review and meta-analysis of five randomized clinical trials found evidence that aerobic exercise (cycling, running, and circuit training for at least 15 minutes 2-3 times a week) led to significantly less fatigue. Even for those patients who did not experience a significant difference in fatigue, exercise did NOT increase fatigue and incorporating it may improve physical health, disease activity, quality of life, and chronic pain [22].

It’s also worth pointing out here that these are relatively short periods of exercise and only needed a few times per week. There’s no need to risk overexertion by pushing yourself to exercise for hours every day and doing so would be more harmful than helpful.

With any healthy habit, it’s better to maintain consistency vs. pushing yourself too far and giving up after one difficult session. If you can only do a few minutes of exercise, great! A few minutes are more than nothing. Keep going and you’ll be able to increase your endurance over time. 

Try Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is another option to combat chronic fatigue and improve emotional resilience. Cognitive behavioral therapy is the process of working with a licensed therapist or psychologist to identify dysfunctional automatic thoughts, recognize when they come up, and intentionally reframe them to develop a more positive outlook [23].

A 2019 randomized controlled trial involving 333 RA patients in the UK (average age 60, 80% women) found that patients who attended group cognitive behavioral courses for 26 weeks had reductions in fatigue that were 1.5 times greater than those in the control category [2].

The group therapy category had slightly improved emotional fatigue and the experience of living with fatigue compared to the control category. These improvements were sustained for at least two years! 

The results achieved with CBT show that mental health interventions can be just as important as nutritional or even pharmaceutical interventions in treating chronic fatigue and chronic autoimmune disease, where many patients can feel isolated and experience a lack of understanding even from those closest to them. Cognitive behavioral therapy, individually or in a group setting, can help patients feel less alone, become more resilient to challenges, and build connection to others and themselves. 

Practice Mindfulness 

Mindfulness practices like guided imagery, goal setting, coping strategies, and self-management have also been shown to be helpful in reducing RA fatigue [21].

The mind is a powerful tool, and rheumatoid arthritis patients’ perceptions of their condition and feeling fatigued play nearly an equal role to the symptoms themselves. We know this from observing the placebo effect, where participants may initiate biological changes just by believing that they are receiving a therapy. 

Mindfulness strategies can help reprogram the brain to positively change a patient’s outlook on their symptoms. This reduces symptom severity by improving patients’ mental resilience and teaching strategies to use during stressful life events. 

Addressing Fatigue During an RA Flare-Up

Beyond chronic symptoms, an RA flare can happen due to a number of factors that trigger the immune system such as consuming reactive foods, going through a stressful period, or environmental triggers. These triggers activate the autoimmune response and increase systemic inflammation, often worsening RA symptoms like fatigue, joint pain, and possibly mental health disturbances [24, 25, 26].

When a flare happens, the cause needs to be addressed, whether that’s stress, an environmental component, or something else. If you’re paying close attention to your body, you may be able to get ahead of a predictable flare by doubling down on self-care and rest as soon as you notice a change in your symptoms. You can try to: 

• Alternate heat/cold therapy using heating pads and cold packs on painful joints
• Take warm baths 
• Practice regular, deep breathing to calm the stress response
• Try slow movement like yoga or tai chi to keep your muscles loose and prevent joint damage
• Stick to foods you know will not cause distress to your gut
• Minimize sleep disturbances and maintain a sleep schedule
• Use meditation or other mindfulness techniques to navigate any emotional responses that come up
• See a therapist to talk through what’s going on

A flare-up of RA doesn’t have to completely knock you out and put a stop to all the progress you’ve made with natural remedies and maintaining your everyday well-being. In fact, a flare is the perfect time to make sure you’re implementing everything you’ve learned to address your symptoms. A flare is a reminder to take good care of yourself and lean into what makes you feel good in the long term. 

Resolve RA Fatigue Naturally 

RA fatigue may be an underappreciated symptom of rheumatoid arthritis, but it doesn’t have to go untreated. Many options can help reduce fatigue, improve energy levels, and get you back to a fulfilling life. Along with a good diet and optimized sleep, a consistent aerobic exercise regimen is especially important for reducing fatigue and building strength over time. Mental health strategies like cognitive behavioral therapy, guided imagery, and coping strategies can also be helpful to build mental and emotional resilience. 

If you’re interested in collaborating with a healthcare professional to address rheumatoid arthritis symptoms naturally, reach out to us at the Ruscio Institute for Functional Medicine and set up a consultation.