Fatigue Management Patient Information

Occupational Therapy DepartmentHighland Rheumatology Unit Ross Memorial HospitalFerry RoadDingwallIV15 9QTTel : 01349 868 766

Occupational Therapy Service

The people who work for NHS Highland are committed to improvingthe quality of care to patients, their relatives and their carers.

ContentsIntroduction AbouttheFatigueManagementFile WhatisFatigue? Howcommonisit? Symptoms Whatcausesit? Impactoffatigue Howisitmanaged? Howdoesenergyenterthebody? /Whatdoesthebodyuseforfuel?

Fatigue Management Toolbox FatigueImpactScale Energyconservation Movement,exerciseandrest Talking Education Mentalexhaustion Relaxation Adaptthinking Rewarding Relationships 4Ps:Prioritising,Planning,Pacing,Positioning Self Management for fatigue ActivityCycle.Boomorbust Wheeloflife CopingwithsetbacksUnhelpful thinking

Tools to help Prioritisingtool Planningandpacing Howtosetagoal Weeklydiary

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Introduction : About the Fatigue Management FileThe file provides information to enable you to understand more about what fatigue is, why it happens and suggests ways in which to manage it.

• Anoverwhelmingsenseofexhaustionwithdecreasedcapacityforphysicalandmentalworkthatissustainedandnotrelievedbyrest.

(Carpenito 1993)

Introduction : What is Fatigue?

Fatigueisacommon,butpoorlyunderstood,symptomininflammatoryarthritis.Between40-80%ofpatientswhoattendhospitaloutpatientshavesignificantlevelsoffatigue.Fatigueisshowntobestronglyassociatedwithpain,butcanalsobelinkedtodiseaseactivity,depression,fibromyalgiaandsomemedications.

Prolongedandrecurringfatiguecanmakeitdifficulttomaintaindailyactivities.Itcanalsocauseirritabilityandeffectconcentration.

How common is it?• Morecommoninwomenthanmen.• Morecommoninthosewhohaveexperiencedfatigueoranxiety/

depressioninthepast.• 90%ofindividualswithLupus(SLE)andmanypeoplewithRAreport

symptomsoffatigue.• ClassicsymptomofFibromyalgia.

• Reducedappetite• Poorconcentration • Needforfrequentrest • Physicaldiscomfort • Havingtopushselftodothings• Weariness,weakness,lackofenergy,• exhaustion,difficultycarryingoutusualactivities• Moodchanges• Irritability• Disinterest• Increasedneedforrest

Symptoms: The most frequently reported symptoms of fatigue are:

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Impact of Fatigue

Physical-anaemia;poorsleep;“deconditioning”;overdoingthings;overusingjoints,reducedenergylevels,needtoslowdownnormalpace,generalsenseofsluggishness,increasedneedforsleepandrest.

Sensory - increased pain due to muscle stiffness, increased pain due toimmobilityandlackofexercise. Thoughts / Cognitive-difficultyconcentrating,difficultyfocusingattentiononthings,difficultyrememberingthings,feeling“overloaded”.

Feelings / Emotions:stress;worry;“negativethoughts”;depressionorfeelinglow;hidingillnessfromothers;workpressures,frustration, irritation, lackofmotivation,feelingsofneverbeing“normal”again,feelinglikepeopledonottrulyunderstand,moodchanges. Behavioural-avoidinggoingout,avoidingusualactivities,seeinglessoffriends/family,acceptingfewerresponsibilitiesatwork,reducingworkhours,takingextradaysoffwork. Environmental: noise, too high/low temperatures; awkward workenvironments;uncomfortablefurniture;trafficandqueues!! Severity - changes from day to day, may feel more fatigued after certainactivities, tiredness may last for days, may experience peaks and troughs,severitymaybeinresponsetosymptoms(e.g.pain,nauseaandvomiting,etc.) Dimensionsreference:Cox(2001)

• Primary fatigue–thediseaseprocessitself.• Secondary fatigue–anxiety,fear,frustration,depression,

de-conditioning,drugsideeffects,exertion,environmente.g.heat,cold,sleepdisturbance,orbeingoverweight.

What causes it?Thecausesoffatiguearemanyandvariedbutcanbecategorisedby:

Everyone feels fatigued as some stage but when this persistently affects daily activities it can then become a problem.

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How is Fatigue Managed?

• IfFatigueisongoingalwaysdiscusswithyourGPorSpecialistNurse/Consultantsoothermedicalreasonsforfatiguecanbeeliminated

• Self-Managementcopingstrategies

How does energy enter the body? What does the body use for fuel?

• Areyougettingenoughrestfulsleepatnight,7-9hrsisrecommended.Areyouabletohavearestafterlunchtore-chargeyourbatteries,30mins–60mins.Avoidtoomanynapsduringthedayasthiscouldimpactonyoursleepquality.

• Keepadiaryofyourfoodintake,isitsufficient?AhealthybalancedietakintotheMediterraneandietiswhatisadvocated.

• Hydration-areyoudrinkingenoughfluidinadayapprox2pintsoffluidadayforwomenand3pintsformeniswhatisrecommended.

Imagine your body is your car, if the wrong fuel or oil goes into it the car doesn’t work properly.

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Fatigue Management ToolboxThe fatigue management toolbox gives you self-assessment, information and self-management activities to help you manage your fatigue.

Fatigue Impact Scale• Completescaleandusetohighlightsituationswhichmaycausean

increaseinfatigue.

Energy Conservation

• Understandinghowenergyorfuelgetsintothebodyi.e.Diet,HydrationandSleep/Rest.Behonestwithyourselfandkeepadiaryforaweekofallyoueat,drinkandrest/sleep.Understandhowallphysicaloremotionaldailyactivitiesneedenergytobeundertakene.g.gettingdressedorworryingaboutpayingbills.UseEnergyConservationtechniquestobecomemoreenergyconsciousandenergyefficientenablingyourbodytoretainmoreenergyandhelpyoubettercope

withcarryingoutyourdailyactivitiesespeciallythoseimportanttoyou.

• Canyousavetimeandenergywhilstdoingtasksi.e.washing/dressing,foodpreparation.

• Mobilisingathomeareyoustrugglingusingmoreenergythanneededgettingoffchair,bedortoiletgoodheightscansaveenergy.

• Ifyousittopreparemealsthiscansaveenergy.

• Dressing/kitchenequipmentcanfacilitateenergyconservation.

• Acertainamountofexerciseisproventoincreaseenergylevelsandreducefatigue;helpscombatthe‘deconditioning’ofthemuscles.Increasingmovementathomeandnotsittingorlyingdownforlongspellscanbeviewedasexercise.

• Experimentwithdifferenttypesofexercise,durationandtimeofday.Thiswillhelpyouestablishwhatworksbestforyou.

Movement, Exercise and Rest

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Talking•Shareproblems.•Makeothersawareofthedifficultieshelpthemtounderstand.•Talkingcanmakethesituation“normal”andhelpyourealiseyou arenotalone.•Writedownquestionstoaskyourdoctor/therapist/nurse.

• Stretchfrequentlyincreasingoxygenintothebody.

• 30-60minsrestorrelaxationintheafternooncanre-chargeenergybatteries.

• Stopbeforebecomingovertiredi.e.ifyouarefatiguedafter20minutes,exercisefor15minutesthenrest.

Education• Increasedknowledgeandunderstandingoftheconditioncan

helptodecreaseanxietyandworryaboutthefuture,usingup lessenergyworryingaboutaproblemcanhelpreducefatigue.

Mental Exhaustion•Beawareofyourlimitations.•Informotherswhenyoufeeloverwhelmedor“overloaded”.•Minimisedistractionsinyourenvironmentwhentryingto concentrateonatask.•Keepadiarytohelpyourememberyourplanfortheday/week.•Gaincontrol–askpeopletorepeatinformationorgivemessages moreslowly.

Relaxation•Seerelaxationasan“investment”.•Mayhelppaincausedbymuscletensionresultinginincreasedfatigue.•Allowsyoutoachievegreaterself-esteem.•Increasesconfidence.•Givespeaceofmind.•Canreducefatiguelevels.

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Adapt thinking

•Commonforpeopletoplaceunrealisticandunfairexpectations onthemselves.•Peoplethink“Ishould”,“ought”or“must”.•Trytoreplacewiththoughtprocessesthatgivemorecontrolsuch as“Ichoose”.

Rewarding Self/Treats

•Acknowledgeeffortsandpraiseself.•Taketimeandrewardselfspendingtimedoingsomethingthatyou enjoyaftercompletingtasks.•Timeoutinvolvesbeingphysicallyandmentallyremovedfrom sourcesofstress.•Reflectuponpreviousexperiencestohelporganise,planand prepareforfutureactivities.

Relationships

•Planyourdaytoconserveyourenergysothatyoucanspend qualitytimewithyourpartner/family/friends.•Fatiguemayaffectyoursexualrelationship,forexample:anxiety surroundingsexsuchaspainduringintercourse.Yourbodyimage maybealtered.Talktoyourpartnerandmakeaplanfortimetogether.

Prioritising

•Prioritisethoseactivitieswhichareimportanttoyoueitheron practicaltermsoremotionally.•Organiseyourdayorweekontheseterms.•Considerwhichtimesofthedayarebestforyou.•Considertheimportanceofsocialandleisureactivitieswhichareoftenforgottenorstopped.

The 4 P’s

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Planning•Organiseyourdayandweek.•Considerwhichtimesofthedayarebestforyou.•Avoidunnecessaryexertion(e.g.goingup/downstairs10timesaday).•Trytospaceactivitiesoutduringtheweekandnotconcentrateall activitiesintooneday.•Recognisehowsomeactivitiescouldbe‘heavier’foryoutoundertake,soplantomixinheavierandlighteractivitiesonadailybasis.

Pacing•Doatimedactivityandhaveashortrestuntiltaskiscomplete,keeppacingwithinyourplan,don’tkeepgoinguntilyou’reexhaustedas thisrepeats‘BoomandBust’.•Itisbettertotakealittleextratimetocompleteonetaskand beabletocontinue,thantofinishonetaskquicklyandfeeltootiredtocontinue.•Ifyoucompletelydrainyour‘batteries’youhavetowaitalongtimeforthemtorecharge,bettermakingregular‘topups’,pacinghelps youdothat.•Overaperiodoftime,whenyouarepacing,youshouldbeableto increaseyouroverallactivitylevelswithoutilleffects.Somepeoplecallthisincreaseinactivity‘gradedactivity’butformanypeople thiswillhappennaturallyasyougetbetteratpacing.•Pacinggivesyouawarenessofyourownlimitations,whichenables youtopositivelyplanthewaythatyouuseyourenergy,maximisingwhatyoucandowithit.

Positioning• Useagoodposturewhenstandingandsitting–asuprightas

possible.Tryandavoidyourneck‘pokedforward’asyouread orworkatatable/desk.Keepyourbackasstraightasyoucan.

Havegoodsupportiveseating.• Becomemoreawareofhowyousit,standandwalk.Poor

postureusesupmoreenergyandcanincreasefatigueanpain.• Avoidstayinginonepositionforalongtime–thisusesmoreenergy

changepositionregularlyandgiveyourselfregularstretch• Analysethebodypositionsyouusewhendoingactivities–couldyoubemoreefficient?

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TheFatigueImpactScalewasdevelopedtomeasuretheeffectoffatigueonlife‘measuringtheeffectoffatigueonactivities…ismoresensitivethansimplyaskingpeopletoratetheirfatigue’(Fisk et al 1994a).

TheFatigueImpactScaleassessesperceivedfatigueimpactonthinking/cognitivefunctioning(10items),physicalfunctioning(10items)andpsychologicalfunctioning(20items).

Itratestheextenttowhichfatiguehascausedproblems0-noproblem,4-extremeproblem,withamaximumFISscoreof160.

Youthenreviewareaswithhighscorestoidentifyareastoworkonorareasofstrength.

Fatigue Impact Scale

1Ifeellessalert

2IfeelthatIammoreisolatedfromsocialcontact

3Ihavetoreducemyworkloadorresponsibilities

4Iammoremoody

5Ihavedifficultypayingattentionforalongperiodoftime

6IfeellikeIcannotthinkclearly

NO. QUESTION Rating

8Ihavetorelymoreonotherstohelpmeordothingsforme9Ihavedifficultyplanningactivitiesaheadoftimebecausemyfatiguemayinterferewiththem10Iammoreclumsyanduncoordinated11IfindthatIammoreforgetful12Iammoreirritableandmoreeasilyangered13Ihavetobecarefulaboutpacingmyphysicalactivities

14Iamlessmotivatedtodoanythingthatrequiresphysicaleffort

7 Iworklesseffectively.(Thisappliestoworkinsideoroutsidethehome)

0 No Problem1 Small Problem2 Moderate Problem3 Big Problem4 Extreme Problem

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16Fatiguelimitsmyabilitytotraveloutsidemyhome

17Ihavetroublemaintainingphysicaleffortforlongperiods

18Ifinditdifficulttomakedecisions

19Ihavefewsocialcontactsoutsideofmyownhome

20Normalday-to-dayeventsarestressfulforme

21Iamlessmotivatedtodoanythingthatrequiresthinking

22Iavoidsituationsthatarestressfulforme

23Mymusclesfeelmuchweakerthantheyshould

24Myphysicaldiscomfortisincreased

25Ihavedifficultydealingwithanythingnew

26Iamlessabletofinishtasksthatrequirethinking

27Ifeelunabletomeetthedemandsthatpeopleplaceonme

28Iamlessabletoprovidefinancialsupportformyselfandmyfamily

29Iengageinlesssexualactivity

30IfinditdifficulttoorganisemythoughtswhenIamdoingthingsathomeoratwork31Iamlessabletocompletetasksthatrequirephysicaleffort32IworryabouthowIlooktootherpeople33Iamlessabletodealwithemotionalissues34Ifeelsloweddowninmythinking35Ifindithardtoconcentrate36Ihavedifficultyparticipatingfullyinfamilyactivities37Ihavetolimitmyphysicalactivities38Irequiremorefrequentorlongerperiodsofrest

NO. QUESTION Rating15Iamlessmotivatedtoengageinsocialactivities

39IamnotabletoprovideasmuchemotionalsupporttomyfamilyasIshould40Minordifficultiesseemlikemajordifficulties

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Self-Management for Fatigue: Activity Cycle / Boom or Bust

Oftenpeoplewithfatiguedescribeashavingvaryingamountsofenergyfromonedaytoanotherorevenwithinthesameday.Thislackofenergymayleadpeopletoattempttodotoomuchonabetterdayandthenspendseveraldaysrecoveringfromit.ThisisreferredtoastheBoom and BustapproachorActivity Cycle:

Good day

Over-activity

Prolonged Rest

Increased Fatigue

Theproblemofstayinginthisactivity cycle is that everytimeyouoverdo it, you aremore likely to avoid doingtheseactivitiesinthefuture.

• Thereisworkthat“hastobedone”andtryandcraminasmuchactivityaspossibleinaperiodoftheday.• You’reblinkeredtogettingthejobdone.• Oftenfeelguiltyaboutoverloadingothers.• Trytoignoreorbeatthelossofenergy.

What are the negative consequences of the Activity Cycle?

• Setbacks,recurringfatigue.• Moretemptingtoavoidactivities.• Hardertomakelongertermprogresswithactivity.• Fatiguedecideshowmuchyoudo,notyou.• Feelingsoffrustrationandfailure.

People stay in the Activity Cycle because

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How can this ‘boom and bust’ approach to activity be changed?

• Acknowledgethatthisishowyoutendtoapproachactivity.• Starttoanalysehowmuchofanactivityyoucandoonagood

dayandabadday,theaimbeingtosustainthesameamounteach day. In practice this will normallymean that you set abaseline of activity, which is initially lower than you wouldnormallyattemptonagoodday.

• Keepanactivitydiary,payingattention towhichactivitiesarehighonenergyrequirement.

• Usethe4PsPrioritise,Plan,PaceandPositioning.• Setrealisticgoalsensuretheyareachievableasitsbetternotto

setselfuptofail.

Ask yourself the ‘Readiness Ruler’ questions

• HowImportantisitformetomakeachange?And• HowconfidentdoIfeelthatIcanmakechangestomylifestyle?

Set realistic and timely goals to help bring about change.

Taking a balanced, steady approach to activity counteracts the common tendency to swing from one extreme to another.

It avoids the inevitable ill effects that follow, so you can start the process towards recovery.

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Forourhealthandwellbeingthereisaneedtoretainabalancebetweenthedifferentareasofourlives.Thiscanbechallenging.Attimes,oneareamaytakeupmoreofourtimeandenergyandthisistobeexpected,however,iftheimbalancecontinuesforasustainedperiodoftimethenotherareascanmissout.Thewheeloflifehelpsyoulookatthebalancebetweenyourareasoflife,andhelpyouprioritiseactivitieswhichyouwouldliketoparticipateinagain.Thisisadynamicprocess,willbeeverchangingsoyoucanrepeatthisexerciseatdifferenttimes.

Self-Management for Fatigue: The Wheel of Life

Scoreeachsegmentofthecircleoutof10forhowsatisfiedyouarewiththatarea0=leastsatisfied,10=mostsatisfied.Lookatthesegmentsthatscoredthelowerandask: • Whatwould10outof10feel,lookandsoundliketoyou?

• Isthatunrealistic?• Howwouldyourlifebedifferentifyouscored10outof10inthatarea?• WhatcanyoudotomoveyourscoreupjustONEpoint?• Usethespacebelowtowritesomenotesinanswertothesequestions.

Leisure & Social Friends & Family

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Notes:

To complete the wheel of life:

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Self-Management for Fatigue: Coping with SetbacksMostpeoplewithfatiguewillexperiencesetbacks;timeswhensymptomsworsenforaperiodoftime.Itcanbedifficulttomaintainyourlevelsofactivityduringthesetimes.Differentthingswillprovokesetbacks,andtheymaylastforvaryinglengthsoftime.Eachpersonwillhavedifferentwaysofdealingwithasetback.Thepurposeofthishandoutistoencourageyoutobecomeawareofthosethingsthatprovokeasetbackforyou,andtodevelopaplanforcopingwithasetbackwhenithappens.

What provokes a setback?Setbacksdon’talwayshaveclear-cutcauses,butthereareanumberofthingswhichcancontributetoone.

Overdoing it–Thismaybetheresultoftakingontoomuch,orsimplyasaresultofdoingoneactivityfortoolong.Setbackscanbestartedifyoufailtopaceyourselfproperly,orifyoufailtoplan,prepareandprioritise.

Stress–Aperiodofstressinyourlifemayprovokeasetback.Beawareofthosethingsthatupsetyouandspotthesignsthatyouarebecomingundulystressed.Stressmanagementmaybeespeciallyhelpfulatthesetimes.

Periods of illness–Followingaflare-upofyourconditionyoumaybemorepronetoasetback.Remembertorestartactivitiesandexercisegraduallybypacingyourself.

Low mood/seasonal factors–manypeoplefindthatthereisaninteractionbetweentheirframeofmindandtheirenergylevels.

Notallthesefactorsapplytoeveryone.Itisworthrecognisingasmanysignsandcharacteristicsfromyourownexperienceofsetbackstohelpyounexttime.Usethespacebelowtolistthosewarningsignswhichyouhavenoticedbefore,andaddanynewonesasyoubecomeawareofthem.

Warning signs:

Evenwiththebestofplanning,itmaybeimpossibletoavoidasetback.However,ifyoudohaveone,couldyouuseitasawaytolearn?Didyouignorethesigns?Whatcouldyouhavedonedifferently?

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Compromise:Areyouaskingtoomuchofyourselfatpresent?Don‘tbeafraidtostepbackandreconsideryourexpectationsduringasetback.Remembertorecognisewhatyouareachieving!

Socialise:Ifyou’reverytired,it’seasytofeellikeisolatingyourself.Rememberthatbeingintouchwithsomeonecanbehelpful,sowhataboutgivingsomeonearing,orinvitingafriendround?

Pamper:Ifthegoingistough,paceyourselfandgiveyourselfabreak.Ifamassageorrelaxingshowerorbathhelps,whynot?Decidenowhowyouwillindulgeyourselfasakindofcompensationnexttimeasetbackoccurs.

Thinking: Rememberthewaywethinkinfluenceshowwefeel.Inthemidstofasetbackitiseasytoslipintobadhabitsanddwellonthenegatives.Trytobeawareofthis,andtryoutdifferentwaysofthinking.

Setback Management using your coping strategies

Animportantpartoflearningtomanageyourfatigueislearningtomanagesetbacksasbestyoucan.Thismeansthatyouwillbeabletogetoveryoursetbackmorequickly,andfeelmoreconfidentinthewayyouhandlesetbacks.Duringtheprogrammewehavediscussedanumberofideasformanagingthem,andherearesomereminders:-

Relaxation:remembertheimportanceofproper,recuperatingrelaxation?Trytouseyourfavouriterelaxationtechnique.

Planned rest: whathaveyoufoundoutaboutthemosteffectiveuseofrest?Isitplanned,timelimitedandenjoyable?

Exercise: It’stemptingtostopcompletelywhenyouarefatigued–don’t.Rememberwhatyouhavelearnt,andadjustyourbaselineaccordingly.

Prioritise: Putyourenergyintothemostimportantareasofyourlifefirst.

Notallthesestrategieswillapplytoyou,andyoumayhavedevelopedsomeadditionalideasforsuccessfullymanagingorreducingthelengthofaset-back.Writedownthoseideasthatyouhaveformanagingyourownsetback,andaddanynewonesthatmayhelp.

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Unhelpful ways of thinkingUnhelpful ways of thinking

Description Example

Jumping to negativeconclusions

Over generalisation

All-or-nothing thinking/black-and-white thinking

Lookingatasituationastwoextremesonly.Therearenoin-betweensorshadesofgrey.

“IfIdon’tsucceedatdoingallthehouseworkthenI’matotalfailure.”

Makinganegativeassumption;becausesome-thinghasgonewrongonceortwice,itwillalwaysdoso.

“WhenItriedtodoexercisebeforemypainincreased,somypainisboundtoincreaseifIexerciseagain”.

‘Should’ and ‘must’statements

Fixedexpectationsonhowyouthinkyouorothersshouldbehave.

“Ishouldbeabletovacuumthehouseinonego;Imusttryharder.”

Catastrophising Thinkingabouteventsasiftheyarealotmorenegativethantheyare.

“Mypainisreallybadtoday,Imustbedoingpermanentdamagetomybody.”

Emotionalreasoning

Takingafeelingasbeingevidenceoffact.

“Ifeelanxious,Iknow somethingdangerousisgoingtohappen.”

Labelling Attachingalabeltoyourselforotherswithoutconsideringevidencethatdoesnotsupportit.

“I’museless.”“Theyaresoinconsiderate.”

Mind-reading Believingthatyouknowwhatothersarethinking.

“MyfriendsmustthinkI’mareallyboringpersonandtheydon’treallywanttobeherewithme.”

Personalisation Blamingyourselfforanythingunpleasantandtakingtoomuchresponsibilityforthingsthatarenotunderyourcontrol.

“It’smyfaultthat.............”

Tunnel vision Focusingsolelyonthenegativeaspectsofasituation.Thewholepictureiscolouredbywhatmaybeasinglenegativedetail.

“I’minasmuchpainasIwas2monthsago;Ihaven’timprovedatall.”

Drawinganegativeconclusionwhenthereisnoevidencetosupportit.

“Theywon’tlikeme,sowhyeventrytojoinin?”

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Listactivitiesortasksyouneedtodofortheweek.Whenyouhavelistedalltasks,prioritisetheseintowhatyouconsidertobehigh,mediumandlowpriorities(i.e.putthetasksmostimportanttoyouinthehighprioritycategory).

Tool for PrioritisingMediumPriority

HighPriority

LowPriority

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Identifyhigh,mediumandlowenergyactivities.Fromthelistofweeklytaskstodo,planwhenyouaregoingtocarryouteachtask,usingpacingtocarryitthrough

Tool for Planning and PacingM

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Step1-whatwouldyouliketochange?Yourgoal

Step2-whatchangeswouldhelpyoutoachievethischange?

Step3-whatsmallchangescanyoumaketohelpyouachieveyourgoal?

Step4-howcanyousustainthischangeandexpanditintootheraspectsofyourlife?

Example

Step1-returningtoapreviouslyenjoyedactivity–baking–yourpriority

Step2-usingpre-packedbakingingredients,allocatingtimetocarryoutenjoyableactivity–yourplan

Step3-buyinprepackedingredientstocarryoutbakingwhenfeeling physicallyable,allocatingtimetoundertakeactivitywithrest spellsatendpointsofactivityandusingaseattohelpconserve energywhilstcarryingoutactivity–pacingandpositioning

Step4-prioritisingthisactivityasenjoyableandprovidingasenseof achievement,identifyanothergoalandusesimilarquestions

How to set a goal using the 4 Ps?

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Weekly Diary

• Itisbelievedthatpersonaldiariesthatrecordvaryinglevelsofenergy/fatigueduringthedaycanhelpwithplanningandpacing.• Itisalsorecommendedtorecordmoodlevelsthroughouttheday.

Thisleafletisavailableindifferentformatsonrequest.Theseincludelargefont,audiotypeanddifferentlanguages

Issue No. 2 Date of issue : March 2018 Review date : March 2020

Devised by Amanda Trafford & Val Little, Occupational Therapy (2014)

Reviewed by Val Little and Toria Macdonald, Occupational Therapy (2018)

March2018.NC17-00363