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If you have Chronic Obstructive Pulmonary Disease (COPD), other respiratory disease, Long COVID or ME/CFM, then you probably also suffer with fatigue. In medicine we describe fatigue as a “sensation of overwhelming tiredness, lack of energy, and feeling of exhaustion that is not relieved by rest and interferes with usual functioning.” Fatigue is a multi-component symptom, one questionnaire, the Multidimensional Fatigue Inventory (MFI-20) describes subjective fatigue as encompassing five different components; general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue, such as having difficulty concentrating.

Many conditions are accompanied by fatigue but it is particularly profound in respiratory disease. There are different reasons for this, the obvious one being a lack of oxygen to the cells, but we now also know that in COPD, and other conditions, the immune system is chronically elevated which causes the “flight or fight” response to remain permanently raised. The damaged lungs release pro-inflammatory cytokines (such as TNF-alpha and Interleukin-6) into the bloodstream. These inflammatory chemicals can cross the blood-brain barrier where they trigger something known as “sickness behavior." This is a coping mechanism - your brain wants to help you heal and it manifests as a profound lack of motivation.

This is all good if the inflammation is short lived (like having a cold that recovers in a week or so) but if the inflammation is chronic and persistent, as it is in COPD, then the “sickness behaviour” can in fact make us sicker.

What can help treat this fatigue? A review paper published last year in Respiratory Medicine by Zhang and colleagues (2025) looked at 35 studies that considered fatigue in COPD and found four things that were effective in significantly reducing it. Pulmonary rehabilitation, aerobic exercise, progressive muscle relaxation and acupressure (although the confidence of this data was lower than the others).

Exercise and pulmonary rehabilitation work by improving the cardiovascular system, building strength in the peripheral and respiratory muscles and helping improve respiratory patterns. Pulmonary rehabilitation is effective for people with high initial levels of fatigue and lower levels and even appears to improve quality of life most in those with high levels of fatigue (Maarten Van Herck et al, 2019).

In one study from my team, we showed improvements in General Fatigue, Physical Fatigue and Reduced Activity after a seven-week pulmonary rehabilitation programme (Lewko et al, 2013). Whilst there were no changes in the Motivation or Mental Fatigue we would argue that seven weeks may be too short a period to achieve change in these areas of fatigue.

In fact, motivation is an interesting concept as we often “wait for the right motivation” to start a new plan or hobby, but motivation is triggered by activity - once we start doing the activity and see results we are more likely to feel motivated to continue.

If you are fatigued, and waiting for the motivation to get started with an exercise programme you’d be better off starting, and perhaps, when the benefits kick in then so will the motivation to continue. Click on the link below to find out more about my online pulmonary rehabilitation programme.

https://betterbreathingphysio.com/pulmonary-rehab-programme/

References

Lewko A, Bidgood PL, Jewell A, Garrod R. Evaluation of multidimensional COPD-related subjective fatigue following a pulmonary rehabilitation programme. Respir Med. 2014 Jan;108(1):95-102. doi: 10.1016/j.rmed.2013.09.003. Epub 2013 Sep 14. PMID: 24084060. https://pubmed.ncbi.nlm.nih.gov/24084060/

Van Herck M, Antons J, Vercoulen JH, Goërtz YMJ, Ebadi Z, Burtin C, Janssen DJA, Thong MSY, Otker J, Coors A, Sprangers MAG, Muris JWM, Prins JB, Spruit MA, Peters JB. Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis. J Clin Med. 2019 Aug 20;8(8):1264

https://pmc.ncbi.nlm.nih.gov/articles/PMC6722504/

Xiaona Zhang, Jiali Xue, Yan Chang, Rui Zhang, Jie Zhao, Xindan Li, Hongyan Lu, Xirui Jiang, Fang Yu, Pengfei Yang. Non-pharmacological interventions for fatigue in patients with chronic obstructive pulmonary disease: a systematic review and network meta-analysis,

Respiratory Medicine, Volume 248, 2025.  https://doi.org/10.1016/j.rmed.2025.108409.

If you have Chronic Obstructive Pulmonary Disease (COPD), other respiratory disease, Long COVID or ME/CFM, then you probably also suffer with fatigue. In medicine we describe fatigue as a “sensation of overwhelming tiredness, lack of energy, and feeling of exhaustion that is not relieved by rest and interferes with usual functioning.” Fatigue is a multi-component symptom, one questionnaire, the Multidimensional Fatigue Inventory (MFI-20) describes subjective fatigue as encompassing five different components; general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue, such as having difficulty concentrating.

Many conditions are accompanied by fatigue but it is particularly profound in respiratory disease. There are different reasons for this, the obvious one being a lack of oxygen to the cells, but we now also know that in COPD, and other conditions, the immune system is chronically elevated which causes the “flight or fight” response to remain permanently raised. The damaged lungs release pro-inflammatory cytokines (such as TNF-alpha and Interleukin-6) into the bloodstream. These inflammatory chemicals can cross the blood-brain barrier where they trigger something known as “sickness behavior." This is a coping mechanism - your brain wants to help you heal and it manifests as a profound lack of motivation.

This is all good if the inflammation is short lived (like having a cold that recovers in a week or so) but if the inflammation is chronic and persistent, as it is in COPD, then the “sickness behaviour” can in fact make us sicker.

What can help treat this fatigue? A review paper published last year in Respiratory Medicine by Zhang and colleagues (2025) looked at 35 studies that considered fatigue in COPD and found four things that were effective in significantly reducing it. Pulmonary rehabilitation, aerobic exercise, progressive muscle relaxation and acupressure (although the confidence of this data was lower than the others).

Exercise and pulmonary rehabilitation work by improving the cardiovascular system, building strength in the peripheral and respiratory muscles and helping improve respiratory patterns. Pulmonary rehabilitation is effective for people with high initial levels of fatigue and lower levels and even appears to improve quality of life most in those with high levels of fatigue (Maarten Van Herck et al, 2019).

In one study from my team, we showed improvements in General Fatigue, Physical Fatigue and Reduced Activity after a seven-week pulmonary rehabilitation programme (Lewko et al, 2013). Whilst there were no changes in the Motivation or Mental Fatigue we would argue that seven weeks may be too short a period to achieve change in these areas of fatigue.

In fact, motivation is an interesting concept as we often “wait for the right motivation” to start a new plan or hobby, but motivation is triggered by activity - once we start doing the activity and see results we are more likely to feel motivated to continue.

If you are fatigued, and waiting for the motivation to get started with an exercise programme you’d be better off starting, and perhaps, when the benefits kick in then so will the motivation to continue. Click on the link below to find out more about my online pulmonary rehabilitation programme.

https://betterbreathingphysio.com/pulmonary-rehab-programme/

References

Lewko A, Bidgood PL, Jewell A, Garrod R. Evaluation of multidimensional COPD-related subjective fatigue following a pulmonary rehabilitation programme. Respir Med. 2014 Jan;108(1):95-102. doi: 10.1016/j.rmed.2013.09.003. Epub 2013 Sep 14. PMID: 24084060. https://pubmed.ncbi.nlm.nih.gov/24084060/

Van Herck M, Antons J, Vercoulen JH, Goërtz YMJ, Ebadi Z, Burtin C, Janssen DJA, Thong MSY, Otker J, Coors A, Sprangers MAG, Muris JWM, Prins JB, Spruit MA, Peters JB. Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis. J Clin Med. 2019 Aug 20;8(8):1264

https://pmc.ncbi.nlm.nih.gov/articles/PMC6722504/

Xiaona Zhang, Jiali Xue, Yan Chang, Rui Zhang, Jie Zhao, Xindan Li, Hongyan Lu, Xirui Jiang, Fang Yu, Pengfei Yang. Non-pharmacological interventions for fatigue in patients with chronic obstructive pulmonary disease: a systematic review and network meta-analysis,

Respiratory Medicine, Volume 248, 2025.  https://doi.org/10.1016/j.rmed.2025.108409.