Cancer-related fatigue: evidence-based occupational therapy management

1. Assessment by the occupational therapist

• Fatigue severity, daily pattern, triggers, and recovery time. A brief daily fatigue and activity diary is useful.
• Effect on ADLs and IADLs: bathing, dressing, meal preparation, childcare, work, community mobility, leisure, and social roles.
• Sleep quality, pain, breathlessness, mood, cognition, nutrition, medication effects, and activity level.
• Home, work, and caregiver demands.
• Patient priorities and valued activities using an occupation-centred tool such as the Canadian Occupational Performance Measure (COPM).
• Screen and refer promptly for reversible contributors: anemia, infection, uncontrolled pain, insomnia, depression/anxiety, hypothyroidism, malnutrition, medication adverse effects, and cardiopulmonary problems.

2. Energy conservation and activity management

• Plan: schedule high-demand tasks for the time of day when energy is best.
• Prioritize: distinguish essential tasks from tasks that can be postponed, delegated, simplified, or stopped.
• Pace: use short activity periods with planned breaks before exhaustion occurs. Avoid the "do everything on a good day, crash the next day" cycle.
• Position: sit for grooming, cooking, showering, and food preparation; use good body mechanics.
• Simplify: use ready-prepared food, online shopping, lightweight equipment, a shower chair, trolley, long-handled aids, or adaptive clothing as appropriate.
• Delegate: involve family or carers in physically demanding and lower-priority tasks.
• Balance: create a realistic weekly routine that includes self-care, productive activity, rest, physical activity, pleasurable occupations, and social contact.

3. Graded, occupation-based physical activity

• Begin with the person's current tolerance and medical clearance.
• Set functional goals, for example: "walk to the local shop," "prepare one simple meal," or "return to one household role."
• Use graded walking, cycling, gentle strengthening, stair practice, gardening, or meaningful household activity.
• Increase duration or intensity slowly and review fatigue response the next day.
• Promote both aerobic and resistance activity where appropriate.
• Avoid prolonged inactivity unless medically indicated.

4. Sleep and rest management

• Establish a consistent wake-up and bedtime routine.
• Use the bed primarily for sleep rather than prolonged daytime resting, if medically appropriate.
• Plan short, timed rests rather than long or late naps.
• Reduce late caffeine, screen exposure, and stimulating activity before bed.
• Identify sleep-disrupting symptoms such as pain, hot flushes, nocturia, anxiety, and breathlessness, and refer to the oncology team.
• For persistent insomnia, refer for cognitive behavioural therapy for insomnia (CBT-I).

5. Psychoeducation, cognitive and behavioural strategies

• the difference between CRF and ordinary tiredness
• monitoring fatigue and identifying triggers
• realistic goal setting
• problem-solving barriers to activity and roles
• managing fear of activity or fear of fatigue
• self-compassion and coping with changed abilities
• communicating needs to family, employers, and the healthcare team

6. Work and role rehabilitation

• complete work-task and ergonomic analysis
• recommend flexible schedules, phased return to work, extra breaks, reduced workload, task rotation, seated work, remote work, or pacing strategies
• advise on cognitive supports: calendars, written checklists, alarms, simplified routines, and reduced multitasking
• facilitate communication with the employer, where consent is given
• help the person retain valued roles through adaptation rather than withdrawal.

7. Referral and interdisciplinary management

Evidence summary

Example SMART OT goal

Within 2 weeks, the patient will prepare a simple evening meal on 4 days per week using seated preparation, task pacing, one planned rest break, and family assistance for heavy items, while keeping post-activity fatigue at or below their agreed manageable level.

Occupational Therapy Intervention Plan for Cancer-Related Fatigue

Problem statement

Example six-week session plan

Session 1: Evaluation and education

• Occupational profile and COPM.
• Assess fatigue severity, pattern, sleep, mood, pain, daily roles, home demands, and work demands.
• Start a 7-day fatigue, activity, and sleep diary.
• Explain CRF and establish 1-2 meaningful functional goals.

Session 2: Energy conservation and home routines

• Review diary for fatigue triggers and high-energy tasks.
• Teach Plan, Prioritize, Pace, Position.
• Modify one routine, for example showering, cooking, laundry, or dressing.
• Provide caregiver education where appropriate.

Session 3: Graded activity and meaningful occupation

• Begin an individualised graded activity programme following oncology team clearance.
• Use a meaningful activity such as walking to the garden, meal preparation, or light housework as the activity context.
• Teach monitoring for overexertion and planned rest.

Session 4: Sleep, stress, and cognitive strategies

• Review sleep routine and daytime rest pattern.
• Teach relaxation, mindfulness, activity scheduling, and problem-solving.
• Address cognitive fatigue with checklists, calendars, reminders, and reducing multitasking.

Session 5: Role resumption and environmental adaptation

• Address return to work, study, parenting, household, community, or leisure roles.
• Trial adaptive equipment or workplace/home modifications.
• Develop a written fatigue-management plan for difficult days.

Session 6: Review and discharge planning

• Reassess COPM, fatigue score, participation, and goal achievement.
• Create a self-management plan with warning signs that require medical review.
• Coordinate referrals for physiotherapy, exercise oncology, dietetics, psychology, social work, vocational rehabilitation, or palliative care as indicated.

Safety and referral points