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

Recent guidelines supporting cancer-related fatigue rehabilitation

1. ASCO-Society for Integrative Oncology Guideline Update, 2024

• graded activity and meaningful occupation-based movement
• fatigue education and self-management
• activity scheduling and pacing
• behavioural strategies consistent with CBT principles
• referral and collaboration with physiotherapy, exercise oncology, psychology, and medical oncology
• adaptation of daily routines, work, self-care, and leisure to maintain participation.

2. NCCN Cancer-Related Fatigue Guideline, Version 2.2025

• screen fatigue using a 0-10 rating scale and assess functional impact
• identify treatable contributors such as pain, anemia, sleep disturbance, medication effects, emotional distress, nutritional problems, infection, and comorbidity
• recommend physical activity/exercise when clinically safe
• begin with low intensity and progress gradually
• use education, coping strategies, sleep management, activity management, and referral to rehabilitation professionals as indicated.

3. Clinical Practice Guideline for Screening and Assessment of CRF, 2022

• EORTC QLQ-C30 fatigue items for screening
• FACIT-Fatigue
• Revised Piper Fatigue Scale
• PROMIS Fatigue Short Form

4. ASCO Exercise, Diet, and Weight Management During Cancer Treatment Guideline, 2022

• begin at the patient’s current capacity
• use meaningful, achievable activity goals
• grade duration and demand gradually
• build activity into real routines such as walking for errands, meal preparation, gardening, stairs, or community mobility
• refer to physiotherapy or exercise oncology for complex exercise prescription, gait issues, balance impairment, neuropathy, bone metastases, or significant deconditioning.

5. ESMO Clinical Practice Guideline for Cancer-Related Fatigue, 2020

• systematic assessment of fatigue and associated symptoms
• management of contributing medical and psychological factors
• physical activity/exercise
• psychoeducation and psychosocial interventions
• individualised treatment based on disease status and patient goals.

Evidence-based rehabilitation message for an OT plan

1. Screen and assess CRF regularly.
2. Identify and address treatable causes with the oncology team.
3. Recommend tailored exercise or physical activity, rather than prolonged rest.
4. Use CBT-informed strategies, mindfulness, and psychoeducation.
5. Support participation through pacing, energy conservation, task modification, adaptive equipment, role adaptation, sleep routines, and return-to-work planning.
6. Use multidisciplinary rehabilitation, involving OT, physiotherapy/exercise oncology, psychology, dietetics, nursing, oncology, and palliative care as needed.

Guideline-Based OT Treatment Protocol

Cancer-Related Fatigue Rehabilitation in Adults

1. Eligibility and triage

Appropriate OT referral

• interferes with ADLs, IADLs, work, caregiving, sleep, community mobility, social participation, or leisure
• persists despite ordinary rest
• causes activity avoidance, inconsistent activity patterns, or a "push-crash" cycle
• is associated with difficulty planning, pacing, prioritising, or resuming life roles.

Medical review before rehabilitation progression

• anemia, infection, fever, dehydration, electrolyte disturbance
• uncontrolled pain, nausea, breathlessness, or sleep disturbance
• medication adverse effects
• depression, anxiety, or suicidal thoughts
• malnutrition/cachexia
• thyroid, cardiac, pulmonary, neurological, or endocrine problems
• suspected disease progression.

Exercise and activity precautions

2. Recommended service delivery

3. Baseline OT assessment

A. Fatigue assessment

• FACIT-Fatigue
• PROMIS Fatigue Short Form
• Revised Piper Fatigue Scale
• EORTC QLQ-C30 fatigue items

B. Occupational assessment

• ADLs: bathing, dressing, toileting, mobility, feeding
• IADLs: cooking, shopping, cleaning, laundry, medications, financial management
• work, study, childcare, caregiving, driving, and community roles
• rest and sleep patterns
• physical activity level and barriers
• cognitive fatigue: attention, memory, planning, multitasking
• environment: stairs, bathroom access, seating, transport, work demands
• meaningful roles and goals.

C. Fatigue and activity diary

• fatigue rating on waking, midday, evening, and after high-demand activity
• activity performed and duration
• rest periods
• sleep duration/quality
• pain, breathlessness, mood, and treatment-related symptoms
• next-day fatigue response.

4. Core OT intervention package

Module 1: CRF education and self-management

Intervention

• related to cancer or cancer treatment
• physical, cognitive, and emotional
• often not fully relieved by sleep or rest
• managed better by an individualised balance of activity, planned rest, coping strategies, sleep support, and treatment of contributing symptoms.

• planned restorative rest and prolonged inactivity
• graded activity and overexertion
• manageable fatigue and warning signs requiring medical review.

SMART goal

Within 1 week, the patient will identify three personal fatigue triggers, three fatigue-management strategies, and two warning signs that require contact with the healthcare team, using teach-back with no more than one prompt.

Module 2: Energy conservation and activity pacing

Intervention: the 4 Ps

Additional strategies

• Sit for showering, grooming, dressing, food preparation, and laundry folding when appropriate.
• Use a shower chair, trolley, reacher, long-handled sponge, perching stool, lightweight cookware, or adaptive clothing as indicated.
• Keep frequently used items within easy reach.
• Use delivery services, meal preparation shortcuts, family help, and delegated chores.
• Apply the "stop before depletion" principle, particularly on days of chemotherapy or radiation-related symptom escalation.

SMART goal

Within 2 weeks, the patient will use at least four energy-conservation strategies while completing one identified IADL, on at least 4 days per week, without severe post-activity fatigue escalation the following day.

Module 3: Graded physical activity embedded in occupations

OT role

• identifies meaningful activity goals and participation barriers
• integrates movement into routines and valued occupations
• modifies tasks and environments
• supports adherence, pacing, confidence, and symptom monitoring
• coordinates referral for formal exercise testing or complex physical rehabilitation.

Starting approach

• walking indoors/outdoors
• seated pedalling
• light gardening
• supported household mobility
• stair practice where safe
• simple resistance exercises prescribed by physiotherapy or exercise oncology
• yoga, tai chi, or qigong when accessible and medically appropriate.

Progression rule

SMART goal

Within 4 weeks, following medical clearance, the patient will complete a meaningful graded activity programme for 10-20 minutes on 3 days per week, using pacing and planned rests, with no unsafe symptoms and no sustained increase in fatigue for more than 24 hours.

Module 4: Sleep, rest, and daily-routine management

Intervention

• Establish a consistent wake-up time and bedtime.
• Structure a daily routine with self-care, movement, meaningful activity, meals, social contact, and rest.
• Use short planned rests rather than prolonged daytime sleeping where possible.
• Avoid late-day naps if they interfere with night-time sleep.
• Establish a calming pre-sleep routine.
• Refer for CBT-I or medical review if insomnia, pain, hot flushes, nocturia, anxiety, sleep apnea, or medication effects are suspected.

SMART goal

Within 4 weeks, the patient will follow a consistent sleep and rest routine, including three agreed sleep-support strategies, on at least 5 nights per week, as demonstrated in a sleep diary.

Module 5: CBT-informed fatigue management and mindfulness

OT interventions

• graded goal setting
• behavioural activation through meaningful occupations
• identifying unhelpful patterns, such as avoiding all activity or overdoing activity
• problem-solving barriers
• self-monitoring of activity and fatigue
• relaxation breathing, body scan, brief mindfulness during activities
• cognitive compensatory strategies for fatigue-related attention or memory problems:
  • written checklists
  • visual schedules
  • alarms
  • single-tasking
  • reduced environmental distraction
  • planned cognitive rest.

SMART goal

Within 5 weeks, the patient will independently use one pacing or problem-solving strategy and one relaxation or mindfulness strategy on at least 4 days per week to manage fatigue-related activity barriers.

Module 6: Role resumption, work, and participation

Intervention

• Home management: seated meal preparation, batch cooking, delivery shopping, task delegation.
• Parenting/caregiving: prioritised routines, shared responsibilities, seated play, planned recovery periods.
• Work/study: phased return, flexible schedule, remote work, reduced travel, task rotation, seated workstations, scheduled breaks, reduced multitasking, written instructions, and workload prioritisation.
• Leisure/social roles: shorter visits, rest before and after events, accessible transport, participation in lower-demand but meaningful activities.

SMART goal

Within 6 weeks, the patient will resume or adapt one identified valued role, such as meal preparation, social participation, caregiving, study, or selected work duties, at least once weekly using their written fatigue-management plan.

5. Six-week intervention schedule

6. Outcome evaluation and discharge criteria

Review at week 6

• fatigue outcome measure
• COPM performance and satisfaction ratings
• fatigue/activity and sleep diary
• participation in target ADL/IADL, work, caregiving, and leisure roles
• patient confidence in self-management.

Indicators of successful response

• improved fatigue self-management knowledge
• reduced interference of fatigue with daily occupations
• regular use of pacing and energy-conservation methods
• improved activity consistency and less push-crash behaviour
• progress toward safe, graded physical activity
• improved sleep routine or appropriate referral for persistent sleep problems
• resumption or adaptation of at least one meaningful role.

Discharge when

• patient independently uses the fatigue-management plan
• goals are met or transitioned to longer-term rehabilitation/community services
• symptoms are stable and appropriate supports are in place
• further OT needs are not identified.

Continue or refer when

• fatigue remains moderate to severe and participation is substantially limited
• a new medical cause is suspected
• the patient requires formal CBT, physiotherapy, exercise oncology, vocational rehabilitation, dietetics, psychology, or palliative care input.

7. Clinical documentation statement

Patient presents with cancer-related fatigue causing reduced participation in [identified occupations]. OT intervention will use guideline-supported fatigue education, activity pacing, energy conservation, occupation-based graded activity, sleep and routine management, CBT-informed self-management, environmental adaptation, and role resumption strategies. Progress will be monitored using [fatigue measure], COPM, patient diary, functional observation, and goal attainment.

Evidence base

• [Practice Guideline . 2024] Bower et al. Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update. Journal of Clinical Oncology. PMID: 38754041.
• [Practice Guideline . 2022] Fisher et al. Screening and Assessment of Cancer-Related Fatigue: A Clinical Practice Guideline for Health Care Providers. Physical Therapy. PMID: 36179114.
• [Practice Guideline . 2022] Ligibel et al. Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline. Journal of Clinical Oncology. PMID: 35576506.
• [Systematic Review . 2024] Gray et al. found support for resistance training in cancer survivors with CRF, though programme selection must remain individualised. PMID: 37345506.
• Nonpharmacological approaches including activity enhancement, education, psychosocial support, stress management, sleep interventions, and mind-body approaches are supported in cancer fatigue management. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, p. 7060.