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Dear Dr. Roach: My wife is 77 years old, goes to bed at 9 or 10 p.m., wakes at 10 a.m. and is exhausted by noon. She has severe arthritis, peripheral artery disease, scoliosis and depression. She has had many surgeries on her back, joints and blood vessels. In addition to fatigue, she experiences tingling in her hands and feet, and severe back pain, especially when standing and walking. She has had no success with pain management for her back, and has a clean bill of health from her neurologist and cardiologist.

Exercise/activity results in being tired (with her back pain, exercise is a two-minute walk then rest). She takes an hour nap every afternoon.

We go from doctor to doctor and the fatigue source remains undiagnosed. Any suggestions?

G.W.

G.W.: Fatigue is one of the most difficult symptoms to diagnose and treat, since there are so many possible causes. In her case, the underlying conditions that you have mentioned — arthritis, peripheral artery disease and depression — all may have fatigue as a significant part of their symptomatology. Further, the medications used to treat these conditions often cause severe fatigue and sleepiness, which is confused with and sometimes goes along with fatigue. I can't tell you how many people treated for chronic pain write to me complaining of fatigue and feeling like a "zombie."

Depression can cause of fatigue, but it also can be an reaction to chronic pain and fatigue.

While I can't give specifics on how to help your wife, an experienced doctor can review all the medications to see if they are likely to be doing more harm than good. He or she will consider treatment for depression that may help the fatigue, in particular. Other effective treatments include a graded exercise program ("graded" means starting very slow and building up), which helps more than half of people improve. Finally, optimal treatment of her underlying conditions may help, though I'm sure her doctors are trying that now.

Dear Dr. Roach: A friend has been diagnosed with spinal stenosis. She's 85 years old. She tried a cortisone shot, with very short-lived relief, and physical therapy, to no avail. She's been prescribed pain pills, which cause her to sleep more than you'd expect for her age. Her doctor seems to be out of options.

I read an article about laser treatment for this area. Do you think this might help?

M.R.

Dear M.R.: "Spinal stenosis" is the term we use to describe compression of the spinal cord or nerve roots by bony structures in the spine. This may be a result of arthritis, skeletal disease and many other conditions. One common finding is difficulty after walking, causing someone to want to sit or lie down. I often see people with spinal stenosis who lean over while walking, as though they are walking into a stiff wind. Many sufferers can walk for prolonged periods with a shopping cart, because the leaning-over position relieves the pressure on the nerves.

Surgery for spinal stenosis can be challenging, and in an 85-year-old, the risk of complications is higher, but with a surgeon may be appropriate. There may still be additional medical therapies she hasn't tried before doing so.

Only a surgeon can appropriately choose the tools for a given surgery. However, having looked over the research in this area, there is no evidence that laser offers any advantage over traditional surgery.

Email questions to ToYourGoodHealth@med.cornell.edu.

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