Symtom Awareness
Coping with Fatigue
Causes of Fatigue in MS
Fatigue can be one of the most challenging symptoms of MS. It is also one of the "invisible symptoms" and can easily be misunderstood by others who are unfamiliar with the effects of MS. Friends, family, and even coworkers may question how someone can appear perfectly normal while claiming to be overwhelmed with fatigue. Some may think that the person is simply being lazy or needs to be motivated to snap back to normal. But no degree of motivation will help most forms of fatigue found with MS.
Individuals with MS may experience fatigue as a result of a number of reasons. Common causes include:
- demyelination
- spasticity
- sleep deprivation
- overexertion
- becoming overheated
- side effects from medications
- stress
- depression
- poor nutrition
- infection (particularly urinary tract
- infection, for which fatigue may be the primary symptom)
- kidney disease
- anemia
- other medical conditions
Regarding demyelination, individuals with MS often experience fatigue as a result of damaged myelin (protective nerve covering) and axons (nerve fibers). As the body requires increased effort to send nerve impulses along a damaged nerve, valuable energy is used up and the person becomes fatigued. This type of fatigue is often evident when a person with MS exercises beyond his or her limitations, possibly with the added stress of using weights.
Spasticity is a symptom of MS that can greatly contribute to fatigue. Stiff muscles require more energy to move and to control. This is one reason why treating spasticity through stretching exercises, physical therapy, and/or medications, can help reduce the amount of fatigue someone experiences.
Sleep deprivation is another difficulty often associated with MS that can directly impact one's level of energy throughout the day. Sleep may be interrupted several times each night by such symptoms as spasticity or urinary frequency (having to visit the bathroom often). Treatments sometimes used to fight fatigue, particularly excessive daytime napping or caffeine late in the day, can also contribute to difficulty sleeping.
Strenuous exercise, including exercise that uses weights, can completely drain a person's energy. Excessive exercise, as well as a warm environment, can also increase temperature, which can slow down nerve impulses and lead to fatigue. Ironically, keeping muscles inactive will lead to de-conditioning, and this too can also cause fatigue.
Many people with MS experience a type of fatigue known as "lassitude," which is extreme sleepiness during the day. This can come on suddenly and is thought to be a result of chemical changes in the brain.
Treatment for Fatigue in MS
When a physician treats an individual with MS who is suffering from fatigue, the doctor has many issues to consider. The physician must look at the person's lifestyle (for things such as overexertion and heat exposure), other symptoms (including spasticity, urinary frequency, and sleep problems), emotional state (to look for depression and stress), physical condition (including poor nutrition, possible infection, and other superimposed medical conditions), and medications that the individual is taking which could include fatigue as a side effect. These are all possible causes that the physician must consider before determining that demyelination or lassitude are the culprits. Chances are, a combination of factors is involved with each person's fatigue.
The first line of treatment is to address the issues that can directly cause fatigue. The physician will need to identify these causes and develop a plan for the patient to follow.
The physician may suggest changing medications if they are thought to contribute to fatigue. The physician may also treat the other MS symptoms (such as spasticity, urinary frequency, and sleep problems) as well as infection or any other conditions through health-maintenance strategies and/or medication. Good nutrition and a healthy lifestyle may be emphasized to be sure an individual is getting the food, vitamins, exercise, and rest that he or she needs. Treatment may also be recommended for emotional problems such as depression.
Energy conservation is an important part of the treatment plan to fight fatigue. Scheduling, planning ahead, using adaptive equipment, and learning tips to make household chores easier and cooking less complicated, can greatly impact the amount of energy used throughout the day. Taking breaks and spreading out activities will also have a positive effect on energy.
Carefully monitored aerobic exercise can build endurance, keep muscles moving, and actually increase energy in the long run. Individuals with MS should be careful not to overstress muscles when using weights in their workouts. Yoga has also been found to help individuals feel less fatigued.
In addition to the many types of strategies that may be used to fight fatigue, MSAA has been actively involved in the research and distribution of "cool suits" to provide temporary relief from fatigue for a portion of the MS population. Studies have shown that nerves with damaged myelin are sensitive to changes in temperatures, noting that a rise in temperature may cause a failure in the effective transmission of signals from the brain to the body (nerve conduction), and a reduction in temperature may allow more signals to be transmitted across the damaged nerve.
Cooling therapy, when used correctly, may help reduce some symptoms of MS, including problems with fatigue (as well as vision, spasticity, motor function, and cognition). Cooling needs to be controlled and done slowly through special equipment; otherwise it will not relieve any MS symptoms, and will result in shivering and vasoconstriction. As with any therapy, not all people receive the same benefit or any benefit at all. Cooling therapy should be viewed as an adjunct to disease modifying drugs, not as an alternative, and should only be done with the approval of a medical professional.
MSAA has recently published a new edition of its booklet, Multiple Sclerosis and Cooling. To receive a free copy, please call MSAA's Helpline at (800) 532-7667.
Medications are sometimes prescribed to fight fatigue. Modafinil (Provigil®) is the newest and one of the most commonly prescribed drugs for MS fatigue and lassitude. Other drugs prescribed include: amantadine (Symmetrel®); antidepressants fluoxetine hydrochloride (Prozac®), paroxetine (Paxil®), and sertraline (Zoloft®); and tricyclic antidepressants protriptyline (Vivactil®, Triptil®) and nortriptyline (Pamelor®, Aventyl®). The effects of these drugs differ between individuals and can change over time for a person taking the drug(s). Physicians may need to try various medications and dosages, possibly using a combination of drugs, to see what works best for a patient. Stimulants such as pemoline (Cylert®) and methylphenidate (Ritalin®) are used infrequently because of potential liver toxicity and addiction, respectively.
In conclusion, the significant fatigue that is experienced by many individuals with MS can be caused by a variety of factors. Visiting one's physician, following his or her treatment plan, taking steps to conserve energy, and looking into additional strategies such as cooling, yoga, and moderate exercise (all under the guidance of a physician), are the best ways to approach this challenging symptom.
