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MS research update - Managing fatigue with exercise, education or medication: what works best? - 30 June 2014

Summary

Fatigue is one of the commonest symptoms of MS and it can have a major impact on people's lives. This study reviewed the existing research on treatments for fatigue, assessing the evidence and evaluating the effectiveness of each treatment.

The review found that exercise and education treatments appear to have a stronger and more significant effect on reducing the impact or severity of fatigue compared to two commonly prescribed fatigue medications, amantadine and modafinil.

The authors suggest that based on the evidence, exercise and education treatments should be the initial treatment choice for people with MS who are reporting disabling fatigue. Although they recommend that a range of fatigue management treatments, including exercise, education and medication, are needed to successfully manage fatigue.

Background

Fatigue is one of the commonest symptoms of MS and it can have a major impact on people's lives. There are a variety of causes and consequences of MS fatigue. Treatment is based on helping someone find ways of managing their life to prevent or lessen the impact of fatigue, this often involves a variety of techniques and health professionals, such as occupational therapists or physiotherapists.

The body of research investigating the effect of MS fatigue management treatments is growing, however to date it appears that no review has looked at all of the results to compare the types of treatment. This study pools the previous research in order to assess the evidence and evaluate the effectiveness of exercise, education and medication treatments for fatigue.

How this study was carried out

This study was a review which pooled the previous research into treatments for fatigue. To be included in the review the studies needed to be randomised controlled trials and investigate fatigue in MS. 25 studies met the criteria and were included in the analysis.

The review summarised the research trials done on three types of fatigue management treatments in order to assess the evidence and evaluate their effectiveness. The three types of treatment assessed were:

  • Exercise. Including physical and exercise therapies such as aerobic, aquatic, and inspiratory muscle exercise; vestibular rehabilitation programmes; progressive resistance training; climbing; and yoga.
  • Education. Including cognitive behavioural therapy, mindfulness-based interventions; patient education; group fatigue/energy management programs; and self-management programmes.
  • Medication. The studies assessed were restricted to those trials looking at the effects of amantadine or modafinil.

The review assessed 18 rehabilitation trials, including 10 exercise trials, 8 education trials and 7 medication trials. In total these 25 studies included 1,499 participants.

What was found

The review found that exercise and education treatments (commonly referred to as rehabilitation) appear to have a stronger and more significant effect on reducing the impact or severity of fatigue compared to two commonly prescribed fatigue medications, amantadine and modafinil.

However the authors do note that in the exercise and education trials the effect of the treatment on fatigue does vary and not everyone benefited. Additionally there were so many types of intervention trialled that it is difficult to draw any conclusions as to what exactly are the best components for treating fatigue, for example, there were 10 trials looking at exercise, but it is not clear which exercises work best.

What does it mean?

The authors suggest that exercise and education treatments should be the initial treatment choice for people with MS who are reporting disabling fatigue. Currently such rehabilitation treatments are considered as an alternative or supplemental treatment option.

They conclude that medications are important but as there are many causes and consequences of fatigue, they do not often enable people with MS to cope with their difficulties. They recommend that people with MS experiencing fatigue and their health professionals should consider a range of fatigue management treatments, including exercise, education and medication, to successfully manage fatigue.

Comment

Although the review assesses studies that examine the effect of modafinil on fatigue this drug is not licensed in the UK for the treatment of MS. It is a drug that promotes wakefulness and is licensed for treating people who experience excessive sleepiness due to narcolepsy. Although scientific research has suggested that it may be an effective treatment in MS, following the findings of a safety review by the European Medicines Agency, it recommended that modafinil should only be used in the treatment of narcolepsy, as this was the only condition where it considered the benefits of the drug outweighed the risks.

Asano M, Finlayson ML.
Meta-analysis of three different types of fatigue management interventions for people with multiple sclerosis: exercise, education, and medication..
Mult Scler Int. 2014;2014:798285.
abstract
Read the full text of this paper

More about fatigue

Fatigue is believed to be the most common symptom in MS and it can often have a major impact on people's lives. The causes of fatigue in MS are not well understood and it is thought to be a combination of factors. It can be caused by the MS itself, through 'short-circuiting' nerves and it can be caused partly by other factors, including heat, inadequate diet, poor fitness and stress. As there are several causes of fatigue, there are also a number of ways that it can be managed and its impact reduced. Most management techniques revolve around ensuring the best levels of energy are available and then using the energy in the most efficient way.

How to maximise energy

  • Sleep. Poor sleep can make fatigue worse. Establishing a bedtime routine, avoiding caffeine and winding down before bedtime can improve sleep quality.
  • Heat. Many people find that heat makes their MS worse and can make them feel more fatigued, especially during the summer months. There are several tips for keeping cool on our website, including having regular cold drinks and tepid showers.
  • Nutrition. A poor diet and nutrition can make fatigue worse. Sugary snacks might give an initial boost, blood sugar levels quickly drop again leaving energy levels low. A balanced diet can help reduce fatigue and improve energy levels, but preparing food can be tiring work. There are a number of suggestions in Living with fatigue for reducing the impact of fatigue when preparing and eating meals.
  • Relaxation techniques. Relaxation can help with fatigue as it promotes good sleep patterns, increases benefit from rest periods during the day and can be used to manage stressful situations.
  • Exercise. In the past, people with multiple sclerosis were advised to avoid exertion but now it is known that muscles that are not used regularly become weakened and require more energy to do tasks, making fatigue worse. Exercise can be something energetic or something more leisurely. 

How to use energy efficiently

  • Planning. This involves taking some time to stop and think about what needs to be done and what can be achieved. Avoid doing too many energy-demanding activities in a short period of time.
  • Prioritising and delegating. If energy is limited, this involves working out what are the most important tasks that need to be done and what can wait for another day when energy levels might be higher. Alternatively, the task can be shared or someone else can be asked to help out.
  • Organisation. It is helpful to have everything to hand when doing a task, this prevents unnecessary rushing around gathering items.
  • Pacing. This involves taking planned breaks or rests within or between activities, doing things more slowly when energy levels are lower, or breaking tasks up into smaller activities.

More suggestions can be found in Living with fatigue which can be read online, downloaded as a pdf file or ordered as a printed version.

Research by topic areas...

Assessment tools

Soler García A, González Gómez A, Figueroa-Ortiz LC, et al.
Relationship between contrast sensitivity test and disease severity in multiple sclerosis patients.
Arch Soc Esp Oftalmol. 2014 Jun 19. [Epub ahead of print]
abstract

Moster S, Wilson JA, Galetta SL, et al.
The King-Devick (K-D) test of rapid eye movements: a bedside correlate of disability and quality of life in MS.
J Neurol Sci. 2014 Jun 2. [Epub ahead of print]
abstract

Sehle A, Vieten M, Sailer S, et al.
Objective assessment of motor fatigue in multiple sclerosis: the fatigue index Kliniken Schmieder (FKS).
J Neurol. 2014 Jun 22. [Epub ahead of print]
abstract

CCSVI

De Pasquale C, Pistorio ML, Veroux M, et al.
Cognitive functioning and subjective quality of life in relapsing-remitting multiple sclerosis patients before and after percutaneous transluminal angioplasty: a preliminary report.
Neuropsychiatr Dis Treat. 2014;10:1039-44.
abstract
Read the full text of this paper

Disease modifying treatments

Miller AE, Macdonell R, Comi G, et al.
Teriflunomide reduces relapses with sequelae and relapses leading to hospitalizations: results from the TOWER study.
J Neurol. 2014 Jun 28. [Epub ahead of print]
abstract

Willis H, Webster J, Larkin AM, et al.
An observational, retrospective, UK and Ireland audit of patient adherence to subcutaneous interferon beta-1a injections using the RebiSmart(®) injection device.
Patient Prefer Adherence. 2014;8:843-51.
abstract
Read the full text of this paper

Roche J, McCarry Y, Mellors K.
Enhanced patient support services improve patient persistence with multiple sclerosis treatment.
Patient Prefer Adherence. 2014;8:805-11.
abstract
Read the full text of this paper

Evans C, Zhu F, Kingwell E, et al.
Association between beta-interferon exposure and hospital events in multiple sclerosis.
Pharmacoepidemiol Drug Saf. 2014 Jun 21. [Epub ahead of print]
abstract

Other treatments

Andersson KE.
Current and future drugs for treatment of MS-associated bladder dysfunction.
Ann Phys Rehabil Med. 2014 Jun 2. [Epub ahead of print]
abstract
Read the full text of this paper

Cameron MH, Bethoux F, Davis N, et al.
Botulinum toxin for symptomatic therapy in multiple sclerosis.
Curr Neurol Neurosci Rep. 2014 Aug;14(8):463.
abstract

Physical activity

D'hooghe MB, Feys P, Deltour S, et al.
Impact of a 5-day expedition to machu picchu on persons with multiple sclerosis.
Mult Scler Int. 2014;2014:761210.
abstract
Read the full text of this paper

Chua MC, Hyngstrom AS, Ng AV, et al.
Movement strategies for maintaining standing balance during arm tracking in people with multiple sclerosis.
J Neurophysiol. 2014 Jun 25. [Epub ahead of print]
abstract

Rehabilitation

Ternes AM, Fielding J, Addamo PK, et al.
Concurrent motor and cognitive function in multiple sclerosis: a motor overflow and motor stability study.
Cogn Behav Neurol. 2014 Jun;27(2):68-76.
abstract

Symptoms and symptom management

Adamczyk-Sowa M, Pierzchala K, Sowa P, et al.
Melatonin acts as antioxidant and improves sleep in MS patients.
Neurochem Res. 2014 Jun 30. [Epub ahead of print]
abstract

Lew-Starowicz M, Rola R.
Correlates of sexual function in male and female patients with multiple sclerosis.
J Sex Med. 2014 Jun 26. [Epub ahead of print]
abstract

Carvalho LS, Matta AP, Nascimento OJ, et al.
Prevalence of temporomandibular disorders symptoms in patients with multiple sclerosis.
Arq Neuropsiquiatr. 2014 Jun;72(6):422-5.
abstract
Read the full text of this paper

Denys P, Phe V, Even A, et al.
Therapeutic strategies of urinary disorders in MS. Practice and algorithms.
Ann Phys Rehabil Med. 2014 Jun 4. [Epub ahead of print]
abstract
Read the full text of this paper

Prévinaire JG, Lecourt G, Soler JM, et al.
Sexual disorders in men with multiple sclerosis: evaluation and management.
Ann Phys Rehabil Med. 2014 Jun 3. [Epub ahead of print]
abstract
Read the full text of this paper

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