| Fatigue Management: An Interdiscliplinary Approach |
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Fatigue is something we have all felt and is a normal consequence of physical or
mental exertion and emotional stress. Typically, energy is restored with rest and
sleep. However, multiple sclerosis is uniquely associated with fatigue that can
interfere with all aspects of life. This type of fatigue is not as easily
resolved as “normal” fatigue and is the most common symptom/complaint of MS,
with 75-95% of people with MS experiencing fatigue. “MS fatigue” occurs daily,
worsens as the day progresses and worsens with heat. It often interferes
with physical activity and therefore results in changes in strength, mobility and function.
The definition offered by the development panel for the fatigue guidelines established by
the MS Council for Clinical Practice Guidelines is “a subjective lack of physical and/or
mental energy that is perceived by the individual or caregiver to interfere with usual
and desired activities”. The biologic basis of MS fatigue is uncertain but is
generally experienced as a constant underlying lassitude.
It is important to be aware of your fatigue and learn what factors may increase your fatigue.
Fatigue can be affected by factors unrelated to your MS, such as depression, sleep
deprivation, deconditioning, dietary factors and medications. Because of the
complex nature of fatigue, more than one treatment in managing fatigue is best.
The first step is identifying fatigue as a problem. As stated earlier, many people
experience fatigue but it must be determined if the fatigue is limiting function or
interfering with quality of life as well as determining whether the fatigue is acute
or chronic. The MS Council for Clinical Practice Guidelines for Fatigue recommend
“determining if fatigue has been present on more than 50% of the days for more than
6 weeks or if there has been a significant development or increase in fatigue
in the past 6 weeks, and if fatigue is reported to limit functional activities
or interfere with quality of life”. A thorough evaluation is required to
determine the potential causes and severity of fatigue as well as its effects on function.
This may include questionnaires and surveys to determine current patterns of fatigue
and self-management strategies. If it is determined that fatigue is consistent with
non-MS causes such as those stated above, then further testing may be required.
For example, if a preliminary evaluation reveals that fatigue is recent in onset
concurrent with sleep disturbances, further testing may be required to
determine the etiology of the sleep disturbance prior to treatment.
Ultimately, treatment directed at the cause of the non-MS fatigue is
recommended. Follow-up assessment is important to determine the effectiveness
of the recommended treatment strategy.
If it is determined that MS fatigue is the primary reason for fatigue, an
interdisciplinary approach (an approach utilizing more than one healthcare
professional in a coordinated fashion) is crucial to determining a proper treatment plan.
Health care professionals often involved in the assessment and management of
fatigue are: Physician, Nurse, Physical Therapist, Occupational Therapist and
Psychotherapist.
Initial management of MS fatigue usually includes education and counseling in
areas of lifestyle modifications as well as medications. The lifestyle modifications
may include adjusting activity levels, time management strategies, adjusting
diet and starting a prudent exercise program. Medications used for the treatment
of fatigue in MS are Amantadine, Pemoline and Modafinil.
If the initial management of MS fatigue is ineffective referral to allied health
professionals is indicated. Physical and occupational therapists with expertise in
exercise and energy conservation strategies will assess the individual and make
recommendations to manage fatigue. Assessments will include evaluation of current
activities, level of fitness, available equipment and environmental factors.
An activity diary is recommended in order to analyze current activities.
This analysis can help the therapist and patient understand what may be making
the fatigue worse and what helps in managing the fatigue. The patient and
therapist work together to set realistic goals and priorities which help conserve energy.
Petajan, et.al., (1996) studied the effects of a 15 week aerobic exercise program on
people with MS. Results of the studies showed significant increases in VO2 max, a
measure of aerobic capacity. This improvement was found to be independent of
neurological impairment. This finding is important for the improvement of overall
health, quality of life and a greater capacity to perform activity.
The Heuga Center conducts fitness evaluations on individuals using upper and
lower extremity ergometry. The fitness evaluation is a graded exercise
evaluation to determine the appropriate level of exercise for each participant,
while avoiding fatigue during exercise. Utilizing a rate of perceived
exertion (RPE) scale allows each person to individualize their exercise intensity.
The RPE scale is a 0-10 scale in which 0 indicates “nothing” and 10
indicates “maximal” exertion. Finding an appropriate level of exercise
intensity will help decrease fatigue during and following the exercise session.
Adaptive equipment and modifying work and home environments can be beneficial as
a fatigue management strategies. These energy conservation techniques may include
use of mobility or self-care equipment to decrease effort with movement, improve
body position with activities and provide effective compensation for activities
of daily living. Physical and occupational therapists with expertise in adaptive
equipment and energy conservation techniques are good resources for these fatigue
management strategies.
It has been established that fatigue is a very common symptom of MS and often
difficult to manage. Medications alone are not enough. An interdisciplinary
approach that includes a careful history to differentiate primary MS fatigue from
secondary causes, education in fatigue management strategies and a guided program
of regular physical activity is most successful. |
| - reprinted with permision from- The Heuga Center. |
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