Immunological And Inflammatory Processes
The immune system plays a key role in aetiology and progression of MS. In general, immunological processes in the CNS and the body can interact through multiple pathways. In MS, the relative contributions of central and peripheral immunological events during the induction and early inflammatory phase of MS are not fully understood. In particular, it remains to be clarified whether a primary immunological process takes place in the brain and spreads to the periphery or whether immune activation begins peripherally before being transferred to the initially unaffected CNS . The latter possibility is supported by the fact that highly effective immunomodulatory treatments for MS have peripheral targets. Regardless of where the initial immune response occurred, myelin damage in the CNS is thought to lead to the release of antigens to the periphery. This, in turn, primes immune responses in lymphoid tissue and triggers the invasion of lymphocytes into the CNS. While peripheral immune responses may be the driving force at the early stage of MS, evidence suggests that later in the disease, the immune response is shifted and compartmentalised to the CNS in lymphoid-like follicles in the meninges that maintain chronic inflammation.
What Is The Role Of Fatigue In Multiple Sclerosis
Fatigue is one of the most common symptom of MS, reported by at least 75% of patients with the disease. Fatigue is described as an overwhelming feeling of lassitude or lack of physical or mental energy that interferes with activities.
An estimated 5060% of persons with MS describe fatigue as one of their most bothersome symptoms, and it is a major reason for unemployment among MS patients. One should rule out comorbid medical conditions, such as infections, anemia, vitamin deficiencies or thyroid disease, before attributing fatigue to MS.
What Causes Fatigue In Ms
The causes of fatigue in MS are not well understood. Fatigue is thought to result from different factors, partly caused by multiple sclerosis itself and partly by other factors that affect people with MS more than those without the condition.
Primary fatigue is thought to be due to nerve messages from your brain and spinal cord having to navigate the areas of damage caused by your MS. It takes more energy to send and deliver messages to other parts of the body, like the muscles in your arms and legs, causing a build-up of fatigue.
Secondary fatigue is caused by the effect of living with MS. For instance, MS symptoms such as depression, being in pain or by having sleep disturbed by spasms or needing to go to the toilet more often can all make fatigue worse.
Fatigue may also occur as a side effect of various medications or be the result of inactivity, stress, poor diet or an infection. If you have other medical conditions, this can also cause or worsen fatigue.
Fatigue for many people is the result of a combination of several factors which can make you feel tired and lacking in energy. Once youre aware of these factors, you can review whether they apply to you and begin making changes.
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Using Your Energy Efficiently
As well as making positive lifestyle choices to increase the energy you have, the other side to managing fatigue is to use that energy in the most efficient way. You need to:
Plan ahead and balance your busy diary between essential everyday tasks and fun activities to boost your mood. Try to prioritise so that you can use precious time wisely.
Delegate you may find this hard at first as you mistakenly think this is a loss of control, but actually, delegating allows you to take back control and focus on what is most important. Think of yourself as the CEO of your life, delegating lower priority tasks. Likewise, consider how everyday tasks can be done in a more time-efficient way.
Pace yourself and rest when you need to. By saving energy you can put it towards what is most important to you.
Krupp’s Fatigue Severity Scale
Many studies of MS-related fatigue have used the Fatigue Severity Scale to identify fatigued patients. Initially designed to identify common features of fatigue in both MS and lupus patients, the Fatigue Severity Scale assesses the impact of fatigue on multiple outcomes, with a physical focus. Each of 9 responses is provided on a 7-point Likert scale. Prior studies have shown acceptable internal consistency and stability over time, and sensitivity to change afforded by clinical improvement. The Fatigue Severity Scale has been shown to differentiate between subgroups of patients with MS, chronic fatigue syndrome, and primary depression. Moreover, the scores correlate with other scales commonly used in MS, including the Modified Fatigue Impact Scale and Fatigue Descriptive Scale.
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Take Good Care Of Your Overall Health
Maintaining a healthy weight and optimal blood pressure and cholesterol levels, and avoiding type 2 diabetes can all help with MS fatigue, says Dr. Conway.
“A healthy diet and a regular exercise program can really help, says Cohen. If you are physically out of shape and overweight, everything you do requires more energy.
How Ms Fatigue Is Different To Other Types Of Fatigue
Ordinary fatigue is described as a sensation of muscular tiredness and weakness. It is the tired feeling everyone experiences after an excessively busy day or a lack of sleep. It is the type of fatigue that is usually managed by rest and a good nights sleep. Ordinary fatigue is quite different to the fatigue experienced in MS.
Fatigue associated with MS is described as an overwhelming sense of tiredness that can occur at any time of the day without warning. MS-fatigue usually occurs more rapidly, lasts longer and takes more time to recover from than ordinary fatigue.
MS-fatigue can occur for no apparent reason or after relatively mild exertion, such as a short period of walking, writing or reading, with an immediate need to rest.
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Exercise Can Boost Energy
Certain types of easy exercise, such as gardening and yoga , have been shown to boost energy levels, reduce stress, improve joint range of motion, help manage spasticity, and increase strength. Because of its natural buoyancy, water allows many men and women with MS to perform exercises they cannot do outside of the pool. Water exercise helps increase flexibility, strengthen the upper and lower extremities and trunk, improve ambulatory skills, increase coordination and balance, and condition the overall body to raise endurance levels and lessen fatigue.
For more information on the benefits of aquatic therapy and aquatic exercise for individuals with MS, please see the Health and Wellness column from the Summer/Fall 2012 issue of The Motivator. This may be found on MSAAs website at mymsaa.org/publications/motivator/summer-fall12/health
Ms Fatigue And The Central Nervous System
Some studies suggest certain parts of the brain are linked to MS fatigue. But no single area of the brain has been identified. It could be caused by damage in several areas of the brain or spinal cord.
Some researchers suggest fatigue might be caused by the way that the brain adapts to the impact of MS. MRI scans of people who have fatigue show they use larger areas of the brain to carry out activities than people without fatigue.
Perhaps the brain is finding new routes for messages when the usual nerve paths have been affected. Finding new routes might mean it takes more energy to carry out an action, and this might cause fatigue.
But there are other processes in the brain and spinal cord that might also have an effect. We dont yet know for sure if there is an exact link between nerve damage and fatigue.
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Conflict Of Interest Statement
MAC, SSA, NR, RA and JPL declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. AC gave expert testimony for CSL Behring, Novartis, received grants from Biogen, Novartis, CSL Behring, GE Neuro, Octapharma, and gave lectures for Genzyme.
What Is Ms Fatigue
MS fatigue is very different from the feeling of being tired or exhausted that people without MS may experience following heavy exercise or a busy day at work. It involves a sudden loss of energy and not being able to continue an activity. Fatigue can be either physical or mental fatigue or both at the same time.
Fatigue feels as if I am an inflatable, and someone has pulled the airstopper out! My brain goes fuzzy, I cant think clearly, my speech slurs and my eyesight goes. Swallowing becomes more difficult, my balance gets worse and my legs feel heavy and clumsy.
Unlike the limits of normal, everyday tiredness, which may give a little when pushed against, MS fatigue can feel like a barrier. It can be difficult to recognise what your limits are until youve overstepped them.
Whilst recovery from everyday tiredness is relatively swift, you may find that it takes much longer to build your energy levels back up again after an episode of fatigue.
Fatigue feels like being weighed down, as if youre trying to walk up to your neck in a deep, muddy river in heavy, wet clothes carrying shopping bags full of rocks.
As an ‘invisible’ symptom of MS, fatigue is sometimes not properly understood by family, friends or colleagues. Until it is experienced, it is hard to understand the impact of fatigue and how debilitating it can be. Fatigue is a major cause of stopping working or reducing working hours.
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How To Treat It
If youre experiencing fatigue, make an appointment with your doctor to discuss possible treatment options. A doctor will likely want to run some tests to find out more about what may be causing your fatigue.
Based on the results of these tests, your doctor may prescribe medications or recommend counseling, physical therapy, and occupational therapy.
Not Drinking Enough Water
It’s common for people with MS to cut back on water, especially if they experience problems with urinary urgency or nocturia. Some people with MS also reduce fluid intake when they are going out or traveling, as getting to a restroom may be difficult. It’s important to drink plenty of water throughout the day if you have MS. Avoid caffeine and alcohol, which act as diuretics and can dehydrate you more.
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Lifestyle Changes To Cope With Ms Fatigue
If you’re suffering from MS-related fatigue, it’s important to see your doctor first to pinpoint the causes of your fatigue. Fatigue is often related to MS symptoms and medical conditions that need treatment. However, there are also a few simple lifestyle changes that can help you cope with fatigue.
Embrace the nap. Used appropriately, napping can help give you a real energy boost. The ideal nap lasts 10-30 minutes. It should be a time for quiet rest. Even if you don’t fall asleep, the rest will still help recharge you. You can nap up to three times a day. Talk to your doctor or occupational therapist about the best nap schedules for you napping shouldn’t get in the way of a good night’s sleep.
Keep cool. Hot temperatures can make fatigue worse. Talk to your doctor or occupational therapist about ways to beat the heat. Having a cool drink, staying in the shade, taking breaks when you get overheated, and using air conditioning can all help you stay cool and refreshed.
Exercise. Does the thought of exercise make you feel exhausted? Believe it or not, exercise can actually help you feel less tired and give you more energy. Check with your physiotherapist to find the exercise that’s right for you, and inform your doctor before starting any new exercise program.
Prioritize. We only have so much energy. Don’t waste time and energy on things that aren’t really important to you. Focus on the things that matter, and schedule them for times when you have the most energy.
What Causes Fatigue In Patients With Multiple Sclerosis
The exact cause of MS-related fatigue is still unknown. There are several theories on the subject:
- One theory is that fatigue is related to the general activation of the immune system. Chemical messengers are called cytokines these levels are higher in patients with MS and may be higher still in patients with fatigue. One way of describing this is that you may feel like you have a virus all of the time.
- Another theory is that people with MS may have to use more parts of their brain to do the same task as someone without MS in essence, they are working harder.
- Another theory is that fatigue is related to reduced electrical transmission of signals in the brain.
Whatever the theory, we know that fatigue from MS is a very real part of the disease.
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Pathophysiological Concepts Of Fatigue
This article focuses on four main classes of potential pathophysiological mechanisms of fatigue in MS :
Pathophysiological mechanisms of fatigue discussed in this article. White and grey boxes represent classes of mechanisms and specific mechanisms, respectively directed arrows and circle-ended arrows represent direct and mediating effects, respectively. Due to space limitations, only one mechanism per arrow is shown see main text for other mechanisms. CNS, central nervous system DA, dopamine GM, grey matter NAWM, normally appearing white matter WM, white matter.
Structural damage of white matter and grey matter ,
Inflammatory processes ,
Maladaptive network recruitment due to distributed lesions or inflammation,
Metacognition of interoception of dyshomeostatic states.
Tips To Conserve Energy
Use Adaptive Aids.Reachers, dressing aids, and other adaptive equipment can significantly help conserve energy when dressing, bathing, and performing other household and personal activities. Many of these items may be obtained through MSAAs Equipment Distribution Program . Please visit mymsaa.org or call 532-7667 for more information.
Shop from Home.Rather than using valuable energy walking around stores, use catalogs or order items online. In addition to avoiding the crowds and exhaustion from walking through stores or malls, ordering clothes allows you to try them on at your leisure when your energy level is highest. Many grocery stores also offer online ordering with either free delivery or a minimal charge for delivery.
Take Fewer Steps.Try to take care of as many things as possible in one room to eliminate extra trips.
Consider Telecommuting.A great way to conserve energy is to reduce the amount of time spent traveling to and from work. Ask your employer about working part of the week from home.
Dont Get Overheated.This can cause fatigue. Wear your cooling vest or other cooling apparel and try to go outside either early in the morning or later in the evening, when temperatures are at their coolest.
Antidepressants
Selective Serotonin Reuptake Inhibitors including Zoloft® , Paxil® , and Prozac®
Wellbutrin® is a NDRI antidepressant , and is one of the most energizing and most effective of the non-SSRI antidepressants against fatigue.
Stimulants
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Specific Interests Of Tdcs In The Management Of Ms
tDCS and Brain Functional Connectivity
The modulatory effects of tDCS in terms of the rs-FC of various networks have been supported by numerous fMRI and MRS studies. For instance, anodal tDCS over the left DLPFC increased its connectivity with the right hemisphere and modified the rs-FC in the fronto-parietal networks . In addition, the tDCS effects on brain networks connectivity were demonstrated following motor cortex, left and right inferior frontal gyri stimulation. Anodal stimulation of the former would lead to FC changes some of which occur within the cortico-striatal and thalamo-cortical circuits . Furthermore, acting on the left or right IFG had an important impact on the rs-FC of the language network .
Therefore, based on these data, tDCS might be beneficial in modulating MS-fatigue networks and restoring brain FC through several potential mechanisms.
tDCS, Conduction Failure, and Axonal Degeneration
Beyond demyelination, MS can lead to axonal degeneration, associated with irreversible deficits. Notably, two recent animal studies have documented a positive effect of tDCS on the activation and migration of neural stem cells . Therefore, tDCS could be helpful in promoting the regeneration processes and ameliorating various MS symptoms in the course of the disease.
tDCS and Inflammation-induced Synaptopathy
Heterogeneous Concepts Of Fatigue
Concepts of fatigue vary remarkably in the literature. For example, fatigue has been described as a feeling arising from difficulty in initiation of or sustaining voluntary effort, an overwhelming sense of tiredness that is out of proportion or as a feeling that relates to the lack of motivation to deploy resources and engage in high effort performance to cope with their situation.
In an attempt towards standardisation, a recent taxonomy distinguishes two major dimensions of fatigue: perception of fatigue and performance fatigability. The latter refers to objectively measurable aspects of fatigue, for example, the observable decrease in performance during a cognitive or motor task. By contrast, the perceptual dimension is inherently subjective and cannot be assessed directly by an external observer. From a pathomechanistic perspective, these two dimensions are distinct: explanations of fatigability can, in principle, be derived from physiological and biochemical principles. By contrast, understanding the subjective perception of fatigue requires a cognitive perspective, in particular, concepts of interoception and metacognition.
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Overwhelming Disruptive And Difficult To Explain Fatigue Is The Most Common Ms Symptom
Everyone knows what it feels like to be tired. But MS fatigue is different from regular fatigue.
- It can come on suddenly, even after a good night’s sleep.
- It generally worsens over the course of the day.
- It tends to increase with heat and humidity.
Your MS fatigue is likely to feel different from anything you’ve felt before.
It may feel totally overwhelming at times, yet it remains invisible to other people. It can be one of the hardest symptoms for family, friends, and colleagues to understand.
You might find that fatigue interferes with every aspect of your life. To combat fatigue and take back control, get to know this symptom, factors that can worsen it, and ways to manage your energy.