Managing Fatigue in Multiple Sclerosis

When someone says they are tired, our first instinct is to offer them a way to relax and unwind. A good book, a hot cup of tea, or even an episode of their favourite series can be rejuvenating. 

However, fatigue in Multiple Sclerosis (MS) is unlike any other kind of exhaustion. It is bone-tiring exhaustion, where even your mind has turned numb (lassitude). It is one of the most debilitating and pervasive symptoms experienced by individuals with MS. 

MS-related fatigue can be extreme and overwhelming, significantly impacting a person’s quality of life. Although a result of the disease itself, other contributing factors can include poor sleep habits, inactivity, depression, and medications.

So what is it that we can do to make this kind of fatigue less onerous for the patient? Read on to know.

What is Multiple Sclerosis?

Multiple Sclerosis is an autoimmune, neurodegenerative and inflammatory condition  that attacks the central nervous system (CNS). It corrupts the immune system, making it work against the body.

MS is a demyelinating disorder of the CNS, caused by breakage in the myelin sheath (a thin layer covering the axons of the neuron). When the myelin along with the nerve fibers are attacked and destroyed, scar tissue disrupts the communication routes between the CNS and the rest of the body.

Understanding Multiple Sclerosis Fatigue

Multiple Sclerosis fatigue is not your typical tiredness. It is often described as an overwhelming and persistent sense of exhaustion that is not proportionate to the person’s level of activity. This type of fatigue is different from the tiredness one might experience after a busy day; it can occur suddenly and can be extremely debilitating. It occurs in more than 75% cases and at any stage of the disease.

Fatigue in MS can interfere with daily activities, work, and social life. It affects not only physical abilities but also cognitive function and emotional well-being. Coping with extreme fatigue is a significant challenge for individuals living with MS. This is why it must be managed.

Lassitude is the term commonly used to refer to MS-related fatigue.

Characteristics of lassitude

People with MS can experience fatigue brought on by other factors such as vitamin deficiencies. It is important to ascertain whether the fatigue is related to the disease and not any other issue, as the treatment may differ. 

Fatigue can take on different forms. Bladder dysfunction leading to multiple night awakenings can cause sleep deprivation which can lead to fatigue. Similarly, depression (brought on by an MS diagnosis, perhaps) can also cause fatigue. Patients who need to make considerable effort to perform daily tasks can also experience fatigue. 

But what is lassitude? And how is it different from the types of fatigue mentioned above?

• Lassitude occurs on a daily basis
• It may occur early in the morning, in spite of sleeping well the night before
• It tends to worsen as the day wears on
• Heat and humidity can make it worse
• It is the ‘uninvited’ symptom and can come on at any time of the day
• It is far more severe than normal fatigue
• It interferes with the quality of life and day-to-day functioning

Causes of fatigue in MS

The exact cause of fatigue in MS still remains unknown. However there are several theories that say:

1. Fatigue may be related to the general activation of the immune system. The high levels of cytokines may be a contributing factor.
2. Patients with MS may have to use more parts of their brain to perform the same task as someone without MS; fatigue may be a result of them having to work harder.
3. It is brought about by the reduction in electrical transmission of signals in the brain.

Other causes may include, restless leg syndrome (common to patients with MS), sleep apnea, alcohol or drug use, anemia, or reduced thyroid function. 

Symptoms of fatigue in MS

There are two types of fatigue caused by MS, each having its own symptoms.

The first type is a feeling of general exhaustion. It could appear like feeling groggy for not having slept well the night before (when in truth, the patient may have slept well enough). This kind of fatigue makes the patient feel more and more gloomy as the day progresses, especially in the afternoons, or just after performing an activity. The patient may find it difficult to multi-task or perform as many activities as they used to previously (before MS).

The second type is muscular fatigue. Repeated or prolonged activity may cause extreme muscle tiredness. For example, after walking for a while, the patient may find that they are dragging one leg. 

The thing to understand about fatigue is it interferes with regular activity. And when this happens, the patient may feel emotionally bogged down. This can lead to depression, which can lead to further exhaustion. It is a vicious cycle. And it needs to be managed effectively.

MS fatigue management

The first step to managing fatigue in MS is making certain lifestyle changes. These include:

• Eat well-balanced meals
• Regular exercise with a cardiovascular component
• Break your day into sessions of work and rest
• No smoking
• Limit intake of alcohol
• Avoid recreational drugs completely
• Limit work that can make your muscles tense
• Recharge batteries with an afternoon nap, a do-nothing day, etc
• Avoid over-filling your day; to-do lists are not going anywhere, but you can do with some rest
• Identify environmental triggers; avoid spending too much time in the sun (especially from mid-mornings to early evenings), hot showers, passive smoking
• Manage stress and adjust expectations (especially those you have from yourself)
• Practice relaxation techniques likes visualisation, breathing exercises, etc
• Ask for help

Fatigue management with therapy

Making lifestyle changes is one part of fatigue management. The other part includes some therapies and strategies devised by your doctor. This will typically include:

• Occupational therapy to make it easier to perform everyday routine activities at work and home
• Physical therapy to perform daily tasks without using too much energy
• Sleep regulation
• Stress management
• Heat management

Treating fatigue medically

While limiting the number of medicines is always a good idea, there are times when simply managing fatigue may not work well enough for you. At such times, your doctor may prescribe symptomatic medications like aspirin, modafinil, amantadine, etc. to help manage the exhaustion as well as replenish energy reserves. 

Disease-Modifying Therapies (DMT) indirectly help manage fatigue by reducing disease activity.

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