Physical therapist, UC Health; Cochair, International Organization of MS Rehabilitation Therapists (IOMSRT)

Patricia Bobryk, MHS, MSCS, PT, ATP

 one of the most common symptoms and reportedly affects up to 80% of individuals living with this diagnosis.

 It is one of the most debilitating symptoms, affecting not only day-to-day functioning but quality of life. Although the decision to leave the workforce is multifactorial, fatigue and pain are among the drivers for persons with MS (PwMS) to consider an early departure from their employment.

 Fatigue in MS may be defined as “a subjective lack of physical and/or mental energy that is perceived by the individual or caregiver to interfere with usual or desired activities,” 3 but MS fatigue is pervasive and can even occur at rest.

The pathophysiological mechanisms underlying MS fatigue are not well understood. Proposed pathological processes include neuronal factors such as dysfunction of premotor, limbic, basal ganglia, or hypothalamic areas; disruption of the brain, hormone, and gland interactions, leading to low arousal; alteration in serotonergic pathways; changes in neurotransmitter levels; and altered central nervous system functioning caused by a disruption of the immune response.

 Fatigue can originate from primary or secondary causes. Sleep quality, pain, depression, spasticity, medication adverse effects, physical conditioning, and temperature sensitivity, as well as comorbidities, must be considered and treated for the comprehensive management of this complex symptom. Even with careful medical management, treatment strategies remain focused on the nonpharmacological approaches.

A team approach to fatigue management is essential. Engaging rehabilitation professionals with experience in MS soon after the diagnosis is key for providing interventions to manage symptoms, maintain and improve function, and to educate and support participation in lifestyle modifications. Collaboration between primary care physicians, neurologists, nurses, physical therapists, occupational therapists, mental health professionals, and others optimizes care for the best outcomes.

Physical therapy interventions focusing on the impact of exercise on fatigue will be highlighted in this review. It is key to remember these strategies are always best employed in the environment of the comprehensive team approach. A thorough physical therapy evaluation should be completed to determine potential sources of fatigue, but it is only a piece of the total fatigue profile. It is imperative to perform a high-quality assessment because the rehabilitation interventions can only be as good as the information on which they are based. The physical therapy evaluation may include the Timed 25-Foot Walk test; Manual Muscle Test; 6-Minute or 2-Minute Walk tests; assessments of spasticity, gait, mobility and functional skills, posture, and motor control; and a measurement of cardiovascular fitness. Self-reported measurements of fatigue are helpful, and include the Modified Fatigue Impact Scale, Fatigue Severity Scale, and the Visual Analog Scale (

). Other tools that may contribute to the fatigue evaluation are the Epworth Sleepiness Scale, Patient Health Questionnaire-9, and activity diaries.

Does Physical Activity Decrease Fatigue in MS?

Despite common knowledge that physical activity is beneficial in decreasing deconditioning and thereby has a positive impact on fatigue, there are lower levels of activity participation in PwMS.

 A portion of MS fatigue may be because of these deconditioning effects. A systematic review published in 2020 reported that physical exercise significantly reduces fatigue in PwMS.

 Recorded benefits of regular exercise included increased cardiorespiratory fitness, increased muscle strength and endurance, reduced body fatigue, improved mood, and increased ability to perform daily tasks. Early therapy intervention with ongoing follow-up may have the greatest and longest-lasting influence on fatigue.

Types of Exercise With Greatest Impact on Fatigue Reduction

A network meta-analysis comparing different types of exercise and their effect on MS fatigue also validated that exercise was an effective way to decrease this symptom.

 The analysis reviewed 58 studies looking at physical fatigue and total fatigue in MS. Exercises were categorized as follows:

Mind-body exercises (such as yoga or Pilates)

Among the different exercise modalities, combined exercise(combining 2 or more physical activities within a session) was noted to be the most effective method for improving both physical and total fatigue. Resistance training was also found to be an effective tool for lowering total fatigue among PwMS.

The National Multiple Sclerosis Society (NMSS) convened a panel of clinical and research experts to reach a consensus on optimal exercise and lifestyle physical activities for PwMS across the disability spectrum.

 The NMSS made the following recommendations:

Early evaluation by a physical or occupational therapist or exercise or sport scientist, experienced in MS, is recommended to establish an individualized exercise and/or lifestyle physical activity plan.

Considering comorbidities and symptom fluctuations, health care providers should encourage at least 150 min/wk of exercise and/or at least 150 min/wk of lifestyle physical activity.

Progress toward these targets should be gradual, based on the person’s abilities, preferences, and safety.

If disability increases and exercise or physical activity become more challenging, referrals to specialists are essential to ensure safe and appropriate prescriptions.

When physical mobility is very limited, exercise should be facilitated by a trained assistant.

Applying Exercise Interventions for Best Fatigue Management Results

Thermosensivity is often a trigger for MS-related fatigue. Increased core temperature that is generated from exercise or exposure to a warm environment can exacerbate fatigue. Utilizing cooling strategies either by precooling (ie, cool shower) or employing cooling devices or strategies (ie, cooling vest, scarves, drinking cold water, or lower room temperature) was shown to have a beneficial effect on fatigue, physical activity, and the quality of life of PwMS.

Different strategies for exercise application have been considered to optimize outcomes. Utilizing an intermittent training strategy, which employs periodic breaks during the activity, has been shown to allow for greater workloads of walking to be performed with less fatigue in PwMS.

 High-intensity interval training is another method of exercise that has proven safe and effective in MS and may decrease the deleterious effects of increased core temperature.

Despite our knowledge of the benefits of exercise in MS, exercise intensity and duration have often been underprescribed. Old, now-refuted fears of exercise causing a relapse or disease progression may prevent PwMS from working at a level that would provide the greatest impact. Exercise safety has been well established through several studies and does not pose a threat of increased relapse rates.

Fatigue management in physical therapy should not happen in isolation. A comprehensive, collaborative, and multidimensional team approach including pharmacological and nonpharmacological interventions is required for best outcomes. Early education and recommendations for lifestyle modifications with careful ongoing evaluations are the cornerstone for positively impacting the effects of fatigue in MS.

REFERENCES
1. Minden SL, Frankel D, Hadden L, Perloffp J, Srinath KP, Hoaglin DC. The Sonya Slifka Longitudinal Multiple Sclerosis Study: methods and sample characteristics. 

. 2006;12(1):24-38. doi:10.1191/135248506ms1262oa
2. Strober LB, Callanan RM. Unemployment in multiple sclerosis across the ages: how factors of unemployment differ among the decades of life. 

. 2021;26(9):1353-1363. doi:10.1177/1359105319876340
3. Lapierre Y, Hum S. Treating fatigue. 

. 2007;14(2):64-71.
4. Krupp LB. Fatigue in multiple sclerosis: definition, pathophysiology and treatment. 

. 2003;17(4):225-234. doi:10.2165/00023210-200317040-00002
5. Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. 

. 2005;11(4):459-463. doi:10.1191/1352458505ms1188oa
6. Razazian N, Kazeminia M, Moayedi H, et al. The impact of physical exercise on the fatigue symptoms in patients with multiple sclerosis: a systematic review and meta-analysis. 

. 2020;20(1):93. doi:10.1186/s12883-020-01654-y
7. Torres-Costoso A, Martínez-Vizcaíno V, Reina-Gutiérrez S, et al. Effect of exercise on fatigue in multiple sclerosis: a network meta-analysis comparing different types of exercise. 

. 2022;103(5):970-987.e18. doi:10.1016/j.apmr.2021.08.008
8. Kalb R, Brown TR, Coote S, et al. Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. 

. 2020;26(12):1459-1469. doi:10.1177/1352458520915629
9. Bilgin A, Kesik G, Ozdemir L. The effects of cooling therapies on fatigue,
physical activity, and quality of life in multiple sclerosis: a meta-analysis. 

. Published online August 31, 2022. doi:10.1097/RNJ.0000000000000388
10. Karpatkin H, Cohen ET, Rzetelny A, et al. Effects of intermittent versus continuous walking on distance walked and fatigue in persons with multiple sclerosis: a randomized crossover trial. 

. 2015;39(3):172-178. doi:10.1097/NPT.0000000000000091
11. Hubbard EA, Motl RW, Fernhall BO. Acute high-intensity interval exercise in multiple sclerosis with mobility disability. 

. 2019;51(5):858-867. doi:10.1249/MSS.0000000000001866
12. Pilutti LA, Platta ME, Motl RW, Latimer-Cheung AE. The safety of exercise training in multiple sclerosis: a systematic review. 

. 2014;343(1-2):3-7. doi:10.1016/j.jns.2014.05.016

Articles

Fatigue, although not immediately visible, is among the most debilitating symptoms of multiple sclerosis, affecting not only patients' day-to-day functioning but their quality of life.

Physical Therapy Approach for Fatigue Management in Multiple Sclerosis

“It can be very overwhelming, particularly for the newly diagnosed, with all of this information coming in. If you can convey to the patient that you have this team of people, particularly the core team of people…that is going to provide care, be your advocate, and provide the resources and education for you—there is great comfort in that.”

As has been the trend across medicine in recent years, many practices have begun to implement a more comprehensive approach to patient care. For those with multiple sclerosis (MS), this model of care allows for a more holistic treatment regimen that is able to address the needs of the patient with regard to treatment and disease management.

One common member of this care team model is a physical therapist or rehabilitation specialist, such as Patricia Bobryk, MHS, PT, MSCS, ATP. A physical therapist at UC Health and the cochair of the 

International Organization of MS Rehabilitation Therapists (IOMSRT)

, Bobryk explained that incorporating this approach to MS care provides a more all-encompassing model that can address not only clinical disease progression, but symptomatic issues and other “invisible” consequences of the disease. This approach, she noted, particularly blends with the increased voice of the patient in the shared decision-making process.

, Bobyrk offered her expertise in the care of this patient population, expressing the importance of consistent messaging for patient education among the individual team members as well as the need for the incorporation of key members early in the disease process.

Videos

The physical therapist at UC Health and cochair of the International Organization of MS Rehabilitation Therapists discussed the importance of the care team for patients with MS and the role effective communication plays. [WATCH TIME: 4 minutes]

Effective Comprehensive Care Team Communication in MS: Patricia Bobryk, MHS, PT, MSCS, ATP

“If a patient walks away knowing that maybe they don’t have the solution yet for [a given] issue, but it’s being addressed and they’re going to see the appropriate professional that’s going to help them with it, they’re going to walk away fulfilled and [feeling that] their needs have been met.”

For patients with multiple sclerosis (MS), there are several symptoms and consequences of the disease that allow them to benefit from engaging in rehabilitation strategies. Because of this, those patients who have access to larger care teams are often seen by a physical or occupational therapist who specializes in the management of MS.

Patricia Bobryk, MHS, PT, MSCS, ATP, offers this type of care, and spoke with 

 in an interview about the benefits it can provide. Specifically, Bobryk, who is a physical therapist at UC Health, and the cochair of the International Organization of MS Rehabilitation Therapists (IOMSRT), explained that this type of care is particularly helpful in addressing the patient-focused needs around issues with mobility and speech, for example. She added that the need to provide patients with MS the care that they feel they require is critical to their long-term outcomes.

Bobryk also shared her insight into how this focus on patient-centered care and shared decision-making melds nicely into the ongoing shift to the use of comprehensive multidisciplinary care teams to manage disease. Interplay between the physical therapist, speech pathologist, MS specialist, and other members of the team is critical to ensuring that patients’ needs are met—something that can only be achieved by proper referral and communication.

With the field of multiple sclerosis care focusing on the importance of patient-reported outcomes and shared decision-making, the physical therapist at UC Health and cochair of the International Organization of MS Rehabilitation Therapists offered commentary.

The Critical Nature of Patient-Focused MS Care: Patricia Bobryk, MHS, PT, MSCS, ATP

“Unfortunately, if patients get a referral for therapy and they’re not directed to specialized care, they might just say, ‘Oh, the corner therapist is more convenient to me.’ And maybe they’re getting good care there, but maybe it’s an ortho-based philosophy of care, which is not the most effective or efficient or the standard of practice for MS care.”

For patients with multiple sclerosis (MS), like many neurologic and neurodegenerative diseases, the need for physical therapy and rehabilitative medicine as a part of the care paradigm is imperative to ensure good outcomes. Although many patients seek care at larger institutions with multidisciplinary care teams, there remains a gap in access to good rehabilitative professionals for a number of the 2 million individuals in the US with MS.

Patricia Bobryk, MHS, PT, MSCS, ATP, explained to 

 that the reasons for this stem from a number of places, including the supply-and-demand issue related to the number of available physical therapists with specialized training. Patients with MS often require a specific approach that not all rehabilitative professionals can provide without proper education. This can lead to individuals utilizing benefits to see providers who may not be able to offer them the precise type of care they require.

To find out more about these challenges and the efforts that are ongoing to address them, Bobyrk, who is a physical therapist at UC Health and the cochair of the 

, shared her insight from more than 20 years of experience in the field. She also spoke to the underutilized tools and underrecognized needs that must be used and met for these patients—the care for much of which may only be available from specialized clinicians.­

Amid an ongoing national shortage of clinicians who treat neurologic diseases like MS, the cochair of the International Organization of MS Rehabilitation Therapists discussed the availability of rehabilitation professionals for patients.

The Availability of MS Rehabilitation Therapists: Patricia Bobryk, MHS, PT, MSCS, ATP

“Establishing those relationships [with patients] are really key early on [in care]. We can do baseline testing and we can get to really know a person, early on, so we know where their level of function is, we can understand what their goals are and what’s important to them. If we establish that early on, we can help promote that health and wellness and quality of life throughout the continuum of MS.”

 would likely benefit from engaging in rehabilitation strategies to aid in the management of symptoms and disease-related challenges, many patients do not reap these benefits early enough in the disease process.

 Additionally, there remains a longstanding need for more inquiry into the optimal implementation of the many varied modalities through which rehabilitative treatment can be applied.

Not unlike the conversations around the benefits of early initiation of disease-modifying therapy, many physical therapists and rehabilitation specialists have called for the earlier introduction of treatment. One such specialist is Patricia Bobryk, MHS, PT, MSCS, ATP, physical therapist, UC Health, and cochair, 

, who explained that early introduction of these approaches to patients can reap benefits for them in several ways—particularly in establishing an accurate baseline and long-term goals.

, Bobyrk explained the current state of rehabilitative care for patients with MS and the importance of initiating that care process early on, as well as how it fits into the comprehensive care model. She provided insight into the drivers of referrals to specialists like herself and how she’s gone about promoting the need for rehab for these patients.

REFERENCES
1. Rohrig M. Physical Therapy in Multiple Sclerosis. National Multiple Sclerosis Society. Published 2018. Accessed September 9, 2021. https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clinical_Bulletin_Physical-Therapy-in-MS-Rehabilitation.pdf
2. Motl RW, Sandroff BM, Kwakkel G, et al. Exercise in patients with multiple sclerosis. 

. 2017;16(10):848-856. doi:10.1016/S1474-4422(17)30281-8.
3. Paltamaa J, Sjögren T, Peurala SH, Heinonen A. Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials. 

. 2012;44(10):811-23. doi:10.2340/16501977-1047
4. Etoom M, Khraiwesh Y, Lena F, et al. Effectiveness of Physiotherapy Interventions on Spasticity in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. 

. 2018;97(11):793-807. doi:10.1097/PHM.0000000000000970
5. Khan F, Amatya B. Rehabilitation in Multiple Sclerosis: A Systematic Review of Systematic Reviews. 

. 2017;98(2):353-367. doi:10.1016/j.apmr.2016.04.016

The physical therapist at UC Health and cochair of the International Organization of MS Rehabilitation Therapists spoke to the current standards of rehabilitative care among patients with multiple sclerosis.