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Physical Therapy Approach for Fatigue Management in Multiple Sclerosis

NeurologyLive, November 2022, Volume 5, Issue 6

SAP Partner | <b>IOMSRT 'International Organization of Multiple Sclerosis Rehabilitation Therapists'</b>

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.

FATIGUE IN MULTIPLE SCLEROSIS (MS) IS one of the most common symptoms and reportedly affects up to 80% of individuals living with this diagnosis.1 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.2 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.4 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 (TABLE). 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.5 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.6 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.7 The analysis reviewed 58 studies looking at physical fatigue and total fatigue in MS. Exercises were categorized as follows:

  • Aerobic
  • Resistance
  • Aerobic with resistance
  • Balance
  • Combined exercise
  • Body weight support
  • Mind-body exercises (such as yoga or Pilates)
  • Control

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.

How Much and How Often?

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.8 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.9

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.10 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.11

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.12

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.

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