delays in impulse transmission,
says George Kraft, MD, MS,
Alvord Professor of Research at
the University of Washington
Medical Center in Seattle.
Walking becomes more difficult,
speech slurs, the mind clouds
and an overtaxed nervous system
burns through fuel like a ragged
motor. Fatigue is like a fuel gauge
telling you the tank is empty.
Secondary energy-sappers
include not enough sleep
or quality sleep, depression,
medication, stress, pain, being
out of shape, and the sheer
increase in energy used to get
around and get things done.
Though the causes of fatigue
are understood, it’s not clear
why different people experience
fatigue so differently. Luca
Roccatagliata, MD, PhD, and
his neuroscience colleagues at the
University of Genoa speculate
that anatomical changes to
the brain exist in a complex
biological network that’s different
in every person. Thus, even a tiny
bit of damage in the frontal lobes
can cause it to interact badly with
a healthy deeper region of the
brain, enhancing the nature and
perception of fatigue in some
unique way.
Higher levels of inflammation-related chemicals called
cytokines, which are found in
everything from post-flu fatigue
to other autoimmune disorders
such as lupus and rheumatoid
arthritis, may also play a role.
Researchers hope that
understanding these complex
interactions and understanding
individual predispositions
to fatigue will lead to more
individualized therapies. Until
then, doctors must rely on what
patients tell them with the aid
of standardized questionnaires.
Because fatigue involves different
things for different people, says
Dr. Kraft, he and his colleagues at
the MS Rehabilitation Research
and Training Center at UW
are developing computerized
personal profiling tools that
people can fill out quickly in the
doctor’s waiting room to make
visits more productive.
Treating the ‘vicious triad’
Personalized treatment plans
could better address what Dr.
Kraft calls the “vicious triad”
of physical fatigue, cognitive
impairment and depressed
mood. The best plans combine
medication, when it works, and
careful attention to contributing
factors and lifestyle.
Doctors may try medications
such as the antiviral amantadine
and, more controversially, the
stimulant modafinil (Provigil).
Other stimulants and SSRI
antidepressants have not been
studied in this context, and it’s
not clear that nerve-conduction
agents reduce fatigue.
“When you find a benefit
from medicine, it is cause for
celebration,” says Dr. Krupp,
“because more often than not,
nothing works.”
Lemelle is one of the lucky
ones. “Medication has changed
the ball game for me,” she says.
“I can do things. I can go places.
It’s been the single best thing I
could have done.”
Researchers are testing other
medications, even placebos.
Though some people take
vitamins and other supplements,
doctors sometimes have
concerns about their safety,
cost, effectiveness and potential
for interaction with other
medicines.
Considering the whole picture
Even when medication helps, it’s
important to proactively manage
the fatigue, says occupational
therapist Nancy Lowenstein,
MS, OTR, of Boston University’s
Sargent College of Health and
Rehabilitation. To help people
address it realistically, she looks at
lifestyle factors: Does this person
have young children? Is she
working full time? What part of
her fatigue is ordinary, and what
part is MS?
That kind of approach is
important, according to Dr.
Kraft, who says his patients
don’t often come right out and
say, “I have fatigue.” He thinks
doctors should ask people more
questions to learn how fatigue
may be affecting their lives.
Lowenstein recommends that
people with MS follow a four-point plan to conserve energy.
As Dr. Krupp puts it, “If you
can tailor your output to your
fuel source, you won’t exhaust
yourself.” Lowenstein’s plan
calls for:
