How is fatigue managed in people with multiple sclerosis (MS)?

Managing Fatigue in Multiple Sclerosis

People with MS experiencing fatigue should begin with supervised, tailored aerobic/endurance exercise programs as the foundation of treatment, combined with structured psychoeducational interventions that address thoughts, feelings, and behaviors related to fatigue. 1

Core Treatment Framework

Physical Activity as First-Line Intervention

Aerobic and endurance exercise forms the cornerstone of MS fatigue management, demonstrating the strongest evidence for reducing fatigue severity, improving aerobic capacity, and decreasing depressive symptoms. 1, 2 This approach consistently outperforms pharmacological interventions in clinical trials. 3

Implementation specifics:

• Start with supervised programs that account for current conditioning level, disease severity, and personal preferences 1
• Gradually introduce activity based on current sedentary behaviors, disease activity, comorbidities, and disability level 1
• Include strengthening exercises, aerobic exercise, yoga, or tai chi, all showing significant improvements in physical functioning, quality of life, pain, fatigue, and sleep quality 1
• Transition to long-term unsupervised physical activity as a lifestyle change, which provides sustained benefits beyond structured programs 1

The evidence strongly favors rehabilitation interventions over medication, with exercise showing more significant effects on reducing both the impact and severity of patient-reported fatigue. 3 Recent comprehensive reviews confirm that endurance training programs consistently improve physical and motor fatigue in MS. 2

Psychoeducational Interventions

Patients must access structured, time-limited psychoeducational programs that go beyond simple information provision. 1 These interventions should explore thoughts, feelings, and behaviors related to fatigue. 1

Specific approaches include:

• Cognitive behavioral therapy (CBT), demonstrating moderate improvements in fatigue, distress, cognitive symptoms, and mental health functioning 1, 4
• Group therapy sessions 1
• Psychoeducational self-management programs 1, 5

Critical implementation point: Periodic reassessment and repeated access to these interventions is necessary because fatigue factors change over time and benefits from single interventions may not be maintained. 1 Self-management interventions incorporating educational materials with trained facilitators appear optimal for reducing cognitive fatigue effects. 5

Activity Management Strategies

Implement structured activity pacing and energy conservation strategies to prevent "boom and bust" patterns where patients overexert during good days and crash afterward. 1 Assessment must specifically evaluate for these destructive activity patterns. 1 Structured pacing helps distribute energy expenditure throughout the day and week. 1

Addressing Contributing Factors

Work systematically through modifiable contributors to fatigue:

• Pain management 1
• Sleep quality optimization 1, 2
• Mood disturbances (anxiety, depression) 1
• Physical activity levels 1
• Respiratory insufficiency screening 1
• Nutritional deficits 1

Each of these factors can independently perpetuate fatigue and must be addressed as part of comprehensive management. 1

Clinical Assessment Requirements

Healthcare teams must proactively assess fatigue at every visit rather than waiting for patients to raise concerns. 1 This assessment should include:

• Fatigue severity using validated screening tools 1
• Impact on daily activities, work, and social participation 1
• Current coping strategies 1
• Presence of "boom and bust" activity patterns 1

Regular monitoring should be incorporated into routine clinical care with shared decision-making about intervention options. 6

Pharmacological Considerations

Pharmacological interventions show limited effectiveness for MS-related fatigue. 3, 4 Current evidence demonstrates:

• Amantadine is the only medication currently recommended, though with modest effects 7, 4
• Modafinil, methylphenidate, and ondansetron show little to no effect on fatigue 4
• Pharmacological agents often fail to enable people with MS to cope with existing disabilities 3

The evidence clearly indicates that rehabilitation interventions have stronger and more significant effects than medication for MS fatigue management. 3

Critical Pitfalls to Avoid

The most dangerous error is accepting fatigue as an inevitable symptom without seeking active intervention. 1 Many clinicians acknowledge fatigue's importance but fail to routinely offer advice, interventions, or support. 8

Additional common errors:

• Assuming fatigue correlates with visible muscle weakness or disease stage—fatigue occurs even when motor performance appears normal 8
• Providing generic advice rather than structured, supervised interventions 8
• Offering only pharmacological approaches when non-pharmacological interventions demonstrate superior efficacy 3
• Failing to recognize that approximately 50% of patients with neuromuscular conditions experience severe fatigue regardless of disease activity state 8

Multidisciplinary Approach

Engage a multidisciplinary team including neurologists, MS nurses, occupational therapists, and physiotherapists for comprehensive fatigue management. 7 Healthcare professionals should facilitate shared decision-making about intervention options and ensure access to physical activity and psychoeducational programs. 1 This comprehensive, interdisciplinary approach is required because fatigue affects various components of health and wellbeing. 4