I am often reminded of the time I set out for
what was to be a short shopping trip. It was a struggle just pushing the
shopping cart and then having to put the groceries into my van wasn't easy either.
Trying to lift the bags out of the cart my arms were so tired and weak they
shook. I couldn't wait to get home. Driving was even hard! Even with power
steering I had a tuff time turning the wheel. Having to put my weight into the
wheel just to turn it. Finally I was home! Unfortunately for me, I couldn't
find a parking space near my house and had to park around the corner. Even
with a handicapped sign in front of my home I found someone parked there.
Apparently, they were waiting under the tree while their loved one was in the
doctors office down the street.
My legs grew weary and the load heavier as I tried to make it to my house. I had
to stop at every house along the way to sit on their steps for a few minutes
till I could feel my legs again. By the time I stumbled home, I was
completely and deathly exhausted. I actually thought I was going to
When asked about MS-specific fatigue, many sufferers anecdotally describe it as
"bone-tired" or a "wearing a suit of armor" feeling.
It differs from normal fatigue in that there is generally no easy correlation
between the amount of energy expended and the severity of the weariness.
You would expect someone who just scaled Mt. Olympus to feel extremely
exhausted. You would not expect that same level of exhaustion from someone
who merely cooked a simple dinner. Yet, the problem is not simply an
amplification of normal fatigue. There are many more nuances involved in
MS fatigue is often variable, sometimes unrelenting, and generally appears
regardless of the amount of sleep the patient gets. Some patients find
that although they regularly get a full night’s sleep, they awaken in the
morning unrefreshed. Many require a scheduled nap in the afternoon when
the fatigue is at its worst levels. For me, I have found no connection
between the total rest I get, and the way I feel at any given moment.
There have been times where I have gotten plenty of sleep the night before, but
spent the next day in a zombie-like stupor, where even the simplest task
requires a superhuman effort. On the other hand, there have been times
where I made it through an unusually busy day, yet felt no ill effects for
Not only does MS fatigue drain a patient physically, but it can also cause
mental distress. Remember the child’s game of trying to pat your head
and rub your stomach at the same time? It was hard to concentrate on both
tasks at the same time, so ultimately, you ended up not doing either chore very
well. Many people with MS can relate to that feeling of being mentally
overwhelmed. Often, the dysfunctional nervous system is working overtime,
processing the enormous sensory data that we experience daily. Because the
process is disrupted and inefficient, it may be difficult to hold a conversation
and listen to background music at the same time. Or someone may find it
impossible to drive at night because the array of lights and sounds are
disconcerting. Similarly, I was once struck dumb and unable to answer a
store clerk who simply asked me for my telephone number. Because my senses
were already overloaded from the shopping experience, my brain simply shut down
when faced with a simple question. At that moment I was just mentally worn
What Causes MS-related Fatigue?
Although scientists have no definitive answer, a couple of likely theories are
presented regarding the cause of MS fatigue.
Location, Location, Location. One theory holds that fatigue
is related to the loss of myelin--the protective coating of the nerve fiber.
The locations where the myelin loss occurs are responsible for the severity and
type of fatigue. In this scenario, it is the cerebral abnormalities
themselves that contribute to fatigue. The random placement of myelin
lesions or loss could account for the variety of ways people with MS experience
the symptoms of fatigue.
Interestingly, a 1999 study found fatigue severity did not correlate with myelin
scarring or deterioration as observed on MRI. (1) Correspondingly, a 1998
study suggested that the differences in fatigue levels could not be solely
explained by the degree of disease activity or disability. (2) There is
certainly a great need for more study in this area.
Poor Body Functioning. It has also been speculated that the general
deterioration of overall functioning as a result of having MS may simply exhaust
the body’s storehouse of energy. Muscle weakness and decreased nerve
conduction are the obvious culprits. But some researchers have noted that
altered metabolism and inadequate respiration are other energy-depleters.
Again, further investigation is needed in this area.
Above all, patients must consult with their physician or other health care
professional to determine the value of treatments available for MS fatigue.
The prescription drug, Neurontin®, which is used to control tremors and spasms,
has been reported by some users to relieve fatigue as well (although the reasons
for this are not totally understood). In addition, amantadine (Symmetrel®)
and pemoline (Cylert®) have been helpful to a small number of MS patients.
Unfortunately, others have found them to be complete failures at remitting
fatigue, and have caused unwanted side effects.
Cephalon, Inc. recently reported positive findings from a new clinical study on
the effectiveness of Provigil®.
Generally used for the treatment of narcolepsy, this medication was
statistically successful in reducing fatigue in a study of MS patients.
Because these medications are of limited effectiveness, and can be accompanied
by unwelcome side effects, many patients combat fatigue in other ways.
Patients learn how to simplify and manage their daily tasks more effectively, so
as to save energy. Physical therapy can teach some how to obtain benefits
from using assistive devices to prolong energy. In addition, avoiding
heat, taking scheduled naps, limiting overexertion, managing stress, and
monitoring the effects of medication are other steps taken to combat fatigue.
(1) Fatigue In Multiple Sclerosis: cross sectional correlation with brain MRI
findings in 71 Patients, Bakshi R; Miletich RS; Henschel K; Shaikh ZA;
Janardhan V; Wasay M; Stengel LM; Ekes R; Kinkel PR, Neurology 1999 Sep 22;
(2) Fatigue in Multiple Sclerosis: interrelations between fatigue complaints,
cerebral MRI abnormalities and neurological disability, Van der Werf
SP; Jongen PJ; Lycklama a Nijeholt GJ; Barkhof F; Hommes OR; Bleijenberg G, J
Neurol Sci 1998 Oct 8; 160(2):164-70
In the MS Pipeline: A Vaccine and a Drug That Fights Fatigue
MS is thought to occur when immune cells called T cells start attacking
nerves as if they were foreign invaders, say researchers at Baylor
University in Houston. In an attempt to target this problem, they developed
a revolutionary vaccine, comprised of normal cells that were inactivated by
subjecting them to radiation. The theory was that by injecting these
inactivated T cells back into the body, the doctors could stimulate the
healthy components of the patients' immune systems to fight the actions of
the bad cells and suppress the malfunctioning T cells.
The Texas investigators, led by Jingwu Z. Zhang, MD, vaccinated 65 MS
patients with the inactivated T cells and monitored them for 24 months. The
patients had a significant improvement in disability, and fewer relapses.
Zhang and his colleagues suggest that the vaccine may work by decreasing the
action of the abnormal T-cells and promoting the production of
anti-inflammatory proteins by the normal parts of the immune system.
In an effort to relieve the severe fatigue that afflicts many people with
MS, researchers at Ohio State University in Columbus and Kaiser-Permanente
in San Diego looked at the effects of a drug called Provigil. The drug is
now prescribed to treat narcolepsy, a condition whose chief characteristic
is uncontrollable bouts of falling asleep during the day. The doctors
suggest that Provigil may also help treat fatigue associated with other
conditions, such as chemotherapy and chronic fatigue syndrome.
More than three-quarters of MS patients suffer from fatigue, says Kottil W.
Rammohan, MD, a neurologist at Ohio State University in Columbus. "It is
something that is there with them all the time, and it can be disabling,"
The cause is unknown, but some doctors think it is related to a chemical
imbalance in the brain, possibly associated with the inflammation that is
characteristic of MS. People whose physical symptoms are most serious do not
always suffer the worst fatigue, Rammohan says. In fact, it may be the other
way around -- with the fatigue being most severe in people whose physical
problems are otherwise mild.
Currently, doctors routinely prescribe two drugs, Symmetrel and Cylert, to
treat MS-associated fatigue, but their effectiveness has not been
confirmed -- and Cylert has been shown to damage the liver. Acting on a
suggestion from a colleague, Rammohan and his co-workers decided to test
Provigil, a drug with caffeine-like effects.
The investigators studied 72 patients whose fatigue was severe but whose
physical disability was not as serious. These are "people who are up and
about and working -- or trying to work -- but they are hampered by the
fatigue," Rammohan says.
During four weeks in which the patients took Provigil at a low dose, there
was a "very highly statistically significant" change in their fatigue
levels, Rammohan says. Not only did tests at a higher dose fail to produce a
measurable improvement, but some patients complained of anxiety and
jitteriness. Headache was the most common side effect at both doses.
"I think it's an excellent study and extremely important, because fatigue is
such a disabling symptom" in people with MS, says Robin L. Brey, MD, a
neurologist at the University of Texas Health Science Center in San Antonio,
who reviewed the research for WebMD.
"This is not typical fatigue," Brey says "It is much more severe, and it can
hit a patient suddenly." For example, she says, "the patient may be fine and
then all of a sudden be too tired to walk to his or her car. We haven't had
an effective therapy to deal with that symptom. That's why [this study] is
so exciting and so promising."
State University (http://www.acs.ohio-state.edu/units/research/)
Date: Posted 1/21/2002
Therapy Found To Relieve Fatigue Of Multiple
COLUMBUS, Ohio - For the first time, researchers here have found an effective
therapy that can alleviate the fatigue often accompanying multiple sclerosis.
Many therapies have been developed to treat symptoms of multiple sclerosis,
but few have helped, to any degree, the excessive, debilitating fatigue that
accompanies other disease symptoms in some patients.
Their study appears today in the Journal of Neurology, Neurosurgery and
Dr. Kottil W. Rammohan, neurologist at The Ohio State University Medical
Center, and his colleagues wondered whether the drug modafinil might be
effective in relieving this fatigue. Modafinil is used currently in the
treatment of narcolepsy, a disease in which patients experience uncontrolled
"We were very pleased to find that a medication that was effective against
narcolepsy was able to treat the fatigue associated with multiple sclerosis."
Two doses of modafinil (200 and 400 mg) were compared against a placebo in 72
patients with multiple sclerosis ranging in age from 18 to 65. It was observed
that the 200 mg dose of the drug administered once daily showed highly
significant improvement in patients. Three separate instruments of rating
fatigue were used, and all three showed concordant response to this drug. No
previous drug has been able to show this degree of improvement in treating
multiple sclerosis-related fatigue in any previous clinical trial.
"We were very pleased to find that a medication that was effective against
narcolepsy was able to treat the fatigue associated with multiple sclerosis,"
said Rammohan, lead author of the study.
Rammohan's group also looked at the potential side effects associated with
this medication and found that they were not greater than those experienced by
patients in the study who received a placebo.
"It is always exciting to find an effective therapy that is void of serious
side effects," said Rammohan.
Fatigue is one of the most common and disabling symptoms of multiple
sclerosis. It affects 75 to 90 percent of patients with the disease. As many
as 46 to 66 percent of multiple sclerosis patients experience fatigue on a
Rammohan said that more studies are needed to better understand the dosage and
length of therapy necessary for patients, but he hopes more neurologists will
start using modafinil for the treatment of severe fatigue that often
accompanies multiple sclerosis.
Also participating in this study were researchers at Kaiser Permanente in San
Multiple sclerosis is an unpredictable, progressive disease in which scattered
patches of nerve fibers in the brain and spinal cord lose "myelin," their
protective covering. Resultant loss of neurological function can manifest with
a multitude of symptoms.
In addition to fatigue, patients experience a combination of a number of
symptoms that include visual loss, loss of motor function, sensory impairment,
imbalance, bowel and bladder dysfunction, and sometimes problems related to
cognition, memory and personality. Multiple sclerosis is a common disorder and
affects about 350,000 people in the United States, mostly women.
Note: This story has been adapted from a news release issued by Ohio State
University for journalists and other members of the public. If you wish to
quote from any part of this story, please credit Ohio State University as the
original source. You may also wish to include the following link in any