Addressing and Assessing Fatigue in MS From a Multidisciplinary Approach

Anna Kratz, PhD

This is the first of a 2-part conversation. For part 2, click here.

The wider understanding of multiple sclerosis (MS) gained in the last 30 years of research and disease management has highlighted the importance of approaching the care of patients from several different angles. This multidisciplinary team model has slowly become the ideal route of care, and while many community neurology practices still lack the resources to provide every aspect of that model, the field as a whole has shifted in this direction.

As the comprehensive care model slowly becomes the standard of care for patients with MS, the literature has begun to unveil the benefits. Many of these patients are affected by their disease in a multitude of ways that requires attention from more than just their neurologist— for example, patients often benefit from having access to psychologists, physical therapists, nurse practitioners, and other providers.

Anna Kratz, PhD, associate professor of Physical Medicine & Rehabilitation, and a research nonclinical psychologist, University of Michigan Medicine, is one such provider. As a research focused psychologist, she often looks into the ways clinicians can address the less visible symptoms of the disease. Symptoms such as spasticity, cognitive impairment, and fatigue, among others, place a great burden on patients, and thus require parallel attention.

At the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC), October 25-28, Kratz presented alongside some colleagues on the various ways that fatigue can be addressed from a behavioral and psychosocial point of view. In a conversation with NeurologyLive, she offered an overview of that presentation and the number of ways that fatigue in MS should be assessed and addressed.

NeurologyLive: Could you offer a little background on what you presented?

Anna Kratz, PhD: I gave a talk along with my colleagues, Nora Fritz, PhD, PT, DPT, NCS, from Wayne State University, and Tiffany Braley, MD, MS, from the University of Michigan. We are an interdisciplinary group of collaborators, and we do research together, mostly around MS symptoms and functional outcomes, with cognitive functioning being our main interest. We each spoke in our session, covering the areas of behavioral or psychosocial interventions. I gave a talk on that, Dr. Fritz talked about exercise and physical activity interventions, and then Dr. Braley briefly talked about medical interventions. So, we're kind of covering all of our different disciplines. I wrapped up with a talk about how the best approaches for managing fatigue, which was the main topic of our presentation—why we really need to take a combined approach because there's really no single silver bullet for a patient. For the most part, fatigue is a really complex symptom with a lot of different contributors, and it usually requires a more complex and multifaceted treatment approach.

How important is it for you to have that multidisciplinary team that can address fatigue from several angles?

It's really important to take a multidisciplinary approach to fatigue for a couple of reasons. One is, as I mentioned earlier, that there's a lot of different causes of fatigue. If you're not utilizing 1 of the tools that addresses 1 of the underlying causes of fatigue for a person with MS, you're really missing that opportunity. What we do see, unfortunately, oftentimes, is that fatigue—I often see the word “unseen” or “invisible” used to describe this symptom—isn't as attended to like other invisible symptoms, like pain and depression. But, if we're going to stick with the topic of fatigue, a lot of times people don't even have access to different kinds of treatments, or they're not asked about fatigue much at all, or receive any treatment.

I do think it's important that people at least assess fatigue in patients with MS. First and foremost, that it is tracked over time and it's treated as seriously as mobility issues, for instance, or changes in cognition and motor abilities. Because what we know is that fatigue really impacts people's ability to fully engage in life, and to participate, and to go to work, and to be in other social roles, such as parenting, et cetera. It is on that same level of other problems in MS for a lot of patients. If we're not kind of throwing the kitchen sink at people, at least to the extent that we have in our environment, we're not doing the best for our patients.

I really believe that if we can take this kind of biopsychosocial approach, where we're addressing health behaviors—exercise, sleep—as well as the psychosocial—stress, depression—all the kind of negative cognitions that can come around fatigue, and then also applying any medical kinds of approaches that would be helpful, that's sort of an ideal approach. Then, there are a lot of complementary and alternative approaches that we didn't really cover and that need more research, quite honestly.

What are some of the things that the neurology community should be thinking about when they're meeting with patients in order to assess fatigue?

When you're talking about treating MS-related fatigue, I actually have a real sense of sympathy for a lot of clinicians because it is a really challenging condition to treat. If you're a clinician in a neurology department that maybe doesn't have a lot of multidisciplinary care, you might not have a lot of tools in your toolbox to address fatigue. So, it can be kind of kind of a scary question to ask a patient, right? “How's your fatigue?” Because maybe you've tried the things in your toolbox and they haven't worked, and you don't know what to do next other than potentially refer patients elsewhere. It's a little easier for clinicians who are in a rehab program, say, where there are physical therapists, psychologists, and the like, who are just standing in the wings ready to help and provide more wraparound care for the patients with fatigue.

I'm sympathetic to the challenges. But I expect clinicians to be brave and to start to think about what the things are that they can do besides just treat the patient themselves. I'm hoping that they'll start looking for referral sources. One of the things that I think we really need to do a better job at in MS research and clinical care is providing access to high-quality multidisciplinary care in a way that's accessible. Whether that is digitally delivered interventions that can go across the country, or something else. I'm a psychologist, so we do all no-touch therapy. We can do all of our therapies via Zoom a lot easier than other clinicians can. To what extent can we start rolling out interventions that are just really easily accessible, so that that neurologist who's like, “I don't really know what else to do for this patient, I don't have an MS specialist physical therapist, that would really know what to do with this fatigue,” has somewhere to turn.

There is an example: I designed a website called MyMSToolKit.com, and it is a self-management program based on psychology, and CBT—cognitive behavioral therapy—for fatigue. I think things like that can really embolden clinicians to ask those hard questions and not be afraid of that really big challenge of treating fatigue.

What are some of the tools that are accessible, but also reliable? Or is that another immediate area of need?

We do need more digital and eHealth-type tools for patients with MS. We just have a real scarcity of services and in the multidisciplinary spectrum of care. The kinds of services that are more easily developed then delivered via eHealth, or digital health platforms, do need to be developed. I did mention the My MS Toolkit. I gave another talk on accessible interventions, and as part of preparing for that talk, I really looked to see what is available to MS patients to help them manage symptoms. There wasn't a lot there. There are some apps that are in early development stages right now, and some that are available in other countries but not here yet. So, I think that's all on the horizon. But we definitely, first of all, need to do more development.

Then, I think that those interventions need to undergo the same kind of rigorous trial testing that we do with traditionally delivered interventions to really see if they are helpful. I think just because they're accessible, we shouldn't assume that we should be referring people to them until we have evidence that they are actually effective.

Transcript edited for clarity. For more coverage of CMSC 2021, click here.

REFERENCE
Kratz A. Combined Approaches to Fatigue in MS. Presented at: CMSC 2021; October 25-28; REHAB1.