World MS Day: Improving Fatigue in Multiple Sclerosis

Tiffany Braley, MD, MS

Fatigue is one of the most common symptoms of multiple sclerosis (MS), occurring in nearly 80% of patients, with lasting impacts on an individual’s ability to function at home and work. Despite its high prevalence and significant impact, fatigue is poorly understood and often under-emphasized because of its complexity and subjective nature. While therapeutics to treat the relapses of MS have significantly improved over the years, none of these therapies reverse preexisting tissue damage or control chronic symptoms, such as fatigue, that are all common subtypes of MS.

Each year, on May 30th, the global community comes together to raise awareness for World MS Day, a day dedicated to the disease, which impacts nearly 2.5 million people worldwide. To continue to further conversations around improving care for the disease, NeurologyLive® sat down with MS expert Tiffany Braley, MD, MS, who talked specifically about the ongoing issue of fatigue.

Braley, an associate professor of neurology at the University of Michigan and director of the Multiple Sclerosis and Clinical Neuroimmunology Division, provided perspective on why fatigue remains a significant concern for clinicians and patients alike. Additionally, she spoke about the ways the clinical community is trying to combat this issue, both pharmacologically and nonpharmacologically, as well as the research being conducted in the field.

NeurologyLive®: What are some of the lasting impacts that fatigue can have on patients with MS?

Tiffany Braley, MD, MS: Fatigue can have both immediate and long-term consequences for patients with multiple sclerosis. Certainly, pathological fatigue, which is experienced by the overwhelming majority of people with multiple sclerosis, up to 90%. At some point in their disease course, this can interfere with both mental and physical tasks, as well as someone's social activities. In the long run, the inability to engage in these daily activities or events can have lasting impacts on employment, as well as social or family life. We know that fatigue is one of the main reasons that people with MS will reduce the number of work hours or even leave the workforce. It’s also a common reason for reduced social participation.

What do we know about the current underlying reasons for why there’s this increased fatigue?

MS fatigue isn't always or usually isn't traceable to a solitary cause. That's really important to remember. One of the reasons that MS fatigue is such a challenging symptom to address is because it has many potential causes or contributors that can vary from person to person. We're still trying to fully understand each of these causes and contributors on a more fundamental level. That said, we view fatigue as a multifactorial symptom that in part arises from the underlying biology, potentially, specific nervous system damage or inflammatory changes caused by the MS itself may be the underlying substrate for the fatigue. But ultimately, the substrate for this fatigue can be exacerbated or perpetuated by other common conditions or even behaviors that can vary depending on the person. For example, for someone with multiple sclerosis, they may have some areas of the brain that are affected by the multiple sclerosis that cause fatigue, but they may also have other conditions that are common in multiple sclerosis, such as sleep disorders, pain, or depression, that ultimately can further feed into the fatigue. Additionally, certain behaviors that people engage in to try to combat the fatigue in some cases can make the symptoms worse. Taken together, it's important to keep each of these potential causes in mind when considering specific treatment modalities.

Which areas of research need more attention?

Getting back to diet and exercise, these areas that are getting a lot more attention in the research realm, and It's very exciting. Those are both important areas that really need further exploration. Also, there are some newer modalities that are being studied, including noninvasive brain stimulation. That's something to watch in the future, but I think it's also important to point out that the story may not be entirely written for the existing strategies that are already at hand and already available.

Additional research is being done to see how we can potentially optimize the existing strategies that we already have at hand which are being used in clinical practice. This includes new methods of exploring or combining these existing treatments, using more patient centered measures, especially new fatigue measures, and also the consideration of other factors that can influence the response to these treatments that haven't been explored before. In clinical research, at least not to a significant degree, one thing that we've learned from studying various fatigue treatments for decades, is that there is no single treatment that is uniformly effective for treating multiple sclerosis fatigue.

At least a portion of people, regardless of which treatment you're talking about, will respond to some extent to these existing treatments. We also know that in certain conditions, it's not always a single treatment. We get more benefit from combining different treatment modalities, and I don't think that that's been explored enough in MS fatigue research. Some of the new research that our group has been focusing on over the last few years involves determining specific traits that people may have that predict how they might respond to one treatment or another. Is it possible that if we combine different modalities, pharmacological and non-pharmacological modalities, can we potentially get greater benefit for certain patients?

Transcript edited for clarity.