Fatigue

Fatigue is one of the most common and disabling symptoms in MS, and is experienced by a large number of patients. Patients with MS-related fatigue describe the phenomenon as an overwhelming feeling of weakness not associated with increased physical effort. Patients often report that they experience a rapidly occurring feeling of tiredness that is similar to the feeling of exhaustion that occurs with influenza. MS patients with fatigue often experience symptoms on a daily basis, sometimes up to several hours a day.

MS-related fatigue occurs in two forms: primary fatigue and secondary fatigue.

• Primary or neurological fatigue is a feeling of overwhelming lassitude or tiredness that can occur at any time of the day.
• Secondary fatigue results from disturbed sleep, depression, extra exertion due to impairments, and medication side effects.

Exposure to a warm environment has a significant impact on increasing MS-related fatigue. Fatigue can severely interfere with the person’s ability to carry out activities at home and at work. As fatigue is an invisible symptom, others can misinterpret the behavior of persons with MS, who are experiencing fatigue, as lack of effort. Non-medical approaches to fatigue management include strategies such as moderate aerobic exercise, work simplification, and use of assistive devices such as an electric scooter. While exposure to warm temperatures, heat, particularly when accompanied by high humidity, makes MS fatigue worse, exposure to a cool environment can improve symptoms. Cooling therapies, such as consuming cold drinks, air-conditioning, cooling vests and ice packs, lower body temperature and can reduce fatigue symptoms. Pharmacological strategies for fatigue management include using drugs such as amantadine, pemoline (Cylert ®), modafinil (Provigil ®), and fluoxetine (Prozac ®).

Pain is experienced by two-thirds of all persons with MS over the course of their disease. Unrelieved pain can cause feelings of anxiety, interrupt sleep, and interfere with meeting functional goals. The most common type of pain seen in MS is trigeminal neuralgia, also known as tic douloureux.

• Trigeminal neuralgia involves the second and third divisions of the trigeminal nerve, which innervates the face, cheek, and jaw. In MS, trigeminal neuralgia occurs as a result of demyelinating lesions along the trigeminal nerve pathway. Pain associated with trigeminal neuralgia is characterized by excruciatingly sharp, shock-like attacks, with periods of remission. Touching the face, or facial movements such as chewing or smiling can trigger the pain. Trigeminal neuralgia occurs in 2% of people with MS and is 400 times more common in people with MS than the general population. Carbamzepine (Tegretol ®) or phenytoin (Dilantin ®) are among the drugs that are given to reduce the pain associated with trigeminal neuralgia.
• Some patients experience unusual electrical shock-like sensations felt down the spine and legs when the head is flexed. This is referred to as L’Hermitte’s sign, a signal of loss of myelin in the cervical area of the spinal cord. Another common type of pain experienced by persons with MS is a burning type of pain that occurs most commonly in the extremities.

Mood-altering drugs such as tranquilizers and antidepressants can be used to help interrupt the interpretation of pain signals. Biofeedback, electrical stimulation, and acupuncture can also be used to manage MS-related pain. Medication regimens with standard pain medications, from aspirin to narcotic analgesics, present unique challenges. They may be ineffective, because the source of pain may not be the typical kind that occurs with injury. In addition, narcotic analgesics are always potentially addictive. Pain relief, however, is a primary patient right, and healthcare providers work with MS patients to find a safe and effective avenue.

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Trigeminal neuralgia is 400 times more common in people with MS than in those without MS.

The changes that MS produces in the central nervous system can directly affect sexuality and sexual functioning. More than 90% of men and 70% of women with MS report some change in their sexual life after the onset of the disease. Sexuality is often ignored in patients with MS. For young adults, the population most affected by this disease, sexuality and sexual functioning is an important developmental and personal issue. MS related symptoms of sexual dysfunction in women include a decreased libido, decreased orgasmic ability, and decreased genital sensation. Men with MS may experience erectile, orgasmic, and ejaculatory dysfunction.

Sexual dysfunction in MS is caused by several factors. First, some aspects of sexual dysfunction are caused by the results of neurological impairment. These effects include impaired arousal, sensory changes, reduced vaginal lubrication in women, and erectile dysfunction in men. Second, MS symptoms such as fatigue, spasticity, bowel and/or bladder incontinence, and sensory changes that interfere with sexual activity also impact sexual functioning. The side effects of medications used in MS treatment, such as antidepressants, can create other problems, such as decreased libido, erectile dysfunction, and inability to reach orgasm. Third, disability-related attitudes or feelings, feelings related to body image, concern about being unable to attract a partner, and believing that sexuality is incompatible with disability can all impact sexual functioning.

MS related sexual dysfunction can have a significant impact on self-esteem and self-confidence. As a result of MS symptoms, sexual activity can be difficult, exhausting, painful, and unsatisfying, and can have a profound negative impact on intimate relationships. For example, lack of sexual interest or arousal can be misunderstood and resented by the patient’s partner. Learning new ways to be intimate can be difficult and frightening. As a result of these problems, people with MS may be reluctant to cultivate intimate relationships or become intimate with a new partner.

Effective management of MS related sexual dysfunction focuses on managing MS symptoms to reduce their impact on sexual function, and providing education and counseling for sexual partners. For example, controlling limb spasticity and implementing an appropriate bladder and bowel elimination program to prevent accidents during sexual activity will give patients more confidence in participating in sexual activities. Evaluating the effects of medications that may have a negative impact on sexual dysfunction is an important part of management. Men with MS, who are experiencing symptoms of sexual dysfunction, may benefit from drugs such as sidenafil (Viagra ®), alprostadil (Prostin VR ®), or by using prosthetic devices. Women can use lubricating substances to enhance stimulation. Fertility is generally unaffected by MS, although erectile and ejaculatory problems experienced by some men can interfere with the ability to conceive.

None of the disease-modifying agents used to treat MS are considered safe for use during pregnancy. Women should be advised to seek medical advice before conception in order to review the medications they are taking. A woman who is taking MS disease-modifying drugs should be counseled to weigh the risks of stopping the medications long enough to conceive and deliver a child. Disease-modifying drugs can be resumed after delivery if the mother does not plan to breastfeed. MS does not affect the course of pregnancy, labor, or delivery. Hormones associated with pregnancy appear to have a protective effect on the immune system. Studies indicate that pregnancy does not affect immunologic function, and MS relapses may be less frequent during pregnancy. However, the risk of exacerbation in the few months after delivery has been found to range from 20% to 75%. In addition to considering the unpredictability of MS in relation to the needs of child rearing, couples also need to evaluate their financial and emotional security as a couple, their views about parenting, and their ability to handle role shifts in the family if the need arises.