More MS news articles for January
Symptoms: Fatigue and Pain
Elida J. Greinel, MSN, RN
MS Nursing - Introduction to Multiple Sclerosis Nursing Care
The National Multiple Sclerosis Society
After reading this article, nurses who are new to the care of people
with MS will be able to the following:
Recognize challenges associated with invisible symptoms
Describe characteristics of MS-related fatigue and factors that may contribute
List strategies for managing fatigue
Describe types of MS-related pain
Describe treatments used for pain management
In addition to the other, more obvious challenges associated with treating
a chronic, progressive autoimmune disease, are those posed by the “invisible”
symptoms of MS. The diagnosis and treatment (including both medical and
educational interventions) depend on accurate information about these elusive
symptoms, as well as effective communication between people with MS and
their healthcare team. Nurses play a pivotal role in this process. Because
they tend to spend the most time with patients, they are often in the best
position to recognize the invisible symptoms a patient is experiencing,
assess their impact on day-to-day functioning, interpersonal relationships,
and quality of life, and provide support and management recommendations.
Invisible symptoms can be defined as any that are not obvious to others—even
the healthcare professional.
The invisible symptoms of MS can include parasthesias, cognitive dysfunction,
depression or other mood changes, sexual dysfunction, pain, fatigue, and
even elimination problems. Too often, patients will neglect to mention
symptoms like these, either because they are unaware of their relationship
to MS or because they are too embarrassed to talk about them. An essential
component of every office visit is a careful review of any new or uncomfortable
problems the person is experiencing; this will help to ensure that the
invisible symptoms of MS get the attention they require.
To illustrate the challenges associated with the invisible symptoms
of MS, this module focuses on the diagnosis and management of fatigue and
pain in MS.
Fatigue has been defined by the Multiple Sclerosis Council for Clinical
Practice Guidelines as “a subjective lack of physical and/or mental energy
that is perceived by the individual or caregiver to interfere with usual
and desired activities” (Multiple Sclerosis Council, 1998). The underlying
cause(s) of this unique type of fatigue or lassitude remains unclear, in
spite of the high prevalence of this symptom among people with MS. The
research indicates that 75–95 percent of people with MS experience fatigue,
and 50–60 percent consider it one of their most debilitating symptoms (Fisk,
1994; Freal et al., 1984; Murray, 1985). The impact on an individual’s
quality of life is significant, given that:
Fatigue is a primary factor in the high unemployment rate among people
with MS (Edgley, 1991).
Characteristics of MS-Related Fatigue
Fatigue significantly increases a person’s degree of impairment and disability
and reduces a person’s feelings of self-esteem and control over the illness
(Ritvo et al., 1996; Monks, 1989; Schwartz et al., 1996; Vercoulen et al.,
The following features have been found to distinguish MS-related fatigue
from normal fatigue (Krupp et al., 1988):
Comes on suddenly
Prevents sustained activity
Is worsened by heat
Interferes with responsibilities
Interferes with physical functioning
Causes frequent problems
While every person with MS experiences fatigue from time to time, the fatigue
that requires active intervention can be divided into two types (Multiple
Sclerosis Council, 1998):
Acute fatigue —Any new experience of fatigue or significant increase
in feelings of fatigue that markedly interferes with daily activities or
quality of life
Chronic fatigue —Feelings of fatigue that are present for any amount
of time on 50 percent of days for more than six weeks
Fatigue can appear or markedly increase during an exacerbation, and subside
as the exacerbation resolves (Krupp & Elkins, 2000; Krupp, 2000).
A person’s level of fatigue can increase significantly in conjunction with
an elevated core body temperature caused by warm weather, a hot shower,
over-exertion or strenuous exercise, or a viral illness. The fatigue generally
lessens as the core body temperature returns to normal.
The first step in managing MS-related fatigue is to identify and address
possible contributory factors (Krupp & Elkins, 2000; Schapiro, 2003;
Multiple Sclerosis Council, 1998).
Physical deconditioning — As people with MS become less active and
more sedentary, their muscles become deconditioned. Like anyone else who
is “out of shape,” physical activity becomes more demanding and tiring.
Mobility impairment — People with MS who are experiencing mobility
impairment require increasing amounts of energy to ambulate and carry out
ordinary activities of daily living. This increased expenditure of energy
results in greater fatigue.
Disturbed sleep — Sleep disturbances in MS are common, caused by
a variety of factors including: periodic limb movements that disrupt the
sleep cycle; nocturia; pain from spasticity or other sensory disturbances;
clinical depression (experienced at one point or another by at least 50%
of people with MS).
Medications — Many of the medications commonly used in MS, such
as anticholinergics, analgesics, benzodiazepines, anti-spasticity drugs,
anti-seizure drugs, and the beta interferons, can produce sleepiness
or increased feelings of fatigue.
Co-existing conditions — People with MS are not immune to other
conditions that can produce or increase feelings of fatigue, including
depression, heart disease, and transient viral illnesses.
Primary MS fatigue — a feeling of fatigue that is directly attributable
to the MS disease process—remains as yet unexplained. Possible pathophysiologic
a conduction block involving intracortical circuits (Sandroni et al., 1992);
intermittent conduction blocks in partially demyelinated central motor
pathways (Sheean et al., 1997);
impaired recruitment of alpha motor neurons resulting from corticospinal
tract involvement (Rice et al., 1992); and 4) abnormal coactivation of
agonists and antagonists associated with spasticity (Olgiati et al., 1988).
Management of MS-related fatigue begins by addressing (and eliminating,
if possible) each of the possible contributory factors.
Deconditioning is best addressed by a personalized exercise program
to improve strength, tone, and aerobic conditioning. It has been demonstrated
that aerobic exercise, tailored to the needs and abilities of the individual,
can improve fitness, arm and leg strength, workout capacity, and bladder
and bowel control, and reduce depression, fatigue, and anger (Petajan et
The use of appropriate rehabilitation strategies, including mobility
aids and other assistive devices and energy conservation strategies, can
reduce fatigue caused by mobility mpairment and deconditioning (Di
Fabio et al., 1998). Early physical and occupational therapy assessment
and intervention can enhance function and promote effective energy utilization.
Medication adjustments, including dosing levels and schedules can
sometimes be adjusted to reduce medication-related sleepiness or fatigue.
In some instances, other medications may need to be substituted.
Fatigue that is caused by an exacerbation of MS or by co-existing
medical conditions, will decrease as those conditions are addressed. Fatigue
related to depression is generally responsive to treatment with a selective
serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac®) (Schapiro,
Primary MS fatigue management includes (Multiple Sclerosis Council,
Amantadine (100 mg bid) is an antiviral agent and a dopamine agonist
that has been shown to significantly reduce fatigue in approximately 20–40
percent of mild to moderately disabled people with MS.
Modafinil (Provigil®) (100–200 mg qd) is a wakefulness-promoting
agent that has been shown in a small clinical trial to reduce feelings
of fatigue in some individuals with MS.
Pemoline (Cylert®) (75 mg qd), a central nervous system stimulant
that may be an effective short-term treatment of MS-related fatigue, is
associated with significant side effects at higher dosage levels.
Aerobic exercise, which has been shown to improve cardiovascular
fitness, strength, and health status in people with mild to moderate MS-related
disability, may reduce fatigue in mildly disabled people with MS (Petajan
et al., 1996).
Cooling therapy (e.g., cooling vests, air-conditioning) has been
shown to reduce fatigue in heat-sensitive individuals with MS (Capello
et al., 1995)
Energy effectiveness strategies (e.g., time-management; use of mobility
aids and other assistive technology), while recognized by clinicians as
being effective in helping people to manage their fatigue, have not been
systematically evaluated in controlled trials.
Although the association between MS and pain was made by Charcot as
long ago as 1872 (Charcot, 1872), the common belief among healthcare professionals
until fairly recently was that pain was not a significant problem for people
with MS. We now know that pain syndromes are quite common in MS, affecting
approximately 45–65 percent of patients. (Indaco et al., 1994; Moulin et
al., 1988; Stenager et al., 1991). With 32 percent reporting continuous,
unremitting pain for at least one month, pain may in fact be one of the
most troubling symptoms of the disease (Vermote et al., 1986). MS patients
can experience various types of pain, many of which are quite challenging
Types of MS-Related Pain
MS-related pain can be generally divided into acute syndromes with paroxysmal
onset (lasting less than one month) and chronic syndromes with insidious
onset (that last more than one month).
Acute syndromes include:
Reported by about 9 percent of people with MS, it is 400 times more common
in MS than in the general population (Brisman, 1987; Rushton & Olafson,
Usually experienced as a sharp, searing facial pain; bilateral in 30 percent
Paroxysms can be precipitated by chewing, shaving, and toothbrushing.
Usually responds to anticonvulsant medication (carbamazepine); other medications
include phenytoin, baclofen, clonazepan, lamotrigine, and misoprostol (Jeffery,
Refractory trigeminal neuralgia is best treated with radiofrequency thermal
rhizotomy or glycerol rhizotomy of the trigeminal ganglion.
Painful tonic spasms
Simple flexor spasms, typically brought on by movement or noxious stimuli
— best managed with antispasticity therapy (Jeffery, 2000).
Brief spasms of an upper or lower extremity (also called tonic spinal cord
seizures), which can occur several times per day—usually respond to carbamazepine;
other medications include phenytoin, gabapentin, clonazepan, tizanidine,
and baclofen (Osterman & Westerberg, 1975).
Lightening-like extremity pain
Intense shooting pain traveling through virtually any part of the body,
often precipitated by movement (Vermote et al., 1986).
Generally responds to carbamazepine; can also be treated with phenytoin
Occurs in any disorder that causes damage to the posterior columns of the
cervical spinal cord (Lhermitte et al., 1924).
Sensation of electric shock that travels down the neck (typically in response
to movement of the head and neck), sometimes radiating into the extremities.
Typically responds to carbamazepine (Ekbom, 1991).
Paroxysmal pain tends to resolve on its own after four to six weeks and
may not require prolonged therapy. If medication is needed, the general
recommendation is to initiate treatment with low-dose (100–200 mg bid)
carbamazepine. For persistent pain, the dosage of antiseizure medication
can be gradually raised, and/or a second medication can be added (Jeffery,
Sharp, knifelike pain experienced by 80 percent of people with acute optic
neuritis (may also include deep ache or pressure sensation above or behind
the eye) (Matthews, 1975).
Results from inflammation and demyelination around the optic nerve, and
generally subsides with steroid treatment.
Chronic pain syndromes include
Dysesthetic extremity pain
Most common of the chronic pain syndromes, it is described as a burning
or aching pain, occurring most often in the lower extremities (Indaco et
al., 1994; Vermote et al., 1986).
Probably caused by demyelination within the posterior columns of the spinal
Pain typically more severe toward the end of the day.
Like other chronic syndromes, dysesthetic pain responds less well to carbamazine;
recommended treatments include phenytoin and gabapentin, although this
type of pain can be refractory to treatment (Jeffery, 2000).
Band-like pain in torso or extremities (Jeffery, 2000)
Caused by a lesion in the spinal cord, this pain is characterized by intense
pressure or squeezing in a girdle-like pattern around the torso.
May respond partially to phenytoin or gabapentin.
For resistant cases, benzodiazepines may be helpful.
Back pain and radiculopathy (Jeffery, 2000)
May occur in patients with MS due to: non-MS-related orthopedic problems;
musculoskeletal changes due to impaired mobility; or demyelination, possibly
in the dorsal root entry zone.
Treatment typically occurs in a step-wise fashion (Jeffery, 2000)
Physical therapy and non-steroidal anti-inflammatories
Trial of gabapentin of phenytoin
Other possible medications include: tizanidine, baclofen, clonazepam, or
Managing Refractory Pain
Reports indicate that headache may be associated with MS, even as a presenting
Treatment is generally the same as for non-MS patients.
Headache associated with a relapse often responds to steroid treatment.
Some pain syndromes in MS, particularly the more chronic ones, can be
quite refractory to treatment. Several medications may need to be tried
before an effective one is found, and more than one may be needed at any
given time. Once the pain is brought under control, an attempt should be
made to stop the first medication since treatment with only one medication
at a time produces fewer side effects. In the case of severe, breakthrough
pain, narcotics may be necessary. Because patients with unremitting pain
are at risk for depression, supportive counseling and/or psychiatric intervention
may be required (Indaco et al., 1994; Vermote et al., 1986; Jeffery, 2000).
Nurses play an integral, active, and dynamic role in the management
of invisible symptoms like fatigue and pain. As the member of the healthcare
team who is likely to spend most time with a patient, the nurse is ideally
situated to identify these challenging symptoms and provide education and
support, and implement management strategies designed to meet the unique
needs of each individual.
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1. Invisible symptoms of MS may include
a. Cognitive dysfunction
2. Current pharmacological agents used to reduce symptoms of fatigue include
all of the
d. Sexual dysfunction
e. All of the above
a. Amantadine (Symmetrel®)
3. A careful assessment of all of the following factors is important when
b. Pemoline (Cylert®)
c. Diazepam (Valium®)
d. Modafenil (Provigil®)
MS fatigue-related complaints, except
a. Presence of a bacterial or viral infection
4. Dysesthetic pain is characterized by burning or aching sensation.
b. Age and gender of patient
c. Concomitant medications
5. MS-related pain includes
a. Dysesthetic pain
b. Trigeminal neuralgia
c. Optic neuritis
d. All of the above
Answers: 1 e; 2 c; 3 b; 4 a; 5 d
Copyright © 2004, The National Multiple Sclerosis Society