Exercise, Education, or Medication: Which is Better for Fighting MS-Related Fatigue?

Patient Expert

Fatigue is one of the most common symptoms of multiple sclerosis (MS) affecting up to 90% of people with MS.   Fatigue has the power to negatively impact any aspect of a person's life.   The type of fatigue which people with MS experience is often described as a feeling of extreme mental or physical exhaustion.   It can interfere with one's ability to take care of themselves, function effectively at work, or participate in social activities.

There seems to be no single cause of fatigue in MS, which means that there cannot be only one approach to managing fatigue.   Neurologists will often prescribe medication or recommend rehabilitation (e.g., exercise, energy or fatigue self-management education, and cognitive behavioral therapy) for managing fatigue.   But which approach is more effective?

A number of studies investigating the effects of MS fatigue management strategies exist in the research literature, but until recently there has not been a thorough review comparing the effectiveness of individual types of interventions.   A new review summarizes the available research evaluating three types of fatigue management strategies (exercise, education, and medication) used to target MS fatigue.   Researchers included 25 randomized controlled trials in the review, including 7 medication trials and 18 rehabilitation trials (10 exercise trials and 8 education trials), that involved 1499 people living with MS (Asano et al., 2014).

The goal of the review was to answer the following questions:

-     How effective are exercise interventions for reducing the impact or severity of self-reported fatigue?

-     How effective are educational programs for reducing the impact or severity of self-reported fatigue?

-     How effective are commonly used fatigue medications for reducing the impact or severity of self-reported fatigue?

-     Are MS fatigue rehabilitation interventions (i.e., exercise and educational programs) more effective than the common MS fatigue medications?

The three types of treatment assessed were:

-     Exercise. Including physical and exercise therapies such as aerobic, aquatic, and breathing exercises; vestibular rehabilitation program (e.g., balance training); progressive resistance training; climbing; and yoga.

-     Education. Including cognitive behavioral therapy; mindfulness-based interventions; group psychotherapy; and energy management programs.

-     Medication. Trials included were restricted to studies looking at the effects of amantadine (n=5) or modafinil (n=2).   Other types of pharmacology interventions (e.g., aspirin, aminopyridine, and L-carnitine) were not included.

Trials examining the effect of supplements or interventions that would be atypical in traditional rehabilitation settings were excluded from the review (e.g., bee sting therapy or transmagnetic stimulation field).   Although it is known that heat and humidity and sleep disturbances can aggravate MS fatigue,   the review authors did not find any randomized controlled trials evaluating cooling therapies for managing heat intolerance, treatments for sleep problems, or educational programs for improving sleep hygiene.

What researchers found was that rehabilitation interventions (exercise and education) appear to have stronger and more significant effects on reducing the impact or severity of patient-reported fatigue compared to two commonly prescribed medications (amantadine and modafinil).   These results suggest that rehabilitation interventions should be the initial treatment choice for people with MS who are reporting disabling fatigue, rather than medication alone.

It is difficult to draw conclusions as to which interventions are most effective due to limitations in the trials reviewed (e.g., small sample sizes, different outcomes measured, short duration, etc.).   The 3 exercise trials which showed significant results had investigated aquatic exercise, balance training, and breathing exercises.   Among the education trials, cognitive behavioral therapy won out over standard care, relaxation, and group psychotherapy.   The results of the pharmacological trials were weak and inconclusive.

The authors of this review recommend that a combination of fatigue management treatments, including exercise, education, and medication, are necessary to successfully manage fatigue.   More research is necessary to make more accurate and specific recommendations.

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Asano M, Finlayson ML. Meta-Analysis of Three Different Types of Fatigue Management Interventions for People with Multiple Sclerosis: Exercise, Education, and Medication. Mult Scler Int. Vol. 2014, Article ID 798285, 12 pages, 2014. doi:10.1155/2014/798285

Fatigue. Multiple Sclerosis International Federation, n.d.   Retrieved from http://www.msif.org/about-ms/symptoms/fatigue/