Fatigue

Fatigue image     Fatigue is one of the most common and troublesome symptoms of MS. It is often described as an overwhelming sense of exhaustion that makes even the simplest activities a struggle. Fatigue tends to get worse towards the end of each day, in hot weather, after exercising, or during acute illness. Primary fatigue is caused by MS damage in the brain and spinal cord, causing the passage of messages around nerve damage to require extra energy; secondary fatigue is the result of other MS symptoms, such as pain or disturbed sleep.

  • Wahls Protocol®: The Wahls Protocol®, a series of dietary interventions based on Paleolithic and ketogenic nutrition combined with other relevant modalities (including supplements, stretching, strengthening exercises, electrical stimulation of muscles, meditation, and massage), has been associated with reduced fatigue in clinical studies with MS patients. The first was a small single-group trial in SPMS patients, showing promise with a significant improvement in fatigue1. Next was a randomized controlled study on just the dietary approach in RRMS patients, also resulting in improved fatigue, as well as increased physical quality of life, exercise capacity, and hand and leg function 2. The most recent randomized parallel-arm clinical trial in RRMS patients compared the Wahls and Swank diets, finding that both were associated with clinically meaningful within-group reductions in fatigue and improvements in quality of life (Wahls et al., 2021). The Swank Diet is a low-fat plan proposed in 1950 for MS treatment by Dr. Roy Swank, an academic neurologist at the University of Oregon 3. Swank designed the diet to “slow progression of the disease as well as benefit overall health.”

  • OMS Diet: Greater diet quality according to Overcoming Multiple Sclerosis (OMS) Diet criteria was significantly associated with less severe disability and fatigue 4. The program builds on the preceding work of Dr. Swank, taking into account modern data on fats as well as additional evidence on other dietary factors. The OMS plan, based on research conducted by Dr. George Jelinek, is a whole foods plant-based diet that includes seafood if desired. It aims to significantly reduce saturated fat intake while increasing the intake of omega-3 fatty acids. It recommends getting a variety of fruits and vegetables; omitting all processed foods, eggs, meat, dairy, and saturated fats; and taking 20-40 ml of flaxseed oil daily. In addition to diet, regular exercise and meditation are encouraged.

  • McDougall Diet: Results showed a significant reduction in fatigue associated with the very low-fat plant-based McDougall diet in a randomized controlled single-blind clinical study 5.

  • Keto Diet: In an open (uncontrolled) clinical study in RRMS patients, a modified Atkins keto diet (<20 g carbohydrate per day) followed for six months was associated with decreased fatigue, depression, and disability 6.

  • Anti-inflammatory Diet: Following 12 weeks with the anti-inflammatory diet, MS patients demonstrated a significant reduction in overall, physical, cognitive, and psychological fatigue as measured by the Modified Fatigue Impact Scale (MFIS) and its subscales (p<0.01), as well as a significant increases in physical health quality of life (p<0.001) 7.

  • Massage: Massage has demonstrated a beneficial effect on fatigue in MS 8.

  • Acupuncture: Clinical research has linked acupuncture with reduced fatigue 9. A small study exploring the effects of eight acupuncture treatments combined with health promotion classes on women with MS revealed significant improvements in fatigue as measured by modified fatigue impact scale (MFIS) 10. In another study on fatigue, 12 sessions of acupuncture reduced mean fatigue scores by nearly 30% in non-responders to the conventional medication amantadine 11.

  • Reflexology: Foot reflexology has been found to be effective in reducing fatigue in MS 12,13.

  • Physical activity: Despite it sounding counterintuitive, exercise can be an effective tool in fighting fatigue in MS. Aquatics 14 and strength-training 15 in particular have shown promise.

  • Supplements shown in research to support fatigue prevention and management include the following (each covered in their own section):

  • Acetyl-L-Carnitine

  • Coenzyme Q10

  • Ginkgo biloba

  • EGCG from green tea

  • Melatonin

  • N-acetyl cysteine

  • Vitamin B1

  • Vitamin D

 

References

1. Bisht B, Darling WG, Grossmann RE, et al. A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med. May 2014;20(5):347-55. doi:10.1089/acm.2013.0188

2. Irish AK, Erickson CM, Wahls TL, Snetselaar LG, Darling WG. Randomized control trial evaluation of a modified Paleolithic dietary intervention in the treatment of relapsing-remitting multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2017;7:1-18. doi:10.2147/DNND.S116949

3. Parks NE, Jackson-Tarlton CS, Vacchi L, Merdad R, Johnston BC. Dietary interventions for multiple sclerosis-related outcomes. Cochrane Database Syst Rev. May 19 2020;5:CD004192. doi:10.1002/14651858.CD004192.pub4

4. Simpson-Yap S, Nag N, Probst Y, Jelinek G, Neate S. Higher-quality diet and non-consumption of meat are associated with less self-determined disability progression in people with multiple sclerosis: A longitudinal cohort study. Eur J Neurol. Jan 2022;29(1):225-236. doi:10.1111/ene.15066

5. Yadav V, Marracci G, Kim E, et al. Low-fat, plant-based diet in multiple sclerosis: A randomized controlled trial. Mult Scler Relat Disord. Sep 2016;9:80-90. doi:10.1016/j.msard.2016.07.001

6. Brenton JN, Banwell B, Bergqvist AGC, et al. Pilot study of a ketogenic diet in relapsing-remitting MS. Neurol Neuroimmunol Neuroinflamm. Jul 2019;6(4):e565. doi:10.1212/NXI.0000000000000565

7. Mousavi-Shirazi-Fard Z, Mazloom Z, Izadi S, Fararouei M. The effects of modified anti-inflammatory diet on fatigue, quality of life, and inflammatory biomarkers in relapsing-remitting multiple sclerosis patients: a randomized clinical trial. Int J Neurosci. Jul 2021;131(7):657-665. doi:10.1080/00207454.2020.1750398

8. Field T. Massage therapy research review. Complement Ther Clin Pract. Aug 2016;24:19-31. doi:10.1016/j.ctcp.2016.04.005

9. Karpatkin HI, Napolione D, Siminovich-Blok B. Acupuncture and multiple sclerosis: a review of the evidence. Evid Based Complement Alternat Med. 2014;2014:972935. doi:10.1155/2014/972935

10. Becker H, Stuifbergen AK, Schnyer RN, Morrison JD, Henneghan A. Integrating Acupuncture Within a Wellness Intervention for Women With Multiple Sclerosis. J Holist Nurs. Mar 2017;35(1):86-96. doi:10.1177/0898010116644833

11. Foroughipour M, Bahrami Taghanaki HR, Saeidi M, Khazaei M, Sasannezhad P, Shoeibi A. Amantadine and the place of acupuncture in the treatment of fatigue in patients with multiple sclerosis: an observational study. Acupunct Med. Mar 2013;31(1):27-30. doi:10.1136/acupmed-2012-010199

12. Heidari Z, Shahrbanian S, Chiu C. Massage therapy as a complementary and alternative approach for people with multiple sclerosis: a systematic review. Disabil Rehabil. Aug 1 2021:1-12. doi:10.1080/09638288.2021.1949051

13. Dilek Dogan H, Tan M. Effects of Reflexology on Pain, Fatigue, and Quality of Life in Multiple Sclerosis Patients: A Clinical Study. Altern Ther Health Med. Sep 2021;27(5):14-22.

14. Shariat A, Ghayour Najafabadi M, Soroush Fard Z, Nakhostin-Ansari A, Shaw BS. A systematic review with meta-analysis on balance, fatigue, and motor function following aquatic therapy in patients with multiple sclerosis. Mult Scler Relat Disord. Aug 13 2022;68:104107. doi:10.1016/j.msard.2022.104107

15. Velikonja O, Curic K, Ozura A, Jazbec SS. Influence of sports climbing and yoga on spasticity, cognitive function, mood and fatigue in patients with multiple sclerosis. Clin Neurol Neurosurg. Sep 2010;112(7):597-601. doi:10.1016/j.clineuro.2010.03.006

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