Download Care Pathway

NEUROSCIENCES DIRECTORATE
DEPARTMENT OF NEUROLOGY
Princes Road, Hartshill, Stoke on Trent, ST4 7LN
NORTH MIDLANDS REGIONAL MULTIPLE SCLEROSIS SERVICE
FATIGUE MANAGEMENT GUIDELINES
Fatigue is probably one of the commonest, most disabling and frustrating symptoms
experienced by people with MS, although it may not explicitly be discussed. Fatigue
varies widely both between people with MS and within a person from time to time.
Fatigue is associated with disability and depression and management should
encompass all aspects of the patient’s situation and not just the fatigue. It is
important to distinguish complaints of fatigue and complaints of weakness.
The objectives of fatigue management:
1. Assessment to determine the presence and severity of fatigue and
determine whether fatigue is primary or secondary assessing contributing
factors.
2. Management of fatigue utilising the care pathway to try to ameliorate it
effects
Assessment
In order to identify the presence of fatigue the Modified Fatigue Impact Scale
(MFIS Appendix 1) and the Fatigue Severity Scale (FSS) will be utilised also:
 Identify possible contributing factors such as:
Relapse, medications, sleep disturbances, infections, concurrent illnesses, level of
activity, heat, lifestyle issues – diet and exercise, psychosocial issues, pain,
spasticity, spasms, bladder disturbances, infection and poor nutrition. Assess the
severity of fatigue through patient self-report and the MFIS – Appendix 1.
 Some medications exaggerate fatigue; these should be assessed and
reviewed.
 The patient should be assessed for significant depression and if present
treated
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Management
General advice and training on how to manage fatigue should be given routinely. In
the first instance the following should be promoted:
 Aerobic exercise should be encouraged.
 Temperature control should be emphasised.
 Energy conservation techniques should be advised, used and reassessed
 Any symptoms identified should be treated and the implications re-assessed.
 Fatigue management programmes are advised
 A multi-disciplinary approach should be adopted.
 No medication should be used routinely
 Underlying depression should be treated
 Some evidence for using anti-depressants like Fluoxetine (Prozac) 20mg60mg or Sertraline (Lustral) 25-200mg daily in trying to improve fatigue.
If the above management fails the following pathway should be followed:
 Amantidine – if there are no contra-indications. A small clinical benefit
identified that taking Amantidine (Symmetrel) 100mg taken initially on
waking, then increasing to 100 mg on waking and 100 mg taken before 2pm
can help fatigue in some instances.
If Amantidine fails to be effective after a few weeks then:
 Modafanil (Provigil) 200mg can be used if there are no contraindications like
mitral valve prolapse or left ventricular hypertrophy.
Results of an open-label study on Modafanil in the treatment of fatigue in multiple
sclerosis demonstrated that it improved fatigue at a dose of 200mg but not at
400mg (Zifco et al 2001).
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One study into the efficacy of Modafanil 200mg daily for the treatment of fatigue
in MS demonstrated significant improvement in fatigue versus placebo (Rammohan
et al 2002).
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MODIFIED FATIGUE IMPACT SCALE (MFIS)
Patient Name
Unit Number
Date
Below is a list of statements that describe how fatigue may affect you.
Please read the statement carefully and circle one answer that best indicates
how often fatigue has affected you during the past 4 weeks. Please answer
every question. Choose the answer that comes closest to describing you.
Please ask the interviewer to explain any words that you do not understand.
Because of my fatigue during the past 4 weeks….
Never Rarely Sometimes Often Always
1. I have been less alert
0
1
2
3
4
2. I have difficulty paying
attention for long periods
of time
0
1
2
3
4
3. I have been unable to
think clearly
0
1
2
3
4
4. I have been clumsy and
uncoordinated
0
1
2
3
4
5. I have been forgetful
0
1
2
3
4
6. I have had to pace myself
I the physical activities
0
1
2
3
4
7. I have been motivated
less motivated to do anything
that requires physical effort
0
1
2
3
4
8. I have been less motivated
participate in social activities
0
1
2
3
4
9. I have been limited in
0
1
my ability to do things away
from home
Because of my fatigue during the past 4 weeks …..
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2
3
4
10. I have had trouble
maintaining physical effort
for long periods
Never Rarely Sometimes Often Always
0
1
2
3
4
11. I have difficulty making
decisions
0
1
2
3
4
12. I have been less motivated
to do anything that requires
thinking
0
1
2
3
4
13. My muscles have felt weak
0
1
2
3
4
14. I have been physically
uncomfortable
0
1
2
3
4
15. I have had trouble finishing 0
tasks that require thinking
1
2
3
4
16. I have had difficulty
organising my thoughts
when doing things at home
0
1
2
3
4
17. I have been less able to
complete tasks that require
physical effort
0
1
2
3
4
18. My thinking has been
slowed down
0
1
2
3
4
19. I have had trouble
concentrating
0
1
2
3
4
20. I have limited my physical
activities
0
1
2
3
4
21. I have needed to rest more
often or for longer periods
0
1
2
3
4
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FATIGUE SEVERITY SCALE
During the past week I have found that: Disagree -------------- Agree
My motivation is lower when
I am fatigued
1
2
3
4
5
6
7
Exercise brings on my fatigue
1
2
3
4
5
6
7
I am easily fatigued
1
2
3
4
5
6
7
Fatigue interferes with my physical
Functioning
1
2
3
4
5
6
7
Fatigue causes frequent problems
for me
1
2
3
4
5
6
7
My fatigue prevents sustained
physical functioning
1
2
3
4
5
6
7
Fatigue interferes with carrying
out certain duties and responsibilities
1
2
3
4
5
6
7
Fatigue is among my three most
disabling symptoms
1
2
3
4
5
6
7
2
3
4
5
6
7
Fatigue interferes with my work,
Family, or social life
1
Total Score
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Rammahon, K.W. Rosenberg, JH Lynn, DJ. Blumenfeld, AM. Pollak, CP.
Nagaraja, HN. (2002) Efficacy and Safety of modafanil (Provigil) for the
treatment of fatigue in multiple sclerosis: a two centre phase 2 study Journal
of Neurology Neurosurgery Psychiatry 72: 179-183
Zifco, UA. Rupp, M. Zipko, H.T. Maida, EM. (2001) Modafanil in treatment of
fatigue in multiple sclerosis Results of an open-label study Journal of neurology
765 p 783-787
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