1. What are the most effective treatment approaches to use to reduce fatigue for people with Multiple Sclerosis?
A critical appraisal of the literature
Samantha Turner
Lecturer in Occupational Therapy
MSc Occupational Therapy Student
University of Plymouth
2017
 © Copyright Ian Capper and licensed for reuse under a Creative Commons License.
Background
Fatigue is one of the most common symptoms of Multiple Sclerosis (MS), affecting almost 80% of people with the condition (Khan, Amatya & Galea, 2014). Fatigue can be explained as a lack of physical and/or mental energy which impacts all aspects of daily living (Tur, 2016). There is a vast amount of literature related to approaches to use to support a reduction in fatigue, however within clinical practice it is unclear what approaches are most effective. Fatigue management can be provided in a range of formats including individual, group, online, self-management and teleconference. Literature recommends the use of a wide range of both pharmacological and non-pharmacological approaches including the use of energy conservation education, Cognitive Behavioural Therapy (CBT), exercise and medication.
Process of exploration
Databases searched; PubMed, Cinahl, Medline & Cochrane
Search terms used and MeSH terms identified
Additional hand searching completed
Limits applied to identify appropriateness of articles
283 articles found within the applied limits
17 articles identified after reviewing the titles
Remaining research articles critically appraised
A critical appraisal of the literature was completed as part of a Masters Level 7 module focusing on the use of evidence to influence practice related to fatigue management for people with MS.
© Copyright ”Brain” by Dierk Schaefer and licensed for reuse under a Creative Commons License.
Overview of Literature Appraised
Blikman et al., (2013) completed a systematic review of the literature related to the use of energy conservation management for people with MS. The researchers identified positive outcomes of the use of energy conservation when provided in a group format. Further recommendations were made related to the benefits of individual provision although this was not supported by high quality research.
Khan, Amatya and Galea (2014) identified that non-pharmacological treatment such as energy conservation, exercise and CBT were most effective treatment approaches. This systematic review was focused on a broad range of types of fatigue management therefore it has questionable utility in practice.
Asano and Finlayson (2014) focused more specifically on the use of energy conservation, exercise and medication and concluded that education and exercise were the most effective treatment approaches to use. There was a lack of explanation as to how the participants had been randomised within the trial which could have caused selection bias.
Thomas et al., (2013) completed a group based programme combining CBT and energy conservation techniques called FACETS. The findings identified positive outcomes in relation to measures demonstrating reduced fatigue severity and increased self-efficacy when provided in a group format.
Tur (2016) recently produced an informative literature review summarising that non-pharmacological approaches to fatigue management are favoured overall. From a pharmacological perspective Tur (2016) identified that Amantadine has the strongest evidence base. Overall there was a strong theme identifying the importance of a multi-disciplinary team approach to fatigue management within specialist neurological services. Finally, most of the literature advised provision of fatigue management within a group format rather than individually.
Summary
Energy conservation education, CBT and exercise are the approaches that has the strongest evidence base for effectiveness in reducing fatigue for people with MS
A multi-disciplinary team approach to fatigue management is encouraged
A lack of literature related to provision of fatigue management on an individual basis has been published which opposes clinical practice experience
Further research required relating to individual provision of fatigue management
Next steps
Attend Specialist Section in Neurological Practice Conference in to share the results of the critical appraisal.
Disseminate findings to local practitioners working in neurological services through the regional network group to promote debate and discussion with the aim to improve professional practice.
Acknowledgement: With thanks to Health Education South West for providing funding for a MSc in Advanced Professional Practice in Occupational Therapy with Plymouth University.
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References
Asano, M., & Finlayson, M.L. (2014). Meta-analysis of three different types of fatigue management interventions for people with multiple sclerosis; exercise, education and medication. Multiple Sclerosis International, 1-8
Blikman, L. J., Huisstede, B. M., Koojimans, H., Stam, H. J., Bussman, J B., & Van Meeteren, J, (2013). Effectiveness of energy conservation treatment in reducing fatigue in multiple sclerosis: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. Elsevier.
Khan, F., Amatya, B., & Galea, M. (2014). Management of fatigue in persons with multiple sclerosis. Frontiers in Neurology. 5, 177.
Thomas, S., Thomas, P. W., Kersten, P., Jones, R., Green, C., Nock, A., & Hillier, C. (2013). A pragmatic parallel arm multi-centre randomised controlled trial to assess the effectiveness and cost-effectiveness of a group-based fatigue management programme FACECTS) for people with multiple sclerosis. Journal of Neurology, Neurosurgery and Psychiatry, 84(10),
Tur, C. (2016) Fatigue management in multiple sclerosis. Current Treatment Options in Neurology.