Fatigue in Relapsing-Remitting Multiple Sclerosis Patients - Essay Example

FATIGUE IN MULTIPLE SCLEROSIS Fatigue in Relapsing-Remitting Multiple Sclerosis Patients Question Multiple sclerosis (MS) is a disabling neurological disease that affects mostly young people. In fact, it is the commonest cause of neurological disability among younger adults (Higginson et al. 2006). Multiple sclerosis is classified as remitting relapsing (MS-RR) when the course is fluctuating. About half of the patients develop a degenerative course as time goes on – secondary progressive or MS-SP. The relatively small minority of patients who have a progressive course from the onset of the disease are classified as primary progressive or MS-PP (Higginson et al. 2006, p. 58) Fatigue is very common among patients with multiple sclerosis and yet is it a symptom that is quite poorly defined. (Flachenacher et al., 2002). This very fact makes evaluation of fatigue as a symptom of multiple sclerosis difficult. And yet, since it is such a common complaint of patients with this condition, its evaluation as part of the disease process cannot be ignored. The paper by Flachenecker and colleagues is an important one dealing with the problem of fatigue in relapsing-remitting multiple sclerosis. Of the 151 consecutive patients who entered the study and were given the standardized questionnaires, 94 had the relapsing-remitting type of multiple sclerosis which is our main interest as far as the symptom of fatigue is concerned. One of the most important aspects of this paper in the evaluation of fatigue is the fact that the authors used 4 different fatigue scales namely, Fatigue Severity Scale (FSS), MS-specific FSS, Modified Fatigue Impact Scale (MFIS) and Visual Analogue Scale (VAS). To evaluate a symptom as vague and non-specific as fatigue, it was important that the authors relied not just on one fatigue scale but on four different fatigue scales in order to reduce the incidence of errors. In order for a patient to be included in the “MS-related fatigue group” (MS-F) they had to have stated in the questionnaire that fatigue: 1.is one of their three most disabling symptoms; 2. occurs daily or on most days of the week; and 3. limits their activities at home or at work. Patients who fulfilled none of these criteria were labeled MS non-fatigue group (MS-NF); those who had only one or two of the criteria were labeled “borderline” (Flachenecker et al., 2002 p. 524). This was another way of ensuring that only those who were truly fatigued were included in the group of MS patients with fatigue. It is also significant that Flachenecker, et al. (2002) used a depression screen as part of the evaluation of fatigue in MS. It is common knowledge that fatigue can be one of the most prominent symptoms of depression. The authors used Beck’s Depression Inventory (BDI) and found that there was a significant correlation between FSS and depression. They found that about 16% of the patients met the criteria for full symptoms of depression whereas another 9% could be classified as having mild to moderate depressive symptoms according to the BDI scale. Thus about 25% of the patients could be said to have some degree of depression. The authors therefore concluded that there may be a cause and effect relationship between the depression and fatigue in the MS patients. In other words, the patients who experienced fatigue were probably just depressed and it was the depression that was manifesting itself as fatigue and not the multiple sclerosis per se. They also suggested that a more exact definition of fatigue was required. Other researchers have also found a strong correlation between fatigue and depression (Kroencke, D.C., Lynch, S.G. and Denney, D.R., 2000). They also found a strong correlation between fatigue and disability and concluded that both depressed mood and disability significantly predicted fatigue. The paper by Flachenecker et al. (2002) contributes a lot to the study of fatigue in MS-RR because it was quite well-designed and adequate precautions were taken in the definition of fatigue. In addition, they had a reasonable number of patients with MS-RR as opposed to the other forms of MS. However, there are still limitations to this paper as far as the study of fatigue in MS-RR is concerned. Although Flachenecker et al. (2002) used four different fatigue scales in their research they found a weak correlation between the various fatigue scales. They concluded that: “the weak correlation of the fatigue scales used herein is best explained by the fact that fatigue is a multidimensional symptom with the available tests measuring and weighting different aspects of fatigue.” (p. 525-526) The article by Higginson, Hart, Silber, Burman and Edmonds (2006) deal with the prevalence and severity of symptoms in patients with severe multiple sclerosis and assessed the need for referral for palliative services. Although fatigue as a symptom was identified in some of the patients who were severely affected by MS, the cohort of patients they used was rather small at fifty-two. Furthermore there was only one patient (less than 1%) that was classified as MS-RR. This paper, therefore, contributed little to the study of fatigue in MS-RR patients. The patient with MS who was inquiring about fatigue should be told that fatigue is a very common symptom of MS but that it is quite non-specific and thus it is not always easy to define its implication. Based on these two articles her fatigue could be related to one of two things- either depression or the severity of her MS. She should be advised to undergo comprehensive depression screening in order to discover any undiagnosed depression. If she does have hidden depression she could then receive specific treatment for depression that would likely abate her symptom of fatigue. The decision to advise depression screening is based on the very strong correlation that was found by researchers between fatigue and depression. The depression screening could be arranged by her primary care provider or she could be referred to a Behavioral Health consultant to conduct the screening. On the other hand her fatigue could be related to the degree of disability she is suffering at this time. She may need to be referred for palliative care if her degree of disability warrants it. Therefore evaluation by a social worker may be appropriate. Question 2 There is a patient with MS who is requesting more information on fatigue associated with relapsing-remitting MS. Information provided from two research papers did not satisfy her. Below are some of the steps that would be taken to find out more information for her. An online search could be done using a search engine such as google or yahoo to search for information. By typing in “fatigue; Multiple sclerosis; relapsing- remitting” in the search engine lot of information could be generated that could be shared with the patient. Also information could be obtained from online medical of science libraries that can access current and remote literature on the subject of fatigue in MS-RR such as “PubMed” that accesses Medline articles. Also various books on MS have been written by physicians or laymen with the lay public in mind and a search of online bookshops can reveal some of these that may have the right information the patient needs. There are also other resources such as the Multiple Sclerosis Society. By calling their telephone number literature relevant to the patient’s symptom of fatigue could be obtained and shared with the patient. Finally, there are always local support groups for various chronic or debilitating diseases and information on the local support group for MS could be obtained by the physician and given to the patient to call. In this way meetings could be arranged that she could attend and learn from. By taking these steps enough information can be obtained about fatigue in MS-RR to satisfy the patient and answer her questions. References 1. Flachenecker, P., Kumpfel, T., Gottschalk, M., Grauer, O., Rieckmann, P., Trenkwalder, C., & Toyka, K.V. 2002. “Fatigue in multiple sclerosis: a Comparison of different rating scales and correlation to clinical Parameters.” Multiple Sclerosis. 8:523-526. 2. Higginson, I.J., Hart, S., Silber, E., Burman, R., & Edmonds, P. 2006 “Symptom prevalence and severity in people severely affected by multiple sclerosis” Journal of Palliative Care. 22 (3): 158-165. 3. Kroencke, D.C., Lynch, S.G., & Denny, D.R. 2000. “Fatigue in multiple sclerosis Relationship to depression, disability and disease pattern. Multiple Sclerosis 6 (2): 131-136. Read More