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Ms and fatigue management, tinnitus relief vitamins - How to DIY

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The following overview highlights some of the primary and secondary causes of fatigue in MS, acknowledging that it is a common symptom in a wide range of neurological and nonneurological conditions2, 3.
Research suggests that between 65-97% of people with MS experience significant fatigue4 and it is a presenting symptom in one third of people with MS5. But while it is important to recognise the proportion of people with MS affected by fatigue, and to assess the extent of its impact, it is also important to understand that there may be different physiological mechanisms behind the presentation of fatigue. Asthenia or lassitude which is present at rest and described as an overwhelming feeling of tiredness.
Fatigability or acute fatigue is localised to specific muscle groups and occurs during or after exercise or activity. Worsening of symptoms may be a consequence of fatigue and can induce symptoms such as blurred vision, reduced balance or slurred speech. Understanding the physiological processes that are responsible for the onset of fatigue, can help identify some of the causes of MS related fatigue, which are often complex and interdependent.
Primary fatigue is directly related to the disease process6 and may be the result of inflammation, demyelination or axonal damage12.
It has been hypothesised that in people with MS related fatigue, immune activity may either be the trigger or the result of low glucose metabolism in areas of the brain involved in motor planning including the prefrontal cortex and basal ganglia5, 7, 10.
Herndon suggested that the demyelinated membrane takes longer to recover due to a build up of sodium ions known as 'nerve fibre fatigue' or 'conduction block'15.
Axonal Damage Research studies have observed that where fatigue was experienced in the first two years since diagnosis, brain atrophy occurred over the following six years18.
Central fatigue is not exclusive to MS and can be present in other central nervous system disorders (see figure 1). It is important that people experiencing MS-related fatigue recognise the central role they must play in identifying their own contributory factors. A medication review is an essential part of assessment, as many of the medications used for symptom management and some co-morbid conditions (particularly cardiovascular) report fatigue as a significant side effect.
Traditional advice for managing fatigue includes the 3 'P's approach of Prioritising, Planning and Pacing. Research into the efficacy of energy conservation programmes has pointed to the benefits such programmes offer people with MS fatigue27, 28. The unique nature of fatigue in multiple sclerosis: prevalence, pathophysiology, contributing factors and subjective experience. Modalities of fatigue in multiple sclerosis: correlation with clinical and biological factors.

Reduced glucose metabolism in the frontal cortex and basal ganglia of multiple sclerosis patients with fatigue: A18 F-fluorodeoxyglucose positron emission tomography study.
Motor cortex excitability and fatigue in multiple sclerosis: a transcranial magnetic stimulation study.
Fatigue in multiple sclerosis is associated with the disruption of frontal and parietal pathways. Fatigue in multiple sclerosis is associated with abnormal cortical activation to voluntary movement - EEG evidence. Long-term benefits of exercising on quality of life and fatigue in multiple sclerosis patients with mild disability: a pilot study. The positive effects of a physical activity program for multiple sclerosis patients with fatigue.
Improved fatigue in individuals with multiple sclerosis after participating in a short-term self-care programme. Understanding the causes of fatigue is key to identifying the most effective management strategies. It demonstrates that a multidisciplinary but individualised assessment is pivotal to the success of the fatigue management strategies presented.
The immune system plays a substantial role in MS fatigue and it can be the first symptom of an impending relapse13. Widespread cerebral axonal damage has also been seen to correlate with MS related fatigue and adaptive neuroplasticity19. In MS it is associated with the selective involvement of the frontal cortex, white matter and basal ganglia, which may cause low motivation, low initiative and reduced concentration21, 22. It is these factors that health professionals aim to identify and influence to enable people with MS to regain some control over their fatigue. The MS Trust publication Living with fatigue23 offers ideas to help people identify and address these factors. But the theory underpinning that advice has since been turned on its head and physical de-conditioning has been shown to contribute to fatigue and general poor health in the MS population24.
The delivery of such programmes can vary - a programme designed by the College of Occupational Therapists is delivered on a one to one basis29, whilst the MS Trust supported study into a fatigue management programme taking place at University Hospital Birmingham is delivered in a group format running over several weeks. Key to the effective management of this symptom is accurate understanding of the physiological mechanisms responsible for it, identification of factors which may be contributing to it, and the central involvement of the individual experiencing it.
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In the following article, Helen Rowlands and Fran Jackson explore the complex nature of this symptom, and emphasise the importance of a multidisciplinary approach to its management. Research has also linked fatigue with symptoms of depression and identified it as one of the most common reasons for unemployment amongst the MS population. Higher levels of immune activity are often seen in MS fatigue and may be detected by testing for the presence of certain immune markers8, 9.
This may involve the altered cerebral activity that has been demonstrated by EEG studies where the person with MS related fatigue experienced increased activity in the brain before exercise and decreased cerebral inhibition of activity after exercise20. The frequency with which physical and mental fatigue occur together is compelling evidence for some researchers that fatigue in MS is caused by central abnormalities6.
Health professionals need to support people in identifying the causes and align any interventions with the aim of maximising energy and managing available energy more effectively. Research has demonstrated that aerobic and strength exercises can reduce motor fatigue in MS and that physical activity can significantly improve levels of fatigue25, 26. While such programmes may not offer a 'one size suits all' solution to the management of fatigue in MS, they ought to be considered as part of every individualised assessment.
This type of fatigue is not unique to MS and can present in other autoimmune conditions6, 8, 11. It manifests itself as a worsening of symptoms accompanied by fatigue in a hot environment.
Recent studies also demonstrated an association between fatigue in MS and the reduction of membrane excitability after exercise in the motor cortex of the brain16. In layman's terms, such findings suggest that people with MS related fatigue have to use more brain power to participate in exercise than those with MS not experiencing fatigue. Ideally, people with MS related fatigue will be advised on an appropriate exercise regime by a physiotherapist, but they also need to take responsibility for their ongoing fitness themselves.
Similarly people with MS related fatigue need to use their available energy on essential tasks but save some for enjoyable activities. The suggestion that fatigue in MS involves a central pathology is further supported by the use of sophisticated MRI techniques which have demonstrated a correlation between the number of white matter lesions and grey matter atrophy and fatigue in MS17.

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