The following article is offered as general information related to Transverse Myelitis and is not to be construed as a specific medical recommendation for any individual.  The information is provided without the benefit of a complete history or an examination.  Any decisions regarding diagnosis or treatment should be made in consultation with your personal physician who is best suited to make appropriate medical recommendations for you.

Fatigue is a common complaint of people with TM, but there have been very few investigations into this phenomenon.  It is the most common and most disabling symptom for many people with Multiple Sclerosis.  Despite many attempts to study fatigue in MS, we still do not completely understand its causes or how best to manage it.  However, it is worth looking at what is understood about MS fatigue for clues about how to understand and handle fatigue in TM.  We all use the term ‘fatigue’ to mean different things; and it is recognized that different types of fatigue exist in MS and, presumably, in TM.  Fatigue in MS has been defined as “A subjective lack of physical and/or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities.”

Some of the causes of fatigue in patients with disease of the central nervous system include: 1) weakness, 2) disturbed sleep, 3) medications, 4) depression, 5) nerve fiber fatigue, and 6) infection.  Any of these may occur simultaneously in the same person. 

Weakness 

Many people with TM have weakness of both legs ranging from complete paralysis to mild weakness with fatigability.  An example of motor fatigue would be the person who starts out walking with a fairly normal gait.  However, after they go a certain distance, fatigue kicks in and they start to have a foot drop or a limp.  Those with cervical cord involvement may also have arm weakness.  Fatigue may result from the extra energy required to compensate for this weakness in performance of daily activities.  One approach to minimize this fatigue is to use energy conservation principles and labor saving devices (e.g., motorized scooters).  Many people with TM can benefit from a therapy program of exercise to maximize physical conditioning.  Physical and occupational therapists are the best resources to help an individual look for ways to conserve energy in daily activities and improve conditioning.

Disturbed Sleep 

Many people with or without TM suffer from insomnia and otherwise disrupted sleep that may contribute to fatigue.  Problems that are more common in people with spinal cord injury that may contribute to poor sleep include spasticity, urinary frequency or incontinence, neuropathic pain, restless legs syndrome, and depression. 

Spasticity, or abnormal muscle tone, tightness and spasms due to injury of motor nerve fibers that descend in the spinal cord, may make it difficult to fall asleep or cause multiple awakenings at night.  Symptoms of spasticity may be improved with daily stretching exercises and medications to relax muscles such as Lioresal (Baclofen), Tizanidine (Zanaflex), Dantrolene (Dantrium), Diazepam (Valium) and Clonazepam (Klonopin).   The benzodiazepine class of medications that includes Diazepam and Clonazepam may be too sedating for daytime use for some people, but are great for controlling spasms at night and promote sleep.  Chronic benzodiazepine use is not recommended for simple insomnia, because it may have effects on the stages of sleep.  However, the relatively mild deleterious effects on sleep are overweighed by benefits in many patients with spasticity.

Some people with TM have a neurogenic bladder or abnormal bladder function from spinal cord injury that results in frequent need to get up and urinate during the night (nocturia) with disturbance of sleep.  This problem requires evaluation by a physician and may require referral to a urologist.  Several different bladder problems can occur with spinal cord injury.  One is a “spastic bladder” or an irritable bladder that contracts with even small amounts of urine, giving an inappropriate message that voiding is needed.  This increased urge to void can often be helped by medications such as Detrol and Ditropan.  Another type of voiding problem is the “hypotonic bladder.”  This bladder is “lazy” and does not contract until it is very full.  The person may get up and void only part of the bladder’s contents, because of the incomplete contraction of the bladder wall.  They then return to bed with a bladder that is already half full and have to repeat the voiding cycle several times during the night.  People with this type of bladder dysfunction often benefit from learning how to perform self catheterization of the bladder before bed to empty it completely, which often allows them to sleep through the night.

It is often difficult for people with TM to know which type of bladder problem they have.  Self-report of whether the bladder feels completely emptied is notoriously inaccurate in persons with spinal cord injury.  One simple procedure is to check the post-void residual or amount of urine left in the bladder after urination by either catheterization or ultrasound to see if the bladder is emptying completely during voiding.

Some people with TM have trouble sleeping because of neuropathic pain such as burning, aching, stabbing or shock-like sensations often in the legs or trunk.  These pains may become more distressing as the person lies down to attempt sleep and is no longer distracted by the activities of the day.  There are medications that can be tried for various types of neuropathic pain and these have been discussed in a previous edition of this newsletter.  Restless legs syndrome is a form of abnormal periodic limb movements that can disturb sleep.  In this disorder, the person has an uncomfortable sensation in the legs which is transiently relieved by moving the legs.  This disorder is common enough in the general population and appears to be increased in people with neurologic disorders such as MS.  It can be helped with certain medications.

Medications 

Many of the medications used to treat various symptoms experienced by people with TM may cause sedation and aggravate fatigue.  These include antidepressants, antiepileptic drugs that may be used to combat neuropathic pain, anti-spasticity medications, antihistamines, some blood pressure medications, etc.   It is reasonable to review your medication list with your physician for advice about medications that might contribute to fatigue and then have trials off or on reduced doses of suspect medications under physician guidance.  

Stimulants such as amantadine (Symmetrel), Pemoline (Cylert) and Modafinil (Provigil) have been used to treat MS fatigue with some benefit.  However, some would argue that pharmacologic treatment of fatigue may be more appropriate in MS because the brain is affected by this disease contributing to fatigue, whereas the brain is spared in TM.  There is little research in the area of fatigue and TM to guide us.  Amantadine is very cheap, but may cause confusion or nausea in some people.  There is a risk of liver injury with pemoline.  Modafinil is very effective in MS fatigue, but is still on patent and is very expensive. 

Depression

Depression can also contribute to disturbed sleep by causing difficulties falling asleep – often due to a tendency to ruminate over worries – and by causing difficulty with staying asleep during the night, including a tendency to wake up earlier in the morning than desired.  Depression is associated with the following symptoms:  sad mood, tearfulness, sleep disturbance, appetite changes, lack of motivation and feelings of guilt and poor self-worth.  Depression should be treated with antidepressants and/or psychotherapy.  Some antidepressants are more “alerting” or stimulating than sedating.  This should  be discussed with a physician if fatigue is prominent and treatment with an antidepressant medication is considered.

Nerve Fiber Fatigue 

This is an area of fatigue that we know about from studies of MS.  Some of these observations may be extrapolated to TM.  One of the primary types of tissue damage in MS is demyelination (or removal of myelin, the insulation of the nerve fibers).  When demyelination is present, the nerve fibers may conduct nerve impulses, but fatigue rapidly with heavy use and/or high body temperatures (from heavy activity, high environmental temperature such as a hot day or a hot factory, or fever).  Many people with MS cannot tolerate heat very well because of this phenomenon of nerve conduction failure.  In TM, there may be varying degrees of demyelination and/or injury to the underlying nerve fibers (axons) and it is not well documented what percentage of people with past TM have conduction failure typical of MS.  People with MS and this type of heat intolerance use simple measures such as air conditioning, cool drinks, and avoiding overheating and sometimes use cooling vests to help improve function in the heat.  

Infection 

Common infections such as viral respiratory tract infections (e.g., common colds and sore throats) and urinary tract infections (which are more frequent in people with spinal cord injury) may cause an increase in fatigue. 


The causes of fatigue in TM are complex and multifactorial.  In addition, fatigue is a very common complaint in the general population without TM or MS.  Consideration should be made of whether there could be other underlying illnesses that might contribute to fatigue such as hypothyroidism.   The treatment approach to reduce fatigue in TM should be multifactorial with emphasis on physical therapy and home exercise programs to increase conditioning and stamina, evaluation of sleep and medications, and treatment of depression if present.  There is no easy solution, but hopefully fatigue may be lessened by these approaches. 

References

1. Baum HM and Rothschild BB. Multiple sclerosis and mobility restriction.  Arch Phys Med Rehabil.  1983; 64(12):591-6.
   
2. Herndon RM. Fatigue in Multiple Sclerosis.  MS Connection (newsletter of National MS Society), March 2002, pp. 6-7.
   
3. Multiple Sclerosis Council for Clinical Practice Guidelines. Fatigue and Multiple Sclerosis: Evidence-Based Management Strategies for Fatigue in Multiple Sclerosis Monograph published by Paralyzed Veterans of America, 1998.
   
4. Svensson BB, et al. Endurance training in patients with multiple sclerosis: five case studies. Phys Ther. 1994; 74(11):1017-26.