Front Neurol. 2014 Sep 15;5:177. doi: 10.3389/fneur.2014.00177. eCollection 2014.

Management of fatigue in persons with multiple sclerosis.

Khan F1, Amatya B2, Galea M3.

Thanks Luz,it's a good review

Andrea,  May I suggest a couple article of interest that you may find helpful with pragmatic, clinical applications?  Journal of Rehabilitaion Research & Development (JRRD) Vol 48 Number 5,2011  Decreased Central fatigue in multiple sclerosis patients after 8 weeks of surface functional electrical stimulation.  Ya-Ju Chang, PhD, et.al.  This is an open source article and for further information Dr. Chang's email is [email protected]

An additional article of note is from J Rehabilitation Medicine 2009; 41:674-680.  Functional electrical stimulation-assisted cycling of patients with multiple sclerosis:  biomechanical and functional outcome-pilot study.  Johann Szecsi, MD, et.al.  which suggests that more significantly impaired MS patients may benefit to a greater extent from this type of intervention than those with less functional disability.  A problem as I see it with this study, despite its promising results is that the treatment period ws only 6 sessions total over two weeks.  Even in a health population, this is insufficient for physiological changes of any significance in muscle structure or physiology.  There were improvements in spasticity however that resulted in qualitative improvement in cycling performance.  Professionally, I have seen FES associated with cycling or applied for therapeutic exercise used to great effect to manage tone, with the secondary benefit of promoting better dynamic recruitment and motor coordination by diminishing the increase in tone of the antagonist in response to attempted activation of the primary mover. 

I have used the FES cycle described in the second article which has tremendous flexibility and utilization.  It is equipped with up to twelve FES leads that are programmed to time stimulation of select proximal to distal muscles with the cycling activity (for arms or legs) as well as the ability to use the stimulator as a stand alone for therapeutic and functional activities.  The stimulator has a wide range of pulse widths, amplitude and frequency settings that can be individualized for each patient and each stimulation target.  This unit also has the capacity to record and collect session data  discretely and longitudinally for quantitative analysis of performance over time.  The primary us of the cycle (and its development) was for individuals with SCI who would benefit physiologically from exercise, but who were unable to do so without FES and robotic support.  There is a considerable body of research and evidence of support for this type of intervention in that population.  Given the association of spinal cord pathology and disability among patients with MS, perhaps the broad literature for FES cycling in SCI has application in a number of ways to patients with MS.

Looking at devices not associated with cycling, you may want to check this article out; Neuromodulation. 2014 Jan;17(1):75-84; discussion 84. doi: 10.1111/ner.12048. Epub 2013 Apr 19.  A feasibility study to investigate the effect of functional electrical stimulation and physiotherapy exercise on the quality of gait of people with multiple sclerosis.  Taylor P1, Barrett C, Mann G, Wareham W, Swain I.   It is a nice crossover study that shows greater benefit of footdrop and gluteal stimulation for patients with unilateral footdrop who are functioning at a less disabled level that the patients discussed above.   In this study the addition of FES was shown to have added value compared to PT only. 

Additionally, single channel FES devices may have significant impact among the MS population who are higher functioning (Walkaide, BIoness L300, Odstock to name three) by providing timed sensorimotor stimulation for issues related to foot drip whether from primary motor weakness, decreased sensory input or dynamic recruitment and tonic issues. 

Hi Lisa and thanks a lot for your kind and detailed reply. The articles are interesting: FES plus exercise seemed to be a promising therapeutic option in MS patient. I agree with you, two weeks are really a short training period to gain physiological change in muscle tissue (nor in the neural tissue too). In Lieber (Skeletal muscle structure, function and plasticity) electrical stimulation seemed to make the muscle weaker even if the author admits that "the muscle [stimulated] generates more tension per unit activation energy, which would appear to be a good strategy if the goal is posture-type control" (Lieber, 2009 pag.144). In your experience have the patients treated with therapeutic exercise plus FES shown improvement in core stability muscle activation (i.e. they were able to maintain a position for a longer time)?

Fatigue seems to be equally improved by yoga and exercise,

yoga might be considered a treatment option for patients who are

not adherent to recommended exercise regimens.....Its worth trying.

Recently some evidence about efficacy of so called "alternative medicine" have been published as possibly effective in fatigue due to MS. Some interesting data associate Feldenkrais method with a good improvement of fatigue. 

In 2011 we published this work about efficacy on fatigue of a multidisciplinary intensive approach. Here you find this paper: