in Persons with Multiple Sclerosis]

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1 Faculty BARBARA S. GIESSER, MD Professor of Neurology Vice Chair, Education and Clinical Affairs, Neurology David Geffen School of Medicine University of California, Los Angeles Instructor Bio Barbara S. Giesser, MD is a neurologist at the David Geffen School of Medicine at the University of California, Los Angeles. Dr. Giesser is a graduate of the University of Texas Medical School at San Antonio and has been specializing in caring for persons with MS since Course Overview Fatigue is the most commonly reported symptom in person with Multiple Sclerosis. It interferes with sustained usual function, and is a significant cause of loss of employment and disability in otherwise unimpaired persons with MS. Additionally, contributing factors, such as other symptoms due to MS and co-morbidities can contribute to and worsen primary MS fatigue, and need to be addressed as well. Despite its prevalence, primary MS fatigue is often under recognized and treated in the MS population. This course includes information about the presentation and mechanisms of MS fatigue, as well as treatment strategies for both primary MS fatigue and contributing factors. This NeuroLearn course is designated for a maximum of 1 AMA PRA Category 1 Credits. Course Learning Objectives As a result of this program the learner will be able to identify fatigue in persons with MS, distinguish between primary and secondary causes of fatigue, and implement effective management for this symptom. Specifically: Identify fatigue in persons with MS Distinguish between primary and secondary causes of fatigue Implement the appropriate management for fatigue in persons with MS 1

2 Course Elements Element 1: Recognizing Primary Fatigue At the end of this learning element, the learner will be able to identify primary fatigue in persons with MS. Element 2: Treatment of Primary Fatigue At the end of this element, the learner will be able to treat primary fatigue in MS considering both pharmacologic and nonpharmacologic methods. Element 3: Secondary Fatigue: Iatrogenic Causes At the end of this learning element, the learner will be able to identify and address iatrogenic causes contributing to secondary fatigue in patients with MS. Element 4: Secondary Fatigue: Depression At the end of this learning element, the learner will be able to identify and address depression as a contributing factor to secondary fatigue in patients with MS. Element 5: Secondary Fatigue: Sleep Disturbances At the end of this learning element, the learner will be able to identify and address sleep disturbances as a contributing factor to secondary fatigue in persons with MS. Element 6: Secondary Fatigue: Pain At the end of this learning element, the learner will be able to identify and address pain as a contributing factor to secondary fatigue in persons with MS. Element 7: Secondary Fatigue: Lifestyle Modifications At the end of this learning element, the learner will be able to identify the role of nutrition and exercise as contributors to secondary fatigue in persons with MS and recommend lifestyle modification strategies. Resources Fatigue: What You Should Know A Guide for People with MS Patient Health Questionnaire (PHQ-2) 2

3 References Andreasen A, Jakobsen J, Petersen T and Andersen H. Fatigued patients with multiple sclerosis have impaired central muscle activation. Mult. Scler 2009; 15: Beck AT, Steer RA, Brown G. BDI-Fast Screen for medical patients Manual. 2000; San Antonio, TX. The Psychological Corporation. Braley, T & Avidan, A. Sleep disorders in MS. In: Primer on MS, Barbara Giesser, Ed. Oxford University Press, NY 2011; pp Braley, T & Chervin, R. Fatigue in MS: mechanisms, evaluation & treatment. Sleep 2010; 33 (8): Chwastiak L, Ehde D, Gibbons L et al. Depressive symptoms and severity of illness in MS: Epidemiologic study of a large community sample. Am. J. Psych 2002; 159: Filippi M, Rocca M, Columbo B, et al. Functional MRI correlates of fatigue in MS Neuroimage 2002; 15: Fisk JD, Pontefact A, Ritvo PG et al. The impact of fatigue on patients with MS. Can. J. Neurologic Sciences 1994; Goldman Consensus Group: The Goldman Consensus statement on depression in MS. Mult Scler 2008; 11: Goodin D. Survey of MS in northern California. Northern California MS study group. Multiple Sclerosis 1999; 5(2): Kos D, Kerckhofs E, Nagels G, et al. Origin of fatigue in MS: review of the literature. Neurorehab. & Neur. Rep 2008; 221(1): Kroenke, K., Spitzer, R.L., Williams, J.B. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med. Care 2003; 41: Krupp L, Alvarez L, LaRocca N, Scheinberg L. Fatigue in MS. Arch Neurol 1988; 45: Krupp L, LaRocca N, Muir-Nash J, Steinberg A. The Fatigue Severity Scale: Application to patients with MS and SLE. 1989; Arch. Neurol. 46(10): Lange R, Volkmer M, Heesen C, Liepert J. Modafinil effects in multiple sclerosis patients with fatigue. J Neurol 2009; 256(4): Minden S, Schiffer R. Affective disorders in MS:Review and recommendations for clinical research. Arch. Neurol 1990); 47: Moulin, DE, Foley, KM, Ebers GC. Pain syndromes in MS. Neurology 1988; 38: MS Council for Clinical Practice Guidelines. Fatigue & MS: Evidence based management Strategies for Fatigue in MS. Washington DC PVA (1998). Namerow, N. Multiple Sclerosis and Pain. In: Primer on MS, Barbara Giesser, Ed. Oxford University press 2011; pp

4 Pellicano C, Gallo A, Li X, et al. Relationship of cortical atrophy to fatigue in patients with MS. Arch Neur 2010; 67(4): Pucci E, Branas P, D Amico R, et al. Amantadine for fatigue in MS. Cochrane Database Syst. 2007; Rev. CD Roelcke l, Kappos L, Lechner-Scott J, et al. Reduced glucose metabolism in the frontal cortex and basal ganglia on MS patients with fatigue. Neurology 1997; 48: Sadnovick AD, Eisen K, Ebers G, et al. Causes of death in patients attending MS Clinics. Neurology 1991; 41(8): Sachiffer R, Weitkamp L, Wineman M et al. MS and affective disorder: family history, sex and HLA-DR antigens. Arch. Neurol 1988; 45: Schwartz C, Coulthard-Morris L, Zeng Q. Psychosocial correlates of fatigue in MS. Arch. PM & R. 1996; 77(2): Smith MM, Arnett PA. Factors related to employment status changes in individuals with multiple sclerosis. Mult Scler 2005; 11: van de Beek, M, et al. A Woman with multiple sclerosis and pink saliva. The Lancet Neurology 2003; 2(4): Van der kamp W, Maertens de Noordhout A, Thompson, A, et al. Correlation of phasic muscle strength and corticomotorneuron conduction time in MS. Annals of Neurology 1991; 29: Vucic S, Burke D, Kiernan M. Fatigue in MS: mechanisms and management. Clin. Neurophys 2010; 121: Wingerchuk D, Benarroch E, O Brien P, et al. A randomized controlled crossover trial of aspirin for fatigue in MS Neurology. 2005; 64(7): Zorzon M, de Masi R, Nasuelli D, et al. Depression and anxiety in multiple sclerosis: a clinical and MRI study in 95 subjects. J Neurol 2001; 248(5): Accreditation Statement The American Academy of Neurology Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. American Medical Association Physician Recognition Award : The AAN designates this educational activity for the AMA PRA Category 1 Credits designated with each course. Physicians should claim only those hours of credit that they actually spend in the educational activity. The American Board of Psychiatry and Neurology (ABPN) has reviewed and approved this program as part of a comprehensive CME program, which is mandated by the American Board of Medical Specialties (ABMS) as necessary components of maintenance of certification (MOC). 4

5 Date of Release July 13, 2012 This course is eligible for CME credits for three years from the release date. Registration includes twelve months access to the course. Course access is available at in the My Courses tab upon registration. Contact the NeuroLearn Program: Phone: URL: 5