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ChronicFatigue
Syndrome
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Common psychologicalcomplaints:
D epression 25% of CFS suffer depression 50-75% have had depression in their lifetime CFS is not depression
IrritabilityAnxietyPanic attacks
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E xcluded diagnoses in research studies
O rgan failure : emphysema, cirrhosis,renal/cardiac disease
Chronic infections : AI D S, hepatitis B or CRheumatic/chronic inflammatory disease :SLE , RA, I B S, chronic pancreatitis
Neurological disease : M S, epilepsy, stroke,head injury, neuromuscular disease
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Not excluded, but must be resolved before CFS diagnosis made:
depressionanorexia/bulimiaalcohol/substance dependence
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Clinical PearlT he telltale symptoms of CFS are profound exhaustion and post-exertional malaise ;
significant muscle, joint, or headache pain ;cognitive dysfunction ; and slee p disturbanceT he occurrence of comorbid depression does notrule out a diagnosis of CFSM ore than half of CFS patients become depressedat some point in the course of the illness
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Background
First reported early80s
T hought to besecondary to E BV infection
D efined 1988following C D Cstudies in InclineV illage, N V
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CFS: E pidemiology in U.S.
2.5% of the population aged 18-59 yearsmeet CFS criteria (C D C data)
At least as common among AfricanAmerican and Hispanic patients as it isamong the white populationM ore common in lower-incomeAnnual economic impact of CFS in theUnited States is $18 to $24 billion in lost
productivity, medical costs, and disability benefits
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T o make things more confusing
T ens of millions with fatigue whodo not meet all of the criteria10-25% of general practice patientsc/o prolonged fatigue
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Impact
Average family loses $20k/year D isability comparable toCO PD , RA, M S
25% unemployed or receivingdisability benefits
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Impact
Patient: feels traumatized/stigmatized-need to justify the illnessE mployment : frequent absences, errorsdue to cognitive problems, others feelthey are fabricating the illness
Family/friends : frustration, anger Children: fear parents impendingdemise
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CFS: Immunological Findings
Immune system is up-regulated & commonfindings in CNS include
Increased immunoglobulin G (IgG) and viralcapsid antigen ( V CA) E BV levelsE levated coxsackievirus B , human herpes
virus 6 (HHV
-6), and/or C pneumoniae titersD ecreased percentage of natural killer (NK)cells
Increased levels of cytokines
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CFS: O ther Findings
Neuroendocrine: low cortisol in somestudies
Autonomic dysfunction- association between CFS and orthostaticinstability (Rowe et al, 1995)
not substa ntially co nf irmed Positron emission tomography(PE T ) scans show hypoperfusion inthe frontoparietal/temporal region
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CFS: O ther Findings
D isorder of gene expression?(V ernon et al, 2002): 8 genes expressed
differently in CFS patients looked at peripheral blood mononuclear cells Several involved immune functionKaushik et al (2005): 35 genes involved 16 suggesting T cell activation and changes in
neuronal and mitochondrial function
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General consensusM any factors play a roleHit and run trigger event(stress, virus) disrupts normalimmune/endocrinefunctioning
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O bstacles to clinical care
Is CFS real? 3000 research studies confirm it O ccurs worldwide- research in Japan, United
Kingdom, Israel, Australia, France, ItalyHow to diagnose? Internationally accepted case definitionD
oes diagnosis contribute to illness? V alidation has therapeutic valueHow to treat? Focus on symptoms and functioning
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D iagnostic Considerations
D iagnosis of CFS is one of exclusionB ased on unexplained fatigue for more than 6months accompanied by cognitive dysfunction No clinically available diagnostic tests or laboratory markers for CFSE xtensive immunological testing is notindicated since it is neither diagnostic nor specific for CFSSimilarly, R B C magnesium levels and allergytesting, particularly serological tests for Candida are of no value
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Clinical E valuation
M ost often presents as either acute or gradual onset of fatigue over a period of a
few months
An abse nce o f cog nitive di ff icultiesexcludes a diag nosis of CFS
T rigger points, which suggestfibromyalgia are absent in CFS,although
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35-70% have FibromyalgiaWidespread pain in all 4 quadrants for atleast 3 months11/18 tender pointsfatigueSleep problemsIB S SSxfibro fog
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Clinical E valuation
M ost common abnormalities present onPE are left axillary node involvement
and/or crimson crescents (reddenedanterior tonsillar pilars in the oropharynx)in the absence of pharyngitis
Small, moveable, painless lymph nodes inthe neck, axillary region, and/or inguinalregion also common, but generalizedadenopathy or a single, very large, tender,
or immobile lymph node suggests a
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D ifferential D iagnosis
M ononucleosis Sleep disorders
Lyme disease, infection T hyroid conditions (hypo) D iabetes Hypertension O besity
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D ifferential D iagnosis
Recent pregnancy/childbirth,menopause
M ultiple sclerosis Cancer, s/p recent surgery D epression, B ipolar disorder Chronic diseases- heart failure E ffects of medications/supplements
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Lab testsU se presenting sym ptoms to guidechoicesU/A, CB C with diff
E SR, C-reactive proteinALT (alanine aminotransferase), AS T
(aspartate transaminase), alkaline phosphataseB un, creatinine, electrolytes
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Remember
Not everything may be attributableto CFS! E specially since it can wax and wane
in severityLook for, and treat, comorbid
conditions (IB S, multiple chemicalsensitivities, TM J)
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T reatment:
Symptom relief + improved function1. Lifestyle changes
Prevent overexertion (activity/rest = 1/3)
Reduce stress D ietary restrictions
2. Carefully supervised physical activity Gentle stretching M oderate approach to prevent deconditioning
3. Nutritional supplementation (very common)4. Alternative therapies
5. M edications
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Initial goals
NOT complete restoration of pre-illness functioning
Rather, manage the symptomsHave realistic expectations
O ptimize health,leading to fewer SSx.
No single approach works for everybody: I ndividualized treatme nt isimporta nt !
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1. Lifestyle
Changes
D iet: establish a well balanced diet(avoid weight gain), and try toeliminate food/chemical sensitivitiesChange ones outlook (goal of C B T )
Understand, and adapt to, illness Change beliefs and behaviors that
contribute to symptoms
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New outlook:T hink slow, gradualAvoid push/crash
Avoid extremes of under/over activity,(deconditioning and post exertional malaise)T hink in terms of graded activity and exertion Start slow, intermittent, brief T hroughout the day (rather than all at once) Followed by restD evelop sense of control and self /energy
efficiency
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E nergy M anagement!
E nvelope T heory You have a finite amount of energy
M anage it wisely!Pace yourself Pace yourself: small, manageable portions
D ont forget to deal with feelings! Self criticism: Guilt, Im lazy Fear of not getting better fast enough
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O ther issuesCognitive dysfunction organizers, schedules, written resources
Stimulate mind with puzzles, word/card games Avoid stimulants (precipitates push/crash )D epression, family issues : counseling/ C B T
Support Support groups (www.cdc.gov/cfs/cfssupport.htm) E mpathy: not mentally ill, suffering is real
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Sleep
D eprivation exacerbates fatigue, H/A, joint pain, impaired cognition
Consult with sleep specialistT ry sleep hygiene measures first Light exercise and stretching 4 hours before bedtime
Sleep meds may make problem worse
Start withO T
C, antihistamines
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Pain
Simple analgesics ASA, T ylenol, NSAI D s
Cool/hot packsM editation, Relaxation, D eep
breathing, B iofeedback Narcotics as last resort
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2. Physical ActivityInitial goals very limited Maintain flexibility Minimize deconditioning Develop ability to accomplish ADLs Stevens (2004): after 5-12 minutes on treadmill,
75% of untreated CFS patients took 3 days torecover
Ultimately, one increases exercise toleranceover time
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M ust u ndersta nd:
Gradual exercise will resultin improvement (eventually)O verdoing it will result insymptoms (quickly)
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Starting E xercise:
Sitting/standing, toe raises: 2-4 reps, building to 8Simple stretching, using body weight asresistanceResistance/weights can be slowly added
Goal is increase strength and range of motion, leading to improved ability to doAD Ls
R est 3 x longer than exercise
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Subsequent E xercise:
Light aerobic exerciseWalking, cycling1-3 minutes, several times dailyIncrease duration by 1-5 minutes per week T olerance develops over ensuing 2-6months
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3 . Nutritional supplementation
Studies are inconsistent, although patients frequently report benefitsB 12, C, CoQ10, E ssential FattyAcidsAvoid comfrey, germander (liver toxic),ephedra ( M I, stroke, death), kava, bitter orange (H T N), licorice root (low K),yohimbine (tachycardia, H T N)
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Phyllis B alch: P rescriptio n f or Nutritio nal Heali n g (2006)
(7 million copies sold!)
Acidophilus - for friendly bacteria
Coenzyme Q10 - 75 mg .-enhances immunesystemE ssential fatty acids (fish oil)- 2 gm . dailyM agnesium - 1 gm .- increases energyProteolytic enzymes - 6 times daily - reducesinflammation- promotes nutrient absorption
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V itamins
A- 10k-25k units - enhance immunefunctionB complex injections- 2cc/week -increased energyC- 5k-10k mg .- increases energy
E - 100-200 IU - free radicalscavenger- fights viruses
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H erbs
Astragalus, E chinacea - enhanceimmune functionFresh black walnut hulls, garlic,gentian root, fresh ginger root - rids
body of parasitesGinkgo biloba - improve circulationand brain function
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Colloidal silver- to fight infections
but not too much
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Yoga, Tai
Chi
action in inactionGentle stretchingIncreases balanceand enduranceCombine withdeep breathingto enhance relaxation
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H ydrotherapyUchee Pines Institute,AlabamaRaise body temp. to 1025-45 minutes dailyFill tub with warm water,
sit, add hot water (asmuch as tolerated)Wait
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5 . Medications
Non pharmacological approaches first E specially for pain and sleep
M any meds helpful, but watch for sideeffectsStart with low doses
avoid causing fatigue or sedation many patients are very sensitiveP atie nce/persiste nce, not pills!
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CFS: Clinical Course
Clinical course and symptom severity arehighly variableFrequent alterations between periods of illnessand relative well-being are commonSymptom complex often changes over timeCD C studies found that 40% to 60% report
partial or total recoverySome evidence indicates that the sooner a
patient is treated, the better the chance of improvement
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D elays in diagnosis
and treatmentassociated with poorer
long term outcomes
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CD C research: CFS for two years
or less are more likely to improveT he longer the person is ill, the morecomplicated the course of illnessImprovement rates 8-63% in 2005reviewM edian 40% improve during follow-up5-10% achieve full remission
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2 free C M E credits!
http://www.cdc.gov/cfs/cme/
Select CourseT
wo: WB
1032Scroll down to bottom of pageClick here to read course content, or
www.cdc.gov/ T CE O nlineRegister
T ake the exam!
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