chronic fatigue syndrome 2010 caoe cod

8/8/2019 Chronic Fatigue Syndrome 2010 Caoe Cod

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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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http://www.cdc.gov/cfs/cme/

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chronic fatigue syndrome 2010 caoe cod

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