Transcript Chronic Fatigue Syndrome

2007
CHRONIC FATIGUE SYNDROME
Facts
 Common illness
 Prevalence = 4/1000 population
 As disabling as MS, SLE, RA and other chronic
diseases
 Complex range of symptoms
 Cause and disease process not understood
 Skill full management can improve
functioning
Symptoms
 Fatigue
 New or had a specific onset
 Persistent or recurrent
 Unexplained by other conditions
 Caused reduction in activity characterised by post
exertional fatigue which is delayed by at least 24
hrs with slow recovery over several days
Symptoms
 Fatigue and one of more of the following
 Sleep disturbance – insomnia, hypersomnia, un-
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refreshing sleep, disturbed sleep wake cycle, xs
REM sleep.
Muscle/joint pain
Headaches
Painful lymph nodes without pathological
enlargement
Sore throat
Symptoms
 Fatigue +
 Cognitive dysfunction – difficulty thinking,
inability to concentrate, impairment of short term
memory, difficulties with word finding, planning
organising thoughts, and information processing.
 Physical or mental exertion makes symptoms
worse
 Dizziness
 Palpitations not due to CVS disease
Symptoms
 Fluctuate in severity
 Change over time
 Often associated with prolonged stress
 Often follow a boom and bust cycle
 Deconditioning occurs - loss of physical
fitness as physiological response to
prolonged inactivity
Diagnosis
 Beware red flag features
 Localising or focal neurological signs
 Signs and symptoms of inflammatory arthritis or
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connective tissue disease
Signs and symptoms of cardiovascular disease
Significant weight loss
Sleep apnoea
Clinically significant lymphadenopathy
Investigations
 Arrange following investigations
 Urinalysis – protein, blood, glucose
 FBC, ESR, C reactive protein
 U&E’s, serum Creatinine, LFT’s, TFT’s
 Random blood sugar
 Screening test for gluten enteropathy
 Creatinine kinase
 Serum ferritin children and young people only
Investigations
 Use clinical judgement on additional tests to
exclude other diagnoses
 Do not do
 Ferritin, B12, folate in adults unless anaemic or
abnormal MCV
 Serological testing for viruses/bacteria unless
indicated
Diagnosis
 A diagnosis should be made after other
possible diagnoses have been excluded and
the symptoms have persisted in
 An adult for 4/12
 A child for 3/12
 The diagnosis in a child should be confirmed
by a paediatrician
 Advice on symptom management need not
be delayed until diagnosis established
Diagnosis
 Reconsider diagnosis if patient
has none of
 Post exertional fatigue
 Cognitive difficulties
 Sleep disturbance
 Chronic pain
Diagnosis
 When taking history look for
 Initial pattern of illness
 Precipitating causes
 Factors that perpetuate the fatigue
 Xs physical activity
 Xs cognitive activity
 Noise
 Conflict/stress
 Anxiety
Stages
 There are 3 different stages in the
natural course of CFS
 Acute illness
 Maintenance or stabilisation
 recovery
Definition
 Mild CFS
 Mobile
 Can care for themselves
 Can do light domestic tasks
 Still working or in education
 Have stopped all leisure pursuits
 Often need days off work/school
Definition
 Moderate CFS
 Reduced mobility
 Restricted in all activities of daily living
 Stopped work or education
 Need rest periods
 Sleep is poor quality and disturbed
Definition
 Severe CFS
 Unable to do any activity for themselves
 Or can carry out minimal daily tasks
 Severe cognitive difficulties
 Depend on wheelchair for mobility
 Often unable to leave house
 Often spend most of their time in bed
 Extremely light and noise sensitive
Referral
 Offer referral
 Within 6/12 of presentation to people with mild
CFS
 Within 3-4/12 of presentation to people with
moderate CFS
 Immediately to all people with severe CFS
General Management
 Key elements
 Work in partnership with the person
 Identify and manage symptoms early
 Make an accurate diagnosis
 Consider alternative diagnoses
 Managing severe CFS is difficult and complex ad
requires specialist advice
General Management
 Sleep management
 Illness will not improve while there is sleep
disturbance
 Advise on good sleep hygiene
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Only sleep in bedroom
Regular bedtime and getting uptime
No day time sleeps
No stimulants prior to bedtime – food, drink,
activities
 Amitriptyline 10mg increase by 10mg every 2 weeks
till 30 – 50mg
General Management
 Rest periods = not engaged in physical or
mental activity
 Alternate activity periods with rest periods
 Limit to 30mins per time
 Several per day
 Quiet room, eyes closed, muscles relaxed but not
asleep
 No disturbance
General Management
 Diet
 Well balanced nutritional diet
 Include slow release starchy foods
 Not in NICE
 May tolerate hypoglycaemia poorly aggravating
symptoms so need to eat every 3-4 hrs
 Manage nausea conventionally – eat little and
often, snack on dry starchy foods, sip fulids
 Exclusion diets not recommended
Management
 Mild to moderate CFS
 Activity management
 Goal orientated person centred approach
 Activities have physical, emotional and cognitive
components
 Diary that records cognitive and physical activities,
rest and sleep – establishes a base line to work from
 Gradual increase activity above baseline
 Have a variety of different activities, sleep and rest
Management
 Mild to moderate CFS
 Activity management
 Spread out difficult or demanding tasks over several
days
 Split activities into small achievable tasks
 Goal setting, planning and prioritising activites
Management
 Mild to moderate CFS
 CBT
 Delivered by health care professional trained in CBT
and experience in CFS
 One to one if possible
 Graded exercise therapy GET
 Delivered by healthcare professional trained in GET
and experienced in CFS
 One to one
Management
 Severe CFS
 Refer to specialist services
 Individually tailored activity management
program
 Delivered at home, by telephone, or email
 Drawing on principles of CBT, GET and activity
management.
 Occasionally inpatient assessment and treatment
Detrimental strategies
 Do not use
 Unstructured or vigorous exercise
 Specialist management programs offered by
practitioners with no experience of the condition
 The following drugs
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MAOI’s
Glucocorticoids
Dexamphetamine
Methyphenidate
Thyroxine (Prof Findley does)
Antiviral agents