Chronic Fatigue Syndrome

Report
Chronic Fatigue Syndrome
an integrated approach
Dr Cannell
Midway Surgery St Albans
Royal London Homoeopathic Hospital
March 2004
My Interest and Background
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Aim of this Presentation
My work as a GP and Homeopathic Doctor
My work for the PCT
Cost to the country in 1998 £ 100M
Landmark in 2000: ‘Chief Medical Officer’
I recognise that CFS is a real entity. It is
distressing, debilitating, and affects a very large
number of people…
NICE has just been asked to report on CFS
The Doc and the CFS Patient ….
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The Doc
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‘Its all in the mind’..
A Heartsink? Not enough time?
The Patient …
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wants to be taken seriously
Needs positive help
Find professionals poorly understand it
Find gap in service provision
Factors in developing CFS
(RLHH Patient Survey)
Factor
No %
Possibly %
Definitely %
4.1
31.8
64.2
Continuing Infection
26.9
41.5
31.5
Work stress
22.5
33.1
44.4
41
28.8
30.2
Emotional stress
23.6
35.7
40.7
Food Allergy
23.1
52.2
24.6
Major life event
37.6
36.1
26.3
Hormonal disorder
40.2
45.9
13.9
Other allergy
35.7
47.6
16.7
Viral infection
Relationship stress
Better Prognosis
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(50% adults feel recovered after five yearsbut only 6% adults completely recover)
under 20y of age
have a definite history of mild viral or
infectious illness
symptoms less than 4 years
no severe muscle pains or neurological
symptoms
Worst Prognosis
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If previous psychological disorder
If following a severe infection, meningitis,
encephalitis, Hepatitis B vaccinations
if lack of social support, on going family or
financial problems
If treated by over-emphasising rest, too rapid a
return to work
If does not treat psychological or sleep
disturbances
Poor diet and nutrition
Chronic Fatigue Syndrome Intern.Definition
Major Criteria..must have all
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Severe Fatigue present > than six months
No other medical explanation
A reduced level of activity
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New and definite onset
Not life-long nor due to on-going exertion
Not substantially relieved by rest
Varies from day to day
Major ones plus 4 or more minor features–
that must not pre-date illness
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Short Term Memory impairment
Poor concentration ->reduction of activities
Painful Muscles and Joints
Post-exertional malaise (more than 24 hours)
Sore throats
Tender lymph nodes
Unrefreshing sleep
Headaches – new type or more severe
CFS: other common symptoms
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‘Flu-like symptoms
Visual disturbances
Light and Noise Sensitivities
Abdominal and digestive disorders
Balance disturbance
Chest pains, palpitations
“thermostat problems” (night sweats)
Low blood pressure
CFS: other common symptoms
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Atypical anxiety / depression
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But suicidal thoughts rare
Alcohol, drug & “chemical” intolerances
?? fibromyalgia and chronic
hyperventilation, Irritable bowel syndrome,
hypoglycaemia
Differential diagnosis of CFS
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adrenal insufficiency, thyroid disease
anaemia, (iron, B12, folate)
chronic infections, immunodeficiency states
coeliac disease and food intolerances
auto-immune
malignancy, leukaemias
myasthenia gravis, multiple sclerosis,
mood disorders, depression, occasionally dementia, somatisation disorders,
primary sleep disorders,
rheumatic diseases,
Exclude drug and substance abuse, organo-phosphates toxicity,
Theoretical Mechanisms
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Hypothalamic- Pituitary- adrenal axis
Autonomic system, control of endocrine
function and biological rhythms
Modified immune responses
“Cell Membrane” Ion channels – viruses &
toxins effect
?? synaptic sensitivity to neurotransmitters
KEYNOTE: Check these but usually
normal
Sometimes ….
 Leucopenia
 Raised ESR
 Abnormal RBC morphology (MCV)
 Abnormal LFTs (ALT, AST)
 Thyroid: lowish T4 & TSH
 Thyroid & gliadin antibodies
Useful to check
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Ferritin and Urine!!!
Other auto-antibodies ANA
Anti-viral titres, EBV AB’s serology
Hep A B C Abs
immunological profiles
CFS: other research findings
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Minor ECG & EEG changes
Cerebral & cardiac SPECT scans
31P NMR oxidative metab. in muscle
 hypothalamic-pituitary-adrenal axis
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Low urinary free-cortisol (cf. depression)
Blunted ACTH response to CRH
Increased Synacthen response
Evidence for Treatment of CFS
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Beneficial
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Pacing / Graded Exercise
Cognitive Behavioural Therapy (CBT)
Unknown
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Antidepressants on their own
Corticosteroids / Thyroxine / HRT
Dietary supplements, Melatonin ?NADH?
Homeopathy (recent promising trial)
Acupuncture / osteopathy / massage
Homeopathy and CFS
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Two interesting cases of mine
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Older woman in our PCT seen privately
Young violinist seen at RLHH
Some preliminary evidence for homeopathic
approach
CFS – A Team approach
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RLHH team led by Dr Jenkins
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Clinician, Nurse specialist
Occupational Therapist, Physiotherapist Dietitian
….not yet ..Autogenic Trainer / Cognitive Therapist
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Our PCT Bid for a local team
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Lifestyle Management (LSM)
Role of the Nurse Specialist, based on CBT / Graded Exercise/ Pacing
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6 x 1hr appointments (approx. monthly)
 Pacing advice
 Activity diaries and scheduling
 Energy conservation
 Relaxation
 Management of sleep problems
 Longer term target setting
 Coping with setbacks
Patient assessment of Treatment
Strategies
(RLHH small study of 20 patients)
Treatment
Worst
<<
%
<
%
Same
0
%
Lifestyle Manage.
0
0
8.7
Homeopathy
0
5
35
35
25
0
Antidepressants
0
25
0
25
20
20
Exclusion diet
0
9.5
19
>
%
Best
>>
%
34.8 56.5
14.3 14.3
N/A
%
0
42.9
Work & social adjustment Scale
and CFS (RLHH)
36
35
34
33
Base
Post LSM
1 year
32
31
30
29
(.026) (.036)
Patients with CFS
Nutritional assessment
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Low intakes Ca, Fe, Zn, Vit. D
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lower RBC Mg, serum Zn, Vit B1
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adequate Mg intakes with low RBC Mg
CFS: Supplements
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Zinc? Everybody probably low
Magnesium? No evidence
Vit B12, folate? Poor evidence
Vitamins B1, B2, B6? some evidence
EFA? Some evidence
Anti-oxidants? Some evidence
NADH? Little evidence
Co-Enzyme Q10 ??
CFS: Multi-interventions
For supplements alone
 One positive RCT
 One RCT negative study, positive trend
For RCT of multi-pronged of individualised Rx v placebos
..positive outcome on QoL scores
 Mixed group of CFS and fibromyalgia
 Hormones, multivitamins / minerals + Magnesium
 Targeted extra supplements
 Antidepressants, sedatives, herbal treatments
CFS Organisations
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Westcare UK Residential, 155 Whiteladies Road, clifton,
Bristol. Tel 0117 923 9341
ME Association 4 Corrington Rd, Stanford-le-hope Essex
Tel 01375 642466
Action for ME, PO Box 1302, Wells Somerset Tel 01749
670799
National ME Centre Harold Wood Hospital Harold Wood
Romford Essex
Association of Youth for ME PO Box 605 Milton Keynes Tel
01908 373300
Tymes 9 Patching Hall Lane Chelmsford Essex
Tel 01245 263482
Information for Presentation
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Task force report on CFS / ME September 1998.
A report of the CFS / ME working group. CMO Jan 2002
Effective Health Care. Interventions for the management
of CFS / ME University of York NHS Centre for reviews and
dissemination
Proposal for a West Herts Adult CFS Service. (April 2002)
Guidance on the management of C.F.S / M.E. (for GPS)
Action for M.E. PO Box 1302, Wells, Somerset.
Chronic Fatigue Syndrome ..the facts Oxford university
Press 2000
Dr Weatherly-Jones PhD Randomised controlled triple
blind study of efficacy of homeopathic treatment for
C.F.S. (MRC Grant) proceedings of ISHTAC Conference
2001 Philadelphia
Awdry R . Homeopathy may help ME. Int Journal Alternat
Complement Med 1996. 14: 12 – 16

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