Chronic Fatigue SyndromeFibromyalgia SimilaritiesDifferencesOverlap

1
Chronic Fatigue Syndrome/FibromyalgiaSimilarities
-Differences-Overlap

• Kenneth J. Friedman, Ph.D.
• Associate Professor of Pharmacology and
  Physiology
• New Jersey Medical School
• Newark, NJ 07103

Prepared for the Everglades AHEC
April 11, 2008
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Disclosures for Dr. Friedman

• New Jersey Chronic Fatigue Syndrome Association
  Board Member and Chair of Medical Student
  Scholarship Committee
• P.A.N.D.O.R.A. Secretary, and Chairman of Public
  Policy Committee
• Vermont CFIDS Association Member
• Consultant to MedaCorp provide advice and
  expertise to unknown clients
• Consultant to Hemispherex limited to public
  policy not drug development

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Part I Chronic Fatigue Syndrome
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CFS Case Definition and Criteria

• A CFS patient must have
• Persistent or relapsing fatigue of 6 months or
  longer duration
• Fatigue severity significant enough to greatly
  reduce activities of daily living
• All other known medical conditions excluded by
  clinical diagnosis

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CFS Case Definition and Criteria

• All of the above and concurrently have four or
  more of the following eight symptoms

• Post-exertional malaise lasting more than 24
  hours
• Unrefreshing sleep
• Impaired memory and concentration
• Muscle pain
• Multi-joint pain without redness or swelling
• Headache of a new type or severity
• Sore throat
• Tender cervical or axilliary lymph nodes

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Political History of CFS

• CFS was formally defined in 1988
• CFS is known by other names CFIDS, ME, Myalgic
  Encephalitis, Myalgic Encephalopathy, ME/CFS,
  CFS/ME
• Comparable illnesses have been documented for
  centuries

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Cause/Contributing Factors of CFS

• The cause of CFS is unknown.
• Epstein Barr Virus was at one time thought to be
  the cause.
• Research has shown this to be false
• EBV appears to be precipitate/trigger CFS in some
  patients.
• Not all CFS patients have or had EBV

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Possible Contributing Factors

• Infectious agents
• Immune System Dysfunction
• Sleep disorders

• Dysautonomias
• Neuroendocrine Dysfunction
• Other possible causes

• Current theories
• Multiple factors may be involved
• Final common pathway

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What is CFS?

• Is CFS

• a syndrome?

• a disease?

• an illness?

• a disorder?

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Myths vs.Facts

• Because of the controversial nature of CFS, a
  number of myths surround it. Three of the most
  common myths are

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Fact or Myth?

CFS is a relatively rare disorder.
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MYTH !
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CFS Prevalence

• CFS affects approximately 200-500 per 100,000
  adults
• An estimated 18 of those classified as having
  CFS have been diagnosed by a health care
  professional (CDC)

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Fact or Myth?
The highest prevalence of CFS is among
middle-aged, affluent, white, professional women.
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MYTH !
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CFS Prevalence

• CFS is most common among women between 40-54
  years of age
• CFS is at least as common among black and
  Hispanics as among white women
• Persons of middle-income status are at the
  greatest risk

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CFS Prevalence

• Race
• All races need to be carefully evaluated
• Gender
• Women have a much higher rate of CFS than men
• A ratio of 31

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CFS in the Pediatric/Adolescent Population

• Limited data on this population.
• Pediatric/adolescent CFS prevalent rate appears
  to be lower rate than in adults.
• Newly published pediatric/adolescent CFS case
  definition relaxes some of the more stringent
  adult criteria.

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Fact or Myth?
CFS is a form of depression.
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MYTH !
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CFS and Depression

• CFS and Major Depressive Disorder (MDD) have many
  symptoms in common.
• Both can be overlooked easily.
• Careful evaluation is required.

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CFS and Depression

• Depression is an
• illness that
• MUST
• be diagnosed and treated.

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Differentiating CFS from Depression

• Depressed patients are capable of physical
  activity but lack the motivation.
• CFS patients have the motivation for physical
  activity but lack the capability.

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Diagnosis of CFS

• The diagnosis of CFS
• is primarily one of
• EXCLUSION

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Diagnostic Procedure for CFS
Fatigue

• Symptom Driven Evaluation
• History Physical findings
• Psychological and Neurological examination
• Exclusionary lab tests

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Diagnostic Procedure for CFS
Meets 4 of the 8 Symptom Criteria
1. impaired memory or concentration 2. sore
throat 3. Tender cervical or axillary lymph
nodes 4. muscle pain 5. Multi-joint pain 6. New
headaches 7. Unrefreshing sleep 8.
Post-exertional malaise
No Plausible Explanation
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Diagnostic Procedure for CFS
No Plausible Explanation
Chronic Fatigue 6 months

• Chronic Fatigue
• 6 months

• Provide appropriate treatment
• Reevaluate at appropriate intervals

Significantly affects daily activities and work
No significant impact
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Diagnostic Procedure for CFS
Satisfies 4 or more of the 8 secondary CFS
criteria
Diagnosis of CFS
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Diagnostic Procedure for CFS

• See Appendix for
• Unique aspects of medical history and physical
  examination of CFS patients.
• Recommended laboratory tests and additional
  testing.

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Diagnostic Challenges 1

• Patients with CFS often have a relatively normal
  physical examination
• A diagnosis of CFS cannot be made without a
  proper psychological evaluation

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Diagnostic Challenges 2

• There are plausible explanations of fatigue that
  preclude a CFS Diagnosis
• Narcolepsy
• Sleep Apnea
• Iatrogenic e.g. medication side effects.

• Chronic active hepatitis B or C
• Hypothyroidism

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Diagnostic Challenges 3Conditions with Chronic
Fatigue Symptoms

• Lupus erythematosus
• Lyme disease
• Multiple sclerosis
• Rheumatoid arthritis

• Severe obesity
• Tuberculosis
• Nutritional deficiency, e.g., fad diets,
  supplement use

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Diagnostic Challenges 4 Psychological Issues

• Several psychological illnesses resemble CFS and
  are exclusionary for CFS
• Exclusionary psychological conditions listed in
  appendix.

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Diagnostic Challenges 5Abnormal Patient Reports
and Behavior

• Psychomotor slowing
• Cognitive impairment
• Odd interpersonal behaviors
• Angry, hostile responses
• Suicide risk assessment

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Diagnostic Challenges 6 Autonomic Dysfunction

• Common in a subset of CFS patients
• Rule out types of orthostatic intolerance
• Tilt-table testing may be indicated for some
  patients with appropriate symptom profile

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Diagnostic Challenges 7 The Presence of
Fibromyalgia

• Fibromyalgia may co-exist with CFS
• Emphasis on musculoskeletal pain rather than
  fatigue
• Fibromyalgia will be discussed in Part II of this
  presentation.

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Conditions with Overlapping Symptoms
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Intermission
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CFS Management

• The goal is to
• assist patients to return to as normal function
  as possible
• maximize well-being
• set and maintain realistic expectations
• See appendix for management goals and strategies

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Prognosis

• No long term prognosis can be made
• Lack of treatment may negatively impact prognosis
• The primary care provider can help to improve
  quality of life for people with CFS

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Disability and CFS

• All patients with CFS are impaired and many
  suffer occupational disability
• Application process is protracted and frustrating
• The Primary Care Provider is a major source of
  documentation for disability benefits

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Impact

• CFS has a significant impact on society,
  individually and collectively
• The hardship on individuals is incalculable
• The economic impact alone is estimated to be over
  8.8 billion per year
• Research and education efforts are ongoing

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Conclusion
The goal of primary care providers is to help the
patient reach an improved level of functioning.
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Part II Fibromyalgia
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Fibromyalgia Syndrome (FM or FMS)

• A syndrome characterized by widespread muscle
  pain, fatigue and multiple tender points.
• Tender points- specific places on the body
  neck, shoulders, back, hips, and extremities-
  where patients feel pain in response to slight
  pressure.
• FMS is a chronic condition.

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Fibromyalgia Syndrome

• 80 of patients are women
• Most commonly affects patients aged 35-55 years
  of age.
• Affects 3 6 million Americans.
• The pain and fatigue of FMS can interfere with
  the ability to carry on daily activities.

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Symptoms of FMS 1

• Pain throughout the body and a feeling of
  fatigue.
• Muscles affected are in shoulders, buttocks, neck
  and lower back.
• Pain seems to originate tender points.

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Symptoms of FMS 2

• Pain exacerbated by stress, weather changes, loud
  noises and anxiety.
• Symptoms range from mild to severe.
• Symptoms may be intermittent.

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Specific Symptoms of FMS 1

• Sleep disturbances (which may add to the feeling
  of fatigue).
• Morning stiffness.
• Numbness or tingling of extremities.
• Restless leg syndrome.
• Temperature sensitivity.
• Cognitive and memory problems (Fibro fog).
• Painful menstrual periods.

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Specific Symptoms of FMS 2

• Headaches and jaw pain.
• Sensitivity to odors, bright light, noise, food,
  changes in weather, and medicines.
• Gastrointestinal problems IBS, diarrhea,
  constipation, heartburn and difficulty
  swallowing.
• Women way have pelvic pain, painful sexual
  intercourse
• Frequent urination, strong urge to urinate, pain
  in the bladder.

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Cause

• Cause is unknown.

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Possible Causes of FMS

• Possible causes include
• Imbalance of CSF substances
• Neurotransmitter imbalance in the brain
• Low level of serotonin
• Abnormal sleep lack of non-REM
• Stress
• Infections
• Injuries
• Inherited genetic tendency runs in families

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Co-morbid conditions

• FMS commonly seen in patients with
• Rheumatoid arthritis
• Lupus

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Diagnosis of FMS 1

• Dx of FMS is given only after other muscle, joint
  and gland diseases with similar symptoms have
  been ruled out.
• Detailed medical history and physical exam.
• Blood tests and radiological tests performed to
  exclude other illnesses with similar
  presentations.

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Diagnosis of FMS 2

• There is no diagnostic test for FMS
• There is no object test for FMS
• Patients often accused of faking or imagining
  symptoms.
• Dx best made on the established criteria of the
  American Academy of Rheumatology (ACR).

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ACR Criteria for FMS

• A history of widespread pain lasting more than 3
  months and the presence of tender points.
• Pain affects all 4 quadrants of the body- right
  and left sides, above and below the waist.
• Pain must be present at 11 or more of the 18 FMS
  tenderpoints.
• A designated site is a tender point if a force
  of 4 kg results in pain.

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Treatment of FMS -1

• Goal Manage the symptoms of FMS
• Strategy Assemble a treatment team
• Physician(s)
• Physical therapist
• Other healthcare professionals
• Massage therapist
• Psychotherapist
• Patient participation

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Treatment of FMS 2

• Pharmaceuticals
• Analgesics prescribed for muscle pain
• Antidepressant medications
• Benzodiazepines tranquilizer with hypnotic,
  sedative properties
• Complimentary and Alternative medicine treatments
  (see Appendix for examples)

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Self-Care for FMS 1

• A healthy living program
• Reduce stress avoid stressful situations
• Sleep well good sleep hygiene avoid caffeine
  and alcohol, use a comfortable mattress
• Exercise regularly stretch upon waking low
  impact exercise. Try to maintain body weight.

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Self-Care for FMS 2

• Eat a healthy diet avoid alcohol, caffeine,
  candy, known foods that cause allergic reactions
• Manage symptoms treat symptoms as they arise
• Maintain social contacts social stimulation
  prevents often accompanying depression.

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Summary

• FMS is a syndrome that causes pain and fatigue in
  muscles, joints, ligaments and tendons.
• There is no cure for FMS.
• Treatment of FMS includes
• Medication
• Improvement of general health through self-care.
• Complimentary and Alternative Medicine
• Stress Management

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Comparison of CFS and FMS 1
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Comparison of CFS and FMS 2
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The End!

• Questions?

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Appendix

• Supplemental Information for Lecture

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The Medical History Physical Exam of a CFS
Patient

• MH and PE are almost always more lengthy than the
  allotted time period for a routine MH and PE
• Office visits of a CFS patient require more time
  than office visits of most other patients.

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Suggested Lab Tests for the CFS Patient 1

• Urinalysis
• Complete blood count with leukocyte differential
• Erythrocyte sedimentation rate or C reactive
  protein
• Alanine aminotransferase or aspartate transminase
  serum level
• Albumin

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Suggested Lab Tests for the CFS Patient 2

• Globulin
• Alkaline phosphatase
• Glucose
• Calcium
• Phosphorus
• Thyroid function test (TSH and Free T4)
• Rheumatoid factor (if arthritic complaints are
  present)

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Diagnostic Procedure for CFS

• Additional Testing
• EBV titer
• Tilt table
• Sleep studies
• Other tests as indicated by patient history and
  physical exam.

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Psychological Conditions That Preclude a Dx of CFS

• Bipolar disorder
• Schizophrenia
• Dementia
• Psychotic or melancholic depression
• Anorexia nervosa
• Bulimia nervosa
• Active alcohol or substance abuse (current or
  within preceding two years)

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CFS Management 1

• Provide the patient with general information
  about the nature of the illness
• Educational brochures, materials, etc.
• Resource contact information

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CFS Management 2

• Develop an individualized plan
• Supportive
• Symptomatic

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CFS Management 3Supportive Treatment

• Diet
• Optimal, well-balanced diet
• Weight management issues
• Referral to registered dietitian

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CFS Management 4 Supportive Treatment

• Activity
• Highly individualized
• Paced avoid overexertion find the correct
  balance to prevent boom or bust cycles
• Referral to physical or occupational therapist

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CFS Management 5 Supportive Treatment

• Coping skills
• Counseling
• Cognitive behavioral therapy (CBT)
• Although not a cure for CFS, it can help improve
  function and coping abilities

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CFS Management 6 Symptomatic Treatment

• Although there is no cure for CFS, patients can
  be helped.
• Address the symptoms and tailor a management plan
  accordingly.

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CFS Management 7 Symptomatic Treatment

• Sleep Disturbances
• Establish normal sleep hygiene
• Limit pharmacological agents
• Explain why limit is necessary
• Refer patients to a sleep specialist

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CFS Management 8Symptomatic Treatment

• Cognitive Dysfunction
• Cognitive training is highly specialized form of
  therapy and requires referral to a trained
  clinician

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CFS Management 9 Symptomatic Treatment

• Depression
• Commonly accompanies CFS and must be treated
• Psychological screening instruments

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CFS Management 10Symptomatic Treatment

• Pain
• Simple analgesics
• acetaminophen, aspirin or NSAIDs
• Non-pharmacological modalities
• paced activity, gentle massage, physical therapy,
  TENS units, cool or hot packs

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CFS Management 11 Symptomatic Treatment

• Pain
• Pain management counseling
• Referral to a pain management specialist
• Narcotics are not recommended except in
  consultation with pain management specialists

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CFS Management 12 Symptomatic Treatment

• Dysautonomias
• Increased fluid and salt intake
• Compression garments
• Referral to a neurologist or cardiovascular
  specialist for pharmacological therapy with such
  drugs as fludrocortisone, midodrine,
  beta-blockers or alpha agonists

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CFS Management 13 Symptomatic Treatment

• Other conditions
• IBS
• Fibromyalgia
• TMJD
• Overactive bladder

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CFS Management 14Symptomatic Treatment

• Other conditions
• Pelvic pain
• Pain syndrome
• Multiple chemical sensitivities
• Mitral valve prolapse

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Complementary Alternative Medicine
(CAM)Treatments for FMS 1

• Physical and occupational therapy.
• Learn pain management techniques
• Learn coping techniques (Cognitive Behavioral
  Therapy CBT)
• Massage

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Complementary Alternative Medicine
(CAM)Treatments for FMS 2

• Movement therapies Pilates, Feldenkrais methods
• Chiropractic treatments
• Acupuncture
• Herbs and dietary supplements
• There is little scientific proof that herbs or
  dietary supplements are of benefit.

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CAM Treatments for FMS Massage Therapy

• Choice of therapies Swedish, Deep (Connective)
  Tissue, Shiatsu
• Possible benefits include
• Increased blood circulation
• Loosening of sore muscles
• Increased flow of nutrients to muscles
• Removal of toxins from muscles
• Alignment of muscles and joints
• Relieves stress and anxiety

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CAM Treatments for FMS Acupuncture/Acupressure

• Accupressure application of pressure via
  practitioners fingers at specific points on the
  body to increase the flow of energy through
  disrupted pathways.
• Accupressure insertion of small needles at
  acertain points of the body to restore energy
  flow through disrupted pathways.

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CAM Treatments for FMS Trigger Point
Therapy/Chiropractic Care

• Trigger Point Therapy application of pressure
  for a few minutes at/on specific trigger points
  (points at which muscle pain originates).
• Chiropractic Care realignment of vertebrae of
  the spine. Vertebrae are stretched to relieve
  pressure on nerves.