Chronic Fatigue Syndrome an integrated approach

1
Chronic Fatigue Syndrome an integrated approach

• Dr Cannell
• Midway Surgery St Albans
• Royal London Homoeopathic Hospital
• March 2004

2
My Interest and Background

• 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

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The Doc and the CFS Patient .

• The Doc
• Its all in the mind..
• A Heartsink? Not enough time?
• The Patient
• wants to be taken seriously
• Needs positive help
• Find professionals poorly understand it
• Find gap in service provision

4
Factors in developing CFS (RLHH Patient Survey)
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Prevalence

• 10,000 practice 20 to 200 cases!!
• At Midway Emis audit about 35 coded
• Adults most commonly 20y - 40y
• Children 13 to 15y - can be as young as 5y.

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Better Prognosis

• (50 adults feel recovered after five years- but
  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

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Worst Prognosis

• 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

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Chronic Fatigue Syndrome Intern.DefinitionMajor
Criteria..must have all

• Severe Fatigue present gt than six months
• No other medical explanation
• A reduced level of activity
• New and definite onset
• Not life-long nor due to on-going exertion
• Not substantially relieved by rest
• Varies from day to day

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Major ones plus 4 or more minor features that
must not pre-date illness

• Short Term Memory impairment
• Poor concentration -gtreduction 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

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CFS other common symptoms

• 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

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CFS other common symptoms

• Atypical anxiety / depression
• But suicidal thoughts rare
• Alcohol, drug chemical intolerances
• ?? fibromyalgia and chronic hyperventilation,
  Irritable bowel syndrome, hypoglycaemia

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Differential diagnosis of CFS

• 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,

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Theoretical Mechanisms

• 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

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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

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Useful to check

• Ferritin and Urine!!!
• Other auto-antibodies ANA
• Anti-viral titres, EBV ABs serology
• Hep A B C Abs
• immunological profiles

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CFS other research findings

• Minor ECG EEG changes
• Cerebral cardiac SPECT scans
• 31P NMR oxidative metab. in muscle
• ? hypothalamic-pituitary-adrenal axis
• Low urinary free-cortisol (cf. depression)
• Blunted ACTH response to CRH
• Increased Synacthen response

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Evidence for Treatment of CFS

• Beneficial
• Pacing / Graded Exercise
• Cognitive Behavioural Therapy (CBT)
• Unknown
• Antidepressants on their own
• Corticosteroids / Thyroxine / HRT
• Dietary supplements, Melatonin ?NADH?
• Homeopathy (recent promising trial)
• Acupuncture / osteopathy / massage

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Homeopathy and CFS

• Two interesting cases of mine
• Older woman in our PCT seen privately
• Young violinist seen at RLHH
• Some preliminary evidence for homeopathic
  approach

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CFS A Team approach

• RLHH team led by Dr Jenkins
• Clinician, Nurse specialist
• Occupational Therapist, Physiotherapist Dietitian
• .not yet ..Autogenic Trainer / Cognitive
  Therapist
• 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

• 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

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Patient assessment of Treatment Strategies(RLHH
small study of 20 patients)
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Work social adjustment Scale and CFS (RLHH)
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CFS Quality Life Scores RLHH study Eurogol EQ -5D
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Patients with CFS Nutritional assessment

• Low intakes Ca, Fe, Zn, Vit. D
• lower RBC Mg, serum Zn, Vit B1
• adequate Mg intakes with low RBC Mg

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CFS Supplements

• 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 ??

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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

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CFS Organisations

• Westcare UK Residential, 155 Whiteladies Road,
  clifton, Bristol. Tel [phone]
• ME Association 4 Corrington Rd, Stanford-le-hope
  Essex Tel [phone]
• 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 [phone]
• Tymes 9 Patching Hall Lane Chelmsford Essex
• Tel [phone]

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Information for Presentation

• 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