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

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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

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Factors in developing CFS (RLHH Patient Survey)
Factor No Possibly Definitely
Viral infection 4.1 31.8 64.2
Continuing Infection 26.9 41.5 31.5
Work stress 22.5 33.1 44.4
Relationship stress 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
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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)
Treatment Worst ltlt lt Same 0 gt Best gtgt N/A
Lifestyle Manage. 0 0 8.7 34.8 56.5 0
Homeopathy 0 5 35 35 25 0
Antidepressants 0 25 0 25 20 20
Exclusion diet 0 9.5 19 14.3 14.3 42.9
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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