Chronic fatigue syndrome: Diagnosis and treatment

[Find the meaning and references behind the names: Fam, New, Four, Less, Class, Epstein, Better, Evidence, Links, Vary, Normal, Afr, Pur, Peer, Sleepy, Poor, Hospital, Present, Fever, Pain, Nicolas, Show, Cases, Diet, Feel, Six, Rest, Original, Alter, Sleep, Endurance, Cent, Data, Lack, Age, Viru, Days, Candida, Sore, Middle, Nap, Energy, Last, Fall, Mean, Barr, Female, Strong, General, Angela, Peak, Mental, Short, Common]

Review Article: Chronic fatigue syndrome: diagnosis and treatment 53 Vol 55 No 1 S Afr Fam Pract 2013 Introduction The cause of chronic fatigue syndrome (CFS) remains unknown. Throughout the world, a number of research teams have investigated possible links to a number of infections, including Epstein Barr virus, enteroviruses and poliomyelitis; as well as fungal agents, and, in particular, Candida albicans ) 1,2 Despite extensive studies, the evidence that CFS is caused by any particular infective agent is equivocal. Nor has it been shown that physical, or mental disease or illness, causes chronic fatigue syndrome. This syndrome occurs more commonly in women, with peak incidence in those in the third and fourth decades of their lives. Despite media references to the condition being more common in middle-income groups, evaluation of the social status of those diagnosed indicates that CFS occurs with equal frequency in all social classes. In general, no forms of treatment are shown to alter the condition’s course. The definition of fatigue, accepted by most research groups, is fatigue of new onset, lasting more than six months, with a 50% reduction in activity Symptoms CFS symptoms are muscle weakness and pain, lowgrade fever, sore throat, painful lymph nodes in the neck and armpits, exacerbation of fatigue after moderate or strenuous exercise for periods of 24 hours or more, transient pains in a number of joints, and various disturbances of neuropsychological function, including confusion, irritability, poor concentration, and visual changes 3 One-fifth of family medicine patients present with fatigue, and one-third of adolescents report having fatigue at least four days per week 4 Men and women differ in the way they describe fatigue. Men typically say they feel tired, whereas women say they feel depressed, or anxious 5,6 Sleepiness is the impairment of the normal arousal mechanism, and is characterised by a tendency to fall asleep. People who are sleepy are temporarily aroused by activity, whereas fatigue is intensified by activity, at least in the short term 7 Patients with sleepiness feel better after a nap, but patients with fatigue report a lack of energy, mental exhaustion, poor muscle endurance, delayed recovery after physical exertion, and no restorative sleep Fatigue may be classified as secondary, physiological, or chronic. Secondary fatigue is caused by an underlying medical condition, and may last one month or longer, but it generally lasts less then six months. Physiological fatigue is an imbalance in the routines of exercise, sleep, diet, or other activity that is not caused by an underlying medical condition, and is relieved by rest. Chronic fatigue lasts longer than six months, and is not relieved by rest 8 Epidemiology The mean age of onset in most series is reported as being 35 years. The majority of cases are said to occur between the ages of 18-60 years. Most studies report a predominance among females, although the ratios vary widely. Seventythree per cent of patients shown to have CFS were female 9 The popular perception in the media is that the condition is more prevalent in the middleand upper-social classes. This is not substantiated by objective analysis. There is a wide variation in the incidence of the disease, with near universal acceptance that the prevalence of the condition is probably higher than reported. This is particularly so for epidemiological studies conducted using the original CDC Chronic fatigue syndrome: diagnosis and treatment Revelas A, MD, PhD, General Practitioner, Pathology Department Baltaretsou E , MD, Cardiology Department St Nicolas General Hospital, Greece Correspondence to: Angela Revelas, e-mail: donnoiko 24@yahoo.gr Keywords: symptoms, women,chronic fatigue, illnesses, diagnosis Abstract Chronic fatigue syndrome (CFS) refers to marked and prolonged fatigue, for which no indentifiable cause can be found. Despite the presence of extensive symptoms, diagnosis is made when there is profound fatigue, lasting for a duration of six months, or longer. CFS is frequently seen in association with psychiatric illnesses,such as depression and anxiety, but has not been shown to be casually related to any particular psychiatric disease Peer reviewed. (Submitted: 2011-08-11. Accepted: 2011-11-04.)© Medpharm S Afr Fam Pract 2013;55(1):53-55

[Find the meaning and references behind the names: Daily, Day, Promise, Active, Body, Long, Mash, Memory, Time, Walk, Ill, Multi, Mood, Major, Get, Mass, Post, Severe, Mud, Oxford, Meta, Self, Lower, Weeks, Positive]

Review Article: Chronic fatigue syndrome: diagnosis and treatment 54 Vol 55 No 1 S Afr Fam Pract 2013 criteria, which include the inclusion of suspected cases with psychiatric disease, and also for disease control. Chronic fatigue occurs in all age groups, including children. Women, minorities, and people with lower educational and occupational statuses, have a higher prevalence of chronic fatigue On average, in his or her practice, a typical family physician sees two patients who have had fatigue for six months or longer, for which no explanation can be determined 10 Only two per cent of patients who are chronically fatigued report complete long-term resolution of their symptoms, but 64% show limited improvement. Patients whose symptoms worsen for longer than 24 hours after physical exertion have a poor prognosis 11,12 The Centers for Disease Control provides the following diagnostic criteria for CFS: 13 It is clinically evaluated, unexplained, persistent, or relapsing fatigue, that is: • Of new or definite onset; • Not a result of ongoing exertion; • Not alleviated by rest; • Results in a substantial reduction in previous levels of occupational, social, or personal activity Four, or more, of the following symptoms that persist, or recur, during six, or more, consecutive months of illness, and that do not predate the fatigue: • Self-reported impairment of short-term memory or concentration; • Sore throat; • Tender lymph nodes; • Muscle pain; • Multi-joint pain, without swelling or redness; • Headaches of a new type, pattern, or severity; • Interrupted sleep; • Post-exertion malaise (a feeling of general discomfort or uneasiness) lasting more than 24 hours Exclusion criteria for CFS are: • Active, unresolved, or suspected, disease, that is likely to cause fatigue; • Psychotic, melancholic, or bipolar depression (but not uncomplicated major depression); • Psychotic disorders; • Dementia; • Anorexia, or bulimia nervosa; • Alcohol, or other substance misuse; • Severe obesity (body mass index equal to, or greater than, 45) The University of Oxford’s diagnostic criteria are the following: 14 Severe, disabling fatigue of at least six months’ duration that: • Affects both physical and mental functioning; • Is present for more than 50% of the time Other symptoms, particularly myalgia, and sleep and mood disturbance, may be present. According to the University of Oxford criteria, the exclusion criteria are: • Active, unresolved, or suspected disease, likely to cause fatigue; • Psychotic, melancholic, or bipolar depression (but not uncomplicated major depression); • Psychotic disorders; • Dementia; • Anorexia, or bulimia nervosa Misdiagnosis Whichever definition is being used to define CFS, it should be clearly referenced and substantiated Pathogenesis physiology The mechanisms and pathogenesis of chronic fatigue syndrome are unknown 15 Research studies have examined, and hypothesised about, the possible biomedical and epidemiological characteristics of the disease, including oxidative stress, genetic predisposition, infection by viruses and pathogenic bacteria, hypothalamic-pituitaryadrenal axis abnormalities, immune dysfunction, as well as psychological and psychosocial factors 16 Treatment Cognitive behavioural therapy (CBT), a form of psychological therapy often used to treat chronically ill patients, is a moderately effective treatment of CFS, that “can be useful in treating some CFS patients” 17-20 Since the cause or causes of CFS are unknown, CBT tries to help patients understand their individual symptoms and beliefs, and develop strategies to improve day-to-day functioning 21 Graded exercise therapy Graded exercise therapy (GET) is a form of physical therapy. A meta-analysis of five randomised trials, published in 2004, found that patients who received exercise therapy were less fatigued after 12 weeks than the control participants, and the authors cautiously concluded that GET shows promise as a treatment 22 Meta-analyses confirm the effectiveness of regular structured exercise. Four weeks of aerobic, strength, or flexibility training, is associated with improved energy and decreased fatigue 23 Moderate aerobic exercise, e.g. a daily 30-minute walk, has a more consistently positive impact on fatigue than any other intervention studied 24 With the exception of patients with depression, pharmacological

[Find the meaning and references behind the names: Every, Mcdonald, Rosenthal, Sisto, Range, Knutsson, Change, Christie, Bagnall, Mcguire, Work, Fitzgibbon, Solomon, Mccluskey, Whiting, Arch, Pelosi, David, Soc, Fukuda, Care, Life, Gene, Chung, Ring, Snell, Kelleher, Connor, Int, Low, Nye, Salmon, Straus, Sci, Set, Ann, Reid, Schutte, Kerr, Heijnen, Gentle, Jason, Jain, Central, Hempel, Staff, Brown, Part, Cochrane, Price, Edmonds, Irish, Smith, Danzo, Viner, Rep, Patient, Findley, Edwards, Play, Taylor, Sample, Jama, Due, Balance, Med, Shea, Powell, Home, Gen, Hampton, Peter, Carruthers, Study, Reys, Need, Buchwald, Mcbride, Shen, None, Focus, Kansas, Chambers]

Review Article: Chronic fatigue syndrome: diagnosis and treatment 55 Vol 55 No 1 S Afr Fam Pract 2013 therapy (including stimulants) only has a short-term impact 25,26 Pacing Pacing is an energy management strategy that encourages behavioural change, while acknowledging patient fluctuations in symptom severity, and delayed exercise recovery. Patients are advised to set manageable daily activity and exercise goals, and to balance activity and rest to avoid overexertion, which may worsen symptoms. Many patients perceive that physicians and their staff are more responsive to them when they describe physical symptoms 27 Fatigue, even when linked with a disease process, is associated with an imbalance of sleep, stress, or psychological coping skills. Balancing these factors reduces reliance on, and is more effective than, medication 28 Regular visits, i.e. every two weeks to two months, allow physicians to focus on fatigue as a central problem, and circumvent the tendency for these patients to present at urgent care appointments 29 Medication Medications thought to have the potential to alleviate symptoms include antidepressant and immunomodulatory agents 30 Many CFS patients are sensitive to medications, particularly sedatives, and some patients report chemical and food sensitivities 31 CFS patients have a low placebo response, especially to psychological-psychiatric interventions, perhaps due to patient expectations 32 Conclusion The major criterion for chronic fatigue syndrome is fatigue lasting for more than six months, in the absence of any other medical, or psychiatric cause thereof. There is no evidence that heredity, genetic, or developmental factors, play a part in the onset of CFS. Nor is there any consistent evidence that the condition is associated with particular types of occupation, lifestyle, mental, or physical stress, or preexisting psychiatric illness. Treatment of the condition aims to ensure an adequate degree of rest, in conjunction with a supervised course of gentle graded exercises, throughout the course of the illness. Treatment of specific symptoms, such as muscle pains and depression, is recommended as being appropriate, but in the most cases, the use of narcotic and other addictive forms of medication would appear to be inappropriate. A range of other therapies have been tried at various times, but none have shown any particular benefit yet References 1. Hampton T. Researchers find genetic clues to chronic fatigue syndrome. JAMA. 2006;295(21):2466-2467 2. Kerr JR. Gene profiling of patients with chronic fatigue syndrome/myalgic and encephalomyelitis. Curr Rheumatol Rep. 2008;10(6):482-491 3. David A, Pelosi A, McDonald E, et al. Tired, weak, or in need of rest: fatigue among general practice attenders. BMJ. 1990;301(6762):1199-1202 4. Viner R, Christie D. Fatigue and somatic symptoms. BMJ. 2005:330(7498):1012-1015. 5. Fahln G, Knutsson A, Peter R, et al. Effort-reward imbalance, sleep disturbances and fatigue. Int Arch Occup Environ Health. 2006;79(5):371-378 6. Ter Wolbeek M, Van Doornen LJ, Kavelaars A, Heijnen CJ. Severe fatigue in adolescents: a common phenomenon? Pediatrics. 2006;117(6):e 1078-e 1086 7. Shen J, Botly LC, Chung SA, et al. Fatigue and shift work. J Sleep Res. 2006;15(1):1-5. 8. Brown RF, Schutte NS. Direct and indirect relationships between emotional intelligence and subjective fatigue in university students. J Psychosom Res. 2006;60(6):585-593 9. McBride SJ, McCluskey DR. Treatment of chronic fatigue syndrome. Br Med Bull. 1991;47(4):895-907 10. Fitzgibbon EJ, Murhy D, O’Shea K, Kelleher C. Chronic debilitating fatigue in Irish general practice: a survey of general practitioner’s experience. Br J Gen Pract. 1997;47(423):618-622 11. Taylor RR, Jason LA, Curie CJ. Prognosis of chronic fatigue in a community-based sample. Psychosom Med. 2002:64(2):319-327 12. Bombardier CH, Buchwald D. Outcome and prognosis of patients with chronic fatigue vs chronic fatigue syndrome. Arch Intern Med. 1995;155(19):2105-2110 13. Reid S, Chalder T, Cleare A, et al. Chronic fatigue syndrome. BMJ. 2000;320(7230):292-296 14. Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International chronic fatigue syndrome study group. Ann Intern Med. 1994;121(12):953-959 15. Whiting P, Bagnall AM, Sowders AJ, et al. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA. 2001;286(11):1360-1368 16. Chambers D, Bagnall AM, Hempel S, Forbers C. Interventions for treatment, management and rehabilitation of patients with chronic fatigue syndrome/myalgic encephalomyelitis an updated systematic review. J R Soc Med. 2006;99(10):506 17. Kuratsune H. Overview of chronic fatigue syndrome focusing on prevalence and diagnostic criteria. Nippon Rinscho. 2007;65(6):983 18. Vercaulen JH, Swanink SM, Galama JM, et al. The persistence of fatigue syndrome and multiple sclerosis. J Psychosom Res. 1998;45(6):507 19. Carruthers BM, Jain AK, De Merleir KI, et al. Myalgic encephalomyelitis/chronic fatigue syndrome. Clinical working definition, diagnostic and treatment protocols. Journal of Chronic Fatigue Syndrome. 2003;11(1):7-97 20. McBride SJ, McCluskey DR. Treatment of chronic fatigue syndrome. Br Med Bull. 1991;47(4):895-907 21. Prasher D, Smith A, Findley L. Sensory and cognitive event-related potentials in myalgic encephalopathy. J Neurol Neurosurg Psychiatry.1990;53(3):247-253 22. Whiting P, Bagnall AM, Sawden AJ, et al. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA. 2001;286(11):1360-1368 23. Puetz TW, O’Connor PJ, Dishman RK. Effects of chronic exercise on feelings on energy and fatigue: a quantitative synthesis. Psychol Bull. 2006;32(6):866-876 24. Powell P, Bentall RP, Nye FJ, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ. 2001;322(7283):387-390 25. Blockmans D, Persoons P, Van Houdenhove B, Bobbaers H. Does methylphenidate reduce the symptoms of chronic fatigue syndrome? Am J Med. 2006;119(2):e 23-e 30 26. Edmonds M, McGuire H, Price J. Exercise therapy for chronic fatigue syndrome [Cochrane review]. In: The Cochrane Library, Issue 3, 2004. Oxford: Update Software 27. Salmon P, Humphris GM, Ring A, et al. Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure. Psychosom Med. 2006;68(4):570-577 28. Dowrick CF, Ring A, Humphris GM, Salmon P. Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract. 2004;54(500):165-170 29. Rosenthal TC, Grisworld KS, Danzo A. Puzzling physical conditions. AAFP home study essentials, 334. Leawood, Kan: American Academy of Family Physicians; 2007 30. Solomon L, Nisenbaum R, Reys M, et al. Functional status of persons with chronic fatigue syndrome in the Wichita, Kansas population. Health Qual Life Outcomes. 2003;1(1):48-58 31. McCully KK, Sisto SA, Natelson BH. Use of exercise for treatment of chronic fatigue syndrome. Sports Med. 1996;21(1):35-48 32. Vanness JM, Snell CR, Strayer DR, et al. Sub-classifying chronic fatigue syndrome through exercise testing. Med Sci Sports Exerc. 2003;35(6):908-913.