|
Chronic fatigue
Chronic Fatigue Syndrome (CFS), is a disorder
characterized by profound fatigue that is not improved by bed
rest and that may be worsened by physical or mental activity.
In addition to these key defining characteristics,
patients report various nonspecific symptoms, including:
- weakness,
- muscle pain,
- impaired memory and/or mental concentration,
- insomnia, and
- post-exertional fatigue
lasting more than 24 hours.
In some cases, CFS can persist for years.
The cause or causes of CFS have not been identified
and no specific diagnostic tests are available.
Moreover, care must be taken to exclude other known
and often treatable conditions before a diagnosis of CFS is
made.
An international panel of CFS research experts
convened in 1994 to draft a definition of CFS that would be useful both to
researchers studying the illness and to clinicians diagnosing
it.
In order to receive a diagnosis of chronic fatigue
syndrome, a patient must satisfy two criteria:
A - have severe chronic fatigue of six months
or longer duration with other known medical conditions excluded by
clinical diagnosis; and
B - concurrently have four or more of the
following symptoms:
- substantial impairment in 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
- unrefreshing sleep
- post-exertional malaise lasting more than 24
hours.
The symptoms must have persisted or recurred during
six or more consecutive months of illness and must not have predated the
fatigue.
A number of illnesses have been described that have a
similar spectrum of symptoms to CFS. These include fibromyalgia syndrome,
myalgic encephalomyelitis, neurasthenia, multiple chemical sensitivities,
and chronic mononucleosis.
Although these illnesses may present with a primary
symptom other than fatigue, chronic fatigue is commonly associated with
all of them.
Conditions with similar symptoms
There are a large number of clinically defined, frequently
treatable illnesses that can result in fatigue.
Diagnosis of any of these conditions would exclude a
definition of CFS unless the condition has been treated sufficiently and
no longer explains the fatigue and other symptoms.
These include:
- hypothyroidism
- sleep apnea and
- narcolepsy
- major depressive disorders
- chronic mononucleosis,
- bipolar affective disorders
- schizophrenia,
- eating disorders,
- cancer,
- autoimmune disease,
- hormonal disorders*
- subacute
- infections
- obesity
- alcohol or substance abuse
- reactions to prescribed medications
Other Commonly Observed Symptoms in
CFS
In addition to the eight primary
defining symptoms of CFS, a number of other symptoms have been reported by
some CFS patients. The frequencies of occurrence of these symptoms vary
from 20% to 50% among CFS patients.
They include:
- abdominal pain
- alcohol intolerance
- bloating
- chest pain
- chronic cough
- diarrhea
- dizziness
- dry eyes or mouth
- earaches
- irregular heartbeat
- jaw pain
- morning stiffness
- nausea
- night sweats
- psychological problems (depression, irritability,
anxiety, panic attacks)
- shortness of breath
- skin sensations
- tingling sensations
- weight loss
*Not all hormonal aberrations necessarily
exclude a diagnosis of CFS. See "Hypothalamic-Pituitary Adrenal (HPA)
Axis"
An international panel of CFS researchers was convened
in 1993 to revise the 1988 research case definition and to recommend
guidelines for studies of CFS.
These new guidelines present a research strategy for
evaluation, classification, and sub grouping of fatigued persons.
In essence, patients with fatigue of recent onset are
classified as having:
- prolonged fatigue (persistent or relapsing
fatigue of one month or longer),
- idiopathic chronic fatigue (six months or
longer), and
- CFS (persistent or relapsing fatigue of six
months or longer, with no medical explanation, and meeting specific
symptom criteria).
Persons can be further sub grouped by type of onset
(gradual or sudden), the presence or absence of co-morbid (co-existing)
conditions (including psychiatric conditions), fatigue levels, duration of
fatigue, current level of physical function, and other epidemiologic or
laboratory criteria of interest.
The guidelines also recommend specific medical
evaluations for exclusionary diagnoses and the use of specific instruments
to evaluate neuropsychiatric conditions, fatigue levels, and overall
function.
Guidelines for treatment
A variety of therapeutic approaches have been described as
benefiting patients with chronic fatigue syndrome (CFS).
Since no cause for CFS has been identified and the
pathophysiology remains unknown, treatment programs are directed at relief
of symptoms, with the goal of the patient regaining some level of
pre-existing function and well-being.
Although desirable, a rapid return to pre-illness
health may not be realistic, and patients who expect this prompt recovery
and do not experience it may exacerbate their symptoms because of
overexertion, become frustrated, and may become more refractory to
rehabilitation.
Decisions regarding treatment for CFS or any
chronically fatiguing illness should be made only in consultation with a
health care provider.
The health care provider, together with the patient,
will develop an individually tailored program that provides the greatest
benefit.
This treatment program will be based on assessment of
the patient's overall medical condition and current symptoms, and will be
modified over time on the basis of regular follow-up and assessment of the
patient's changing condition.
Currently, most health care providers with experience
in treating persons with CFS use some combination of the therapies
discussed below.
Persons who have questions about a particular
treatment should contact a qualified health care provider, local medical
society, or university medical school for additional
information.
Some proposed therapy should not aggravate existing
symptoms or create new ones. It should not mask another illness that needs
identification and specific treatment.
Therapy should not impose an excessive financial
burden on the patient.
The Agency for Healthcare Research and Quality has
recently completed an Evidence Report Defining and Managing Chronic
Fatigue Syndrome that can be downloaded from their website.
Non-Pharmacologic Therapy
Physical Activity
An
appropriate amount of physical activity is required by everyone for
physical and emotional well-being. Patients with CFS are no exception.
A key consideration for patients with CFS is to know
how much to do and when to stop the activity. Regardless of the level of
activity a patient with CFS may attempt, the most important guideline is
to avoid increasing the level of fatigue.
In general, health care providers advise patients with
CFS to pace themselves carefully.
The paced activity can be counter-productive if it
increases fatigue or pain. A regular, manageable daily routine helps avoid
the "push-crash" phenomenon characterized by overexertion during periods
of better health, followed by a relapse of symptoms perhaps initiated by
the excessive activity.
Although patients should be as active as possible,
clinicians may need to explain the disorder to employers and family
members, advising them to make allowances as possible.
Modest regular exercise to avoid de conditioning is
important. The program of exercise and/or the exercise itself should be
supervised by a knowledgeable health care provider or physical therapist.
Non-pharmacologic therapies that have a passive physical component
sometimes used by CFS patients include:
- massage therapy
- acupuncture
- chiropractic, cranial-sacral
- massage
- self-hypnosis
- therapeutic touch
These modalities may contribute to feeling better, but they are most
effective when combined with patient-generated activity,
including:
- aquatic therapy
- light exercise (adapted to personal
capabilities)
- stretching
Some patients may tolerate activities such as:
that require more energy.
Education
Learning
about what CFS is a critical component of therapy.
This approach includes learning how to adjust
activities and behaviors that may aggravate the illness.
A formal method to impart this information is known as
cognitive behavioral therapy.
Cognitive behavioral therapy has been shown to
facilitate patient coping and to allow increased activities without
triggering increased symptoms.
Any chronic illness, including CFS, can affect the
patient's family. Family education may foster good communication and
reduce the adverse effect of CFS on the family.
Pharmacologic Therapy
Pharmacologic therapy is directed toward the relief of
specific symptoms experienced by the individual patient.
Patients with CFS appear particularly sensitive to
many medications, especially those that affect the central nervous system.
Thus, the usual treatment strategy is to begin with
very low doses and to gradually increase dosage as necessary and as
tolerated.
It is important to remember that use of any drug for
symptom relief should be attempted only if an underlying cause for the
symptom in question has not been found.
The best example is use of a sleep-enhancing
medication for non-restorative sleep.
Although the patient may state that they sleep better,
the sleep disorder remains obscured and thus treatment of the sleep
disorder not given.
It is also important to remember that all medications can cause untoward side effects, which may lead
to new symptoms
Medications
Medications are
generally the same used to treat depression
(see ‘Medication’)
They are regarded as safe,
but can cause a variety of adverse effects, including kidney damage,
gastrointestinal bleeding, abdominal pain, nausea, and vomiting. Some
patients may become dependent on certain of these agents.
Dietary Supplements and Herbal
Preparations
A variety of dietary
supplements and herbal preparations are claimed to have potential benefits
for CFS patients.
With few exceptions, the effectiveness of these
remedies for treating CFS has not been evaluated in controlled trials.
Contrary to common belief, the "natural" origin of a
product does not ensure safety.
Dietary supplements and herbal preparations can have
potentially serious side reactions and some can interfere or interact with
prescription medications.
CFS patients should seek the advice of their health
care provider before using any unprescribed remedy.
Vitamins, coenzymes, minerals
Preparations that have been
claimed to have benefit for CFS patients include:
- adenosine monophosphate
- coenzyme Q-10
- germanium
- glutathione
- iron
- magnesium sulfate
- melatonin
- NADH
- selenium
- l-tryptophan
- vitamins
Herbal preparations
Plants are known sources of many pharmacological materials.
However, unrefined plant preparations contain variable
levels of the active compound and may contain many irrelevant, potentially
harmful substances.
Preparations that have been claimed to have
benefit to CFS patients
include:
- astralagus
- borage
- seed oil
- bromelain
- comfrey
- echinacea
- garlic
- ginkgo biloba
- ginseng
- primrose oil
- quercetin
- St. John's wort
- shiitake
- mushroom extract
Only primrose oil was evaluated in a controlled
study, and the beneficial effects noted in CFS patients have not been
independently confirmed. Some herbal preparations, notably comfrey
and high-dose ginseng, have recognized harmful effects.
From National
Center for Infectious Diseases, USA.
| 
