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Chronic Fatigue Syndrome an integrated approach

Chronic Fatigue Syndrome an integrated approach. Dr Cannell Midway Surgery St Albans Royal London Homoeopathic Hospital March 2004. 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

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Chronic Fatigue Syndrome an integrated approach

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  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

  3. 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)

  5. 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

  6. 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

  7. Chronic Fatigue SyndromeIntern.DefinitionMajor Criteria..must have all • Severe Fatigue present > 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

  8. Major ones plus 4 or more minor features– that must not pre-date illness • Short Term Memory impairment • Poor concentration ->reduction 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

  9. 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

  10. CFS: other common symptoms • Atypical anxiety / depression • But suicidal thoughts rare • Alcohol, drug & “chemical” intolerances • ?? fibromyalgia and chronic hyperventilation, Irritable bowel syndrome, hypoglycaemia

  11. 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,

  12. 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

  13. 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

  14. Useful to check • Ferritin and Urine!!! • Other auto-antibodies ANA • Anti-viral titres, EBV AB’s serology • Hep A B C Abs • immunological profiles

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Patient assessment of Treatment Strategies(RLHH small study of 20 patients)

  21. Work & social adjustment Scale and CFS (RLHH)

  22. 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

  23. 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 ??

  24. 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

  25. CFS Organisations • Westcare UK Residential, 155 Whiteladies Road, clifton, Bristol. Tel 0117 923 9341 • ME Association 4 Corrington Rd, Stanford-le-hope Essex Tel 01375 642466 • 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 01908 373300 • Tymes 9 Patching Hall Lane Chelmsford Essex Tel 01245 263482

  26. 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

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