Chronic Fatigue Syndrome an integrated approach

Dr CannellMidway Surgery St Albans

Royal London Homoeopathic HospitalMarch 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 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

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

Factors in developing CFS (RLHH Patient Survey)

Factor No % Possibly % Definitely %Viral infection 4.1 31.8 64.2Continuing Infection 26.9 41.5 31.5Work stress 22.5 33.1 44.4Relationship stress 41 28.8 30.2Emotional stress 23.6 35.7 40.7Food Allergy 23.1 52.2 24.6Major life event 37.6 36.1 26.3Hormonal disorder 40.2 45.9 13.9Other allergy 35.7 47.6 16.7

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

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

Chronic Fatigue Syndrome Intern.Definition

Major 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

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

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

CFS: other common symptoms Atypical anxiety / depression

But suicidal thoughts rare Alcohol, drug & “chemical”

intolerances ?? fibromyalgia and chronic

hyperventilation, Irritable bowel syndrome, hypoglycaemia

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,

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

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

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

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

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

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

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

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

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

Treatment Worst<< %

< %

Same0%

>%

Best>>%

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

Work & social adjustment Scale and CFS (RLHH)

29

30

31

32

33

34

35

36

(.026) (.036)

BasePost LSM1 year

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

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 ??

CFS: Multi-interventions For supplements alone One positive RCT One RCT negative study, positive trendFor 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

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

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