Myalgic Encephalomyelitis or Chronic Fatigue Syndrome

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Original Editors - Sarah Carlisle & Jill Thompson from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Chronic Fatigue Syndrome (CFS) is not a single disease but the result of a combination of factors and a subset of disabling chronic fatigue, a broader category defined as unexplained fatigue of greater than or equal to 6 months’ duration. Studies have shown CFS is often triggered by previous illness or stress and significantly limits work, school, and family activities.

CFS also named chronic fatigue and immune dysfunction syndrome, chronic Epstein-Barr virus, myalgic encephalomyelitis, neuromyasthenia, as well as the, “yuppie flu”.

CFS is characterized with overlapping symptoms (about 70%) with Fibromyalgia that have some biologic denominator. (Differential Diagnosis)

 Prevalence

Prevalence depends on which definition used, they type of population that was surveyed, and the study methods. In 2003 CFS ranged from 0.007%-2.8% in the general adult population and from 0.006%-3.0% in primary care or general practice.

Characteristics/Clinical Presentation

Common reported symptoms at onset:

• Sore throat patho, informa
• Fever
• Muscle Pain, psychiatry, patho, informa
• Multiple Joint Pain informa
• Forgetfullness increase
• Prolonged (lasting more than 6 months), overwhelming fatigue commonly exacerbated by minimal physical activity.

• Neurally mediated hypotension (NMH) (May experience lightheadedness, lower blood pressure and pulse, visual dimming, slow response to verbal stimuli)

• Disabling fatigue >/= 6months BMC,Psychiatry
• Sleep Difficulty psychiatry, informa
• Cognitive Impairments psychiatry
• Tender lymph nodes informa
• Individuals with CFS will often also experience anorexia, nausea, drenching night sweats, dizziness, and intolerance to alcohol and other pharmaceuticals that affect the CNS. About 1/3rd are unable to work, and another 1/3rd can only work part-time. Psychiatry

Prognosis

• CFS will vary from person to person but will often follow a course, alternating between periods of illness and relative well-being. Some people may experience partial or complete remission of symptoms, however, they often reoccur. Pathology text
• Longitudinal studies of varying duration have shown that although 17%-64% of patients with CFS improve, less than 10% fully recover, and another 10%-20% worsen during follow-up. Psychiatry
  
  

Associated Co-morbidities

• Hypocortisolism
• Neurally mediated hypotension (NMH) is a common finding in individuals with CFS. Individuals with NMH have a low blood pressure and heart rate; thus, they can experience syncope, visual dimming, or a slow response to verbal stimuli.
• Anxiety
• Depression
• Fibromyalgia
• Multiple Chemical Sensitivities
• Irritable Bowel Syndrome
• Temporomandibular Joint Disorder
  
  

Medications

While studies have investigated the use of various medications, none have been found to have consistent results. However, the following drugs are used to address and manage symptoms:

• Medications to reduce pain, discomfort, and fever
• Medications to treat anxiety 
• Medications to treat sleep disturbance (amitryptyline, nefazodone)
  
• Modafinil
• Medications to treat joint pain (amytryptyline)
• Medications to treat depression (sertralin, paroxetine, nefazodone)
• Anti-inflammatory drugs (aspirin, acetaminophen)
• NSAIDS to address headache relief
• Deydroepiandrosterone (DHEA) was found in a pilot study to significantly reduce the pain, helplessness, anxiety, thinking, memory, and activities of daily living difficulties associated with CFS; however, further research is necessary.
• Based on current evidence corticosteroids cannot be recommended for CFS due to complications of long-term use, Mineralcorticoids and Intravenous Immunoglobulin are not recommended either and need further research
  
  

Diagnostic Tests/Lab Tests/Lab Values

No specific tests that identify CFS have been found. One study reports that patients with CFS have demonstrated abnormal white blood cell count and brain MRI results. Goodman suggests that physicians rule out other diagnoses (from list below: Differential Diagnosis) and make use of the CDC’s criteria to determine if an individual has CFS. The CDC’s criteria are:

1. Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is any of the following:

          a. New or definite onset

          b. Not the result of ongoing exertion

          c. Not substantially alleviated by rest

          d. Results in substantial reduction in previous levels of occupational, educational, social, or personal activities

2. The concurrent occurrence of 4 or more of the following symptoms:

          a. Substantial impairment in short-term memory or concentration

          b. Sore throat

          c. Tender lymph nodes

          d. Muscle pain

          e. Multiple arthralgias (joint pain) without swelling or redness

          f. Headaches of a new type, pattern, or severity

          g. Unrefreshing sleep

          h. Postexertional malaise lasting more than 24 hours

The symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.

Sixteen gene abnormalities have been found in individuals with CFS, some related to immunity and defense; however, further research is needed to determine just how gene expression might effect those with CFS.

Etiology/Causes

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Systemic Involvement

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Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

Physical therapy begins by assessing the patient’s current health status to see if signs of deconditioning exist. If so, Goodman suggests starting with a strengthening program and then progressing to activities that test the cardiovascular system. Physical therapy management of CFS is focused on progressing from minimal activity to 30 minutes of continuous exercise during periods of remission, always focusing on gentle, graded, flexible exercise that is monitored continuously.  Goodman suggests monitoring vital signs and assessing fatigue levels using a 5-point scale during exercise and activities. Education about the syndrome, the importance of exercise, and how to pace oneself in everyday activities to avoid fatigue and relapse is a key component in the management of CFS. One study states that due to the necessary and unique components of helping individuals manage chronic fatigue, physical therapists need to be trained on how to both deliver pain management and exercise programs to these individuals.

Graded exercise therapy (GET) has been shown to be a more effective treatment option than stretching and relaxation exercises for individuals with CFS, while all the above options are important aspects of care for the individual. GET results are still variable (see chart below) and will benefit from further research to determine effects on individuals with CFS.

File:PT Treatment.png

Physical Therapy Management

Alternative/Holistic Management (current best evidence)

Cognitive Behavior Therapy (CBT) has been used to manage CFS, especially in reducing fatigue and decreasing pain.  CBT is one of the few nonpharmacological management techniques recommended for individuals with CFS; however, it, too, has had mixed results in individuals with CFS.  If an individual is experiencing high levels of pain, Marshall suggests other treatment strategies be used in combination because CBT is aimed more specifically at managing fatigue levels.  CBT is an individualized, proactive approach on the patient’s part, involving self-reflection and monitoring in the hopes of discovering what kinds of behaviors or thoughts are causing the CFS symptoms. CBT also involves learning coping strategies and initiating a daily schedule of rest and activity in order to address fatigue levels and optimize function.

Roberts found that individuals with hypocortisolism and CFS do not respond as well as others after 12-15 sessions of CBT . The study questions if these individuals require a longer duration of CBT, a modified version, or a combination of therapies including hydrocortisone replacement therapy . Further studies are necessary in order to address these questions.

Ayurveda, an Indian treatment dating back to 5000 BC, has been suggested to successfully treat individuals with CFS. Ayurveda utilizes several different techniques, ranging from detoxification therapies, herbs, oil treatments, to diet and lifestyle changes. The selection of particular treatments depends on the individual’s presentation.

Magnesium sulfate was shown in one randomized, double-blinded, placebo-controlled study to have a positive affect on individuals with CFS.

According to one study, looking at different interventions used to address symptoms of CFS, acupuncture was the most recurrent treatment mentioned, with massage being the next most frequent, followed by reflexology. The same study found the participants who had had these interventions, reported inconsistent results; some experienced a decrease in pain while others had an increase or no change in pain. Each of these interventions are in need of further research to evaluate their effectiveness.

Marshall stated that in their study, individuals with CFS reported trying to self-manage their symptoms in addition to physical therapy or alternative techniques.  Self-pacing, stretches, breathing exercises, and yoga were among the kinds of activities reported; with stretches and breathing exercises managing pain levels the best (see chart below).

File:Self Management CFS.png

Self-Management of Symptoms

Differential Diagnosis

The following are possible differential diagnoses:

• Fibromyalgia

            Patients usually demonstrate with increased pain, while patients with CFS experience greater fatigue. Some consider CFS and fibromyalgia to be one in the same; others believe CFS is an early form of fibromyalgia.

• Mononucleosis
• Lyme Disease
• Thyroid conditions
• Diabetes
• MS
• Various Cancers
• Depression
• Bipolar disorder
• Myalgic encephalomyelitis
  

Case Reports/ Case Studies

Chronic Fatigue Syndrome and Recovery: www.ncbi.nlm.nih.gov/pmc/articles/PMC3028106/[11].

Resources

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Recent Related Research (from Pubmed)

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References

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