Category: Management

Indications for management in long-term, physically unexplained fatigue symptoms

Abstract:

In meetings arranged by the minister of Public Health, Welfare and Sports between general practitioners and specialists concerning chronic fatigue syndrome (CFS), suggestions for the diagnosis, treatment and assistance and support of patients with protracted physically unexplained fatiguesymptoms, were established in the light of current scientific insight.

The term ‘CFS’ is applicable in cases of fatigue complaints, of at least 6 months’ standing, reported by the patient himself and evaluated medically, for which no physical explanation has been found and which cause considerable disabilities in professional social and/or personal functioning.

The management depends on the duration of the illness. A distinction is made between an acute phase (up to one month after the first consultation; the policy is mostly expectative), a subacute phase (until 6 months after the onset of the complaints and disabilities; the management is aimed at making the patient accept the condition and persuading him or her to make an effort to promote health) and a chronic phase (from 6 months after the onset of the complaints and disabilities; the management is aimed at health-promoting behaviour and cognitions). Further (laboratory) examinations are useful only if the symptoms have not disappeared after one month (this is the case in approximately 20% of the patients); such examinations may be useful in older patients earlier.

It is important that the CFS patient learns to realize that it is useless to continue to spend energy on searching for causes and possible therapies, but that he should try to promote his own health, for instance by means of a quantified programme of activities linked to a time schedule (instead of to a level of fatigue).

Comment in:

Chronic fatigue syndrome. Ned Tijdschr Geneeskd. 1997

Chronic fatigue syndrome. Ned Tijdschr Geneeskd. 1997

 

Source: van der Meer JW, Rijken PM, Bleijenberg G, Thomas S, Hinloopen RJ, Bensing JM. Indications for management in long-term, physically unexplained fatigue symptoms.Ned Tijdschr Geneeskd. 1997 Aug 2;141(31):1516-9. [Article in Dutch] http://www.ncbi.nlm.nih.gov/pubmed/9543738

Managing patients suffering from acute and chronic fatigue

Abstract:

The subjective experience of fatigue is common and debilitating, and affects many individuals in various healthcare settings. The condition requires adequate assessment, innovative planning and interventions, and patient-centred evaluations by the nursing profession. Fatigue, whether acute or chronic, needs to be recognized as a true and valid condition in order for treatment to be successful. There are many considerations to be taken into account when working with the fatigued, and this article suggests how the areas needing most attention may be tackled. Chronic fatigue and acute fatigue can be quite different conditions, requiring different approaches, of which nurses need to be aware. In order to reduce the effects of fatigue on the client, nurses need to fully understand the factors surrounding the phenomenon of fatigue to provide expert care, to help educate the patient, and improve the quality of life.

 

Source: Cook NF, Boore JR. Managing patients suffering from acute and chronic fatigue. Br J Nurs. 1997 Jul 24-Aug 13;6(14):811-5. http://www.ncbi.nlm.nih.gov/pubmed/9283306

 

Chronic fatigue syndrome: an update for clinicians in primary care

Abstract:

Cases of long-standing (6 months or longer) fatigue that are not explained by an existing medical or psychiatric diagnosis are referred to as chronic fatigue syndrome (CFS). CFS is a condition of unknown etiology that presents with a complex array of symptoms in patients with diverse health histories. A diagnosis of CFS is largely dependent upon ruling out other organic and psychologic causes of fatigue. CFS can present the clinician with a unique set of challenges in terms of diagnosis and treatment. A review of recent research suggests that the management of CFS requires an individualized approach for each patient. An historic overview of the condition is presented along with current theories of causation, diagnosis considerations, symptom management, and health promotion strategies.

 

Source: Houde SC, Kampfe-Leacher R. Chronic fatigue syndrome: an update for clinicians in primary care. Nurse Pract. 1997 Jul;22(7):30, 35-6, 39-40 passim. http://www.ncbi.nlm.nih.gov/pubmed/9253014

 

Chronic fatigue syndrome. A practical guide to assessment and management

Abstract:

Chronic fatigue and chronic fatigue syndrome (CFS) have become increasingly recognized as a common clinical problem, yet one that physicians often find difficult to manage. In this review we suggest a practical, pragmatic, evidence-based approach to the assessment and initial management of the patient whose presentation suggests this diagnosis. The basic principles are simple and for each aspect of management we point out both potential pitfalls and strategies to overcome them.

The first, and most important task is to develop mutual trust and collaboration. The second is to complete an adequate assessment, the aim of which is either to make a diagnosis of CFS or to identify an alternative cause for the patient’s symptoms. The history is most important and should include a detailed account of the symptoms, the associated disability, the choice of coping strategies, and importantly, the patient’s own understanding of his/her illness. The assessment of possible comorbid psychiatric disorders such as depression or anxiety is mandatory.

When the physician is satisfied that no alternative physical or psychiatric disorder can be found to explain symptoms, we suggest that a firm and positive diagnosis of CFS be made.

The treatment of CFS requires that the patient is given a positive explanation of the cause of his symptoms, emphasizing the distinction among factors that may have predisposed them to develop the illness (lifestyle, work stress, personality), triggered the illness (viral infection, life events) and perpetuated the illness (cerebral dysfunction, sleep disorder, depression, inconsistent activity, and misunderstanding of the illness and fear of making it worse).

Interventions are then aimed to overcoming these illness-perpetuating factors. The role of antidepressants remains uncertain but may be tried on a pragmatic basis. Other medications should be avoided. The only treatment strategies of proven efficacy are cognitive behavioral ones. The most important starting point is to promote a consistent pattern of activity, rest, and sleep, followed by a gradual return to normal activity; ongoing review of any ‘catastrophic’ misinterpretation of symptoms and the problem solving of current life difficulties.

We regard chronic fatigue syndrome as important not only because it represents potentially treatable disability and suffering but also because it provides an example for the positive management of medically unexplained illness in general.

 

Source: Sharpe M, Chalder T, Palmer I, Wessely S. Chronic fatigue syndrome. A practical guide to assessment and management. Gen Hosp Psychiatry. 1997 May;19(3):185-99. http://www.ncbi.nlm.nih.gov/pubmed/9218987

 

Chronic fatigue syndrome

“Biopsychosocial approach” may be difficult in practice

This week a joint working group of the Royal Colleges of Physicians, Psychiatrists, and General Practitioners in Britain issued a report on chronic fatigue syndrome.’ The report constitutes, arguably, the finest contemporary position statement in the field, and physicians and patients are well advised to read it, but it is sure to engender disagreement on both sides of the Atlantic.

The term chronic fatigue syndrome is relatively new. It first appeared in the 1988 proposal by the United States Centers for Disease Control to formalise a working case definition for symptoms that had been variously named and attributed to numerous causes for over two centuries. Through field testing, the case definition was revised and simplified in 1994. In essence, it classifies a constellation of prolonged and debilitat ing symptoms as worthy of medical attention and study (see box). Related case criteria were developed by consensus at Oxford in 199 .4 Neither the American nor the Oxford criteria assume the syndrome to be a single nosological entity. As the royal colleges’ report concludes, the term chronic fatigue syndrome is appropriate because it carries none of the inaccurate aetiological implications of the alternative acronyms-myalgic encephalomyelitis, chronic fatigue syndrome, and immune dysfunction syndrome.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359057/pdf/bmj00562-0007.pdf

 

Source: Straus SE. Chronic fatigue syndrome. BMJ. 1996 Oct 5;313(7061):831-2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359057/

 

Chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome (CFS) is a medically unexplained illness characterized by chronic, disabling fatigue, impaired concentration, muscle pain, and other somatic symptoms. The conceptual difficulties associated with all medically unexplained illnesses contribute to the controversy surrounding CFS, which has centered around whether it is best regarded as a medical or as a psychiatric condition. Clinically, such an approach is not helpful, and current research suggests that both pathophysiologic changes and psychosocial factors are important. Pragmatic management based on a detailed assessment of the individual is outlined.

 

Source: Sharpe M. Chronic fatigue syndrome. Psychiatr Clin North Am. 1996 Sep;19(3):549-73. http://www.ncbi.nlm.nih.gov/pubmed/8856816

 

Management of chronic fatigue syndrome: case study

Abstract:

1. Chronic fatigue syndrome (CFS) is a complex disorder marked by incapacitating fatigue of uncertain etiology which has resulted in a least a 50% reduction in activity and is of at least 6 months’ duration. 2. Definitive diagnosis can be very challenging. Because no markers objectively identify the presence of CFS, diagnosis depends heavily on the presence of subjective complaints. 3. The current philosophy of CFS management is to use a multidisciplinary approach incorporating these rehabilitation goals: restore a sense of self efficacy and control; gradually increase physical activity; and decrease the restrictions imposed by CFS.

 

Source: Dyck D, Allen S, Barron J, Marchi J, Price BA, Spavor L, Tateishi S. Management of chronic fatigue syndrome: case study. AAOHN J. 1996 Feb;44(2):85-92. http://www.ncbi.nlm.nih.gov/pubmed/8694980

 

Chronic fatigue syndrome: current perspectives on evaluation and management

Abstract:

OBJECTIVE: To describe clinical and laboratory guidelines for assessment and management of patients presenting with chronic fatigue syndrome(CFS).

DATA SOURCES: Relevant international consensus diagnostic criteria and research literature on the epidemiology, pathophysiology, concurrent medical and psychological disturbance and clinical management of CFS.

CONCLUSIONS: Medical and psychiatric morbidity should be carefully assessed and actively treated, while unnecessary laboratory investigations and extravagant treatment regimens should be avoided. No single infective agent has been demonstrated as the cause of CFS, and immunopathological hypotheses remain speculative. The aetiological role of psychological factors is debated, but they do predict prolonged illness. The rate of spontaneous recovery appears to be high. Effective clinical management requires a multidisciplinary approach, with consideration of the medical, psychological and social factors influencing recovery.

Comment in: Chronic fatigue syndrome: is total body potassium important? [Med J Aust. 1996]

 

Source: Hickie IB, Lloyd AR, Wakefield D. Chronic fatigue syndrome: current perspectives on evaluation and management. Med J Aust. 1995 Sep 18;163(6):314-8. http://www.ncbi.nlm.nih.gov/pubmed/7565238

 

The chronically fatigued patient

Abstract:

This article illustrates that the diagnostic evaluation as well as the management of the patient presenting with chronic fatigue can be done in an orderly manner. If a medical illness is the cause of the patient’s fatigue, this is usually evident on initial presentation. A thorough history and complete physical examination, in conjunction with some screening laboratory tests, can rule out most medical causes of fatigue, and any remaining cases declare themselves over the next several visits. If a medical cause is not evident, a further “fishing expedition” is fruitless.

Psychiatric illness, such as depression or generalized anxiety disorder, accounts for another significant proportion of cases of chronic fatigue. As with medical illness, psychiatric illness should be suspected based on history and is not a diagnosis of exclusion. Some patients presenting with chronic fatigue have a history and symptom pattern consistent with the diagnosis of CFS. The cause of this syndrome is controversial and is still unknown. The clinician, however, can offer the patient care in an environment that is respectful of their physical and psychological discomfort and can provide significant symptomatic improvement to the patient.

Lastly, some patients with fatigue do not fit any diagnostic category, including CFS. As with many other common complaints, such as headaches or abdominal pain, although a diagnosis may not be given to the patient, the clinician can do a lot to reassure the patient and assist the patient in living with his or her symptoms. As Solberg eloquently wrote: “[E]valuation of the fatigued patient requires all of a physician’s best attributes–a broad view of disease, psychosocial sensitivity, and a good ongoing relationship with the patient.”

 

Source: Epstein KR. The chronically fatigued patient. Med Clin North Am. 1995 Mar;79(2):315-27. http://www.ncbi.nlm.nih.gov/pubmed/7877393

 

Chronic fatigue syndrome. 1: Etiology and pathogenesis

Abstract:

Chronic fatigue syndrome (CFS) is a disorder of unknown etiology characterized by debilitating fatigue and other somatic and neuropsychiatric symptoms. A range of heterogeneous clinical and laboratory findings have been reported in patients with CFS. Various theories have been proposed to explain the underlying pathophysiologic processes but none has been proved.

Research findings of immunologic dysfunction and neuroendocrine changes suggest the possible dysregulation of interactions between the nervous system and the immune system. Without a clear understanding of its etiopathogenesis, CFS has no definitive treatment.

Management approaches have been necessarily speculative, and they have evolved separately in a number of medical and nonmedical disciplines. The results of several controlled treatment studies have been inconclusive. An accurate case definition identifying homogeneous subtypes of CFS is needed. The integration of medical and psychologic treatment modalities and the use of both biologic and psychologic markers to evaluate treatment response will enhance future treatment strategies.

 

Source: Farrar DJ, Locke SE, Kantrowitz FG. Chronic fatigue syndrome. 1: Etiology and pathogenesis. Behav Med. 1995 Spring;21(1):5-16. http://www.ncbi.nlm.nih.gov/pubmed/7579775