Management of Medically Unexplained Fatigue States PDF

Management of medicallyunexplained fatigue states Matt Jones, AEP What is fatigue? Fatigue as a ‘sign’ • failure of force generation in the muscle • peripheral and central components Fatigue as a ‘symptom’ • everyday phenomenon • may be disease associated (infective, inflammatory, neurological, m...

Management of medicallyunexplained fatigue states Matt Jones, AEP What is fatigue? Fatigue as a ‘sign’ • failure of force generation in the muscle • peripheral and central components Fatigue as a ‘symptom’ • everyday phenomenon • may be disease associated (infective, inflammatory, neurological, mood disorder) • Multidimensional - physical and mental components Medically-unexplained fatigue states Ensure there is no medical explanation for fatigue after careful history examination and laboratory investigation * cancer recurrence * thyroid issues * primary sleep disorder * mood disturbance How common is chronic fatigue? Prevalence estimates Working Group Royal Australasian College of Physicians, including Lloyd A. Chronic fatigue syndrome - Clinical practice guidelines 2002. Medical Journal of Australia 2002;176:S17-55. ME/CFS diagnostic criteria Post-cancer fatigue Definition • Significant fatigue, diminished energy, or increased need to rest, disproportionate to any recent change in activity level • Five or more of: – Complaints of generalised weakness or limb heaviness – Diminished concentration or attention – Decreased motivation or interest in engaging in usual activities – Insomnia or hypersomnia – Experience of sleep as unrefreshing or nonrestorative AND – Perceived need to struggle to overcome inactivity – Marked emotional reactivity (eg sadness, frustration or irritability) to feeling fatigued – Difficulty completing daily tasks attributed to feeling fatigued – Perceived problems with short-term memory – Post-exertional malaise lasting several hours ICD-10 revised Post-exertional exacerbation Post-exertional exacerbation PACE trial Activity pacing and graded activity Management of CFS Initial assessment/interview • Onset of symptoms & time to diagnosis • Sleep-wake cycle • Physical activity vs cognitive activity • Work/Study status • Home status • Support resources • Leisure / recreation: pre- & post- diagnosis • Walking tolerance • (Symptom-limited) functional capacity Activity pacing • Integrated approach; cognitive & physical • Overall aim to stabilise activity patterns • Involves limiting activity to symptom threshold limits • ‘True rests' and detailed scheduling • Micro- and macro-pacing Activity diary Activity monitoring Graded activity — Graded Activity / Exercise ≠ Conventional Exercise. — Symptom limited à post-exertional exacerbation in symptoms — Continuous aerobic activity — Stage 1: — Walk x min every 2nd day (self-paced) — Increase by 10-20% margin every 2 weeks (minimum period) — maximum of 30min un-interrupted — Stage 2: — Walk x min every other day (self-paced) — Increase by 10-20% margin every 2 weeks (minimum period) — maximum of 30min un-interrupted — Stage 3: — Interval training e.g: 9 min walk, 1 min jog = 10mins x 3 = 30mins * Compensate activity during symptom aggravation Evidence for this approach - CFS ITT (n=264) CD (n=168) Evidence for this approach - PCF Inclusion criteria: clinically significant fatigue; completed adjuvant therapy for breast or colon cancer 3-12 months prior; free of comorbid medical or psychiatric conditions that explained ongoing fatigue N = 46 (43 women): Results: • Fatigue improved in both groups from baseline to 12 weeks • Clinically significant improvement in 7/22 in intervention arm versus 2/24 in education arm Summary • Medically unexplained fatigue states, including CFS and PCF, are relatively rare but can be debilitating • There are currently no effective pharmacological treatments, so management focuses on self-management strategies • • • Activity pacing Graded activity CBT/psychologically-informed therapy