Bansal: Investigating unexplained fatigue in general practice with a particular focus on CFS/ME

[mango]

Investigating unexplained fatigue in general practice with a particular focus on CFS/ME

Amolak S Bansal

BMC Family Practice BMC series – open, inclusive and trusted 2016 17:81
DOI: 10.1186/s12875-016-0493-0

Received: 5 February 2016. Accepted: 13 July 2016. Published: 19 July 2016.

Abstract
Unexplained fatigue is not infrequent in the community. It presents a number of challenges to the primary care physician and particularly if the clinical examination and routine investigations are normal. However, while fatigue is a feature of many common illnesses, it is the main problem in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). This is a poorly understood condition that is accompanied by several additional symptoms which suggest a subtle multisystem dysfunction. Not infrequently it is complicated by sleep disturbance and alterations in attention, memory and mood.

Specialised services for the diagnosis and management of CFS/ME are markedly deficient in the UK and indeed in virtually all countries around the world. However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests. The latter include those that assess inflammation, autoimmunity, endocrine dysfunction and gluten sensitivity. Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.

There is presently an on-going debate as to the precise criteria that best confirms CFS/ME to the exclusion of other medical and psychiatric/psychological causes of chronic fatigue. There is also some disagreement as to best means of investigating and managing this very challenging condition. Uncertainty here can contribute to patient stress which in some individuals can perpetuate and aggravate symptoms. A simple clinical scoring system and a short list of routine investigations should help discriminate CFS/ME from other causes of continued fatigue.

Keywords: Chronic fatigue syndrome Myalgic encephalomyelitis CFS/ME Medically unexplained fatigue Diagnostic criteria Scoring system Differential diagnosis

http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0493-0

 

[duncan]

What a crock.

 

[duncan]

Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.

This line of thinking in particular blows me away.

But there is no lack of gems in this abstract. I am puzzled how this kind of stuff gets published.

 

[John Mac]

This line of thinking in particular blows me away.

But there is no lack of gems in this abstract. I am puzzled how this kind of stuff gets published.

Yes, give them a CFS diagnosis as quick as you can and get them out the door

 

[msf]

The ME establishment in the UK is totally compromised, with the possible exception of Julia Newton and those who have just joined the field.

 

[TiredSam]

Every time the name Dr Bansal crops up on this forum I never know what to expect next, he's been spoken of very positively and very negatively at various times by various people. Can't say I'm very impressed with this:

CFS and Treatment
There is a large, and increasing, literature on a wide range of treatments used in CFS/ME. These include immunological and pharmacological treatments, nutritional supplements, adaptive pacing, graded exercise, deep relaxation using different approaches and psychological therapy [5, 6]. Included in the latter is cognitive behaviour therapy (CBT) and various types of life coaching. It would be impossible to cover the merits or otherwise of these treatments in this brief review. However, partly as a result of the unclear aetiology and heterogeneity of the condition, there are no CFS/ME treatments universally accepted by all physicians and patients to provide a permanent cure for the condition. Given that the precise cause of CFS is presently unknown, current treatment strategies should utilise an individualised holistic approach. This should include various combinations of pacing of daily physical and mental activity to prevent relapsing remitting fatigue, optimal diet, appropriate sleep hygiene, pharmacotherapy for any secondary depression/anxiety, graded exercise therapy (GET) and CBT.

The UK NICE guidelines on CFS/ME [65] have focused on GET and CBT in particular. Prinzs et al. [66] advocated the benefits of CBT which was also supported by the uncontrolled study of 125 CFS patients in the Netherlands by Scheeres et al. in 2008 [67] who found benefit in just over a third of the patients. Importantly, while cost outcome ratios were estimated to be highly favourable in each recovering patient, it is unclear whether they were favourable as a total cost of the intervention. The Cochrane review in 2008 also supported the use of CBT in CFS/ME although the benefits were modest and the duration of benefit was far from clear [68]. However, multidisciplinary input with CBT, GET and pharmacological treatment fared no better than exercise, counselling and pharmacological treatment in the Fukada criteria CFS/ME patients reported by Núñez et al. [69]. A year later the PACE trial [70] with much larger numbers of patients confirmed that both CBT and GET were statistically beneficial when compared to adaptive pacing and normal medical care. However, the overall improvement after one year of therapy and input was extremely modest and the number of people who managed to return to work was not reported.

In contrast to individualised CBT, group CBT investigated in the UK provided little improvement in fatigue [71]. Regarding other listening therapies, recent work has found little benefit from supportive listening and pragmatic rehabilitation delivered by nurses compared to treatment as usual offered by general practitioners [72]. Interestingly, multidisciplinary input has allowed a significant number of those with post-infectious CFS to return to work but was totally unsuccessful in those without an infectious onset [73]. Support groups and a positive physician-patient relationship have proven to be beneficial in the long-term management of CFS [74]. Overall, GET has been shown to be helpful in reducing fatigue and with a perception of improved sleep and general well being in those with CFS/ME diagnosed using a variety of criteria [75]. GET also showed little risk of harm to patients but does in my opinion need to be properly supervised by therapists knowledgeable about CFS/ME. The baseline from which the GET is commenced is particularly important as is the rate of increase in the chosen activity. In my opinion the input of a non-judgemental, caring and understanding primary care physician is extremely important in the long term management of those with CFS/ME. The early identification of CFS/ME and its management with firm reassurance, appropriate rest and activity may encourage improvement in a higher proportion than would otherwise be the case.

Also wasn't very impressed by this gem earlier on:

Most of the research on prognosis and treatment outcome has focussed on people attending specialist centres, who may be assumed to have more severe and complex difficulties.

 

[worldbackwards]

Every time the name Dr Bansal crops up on this forum I never know what to expect next,

I think we're getting the idea now

 

[jodie100]

I think this is actually a really good article if you read the whole thing thoroughly and read things in context. I assume it is aimed at GPs and is a good summary of the current state of affairs and how they can diagnose and help M.E. patients given the current limited knowledge of its causes. To me it seems to be advocating for M.E. patients and seeking to improve their treatment and is a step in the right direction. If all GPs had this much knowledge about M.E/CFS it would be an improvement ,so I find it a bit disheartening to see mostly criticisms of it.

 

[duncan]

The very first word of the study is "Tiredness."

For me, that's enough context.

Unfortunately, there is plenty more where that came from.

 

[Comet]

There is also some disagreement as to best means of investigating and managing this very challenging condition.

How about this means of investigation? Listen to patients. Believe what they are telling you. Investigate. Adjust as necessary.

 

[Kati]

Socialized medicine is very reluctant to investigate issues. The book of medicine is already written, they say. Family drs do not have authority to perform many tests, and medical specialties have no room for a disesse such as ours.

The medical profession is moving very slowly. Hopefully things will change soon.

 

[Esther12]

I assume it is aimed at GPs and is a good summary of the current state of affairs and how they can diagnose and help M.E. patients given the current limited knowledge of its causes. To me it seems to be advocating for M.E. patients and seeking to improve their treatment and is a step in the right direction.

It's not critical enough of the rubbish research it cites.

A lot of people here are not going to be cheering baby steps in the right direction when we're in such a dire position and it would be so easy to make huge strides.

 

[alex3619]

Socialized medicine is very reluctant to investigate issues. The book of medicine is already written, they say. Family drs do not have authority to perform many tests, and medical specialties have no room for a disesse such as ours.

The medical profession is moving very slowly. Hopefully things will change soon.

On my reading the medical profession is being driven backwards, largely by forces that are outside the profession and they do not usually challenge. Scientific research still progresses, and we have good research happening, but any breakthrough in research only fixes the specific research issue, not the general problems. Those are largely medico-political, and indeed even cultural.

This is not isolated to socialized medicine either, though arguably the problem is worse there. HMOs and insurance companies similarly limit tests and treatments.

 

[Hutan]

But there is no lack of gems in this abstract. I am puzzled how this kind of stuff gets published.

Here's another one:

However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests.

As in, 'I confidently diagnose you with 'unexplained fatigue'. ? And the utility of that is what?

 

[Hutan]

Ah, silly me. I should have read further:

Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.

As in 'I confidently diagnose you with 'unexplained fatigue'. So now you can stop being anxious, get better and not waste any more of the resources of the health system'.

 

[Kati]

One more reason to get ME out of general practice and into a medical specialty (not psychiatry)

 

[Valentijn]

In Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) fatigue is the predominant and most disabling symptom.

He doesn't even know the main symptoms of the disease he's purporting to give an expert opinion about. PEM is "the predominant and most disabling symptom", not fatigue.

It is frequently accompanied by several other symptoms that suggest a mixture of inflammatory, immune, viral and endocrine dysfunction.

And how exactly is CBT and GET expected to treat a disease involving those symptoms?

Historical
George Beard introduced the term neurasthenia in 1869 to describe an illness with chronic fatigue as its main symptom. This became a ‘respectable’ diagnosis from 1910 until 1980.

Anyone who feels compelled to uncritically discuss neurasthenia as the precursor of ME is blatantly undermining ME as a biomedical diagnosis. There might be an excuse if the author is showing how neurasthenia was hijacked by psychobabblers, much as ME has been, but the word itself is now used to describe a fashionable psychosomatic disorder.

Indeed, fewer than 5–6 % of people with CFS/ME return to pre-morbid levels of functioning in the medium to long term.

Well, he got one thing right at least.

Bansal considers a score of 8 to be diagnostic, so PEM is optional He says it's required in some form, but his description is broad and vague enough that pretty much any exercise intolerance can qualify. And extra points are available for alcohol intolerance, intolerance of meds, cold limbs, and frequent sighing.

A family history of CFS/ME and certain personality traits are also noted to be increased in those with CFS/ME including conscientiousness and high personal and parental expectations. Ciccone et al. while noting a higher prevalence of psychiatric illness and personality disorder in CFS/ME did not find any major correlation between these and levels of physical functioning and disability. More recently we have noted an increased frequency of CFS/ME symptoms in those with borderline personality disorder which has not hitherto been reported. Previous work has also suggested an increased prevalence of childhood physical, emotional and sexual abuse in those with idiopathic chronic fatigue and chronic fatigue associated with medical and psychiatric illness. Borsnini et al. have also confirmed childhood stressors to increase the possibility of subsequent CFS/ME.

He talks about it not really being relevant to symptoms, but sure does spend a lot of time focusing on psychobabble. He's not conveying a good impression of the disease to anyone reading his paper.

Given that the precise cause of CFS is presently unknown, current treatment strategies should utilise an individualised holistic approach. This should include various combinations of pacing of daily physical and mental activity to prevent relapsing remitting fatigue, optimal diet, appropriate sleep hygiene, pharmacotherapy for any secondary depression/anxiety, graded exercise therapy (GET) and CBT.

Pacing and GET are complete polar opposites. How could anyone put them on the same list of recommended treatments? Does he understand that the CBT he's promoting is based on convincing patients that they are not ill at all? Why a prominent mention of pharmaceuticals for mood disorders but not physical symptoms like pain or OI?

A year later the PACE trial with much larger numbers of patients confirmed that both CBT and GET were statistically beneficial when compared to adaptive pacing and normal medical care.

No, it didn't confirm any such thing. In fact, the long-term follow-up study showed CBT and GET to be completely worthless.

All of that said, this paper isn't completely bad. Some of it is even very good. But the author seems to have a complete inability to distinguish between quality and junk research, and it all seems to be accepted and presented as being equally valid.

This often contrasts with Bansal's clinical observations, which generally seem consistent with what patients experience of ME. But those observations are vague and subjective, making them sound rather weak and unconvincing at points.

His list of alternative diagnoses to rule out isn't bad, though I find his attitude to end wasting money on testing after that (unless otherwise indicated) to be rather distasteful. Just because other diseases have been ruled out, it doesn't mean that testing won't reveal problems which can be treated. He also speaks pretty favorably about OI testing, which is a minor miracle in the UK.

Unfortunately, the positive points are often drowned out by the long discussions of the research claiming that we're all nuts, and generally not worth the expense of being tested. He seems to be going for a typical compromise position, based on the undeniable reality he sees in patients, but combined with an inability to question the psychobabble research.

 

[Dx Revision Watch]

https://www.epsom-sthelier.nhs.uk/chronic-fatigue-syndrome

Chronic fatigue syndrome

Our Chronic Fatigue Service (CFS), based at Sutton Hospital, with clinics at St Helier Hospital, provides management and support for people with CFS.

The service was opened in early 2005 under the leadership of Dr Amolak Bansal, consultant immunologist at St Helier Hospital, as part of the Department of Health’s chronic fatigue clinical network collaborative to introduce services for individuals with chronic fatigue syndrome where none existed...

Page includes summary of the clinic's Lifestyle management group programme and links for patient information leaflets, for example, leaflet (under "Re-evaluating thoughts"):

EVALUATE YOUR UNHELPFUL THOUGHTS

"...If you would [sic] further information on challenging unhelpful thoughts there is a helpful chapter in Overcoming Chronic Fatigue: A Self-help Guide Using Cognitive-Behavioural Techniques by Mary Burgess with Trudie Chalder (Chapter8: Overcoming unhelpful thinking patterns pp 86-127)."

 

[Snow Leopard]

http://www.biomedcentral.com/imedia/8748585912018788_comment.pdf
From the peer-review comments:

Line 73: I would omit mention of "Yuppie flu" as overly pejorative and outdated.
‘Yuppie flu eliminated

Seriously... He originally used the words "Yuppie flu"!

Why!?!

 

[Marky90]

It's not critical enough of the rubbish research it cites.

That`s exactly the problem.

I remember when I was studying 1st year experimental psychology at bristol uni, from time to time - under huge time pressure, I had to write summaries about research I didn`t even remotely understand. I still got good grades, through extensive citing, and dubious conclusions.

These people are doing exactly the same - but are paid for it.
The art of fogwriting.