DRG Category: 947
Mean LOS: 4.8 days
Description: Medical: Signs and Symptoms With Major Complication or Comorbidity
Chronic fatigue syndrome (CFS, also known as myalgic encephalomyelitis [ME]) is a unique, controversial, and poorly understood chronic disease that has a sudden onset and lasts for at least 6 months. Some experts recommend that the condition be termed systemic exertion intolerance disease (SEID) to reflect the cardinal sign, postexertional malaise. It is a multiple symptom disease that affects the immune and neurological systems and suggests chronic mononucleosis. The pathophysiology of the syndrome is unclear, but the immune system is upregulated, or stimulated, and the levels of antibodies, especially immunoglobulin G, are increased. Experts suggest that an estimated 800,000 to 2.5 million people have CFS in the United States, but most (up to 90%) have not been diagnosed with the condition.
CFS has been mentioned throughout history but only recently has been defined for adults as a distinct disorder. It is characterized by debilitation, chronic fatigue, and a duration of at least 6 months and often much longer; it causes impaired overall physical and mental functioning. The fatigue is not the result of excessive exertion and is not alleviated by rest. People note worsening of symptoms after mental, emotional, or physical exertion. The Centers for Disease Control and Prevention (CDC) criteria have been formulated to standardize diagnosis and include cognitive difficulties, pharyngitis, lymphadenopathy, muscle pain, joint pain, headache, sleep disturbance, poor sleep, and postexercise malaise. Like many chronic illnesses, CFS is often accompanied by depression. People with CFS generally improve over time, although remissions and relapses are common.
CFS is different from but related to fibromyalgia, a condition that generally occurs in young or middle-aged females and is manifested by pain, stiffness, fatigue, disrupted sleep, and problems with cognition. As compared to the development of CFS, fibromyalgia is related to genetic vulnerability and abuse or other traumatic experiences that occur during brain development (childhood) and persistent stress or distress.
The cause of CFS is unknown but is possibly related to an infectious process such as Epstein-Barr viral infection with immune manifestations. Researchers are investigating whether or not the disease is a syndrome triggered by a virus with multiple contributing factors such as age, sex, toxic and environmental exposure, stress, depression, anxiety, and perhaps a precipitating event (recent trauma or surgery).
CFS appears to have both a genetic and an environmental component, with heritability estimated at 20% to 50%. Several studies have found genetic variants that may influence the development of CFS, but more work is needed to define the pathways that contribute to disease. Several genes have been implicated, including the glutamate receptor ionotropic kinase 2 (GRIK2) and neuronal PAS domain protein 2 (NPAS2). Additionally, an association has been made with HLA-C and HLA-DQB1 alleles, linking the immune system to CFS pathogenesis.
CFS is more prevalent in females than in males, and it tends to affect persons between the ages of 40 and 60 years. It is more common in adolescents than children. It may be underdiagnosed in children and older adults.
Most people who have been diagnosed with CFS are White persons, but experts suggest that the condition is at least as common among Black and Hispanic persons but is underdiagnosed. While little is known about the numbers of gender and sexual minority persons who have CFS, these individuals are at risk because of issues with healthcare access, the stress of discrimination and violence, and higher odds for depression, multiple chronic conditions, and substance use (Downing & Przedworski, 2018).
CFS exists worldwide, but the prevalence is uncertain because of the lack of consistent definitions. In the United States, up to 4 million people may have CFS, but more recent statistics indicate that as much as 1% to 2% of the population is affected. Experts believe that this prevalence statistic is likely also applicable to global populations.
PLANNING AND IMPLEMENTATION
Collaborative
Because there is currently no known cure, treatment of CFS focuses on symptom relief. Some patients experience relief of the symptoms by avoiding environmental irritants and certain foods. Exercise therapy has been shown to improve sleep, physical function, and general health as well as to help people feel less fatigued. Current research has not shown that exercise therapy improves pain, quality of life, anxiety, or depression.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| NSAIDs | Varies by drug | May reduce inflammation, thus reducing symptoms | Efficacy uncertain |
Other Medications: Most medications have proved ineffective. Nonsedating antihistamines, antianxiety agents such as alprazolam, and tricyclic antidepressants may be helpful. Experimental treatments include the antiviral acyclovir and selected immunomodulating agents, such as IV gamma globulin, rintatolimod (Ampligen), transfer factor, and others. Doxycycline is used to treat people with elevated immunoglobulin M C pneumoniae titers.
Independent
It is important to set realistic goals when planning care with the patient with CFS. Teach patients not to overexert themselves. It is believed that stress can prolong the disease or result in an exacerbation. Relaxation and stress-reducing techniques such as hypnosis, massage, biofeedback, and meditation may be useful if sleep patterns are altered. Explain that although the symptoms tend to wax and wane, they are often debilitating and may last for months or even years. The patient therefore needs to reduce their activities when symptoms are more pronounced but also needs to avoid bedrest, which has no proven therapeutic value for patients with CFS. Encourage a graded exercise program and provide an appropriate referral for continuing exercise. Stress the need to progress slowly with exercise to avoid overfatigue. Referring the patient and family to counseling and support groups may assist in developing appropriate coping skills for dealing with a chronic, debilitating illness.
Evidence-Based Practice and Health Policy
Larun, L., Brurberg, K., Odgaard-Jensen, J., & Price, J. (2019). Exercise therapy for chronic fatigue syndrome. Cochrane Database of Systematic Reviews. https://doi.org//10.1002/14651858.CD003200.pub8
- The authors studied the effects of exercise therapy in adults with CFS. They compared outcomes in three groups: exercise group, any other intervention group, and control group. Variables were fatigue, adverse outcomes, pain, physical functioning, quality of life, mood disorders, sleep, self-perceived changes in overall health, and health service resources use.
- They located unpublished and ongoing studies through the World Health Organization International Clinical Trials Registry Platform up to May 2014, including randomized controlled trials about adults with a primary diagnosis of CFS. They found that exercise therapy probably has a positive effect on fatigue in adults with CFS compared to other exercises and the control groups. The authors were not able to determine whether exercise therapy reduces depression or the other outcomes.