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Physical Examination of
Chronic Fatigue Syndrome
Bali Mental Hospital
Shin-Min Lee
May, 2005
Chronic fatigue syndrome (CFS)
• A debilitating and complex disorder
characterized by profound fatigue that is
not improved by bed rest and that may be
worsened by physical or mental activity.
• Persons with CFS most often function at a
substantially lower level of activity than
they were capable of before the onset of
illness.
Chronic fatigue syndrome (CFS)
• In addition to these key defining
characteristics, patients report various
nonspecific symptoms, including
weakness, muscle pain, impaired memory
and/or mental concentration, insomnia,
and post-exertional fatigue lasting more
than 24 hours.
• In some cases, CFS can persist for years.
Chronic fatigue syndrome (CFS)
• The cause or causes of CFS have not
been identified and no specific diagnostic
tests are available.
• Moreover, since many illnesses have
incapacitating fatigue as a symptom, care
must be taken to exclude other known and
often treatable conditions before a
diagnosis of CFS is made.
CFS : Two Criteria (1)
1). Have severe chronic fatigue of six
months or longer duration with other
known medical conditions excluded by
clinical diagnosis;
CFS : Two Criteria (2)
2). Concurrently have four or more of the
following symptoms:
– substantial impairment in short-term memory or
concentration;
– sore throat;
– tender lymph nodes;
– muscle pain;
– multi-joint pain without swelling or redness;
– headaches of a new type, pattern or severity;
– unrefreshing sleep;
– post-exertional malaise lasting more than 24 hours.
CFS : Criteria
• The symptoms must have persisted or
recurred during six or more consecutive
months of illness and must not have
predated the fatigue.
Similar Medical Conditions
• A number of illnesses have been described that
have a similar spectrum of symptoms to CFS
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fibromyalgia syndrome,
myalgic encephalomyelitis,
neurasthenia,
multiple chemical sensitivities, and
chronic mononucleosis
• Although these illnesses may present with a
primary symptom other than fatigue, chronic
fatigue is commonly associated with all of
them.
Other Conditions That May
Cause Similar Symptoms (1)
• In addition, there are a large number of
clinically defined, frequently treatable
illnesses that can result in fatigue.
• Diagnosis of any of these conditions would
exclude a definition of CFS unless the
condition has been treated sufficiently and
no longer explains the fatigue and other
symptoms.
Other Conditions That May
Cause Similar Symptoms (2)
• These include :
– hypothyroidism,
– sleep apnea and narcolepsy,
– major depressive disorders,
– chronic mononucleosis,
– bipolar affective disorders,
– schizophrenia,
Other Conditions That May
Cause Similar Symptoms (3)
• These include :
– eating disorders,
– cancer,
– autoimmune disease,
– hormonal disorders*,
– subacute infections,
– obesity,
– alcohol or substance abuse,
– and reactions to prescribed medications.
Other Commonly Observed
Symptoms in CFS (1)
• In addition to the eight primary defining
symptoms of CFS, a number of other
symptoms have been reported by some
CFS patients.
• The frequencies of occurrence of these
symptoms vary from 20% to 50% among
CFS patients.
Other Commonly Observed
Symptoms in CFS (2)
• They include abdominal pain, alcohol
intolerance, bloating, chest pain, chronic
cough, diarrhea, dizziness, dry eyes or
mouth, earaches, irregular heartbeat, jaw
pain, morning stiffness, nausea, night
sweats, psychological problems
(depression, irritability, anxiety, panic
attacks), shortness of breath, skin
sensations, tingling sensations, and
weight loss.
How Common Is CFS? (1)
• Between 4.0 and 8.7 per 100,000 persons
18 years of age or older have CFS and are
under medical care. (Centers for Disease
Control and Prevention, CDC; from 1989
to 1993)
• Seattle area has estimated that CFS
affects between 75 and 265 people per
100,000 population.
How Common Is CFS ? (2)
• San Francisco, at approximately 200 per
100,000 persons.
• In general, it is estimated that perhaps as
many as half a million persons in the
United States have a CFS-like condition.
Who Gets CFS? (1)
• This question is complex and does not have a
definitive answer.
• The CDC four-city surveillance study of CFS
identified a population of patients that was 98%
Caucasian and 85% female, with an average
age at onset of 30 years.
• More than 80% had advanced education and
one-third were from upper income families.
• However, these data included only patients who
were under a physician's care.
Who Gets CFS? (2)
• There is now evidence that CFS affects all racial
and ethnic groups and both sexes.
• The Seattle study found that 59% of the CFS
patients were women.
• Eighty-three percent were Caucasian, an
underrepresentation, since over 90% of the
patients in the study were white.
• CDC's San Francisco study found that CFS-like
disease was most prevalent among women,
among persons with household annual incomes
of under $40,000, and among blacks, and was
least common among Asians and whites.
Who Gets CFS? (3)
• Adolescents can have CFS, but few studies of
adolescents have been published.
• Adolescents 12 to 18 years of age had CFS
significantly less frequently than adults and did
not identify CFS in children under 12 years of
age.
• CFS-like illness has been reported in children
under 12 by some investigators, although the
symptom pattern varies somewhat from that
seen in adults and adolescents.
• The illness in adolescents has many of the same
characteristics as it has in adults.
Who Gets CFS? (4)
• However, it is particularly important that the
unique problems of chronically ill adolescents
(e.g., family social and health interactions,
education, social interactions with peers) be
considered as a part of their care.
• Appropriate dissemination of CFS information to
patients, their families, and school authorities is
also important.
• CDC and the National Institutes of Health (NIH)
are currently pursuing studies of CFS in children
and adolescents.
Clinical Course of CFS (1)
• The clinical course of CFS varies considerably
among persons who have the disorder; the
actual percentage of patients who recover is
unknown, and even the definition of what should
be considered recovery is subject to debate.
• Some patients recover to the point that they can
resume work and other activities, but continue to
experience various or periodic CFS symptoms.
• Some patients recover completely with time, and
some grow progressively worse.
Clinical Course of CFS (2)
• CFS often follows a cyclical course, alternating
between periods of illness and relative well
being.
• CDC continues to monitor the patients enrolled
in the four-city surveillance study; recovery is
defined by the patient and may not reflect
complete symptom-free recovery.
• Approximately 50% of patients reported
"recovery," and most recovered within the first 5
years after onset of illness.
Clinical Course of CFS (3)
• No characteristics were identified that
made one patient more likely to recover
than another.
• At illness onset, the most commonly
reported CFS symptoms were sore throat,
fever, muscle pain, and muscle weakness.
• As the illness progressed, muscle pain
and forgetfulness increased and the
reporting of depression decreased.
Possible Causes of CFS
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A. Infectious Agents
B. Immunology
C. Hypothalamic-Pituitary Adrenal Axis
D. Neurally Mediated Hypotension
F. Nutritional Deficiency
Treatment of Patients with CFS
• A variety of therapeutic approaches have
been described as benefiting patients with
chronic fatigue syndrome (CFS)
• No cause for CFS has been identified and
the pathophysiology remains unknown
• Treatment programs are directed at relief
of symptoms, with the goal of the patient
regaining some level of pre-existing
function and well-being.
Treatment of Patients with CFS
• Non-Pharmacologic Therapy
– Physical Activity
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Education
Pharmacologic Therapy
Prescription Medication
Experimental Drugs and Treatments
Dietary Supplements and Herbal Preparations
A Brief Explanation of How
CFS Patients are Evaluated by
a Physician