An article in Medscape caught my eye last week. If you suffer from Chronic Fatigue Syndrome, you may find it interesting too.
Dr Paul Auwaerter is based at the Johns Hopkins Division of Infectious Diseases, Johns Hopkins University in Baltimore, Maryland. He reports that some of his most challenging outpatient visits are with patients who describe long-standing problems that include fatigue, perhaps sleep difficulties, and brain fog.
Often they may not be functioning well, perhaps experiencing problems in school or at work. Most of these patients are quite bright; they are analytical and sophisticated. They are hoping that something can be found to explain their fatigue and symptoms.
He explains that patients want to embrace something that makes sense. In fact, science has determined that the human brain likes distinct answers, and that uncertainty seems to amplify problems.
The term “chronic fatigue syndrome” or “myalgic encephalomyelitis” was developed and the defining criteria included:
more than 6 months of symptoms
an inability to perform customary activities.
The term resulted in a fair amount of controversy and sometimes even stigma because many clinicians believe this could be a psychosomatic illness; while others believe it is quite real. There is also symptom overlap with other syndromic problems, including fibromyalgia and irritable bowel syndrome.
“Within this context, the Institute of Medicine (IOM) was charged by several federal agencies to come up with a new name, some subcategories, and other aspects. In sum, the IOM committee decided that it would be important to rename chronic fatigue syndrome something that captures the nature of this. They have called it “systemic exertion intolerance disease,” or SEID.”
The criteria for SEID include:
substantial decline in functional activities for at least 6 months
And then at least one of the following:
cognitive impairment or orthostatic intolerance
Some patients may develop SEID / chronic fatigue syndrome after having an authentic infection from which they never seem to recuperate and for others, there seems to be no precipitating factor. The condition afflicts a large number of people, children and young adults included, and the best treatment strategies -compiled by Simon Wessely and colleagues, (who did a fair amount of work on chronic fatigue syndrome and Gulf War syndrome), and others include:
conditioning to build up tolerance
Once again, a graduated approach to increasing physical activity is one of the most beneficial interventions.
What are your thoughts about these recommendations?
A recent article in www.medscape.com by Alice Goodman summarised an overview of research on fibromyalgia treatment that was presented at the Paris 2014 European League Against Rheumatism Congress.
Winfried Häuser MD, from Technische Universität Munchen is an expert in the field of fibromyalgia. He believes that treatment for people with fibromyalgia should be individualised and include non pharmacalogical approaches, as these are often more effective than drugs. He explained that aerobic exercise is the most effective ‘weapon’ that we have and both healthy people and people with fibromyalgia benefit from continuous physical exercise.
He and his colleagues recently published a network meta-analysis which was an indirect comparison of all available therapies for fibromyalgia. They were unable to find any significant differences in effectiveness between drug and non-drug therapies. While the effects of drugs are lost once the patient stops taking them, the effects of aerobic exercise and multicomponent therapy are sustained but declining at 1 or 2 years.
Dr Häuser advocates a graduated approach to treating fibromyalgia.
Mild fibromyalgia: can be managed with reassurance from the doctor and encouragement to engage in regular physical and mental activities.
Moderate fibromyalgia: should be managed with aerobic exercise and the temporary limited use of drugs.
Severe fibromyalgia: can be managed with aerobic exercise, drugs and the psychological and/or psychopharmalogic treatment of mental comorbidities.
Dr Mary-Ann Fitzcharles, a rheumatologist at McGill University in Montreal who treats people with fibromyalgia, agreed with the patient-tailored approach outlined by Dr Häuser. She cautioned about overmedicating people, and keeping them on continued medications which have side effects. Non Pharmalocological therapies have no risks, she explained.
Dr Fitzcharles went on to say that non pharmacologic therapies are probably the most important ones for people with fibromyalgia. In her experience, every person with fibromyalgia should be managed with exercise, promotion of an internal locus of control and education.
Activity pacing is the key, in order to not overdo or avoid exercise.
Health professionals are trained to objectively analyse presenting signs and symptoms, in order to offer possible solutions to all manner of ‘conditions’. Today I have been exploring Posture, and the role it generally plays in our daily functional activities, and specifically, in chronic pain presentations.
Why is this interesting?
Because we need to be Positioned For Success!
The way we habitually hold ourselves influences all our movements and ultimately affects how we go about accomplishing our everyday activities – whether we are working, playing sport or a musical instrument, relaxing or sleeping.
I did a bit of research around the topic of being positioned for success by being Cognitively/Mindfully and Behaviourally aware of our posture, and the influences we could pay more attention to.
It has been observed that poor posture is widespread in the general population. It appears to be an adaptive, self- perpetuating trait that most people lack the cognitive ability or desire to correct by themselves. (2)
Studies have shown that people in occupations that include prolonged periods of sitting may experience a high incidence of Low Back Pain. (1)
Commonly adopted relaxed postures are often passive in nature with a predisposition to “sway” standing and slumped sitting which can exacerbate pain. (4)
Increased pain does not leave us positioned for success.
Recent studies conclude that
Forward head posture is the most common form of poor posture related to a multitude of myofascial pain disorders and cervical dysfunction. (2) This posture requires the person to flex the lower part of the neck forward and bend the upper portion of the neck backwards.
Adopting passive postures such as sway standing and slump sitting can exacerbate pain in individuals with low back pain. Lumbopelvic stabilising musculature is active in maintaining optimally aligned erect postures, and are less active during adoption of passive postures. The muscles of the lumbopelvic region become deactivated and deconditioned, which increases the load on the lumbar discs and ligaments which in turn could leave the lumbopelvic region vulnerable to strain, instability or injury. (4)
Back pain intensity and referred leg pain could be significantly reduced after sitting with a lordotic posture, demonstrating that a change in posture could have a positive effect on pain location. Centralisation (a change in distribution of referred symptoms from distal to a more central location) was brought about by certain lumbar movements and positioning. (1)
Erect postural alignment in weight bearing positively facilitated the stabilising muscles of the lumbopelvic region. (4) Immediately we are better positioned for success in performing our daily activities.
Postural Training (being Positioned for Success) works on the assumption that an optimally aligned skeletal system reduces stress in its structures. It is recommended as one of the Interdisciplinary treatment components of Cognitive Behavioural Therapy (CBT) for chronic pain.
It usually involves exercises performed repetitively to stretch structures that poor posture tends to shorten
Strengthens structures that poor posture tends to weaken
Creates awareness of desirable posture (2)
Cognitive Behavioural treatment methods have been applied to the most common chronic pain conditions. Posture correction in daily life, by its very nature, is considered Behavioural Therapy as the individual is required to continually monitor his / her improved conditioned posture for success. (2, 3)
These CBT Programmes usually involve multiple components, including
Information to increase knowledge and awareness of the factors influencing the nature and typical course of chronic pain conditions
Basics of pain physiology with the emphasis on chronic pain
Biomedical and bio-behavioural management of the condition
How to self-monitor the signs and symptoms of the condition
Cognitive and behavioural therapies aimed at increasing physical and functional activities and adaptive responses to pain
Skill training such as the use of relaxation, biofeedback, hypnosis and other self-control strategies to modify the perception of pain and related body sensations
Information on the relationship between muscle fatigue, muscle tension and the psycho-physiologic aspect of stress
Introduction to cognitive and behavioural pain and stress-coping strategies (3)
Instructions for Posture Correction to be positioned for success may include
Don’t slouch when sitting on a chair
Don’t sit with legs crossed
Don’t rest chin on hand
If sitting on the floor, sit upright by sitting on folded legs
My sitting posture may prevent me from being Positioned For Success
Rest weight on both feet evenly
Don’t lean against a wall
Sleep on a firm mattress
Sleep on your back
Keep your neck straight by supporting on a low pillow or flattened towel
Bring food to mouth without tilting head forward
Chew looking straight ahead, not downward
Walk with long even strides while swinging your arms
Don’t carry a heavy package with one hand
Don’t thrust head forward
With this information in mind, we could be more mindful to ensure we are better Positioned For Success, without compromising our Postural efficiency.
1. A comparison of the effects of two sitting postures on back and referred pain M M Williams, J A Hawley, R A McKenzie, P M van Wijmen Spine Vol 16, No 10, Oct 1991; 1185-1191
2. Usefulness of posture training for patients with temporomandibular disorders E F Wright, M A Domenech, J R Fischer Jr J Am Dent Assoc 2000; 131; 202-210
3. Posture correction as part of behavioural therapy in treatment of myofascial pain with limited opening O Komiyana, M Kawara, M Arai, T Asano, K Kobayashi J Oral Rehab May 1999; Vol 26; No 5;428-435
4. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population P B O’Sullivan, K M Grahamslaw, M Kendell, S C Lapenskie, N E Moller, K V Richards Spine 2002; Vol 27; No 11; 1238-1244
Which strategies do you employ to ensure you are Positioned For Success?