Fatigue & Weakness

Chronic Fatigue Syndrome

"Yuppie Flu" Affects women 3-4X more than men Previously known as Chronic Epstein Barr Virus CDC reports approximately 500K in US Often occur after an infection or severe emotional or physical shock Severe, unexplained fatigue Lasts >6 months Definite time of onset Not resulting from ongoing exertion Functional impairments Orthostatic hyptension Elevated temp Tachycardia Positive Romberg

How do you diagnose chronic fatigue syndrome?

4 or more of the following symptoms must be present: Impaired memory or concentration, sore throat, enlarged lymph nodes, multi-joint pain without swelling or redness, arthralgia, new patterns of headache, non-refreshing sleep, post exertional malaise that exceeds 24 hours.

What are some precipitating causes of fatigue?

Acute physical weakness, psychological stresses, social stresses

What are some treatments of pain in diabetic polyneuropathy.

Amytriptyline Neurontin Nortriptyline Lyrica (pregabalin)

Myopathy.

Any and all disease of muscle or any type of damage to muscle

Typical presentation of chronic fatigue syndrome.

Arises suddenly in a previously active individual Unremarkable flu-like illness or some other acute stress is recalled with great clarity as the triggering event Unbearable exhaustion

What are some predisposing causes of fatigue?

Being female History of fatigue or depression

Symptoms of Diabetic Polyneuropathy.

Burning sensation in the toes and bottom of feet Develops symmetrically, usually not in hands Significant weakness is unusual, can be very painful

What diagnostics studies are useful in diagnosis of conditions causing fatigue?

CBC UA Glucose Electrolytes ESR Tests for HIV PPD Monospot test TSH Sleep Studies

How do you diagnose chronic fatigue syndrome?

CDC Oxford criteria Personal/medical history Rule out similar illnesses (MS, SLE) Psychological profiling Conventional labs Diagnosis of exclusion

Spinal Cord Injuries.

Central Cord Syndrome - Motor deficits in the upper extremities; injury or edema of the central cord; motor deficits >upper extremities.

What patients should be referred r/t fibromyalgia?

Children with chronic fatigue patients with severe psychiatric illness Patients requiring specialist management of sleep disorders

Motor Neuron Disease.

Class of disorders in which specific nerve cells degenerate and die. Progressive weakness of voluntary muscles throughout the body Weakness is secondary to the degeneration.

What are some clinical presentations r/t psychosocial fatigue?

Delusional thinking Difficult to get up in the morning Lack of interest Poor appetite Male

Treatment of myopathy?

Drug therapy Physical therapy Immunosuppressives Surgery

Definition of Fatigue.

Feeling of weariness, exhaustion, lethargy Loss of energy Loss of muscle power or deficiency in psychic energy

Clinical presentation of fatigue r/t infection.

Fever Chills Lymphadenopathy Splenomegaly Adenopathy Pharyngitis

What are the classes of myopathy?

Genetic (Muscular dystrophy) Metabolic (Mitochondrial) Drug (Statins)

Clinical presentation of fatigue.

History of snoring Excessive daytime sleepiness Obesity with body mass >20% Large Tonsils Systemic hypertension Over age of 65 Caucasian Rigidity Tremors Gait disturances

Clinical presentation of fatigue r/t endocrine/metabolic disorders.

Hypertension Central obesity Skin fragility Emotional lability Muscle wasting

General Management of diabetic polyneuropathy.

Identify level of function H&P Labs/Tests

What is crucial in the diagnosis of fatigue?

Identifying the precipitating factor 85% of patients with c/o fatigue can be diagnosed by a thorough H&P.

Possible etiologies of chronic fatigue syndrome.

Immune responses Multiple chemical sensitivity (MCS)

Guillain-Barre Syndrome.

Immune system attacks peripheral nervous system Varying degrees of weakness starting in the legs progressing upwards Usually at their weakest 2-3 weeks after the first symptoms occurs Nerve conduction velocity and lumbar puncture aid in diagnosis

Ameliorating Factors of fatigue.

Improved with rest Improves on weekends and vacations Post viral infection Use of drugs are causal if fatigue disappears after they are stopped.

What are some clinical presentations r/t neurologic fatigue?

Increased deep tendon responses Visual abnormalities Lhermitte's sign Nystagmus Intention tremor

Tick Bite Paralysis.

Lyme Disease; Rocky Mountain Spotted Fever Neuropathies, Myalgias, fatigue, congnitive dysfunction. Tick induced paralysis begins in the legs 5-6 days afar the tick attaches to the skin. Progresses to complete paralysis over several days Improves within hours after the tick is removed. Complete recovery takes several days.

Treatment of Fibromyalgia.

Management of pain and sleep disturbances Tricyclic antidepressants Lyrica (pregabalin) Exercise Acupuncture Opioid/non-opioid analgesics

Objective measurement of weakness.

Measurable loss of strength by physical exam

Acute Fatigue.

Most often a pro dome or sequelae of an acute viral or bacterial infectious process. May become apparent during the history

Causes of weakness.

Multiple and varied Highly specific Diagnosis of exclusion Muscle disorders - Periodic paralysis, abnormal mitochondrial function Neuromuscular junction disorders - MG, Lambert-Eaton myasthenic syndrome Electrolyte Disturbances CNS Disorders

S/S of myopathy?

Muscle cramps Stiffness Spasm

Upper motor neuron disease.

Muscle spasticity Increased reflexes Pseudo bulbar palsy Ex: Primary Lateral Sclerosis

Lower motor neuron disease.

Muscle wasting Depressed reflexes Bulbar palsy (muscles become atrophic and weak) Ex: Progressive Muscular Atrophy

Subjective measurement of weakness.

No measurable loss of strength

Associated conditions with Fibromyalgia.

Noctural myoclonus Hypothyroidism Myofacial pain syndrome Chronic fatigue syndrome Irritable bowel/bladder syndromes AIDS Many inflammatory rheumatic diseases

Diabetic Polyneuropathy.

Occurs in many patients with IDDM, NIDDM Severity correlated with the severity & duration of hyperglycemia. Affects small unmyelinated nerve fibers which carry information on temperature and pain Early symptoms are reduced pain awareness and inability to detect temperature.

Neuromuscular/Muscle Fatigue

Overuse Deconditioning Neurogenic/myopathic disease

Excessive Daytime Sleepiness.

Overwhelming urge to fall asleep at inappropriate times Relief from nap

Treatment of chronic fatigue syndrome.

Patient management No FDA approved medication Natural therapies (ginseng, EFA, coenzyme Q) Lyrica has had success in managing pain

Central/Psychogenic Fatigue.

Perceived weariness with effort Usually present on awakening Gets better throughout the day Improved on the holidays

What are some perpetuating causes of fatigue?

Physical inactivity Emotional disorders Ongoing psychological or social stress Abnormalities of sleep

Physiologic Fatigue.

Poor quality sleep (insomnia) Prolonged physical activity Dieting (low daily calorie intake) Sedentary lifestyle

Critical Illness Myopathy.

Predisposing Conditions: Acute Respiratory disorder AND concomitant use of high dose IV corticosteroids. ARDS, Pneumonia, Asthma Aminoglycosides Liver and lung transplant

Define Weakness.

Reduction in strength of one or more muscles or muscle groups

Prognosis of critical illness myopathy.

Severity of the underlying disease Age of patient

Signs and Symptoms of Weakness

Specific to either upper motor neuron vs. lower neuron involvement.

Fibromyalgia.

Spontaneous, widespread soft tissue pain, fatigue, sleep disturbance, multiple tender points Musculoskeletal pain that is unrelated to a clearly defined anatomical lesion. Female 30-50years Onset is gradual over a period of months to years Cause unknown

Prevalence of Fatigue.

Twice as common in women than men 5-20% of the general pop experience some type of disability 7th most common complaint in primary care

Systemic Disease

Usually absent in the morning Worsens during the day Grows progressively worse unless underlying cause is identified and treated

Critical Illness Polyneuropathy.

Usually occurs in men >50 Infection, trauma, burns, surgery Develop respiratory failure SIRS/MSOF Unable to wean from vent Moderate to severe symmetrical paresis Muscle wasting, diminished DTRs Difficult to recognize due to encephalopathy, NMBs, ventilatory support.

Chronic Fatigue.

When an organic cause is not initially apparent suspect psychosocial factors Weeks to months in duration May be caused by depression, chronic infection

Symptoms of Fibromyalgia.

Widespread paiin Present for at least 3 months Pain on digital palpation in 11-18 tender points Pain waxes and wanes Muscle or joint pain Fatigue