Nathan Butler

Active Health Clinic

WHAT IS THE RIGHT TREATMENT FOR YOUR PATIENT?

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we

don't know. But there are also unknown unknowns. There are things we don't know we

don't know” Donald Rumsfeld

WHAT IS THE CAUSE?

• Origin unknown

• Viral, neurological, immune dysfunction, deconditioning, psychological, leaky gut...

• CFS/ME is a diagnosis of exclusion and an umbrella term

• It could be all the above or none at the same time

• Multi-factorial as in any chronic condition

• Physical fatigue

• Mental fatigue

• Concentration difficulties

• Sore throat

• Tender Glands

• Joint pain

• Myalgia

• Headaches

• Photophobia

• Bowel problems

• Sleep disturbance

• Temperature regulation

• Dizziness

• Anxiety

• Depression

SYMPTOMS

How do we treat something without knowing the cause?

PATIENT PATHWAYPatient Presentation

Belief/Empathy

Medical assessment and testing to exclude other conditions

Specialist Referral

CFS/ME Diagnosis

Treatment

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is to not go to

sea at all” Osler, 1901

HOW DOES YOUR PATIENT PRESENT?

• What are their primary symptoms?

• Physical, cognitive, pain, anxiety, headache, etc.

• What are their illness beliefs?

• Medical illness, deconditioning, emotional, unsure

If we don’t listen then how can we recommend and appropriate course of action?

ASSESSING YOUR PATIENT

• CFS/ME is a medical diagnosis and should not be trivialised

• Malingerers

• Complainers

• “Your are just depressed, get on with it”

• “We all get tired”

• “It would be great to rest all day”

• Patients are generally high achievers academically, professionally and/or physically

PATIENT ADVICE

• Belief and empathy

• Vicious cycles

• Deconditioning, sleep, social, emotional

The Vicious Cycle of Fatigue

Initial Infection Symptoms

Recovery Stabilise Activity Graded Changes

More Rest Boom / Bust Rest

Decreased Activity Increased Deconditioning

PATIENT ADVICE

• Belief and empathy

• Vicious cycles

• Deconditioning, sleep, social, emotional

• Don’t force ideals or models

• Psychological support ≠ ‘it’s all in my mind’

• Exercise ≠ ‘it’s just deconditioning’

• Flexibility

• Discuss the ‘three P’s’

• Predisposing, precipitating and perpetuating factors

THE THREE P’S

• Predisposing

• Genetic

• Environmental

• Personality

• Perfectionism, anxiety, high achiever

• Lifestyle

• Imbalance in work, rest and play

• Food intolerances

THE THREE P’S

• Precipitating

• Physical

• Infection, injury

• Psychological

• Life events, prolonged stress

THE THREE P’S

• Perpetuating

• Physical deconditioning

• Sleep disturbance

• Psychological

• Anxiety, depression, loss, self worth, financial

• Personality

• Social

• Food intolerances

TREATMENTS

• Evidence based

• Graded Exercise Therapy

• Exercise that doesn’t exacerbate fatigue, pacing, goals, sleep and setback planning

• Cognitive Behavioural Therapy

• Promising treatments

• Pacing

• Food intolerances and nutritional interventions

• Gluten, lactose and fructose

THE TEAM

• GP - ‘The Pitcher’

• Initial contact, assessment, treatment

• Specialist – ‘The catcher’

• Confirmation of diagnosis, medications, treatment

• Therapists – ‘Basemen’

• Exercise Physiologists, Physiotherapists, Psychologists, Dieticians

• Treatment

WHICH TREATMENT?

• Medical, GET, CBT, Nutritional or a combination?

• Listen to your patient

• Initial focus on management and not cure

• By addressing the three P’s it can lead to better management and recovery

• Early intervention

• Team work

• Message of hope

• Belief

There is no one ‘right treatment’ but hopefully there are now more known knowns and less known unknowns but there still are and always will be

unknown unknowns…

Nathan Butler: info@activehealthclinic.com.au