Gloria P. Furst

Chronic Fatigue Syndrome: What Role Does the Autonomic Nervous System Play in the Pathophysiology of This Complex Illness?

Chronic fatigue syndrome (CFS) is a serious health concern affecting over 800,000 Americans of all ages, races and socioeconomic groups and both genders. The etiology and pathophysiology of CFS are unknown, yet studies have suggested an involvement of the autonomic nervous system (ANS). A symposium was organized in December 2000 to explore the possibility of an association between ANS dysfunction and CFS, with special emphasis on the interactions between ANS dysfunction and other abnormalities noted in the immune and endocrine systems of individuals with CFS. This paper represents the consensus of the panel of experts who participated in this meeting.

Exploratory Analysis of the Relationships between Aerobic Capacity and Self-Reported Fatigue in Patients with Rheumatoid Arthritis, Polymyositis, and Chronic Fatigue Syndrome

To determine if self‐reported levels of physical activity and fatigue are related to peak oxygen uptake (VO2peak) and whether these relationships differ among the patient groups (rheumatoid arthritis [RA], polymyositis [PM], and chronic fatigue syndrome [CFS]).

Polyarticular arthritis, independent of rheumatoid factor, is associated with poor functional outcome in recent onset inflammatory synovitis

The biological, physical and functional status change was measured in 104 patients with recent (< 1 year) onset synovitis. Measurements were taken initially and at 1 year. The purpose was to determine which biological and physical measures correlated with poor performance. Patients completed questionnaires quantifying activity, (the Human Activity Profile [HAP] and Sickness Impact Profile [SIP]), pain (Wisconsin Brief Pain Inventory), fatigue (Multidimensional Assessment of Fatigue), sleep, and mood (POMS and CESD). They were evaluated for articular involvement (Ritchie Index) and biological markers of disease activity (platelets, sedimentation rate, C-reactive protein and rheumatoid factor) (RF). In all, 30 men and 74 women participated. A total of 45 patients met the American College of Rheumatology criteria for rheumatoid arthritis (RA); of these, 24 were rheumatoid factor (RF) positive, 18 had spondylitis, and 41 had unclassified arthritis. Low activity level at 1 year (HAP and SIP) correlated with high numbers of inflamed joints initially (p < 0.002); with more than 10 involved joints regardless of diagnostic group (p = 0.001); and joint symmetry (p < 0.009) A high platelet count was associated with low activity level at 1 year (p = 0.01); and high sedimentation rate was associated with more pain (p < 0.05). Low activity level (p < 0.04), fatigue (p = 0.03) and sleeplessness (p = 0.02) were correlated with RF+ RA.

Poster 1: Physical and functional performance in alkaptonuria1

Abstract Objectives: To describe the physical and functional performance in patients with alkaptonuria and to determine if particular impairments correlate with functional performance. Design: Descriptive prospective research study. Setting: Biomedical research facility. Participants: 53 subjects with alkaptonuria (31 men, 22 women; mean age, 43.6y; range, 10–80y). Interventions: Functional questionnaires, history, physical exam (including Schober test), and plain film radiographs. Main Outcome Measures: The Human Activity Profile (HAP), a measure of physical activity, the Health Assessment Questionnaire (HAQ), a measure of activities of daily living and health status, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Fatigue Assessment Instrument (FAI). Results: The adjusted physical activity score (AAS) in the HAP identified 12 subjects who had normal activity, and 14 with mildly, 17 with moderately, and 10 with severely limited activities. The HAQ described 14 subjects with no functional limitation, and 17 with mild, 17 with moderate, and 4 with severe limitations. The FAI identified 27 subjects with normal levels of fatigue and 26 with abnormally increased fatigue. The Physical Component Summary (PCS) score of the SF-36 identified 44 subjects with lower and 9 with higher health scores compared with a normal population. The Mental Component Summary scores of the SF-36 identified 19 subjects below and 34 above the norm. The PCS correlated significantly with total joint abnormal range of motion ( P =.0003), kyphosis ( P =.0011), Schober test (spine flexion) ( P P P =.0336), shoulder severity ( P =.0374), and total spine severity scores ( P =.0023). The AAS correlated significantly with the Schober test ( P =.0213), age ( P =.0225), radiographic total large joint severity score ( P =.0315), total spine severity ( P =.0097), and thoracic ( P =.0449) and lumbar spine severity ( P =.0020). Conclusion: Patients with alkaptonuria have significant impairment, functional limitation, and disability (HAQ; SF-36) compared with a normal population. Disability (SF-36) and functional limitation (HAP) increase with age and clinical and radiographic measures of joint severity in large joints and spine.

Poster 236: Relationships of Body Mass Index with Impairments, Functional Limitations and Disability

made. No biopsy was performed. The patient was treated with intravenous corticosteroids with some improvement in her hemiparesis, but continued to have impairment of mobility and self-cares. Subsequently, she was transferred to acute inpatient rehabilitation, where she made significant functional improvement with physical and occupational therapy. The patient’s anxiety was initially a barrier to therapy participation. Fortunately, her motivation improved considerably after several sessions with our rehabilitation psychologist. Obesity was also contributing to her impaired function, so she was referred for an endocrinology and nutrition evaluation. After 1 month of rehabilitation, she had regained her ability to ambulate safely without a gait aid and perform her self-cares independently. Discussion: Tumefactive MS lesions have atypical imaging features, including size 2 cm, mass effect and ring enhancement. Like other forms of MS, it is more common in females and usually affects individuals in their 3rd or 4th decade of life. Unlike the patient in this case, this rare form of MS usually presents with a combination of motor, sensory, and cognitive symptoms. In addition to the interesting presentation and atypical imaging, this case highlights the important role of inpatient rehabilitation in a patient with acute tumefactive MS. It also illustrates the importance of considering comorbidities, such as obesity and anxiety disorders, when creating a rehabilitation plan. Conclusions: Patients recovering from acute tumefactive MS may benefit significantly from inpatient rehabilitation.

Summary and Discussion of Rehabilitation Section

Each member of the rehabilitation team has a unique contribution to make in helping the CFS patient become more functional. Goals may be to restore lost function, prevent further loss of function, or maintain current levels of function. The physiatrist idcntifies the musculoskeletal and neurological problems which contribute to functional losses in activities of daily living (ADL), household activities, vocational abilities, cognition, exercise tolerance, and socialization. The physiatrist then refers the patient for occupational, physical, or speech therapy as well as vocational counseling and may prescribe anti-inflammatory drugs or other medications to reduce pain. Using a variety of evaluations, the occupational therapist (OT) considers the individuals level of function in productive, leisure, and daily living activities, including motivation, habits, roles, and coptive, physical and psychosocial skills. OT treatment includes providing adaptive equipment and/or techniques to facilitate self-care; therapeutic activities to increase strength, coordination, endurance and cognitive and process skills; recommendations for changes in home or work environment; and the establishment of priorities, activity patterns, and a balance of productive and leisure activities.