Choosing the right treatment for CFS/ME can be complicated. This presentation can help guide you in the right direction.

1. Nathan Butler Active Health Clinic What is the right treatment for your patient?

2. “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

3. 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

4. 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

5. How do we treat something without knowing the cause?

6. Patient Pathway

7. “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

8. 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?

9. 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

10. Patient Advice Belief and empathy Vicious cycles Deconditioning, sleep, social, emotional

12. 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

13. The three P’s Predisposing Genetic Environmental Personality Perfectionism, anxiety, high achiever Lifestyle Imbalance in work, rest and play Food intolerances

14. The three P’s Precipitating Physical Infection, injury Psychological Life events, prolonged stress

15. The three P’s Perpetuating Physical deconditioning Sleep disturbance Psychological Anxiety, depression, loss, self worth, financial Personality Social Food intolerances

16. 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

17. 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

18. 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

19. 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