Everyone knows about broken bones, lacerations, traumatic brain injury, loss of vision, spinal cord injury and other physical injuries that follow automobile accidents, medical malpractice, construction site accidents and product defects. One often ignored after effect is fatigue that can become chronic: chronic fatigue syndrome (CFS). Surveys of injured persons often show that fatigue is one of the most significant long term permanent effects of an injury and in particular injury that results in chronic pain. Fatigue, like pain, doesn’t show up on an x-ray and doctors rarely spend any time trying to help with fatigue. Even when the pain is recognized as an issue, fatigue is often left out of the list of disabilities.
Chronic fatigue syndrome (CFS) is an illness defined by disabling physical and mental fatigue and physical and mental symptoms that are not explained by conventional medical and psychiatric diagnoses. CFS affects between 400,000 and 800,000 people in the United States and has an average duration of 5 years, but symptoms can persist as long as 20 years. The prognosis for recovery of severely ill CFS patients is poor. Despite CFS’s disabling, enduring, and prevalent nature, scant studies have quantified its impact on the health and well-being of those affected, on the health care system, or on society as a whole.
The burden of CFS is poorly recognized, and the illness remains an inadequately managed health problem. Two population-based studies of CFS have been conducted in the United States, and both found that CFS is one of the more common chronic illnesses among women across all racial/ethnic groups and that less than 20% of those who suffer from CFS have been diagnosed by a health care provider. Only three studies, all of which were clinic based, have attempted to quantify the impact of CFS, and each showed that people with the syndrome were likely to have lost their job or to be unemployed. In addition, it was shown that persons with CFS pose a disproportionate burden on the health care system and their families since they are sick for long periods of time and since there is no known cure for the illness.
The ability of an injured person to get back to a functional life is often affected most severely by fatigue. even when a person is physically able to lift and bend and do the tasks of many jobs, the consequence of fatigue is that the person can’t keep any job because fatigue takes them out of a 40 hour work week. As reported in the study The economic impact of chronic fatigue syndrome by Kenneth J Reynolds, Suzanne D Vernon, Ellen Bouchery and William C Reeves, SRA International, Inc., Arlington, U.S.A, Division of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, U.S.A, The Lewin Group, Falls Church, U.S.A:
The magnitude of the economic impact imposed on the individual and on society by CFS is substantial. Approximately one-quarter of persons with CFS, who would otherwise have participated in the labor force, ceased working. For those who continued to work, average income declined by one-third. This represents an estimated annual loss of almost $20,000 for the individual suffering from CFS. This magnitude of loss approximates half of their labor force and household productivity in a given year. The $9.1 billion national loss is comparable to that estimated for other illnesses, such as digestive system illnesses ($8.4 B) and infectious and parasitic diseases ($10.0 B) [19] and is greater than the estimated productivity losses from immunity disorders ($5.5 B), nervous system disorders ($6.4 B), or skin disorders ($1.3) [23]. This estimate does not include health care costs, which are likely to be substantial and does not address reductions in quality of life, which are likely to be large due to the debilitating fatigue.
We estimated annual lost productivity. However, CFS is a chronic illness. The average duration of CFS identified in population studies is 5 years and most patients with CFS seen by health care providers have been ill for more than 6 years. Thus, productivity losses, health care expenses, and reductions in quality of life continue for many years for most affected individuals and thus would have a substantial long-term impact on the standard of living of individuals with CFS and their family members.
It often starts with pain that doesn’t go away and lingers and tortures the injured person 24 hours a day, 7 days a week as reported in a Time Magazine feature article The Right (and Wrong) Way to Treat Pain by Claudia Wallis
With chronic pain, however, the alarm continues to shriek uselessly long after the physical danger has passed. Somewhere along the line–maybe near the initial injury, maybe in the spinal cord or brain–the alarm system has broken down. What researchers have only recently come to understand is that prolonged exposure to this screaming siren actually does its own damage. "Pain causes a fundamental rewiring of the nervous system," says Dr. Sean Mackey, director of research at Stanford University’s Pain Management Center. "Each time we feel pain, there are changes that occur that tend to amplify our experience of pain." That is why it is a mistake, despite our grin-and-bear-it tradition, to ignore or under treat severe pain.
Fatigue is often the most disabling feature of chronic pain. The injured person is often told by the insurance company, their employer or even their own attorney that they can go back to work and so they have no claim for future wage loss. On top of that their fatigue is ignored and not understood to be a part of the injury. It is treated like a form of laziness or lack of initiative. The treating doctor has probably told them that they can physically do the work at their old job or at least at some other less strenuous job. What is missing in this analysis is that if the injured person suffers from fatigue they cannot do the work if it involves a 40 hour job.
Unless a careful workup is done of the existence of fatigue and the connection of fatigue to the injury, the injured person will not be compensated for what can be a significant loss of future earnings.
What needs to be done is an analysis of the injured person by a neuropsychologist or other doctor using The Universal Work Skills Evaluation test. Below is a video showing a truck driver taking the test. Although there is no sound the test shows that the person has chronic fatigue.
http://www.youtube.com/watch?v=DphPP1EHj9M
Doctors have several ways of validating fatigue as a disabling factor resulting from personal injury.
A resident of Honolulu, Hawaii, Wayne Parsons is an Injury Attorney that has dedicate his life to improving the delivery of justice to the people of his community and throughout the United States. He is driven to make sure that the wrongful, careless or negligent behavior that caused his clients' injury or loss does not happen to others.
6 Comments
Lauren Clum, DC
Chronic Fatigue Syndrome is very real, as we see patients with it every day here at The Specific Chiropractic Center. We also see them get better from it, because specific chiropractic helps balance the function of the sympathetic nervous system, so that patients aren't constantly in the stress response that trigger the chronic fatigue in the first place. Relief does exist for chronic fatigue patients!!
Wayne Parsons
Lauren: Thanks for your comments. Do you folks work with other specialists who understand fatigue? I am interested in proving that the fatigue is real when an insurance company says the patient is malingering.I will mention you folks to my clients.
Mike Bryant
This is very good advice. I have to believe that it is missed by doctors and lawyers all the time and can be an essential part of an injured persons issues.
Kelly
You recently posted about chronic fatigue syndrome(CFS). There are two schools of thought in this demolition derby. There is a well funded group of psychiatrists who hypothesize CFS is psychosomatic. The problem with this hypothesis is the same for every other psychiatric disorder - there is no objective evidence of their position. And disagreement with the biomedical evidence is not the same thing as "medically unexplained."
The biomedical side is less well funded, however has more objective evidence of pathology. The World Health Organization exclusively classifies CFS in the ICD-10 under G93.3 other brain diseases. The first name used is myalgic encephalomyelitis, and chronic fatigue syndrome (CFS) and Post Viral Fatigue Syndrome are indexed.
Although somewhere around 30 to 50 percent of patients have acute onset with a viral trigger and the virus continually reactivating it is also hypothesized that other physical stressors beyond viruses and toxins, such as physical injury may trigger this neuroimmune disease. Or a weak immune system resulting from psychosocial stress may predispose the patient to these physical stressors in this multi-system disease. There is some evidence of genetic vulnerability to viral or toxic assault.
The "fatigue" -medically defined as exhaustion -, should be post-exertional malaise, of new on-set resulting from minimal exertion and not resolved by rest in 24 hours. The key to this profound exhaustion is not what a patient can do on the first day, but what they can do the second day.
Think of it as a bank account. Most people have millions of dollars in their account adjusting for age, and easily make withdrawals and have automatic deposits. With CFS (never chronic fatigue as that is one symptom not a syndrome with a unique combination of symptoms and signs) patients have $5 in the bank and when it is spent there is not an automatic deposit! When it is gone it is gone. The test results from the second day are the ones that are pathological. Also, there is very medical evidence correlating fatigue with lack of exercise. Association is not causation.
Beyond that, research definitions are only for research not clinical assessment. The 2003 Canadian clinical definition is the most stringent and will define a subgroup that is very ill. The clinical definition requires post-exertional malaise; sleep disorders (usually cytokine activity); cognitive difficulties such as impaired working memory, slow information processing, and abnormal slow waves on qEEG testing. SPECT and MRI testing also show structural abnormalities; neuropathic pain, severe headaches of new type or onset, pain in neck, shoulders, or back that is burning; and two of the following:
Autonomic nervous system dysfunction (tilt testing)AUTONOMIC MANIFESTATIONS: Orthostatic Intolerance: e.g., neurally mediated hypotension (NMH), postural orthostatic tachycardia syndrome (POTS), delayed postural hypotension, vertigo, light-headedness, extreme pallor, intestinal or bladder disturbances with or without irritable bowel syndrome (IBS) or bladder dysfunction (a common symptom of OI is constipation), palpitations with or without cardiac arrhythmia, vasomotor instability, and respiratory irregularities.
NEUROENDOCRINE MANIFESTATIONS: loss of thermostatic stability, heat/cold intolerance, anorexia or abnormal appetite, marked weight change, hypoglycemia, loss of adaptability and tolerance for stress, worsening of symptoms with stress and slow recovery, and emotional lability.
c.
IMMUNE MANIFESTATIONS: tender lymph nodes, sore throat, flu-like symptoms, general malaise, development of new allergies or changes in status of old ones, and hypersensitivity to medications and/or chemicals.
Duration of one to six months. If appropriate anti-virals and immune boosters given soon enough may prevent disability.
A copy of the full version is here:
http://www.cfids-cab.org/MESA/ccpccd.pdf
If your client doesn't meet these criteria and is simply weary or experiencing a temporary reduction in energy it probably is not CFS - which is a good thing. No one actually believes that someone wants a severe neurological disease that leaves them more ill than patients with end stage renal disease, COPD, or AIDS prior to the last two months AND the stigmatization that accompanies it just to get out of work.
Are some patients situationally depressed? Most patients with chronic disease experience varying levels of depression or anxiety. But it didn't cause their disease. It is the result of the disease. Most CFS patients do not fully endorse the DSM-IVR definition of depression - they don't feel worthless or guilty and they are full of plans for if they are ever well again which in the most severe subgroups is unlikely. But, add medical stigma and sometimes outright ostracization by society and possible family and friends and you'd be situationally depressed also.
Check with the IACFS organization for experts.
http://www.iacfsme.org/
Wayne Parsons
Thanks Kelly. Great information. What do you think we can do to better educate the public and doctors about this situation?
Facebook User
I'd also like to thank Kelly for providing correct information about CFS. Many organizations exist to promote this information as much as possible, so the myths about chronic fatigue syndrome can be overcome. But we especially need doctors to learn about this disease in medical school, and to keep up to date with the developing evidence, treatments and pathology information. Until doctors take it upon themselves to learn the truth about this illness (and others like fibromyalgia), patients will continue to be stigmatized, mistreated, called "hypochondriac" or mentally ill. Until doctors realize that it is their job to find out about and help the growing number of patients suffering from CFS, there will be little hope of recovery. The question is, how do we get doctors' attention and proper care?
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