Minutes of the Exeter Sessional GPs Group
at Darts Farm – 1 February 2011
The meeting was kindly sponsored by:
Fiona Jones
Pfizer
Abby Tregelles
Pfizer
Wioleta Wagstaff
Pfizer
Attendance: 42 members
Welcome:
Hamish Duncan opened the meeting by thanking the reps for sponsoring. He
reminded members to sign the attendance register.
The website is now up and running at http://www.devonsessionalgps.co.uk/ and all
relevant information will be posted including meeting minutes. In the meantime
Emma Green recently sent out an e mail with numerous attachments regarding
upcoming meetings, a couple of initiatives to try to decrease the need for hospital
admission and a locum opportunity. In future the plan is that all that information and
more will be on the website.
Hamish welcomed Dr Mike Jefferys Consultant Physician, Dr Sean Lynch
Consultant Psychiatrist as well as Dawn, Helga and Jess occupational therapists
and also the co-ordinator for the Exeter Chronic Fatigue Syndrome service.
Chronic Fatigue Syndrome Service in Exeter
Dr Mike Jefferys
A multi-disciplinary team.
From 2005 has settled at about 150 patients per year – less the first year when first
introduced, more the second once people became aware of it and there was a
“backlog” of patients, then fairly steady. Was set up as there was a realisation that
these patients needed specialist care but were not fitting well into any service
previously available.
Initial assessment is 60-90 minutes.
Definition: fatigue:
 New or had specific onset
 Persistent
 Unexplained
 Causes significant reduction in activity level
 Characterised by post exertional malaise or fatigue
Patients have often sought other avenues of management previously so they have
expectations related to thyroid, mitochondrial metabolism etc. and these need to be
discussed so that they do not continue with unrealistic ideas picked up from
elsewhere.
Investigations usefully done before referral:
FBC, biochemistry, TFT, inflammatory markers, ferritin in young people, celiac
screen, autoimmune profile if warranted. Best to put results in the letter as the clinic
is held at an outpost in Whipton so not easy to access hospital computer.
Mimics:
 Neurological e.g. multisystem atrophy, autonomic failure, myasthenia gravis,
multiple sclerosis.
 Endocrine e.g. Addisons, thyroid disease, pituitary tumours.
 Sleep apnoea
 Malignancy – especially renal cell cancers
 Psychological e.g. depression, somatisation.
Role of the physician:
 Medical filter
 Affirm diagnosis
 Help with symptom control including optimising management of co-existing
pathology including diabetes, COPD.
Dawn
OT with physical and mental health background. Reminded us that the total therapist
input is only marginally over one full time equivalent – all are part time for the
chronic fatigue service.
Management in line with NICE guidelines:
 CBT
 Graded exercise
 Effective rest
 Grading and pacing
Given choice of group or individual guided self help – for mild only.
Patients learn effective rest and relaxation principles.
8 sessions run fortnightly – gap between sessions is important to allow practising
skills.
Each session lasts 2 hours but there is a break in the middle.
Individual goal setting and a three month review after the course to continue further
goal setting. Usually discharged at that stage.
Severe cases need initial home assessment – done by a consultant and Jess. Those
with co-morbid mental health problems also seen at home. Joint working with reablement team and mental health team.
Web site is being developed on infopoint with protocol and how to refer.
A local support group due to start:
 To start April 2011.
 Initiated by group of patients with chronic fatigue syndrome.
 Not NHS provision but providing help until established.
 Network for carers, family and friends.
 Emotional support.
 Meet monthly at Jurys Inn.
 Provide support and awareness of ME and raise profile of the condition.
 Website is planned.
Helga
OT and yoga teacher
Works mainly around advising effective rest and relaxation.
 First treatment of group programme.
 Ongoing throughout programme.
 Paradox explained – perspective change – get away from the boom then bust
cycle where rest imposed by exhaustion to planned activity and rest.
 Evidence based.
 Mind – body connection.
 Participants expected to practice – positive planning of rest periods.
Techniques:
 Resting postures
 Gentle movement series
 Correct breathing
 Deep relaxation
 Sensory awareness / mindfulness
 Visualisation
 Positive memory bank
Home practice:
 Place / length / time / frequency
 No “BUTS”
 Effective rest and relaxation to prevent boom / bust
 Effective rest and relaxation to initiate change
 Effective rest and relaxation to nourish oneself
 Feel good factor deserved
We did a practice 5 minutes with Helga leading – sitting in resting position,
concentrating on different parts of the body, listening for sounds and concentrating on
breathing.
Jess
Chronic fatigue syndrome programme:
 CBT approach meeting fortnightly for 2 hours.
 Participants use time between sessions to gain confidence.
 Self management strategies then to share experiences with group.
 Seven sessions in group then one individual with OT and a three month
review.
First half of group programme focuses on identifying existing habits and
routines that help or hinder management of fatigue and provides practical tools.
 Concepts – avoid boom and bust i.e. over activity and excessive rest cycle.
 Involve mind activity as well as physical activity.
Tools:
 Effective rest and relaxation.
 Decrease demands – prioritise and delegate.
 Set baseline and avoid boom and bust.
 Improve supply of energy – diet, sleep, relaxation, pleasure.
 Grading activity – setting the challenge according to time, distance and
complexity.
 Mix and match – physical and cognitive activity.
 Use of activity diaries and 1:1 therapy session – look at work, self care and
leisure.
 Use visual analogies – e.g. pillars of rest supporting planned activity, jug of
life – some things give and some things take from it, human battery.
Second half of group programme – cognitive component
 Stress and assertiveness.
 Explore response to stress and how to overcome it.
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Assertiveness – encourage to identify own needs, say no where appropriate to
avoid passive to aggressive swing.
Goal setting and stages of change – SMART goals, graded exercise, Kubler
Ross change curve.
A change questionnaire is given out at the end of the programme.
Guided self-help
 Time limited due to pressures on the service.
 Self management material.
 Sessions look at barriers to change and consolidate on principles explained in
the manual.
 Complex cases need onward referral.
Severe chronic fatigue syndrome
 House or bed bound.
 In depth functional assessment.
 Cognitive difficulty, carer stress, isolation, usually do not have pre-existing
care in place, falls, manual handling issues, tend to overdose on vitamins,
avoid sensory stimulation, nutritional issues.
 Provision of equipment and social services.
 Explore illness perception and motivation to engage.
 CBT.
 Goals established and reviewed.
 Monthly team meetings.
Dr Sean Lynch
Symptom clusters – fatigue, decreased energy, pain, muscular, sleep disturbance etc.
overlapping with somatoform issues.
Risk of associated psychological distress increases with increase in somatic
symptoms.
Diagnostic overlapping – e.g. chronic fatigue, fibromyalgia, irritable bowel.
In chronic fatigue syndrome:
 Fatigue is principal complaint.
 Fatigue of definite onset.
 Fatigue of certain duration (generally over 6 months).
 Fatigue is functionally disabling.
 Fatigue is not relieved by rest.
 Post exercise myalgia.
 Cognitive changes.
 Somatic complaints.
Outcome improved if shorter duration of symptoms.. CBT and graded exercise might
improve the prognosis over time.
Psychological therapy modules:
 CBT – many trials but models vary.
 Other cognitive models not well studied.
 Interpersonal therapy (IPT).
 Psychodynamic therapy.
 Neuro linguistic programming (NLP)?
Psychiatric co-morbidity very common – e.g. 25-50% or even more have depression.
Psychiatrist as diagnostic goal keeper.
Dilemma of case definition.
Patients need several sessions to be persuaded of a label different from what they
want / think is their label – there is a problem of potential loss of engagement with the
patient.
Housekeeping
Emma thanked the whole team for the talk.
Future ESGPG Meetings
Tuesday 1st March 2011 – Hazel Curtis – Community paediatrics and child
development
Tuesday 5th April 2011 – Jane Whitehurst – Hospice update and symptom control
Tuesday 3rd May 2011 – Michael Gibbons – Pulmonary fibrosis and new COPD
guidelines
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Hamish Duncan (chairman and LMC link)
Dr Diane Baker (appraisal support co-ordinator)
Dr Emma Green (educational co-ordinator)
Dr Katherine Wood (funding co-ordinator)
Dr Caroline Burton (treasurer)
Dr Kathryn Shore (minutes secretary)
Dr Clair Homeyard (social secretary)
Dr Francesca Vasquez (social secretary)
Megan James (LMC link)
hamishduncan@hotmail.com
dianebaker625@hotmail.com
dremmagreen@hotmail.com
katherine.wood2@nhs.net
c_burton74@hotmail.com
kathrynshore@btinternet.com
clair_homeyard@hotmail.com
cesca1@hotmail.com
daniel@dbbyles.wanadoo.co.uk