Self-Management of Chronic Fatigue Syndrome in Adolescents

*Katherine Rowe, Amanda Apple and Fiona McDonald*

## **Abstract**

Chronic fatigue syndrome (CFS) or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a condition of unknown aetiology that commonly follows an infection. There are no known predictors for recovery or established treatments. At the Royal Children's Hospital (RCH) in Melbourne, Australia, the majority of young people with CFS are provided with symptom management and lifestyle guidance in an outpatient setting. However, for some, educational or social issues preclude progress and for those who request this assistance, since 2012, the Victorian Paediatric Rehabilitation Service has offered an Intensive Self-Management Program. For this program, participants engage in both group and individual sessions, attending 3 days per week for 4 weeks in small groups of 3–4. Interdisciplinary input is from Occupational Therapy, Physiotherapy, Education and Psychology to assist with goal setting and strategies. Outcome measures are obtained at initial assessment, 6 weeks and 6 months post-program. Support is offered for 12 months post-program. For both the outpatient program and the intensive program the outcomes and feedback from patient and family has influenced the approach and focus. This chapter outlines the current approach and how it has evolved over time.

**Keywords:** adolescent, chronic fatigue syndrome, management, rehabilitation, outcomes

## **1. Introduction**

Chronic fatigue syndrome is a condition of unknown aetiology that commonly follows an infective process in young people. There is a new onset of fatigue for at least 3–6 months that is not relieved by rest and not explained by other medical conditions. Post-exertional malaise, cognitive difficulties and unrefreshing sleep are present. In addition, a variety of somatic symptoms are commonly present such as headache, abdominal or muscle pain, as well as flu-like symptoms without fever, and symptoms associated with orthostatic intolerance [1–5]. The key features and symptom patterns in young people have remained consistent [6–9]. Anxiety and depression may also be present but when compared with population levels, were only mildly increased in prevalence, and generally did not precede the illness. They were understandably associated with diagnosis delay, not being believed or social isolation [8, 10].

There is currently no defined treatment, as the underlying pathology is not well understood [11]. Similarly, there are no known predictors for recovery [10]. When this illness occurs during childhood and adolescence, it is at a period of significant

developmental changes. In those that report recovery, the duration of illness has mean of 5 years and range 1–16 years [10]. With long-term follow-up, there is a significant proportion that does not report recovery [10, 12, 13]. There is disruption to their educational, social and physical activities, which create huge challenges for the young people and their families [14, 15]. It is the commonest cause of reduced time at school [16, 17], and has a significant impact on educational functioning [18]. Hence, in addition to managing symptoms, strategies for coping with this chronic illness and its impact on the young person and the family have been central to its management in this clinic [10]. Although there are other chronic illnesses during childhood and adolescence that have physical, emotional, cognitive or educational impacts [19–23], this illness does affect all these areas. Neglecting these aspects can compound the effect of the illness, and impact on the developmental tasks of adolescence or the transition to or from adolescence. Parents have a role in helping navigate these tasks, as well as trying to manage a child who is unwell [19, 20].

This chapter will outline the management strategies that have been employed in an outpatient setting that have been guided by feedback from young people over a period of more than 25 years; a description of the development since 2012 of an intensive self-management program for those who need additional assistance; and observations about characteristics of participants in the program and their reasons for referral.

#### **2. Outpatient management**

#### **2.1 Chronic fatigue syndrome outpatient clinic at the Royal Children's Hospital**

The Royal Children's Hospital is a specialised secondary and tertiary referral paediatric and adolescent hospital that services metropolitan Melbourne and all rural areas for the state of Victoria including bordering areas in neighbouring states. Furthest distances require 4–5 h of car travel. Referrals are received from family doctors or from specialist paediatricians. Victoria has a population of 6.3 million and is multicultural. There is a universal health system that ensures citizens can access health care free of charge to the family. There is also a private health system that can provide partially subsidised health and allied health care.

The CFS clinic has been functioning since 1989. In the early years of the clinic the Holmes definition and Fukuda criteria for CFS were available [2, 3, 21]. However, acceptance of the diagnosis in young people was uncommon in the medical fraternity. It was well recognised that Epstein Barr Virus (EBV) infection (or glandular fever) could run a prolonged course during adolescence. Irrespective of whether EBV was confirmed, it was assumed in some cases, that this was the cause of these symptoms. Alternative explanations that were entertained were depression, stress, school refusal or somatisation disorder or the possibility of undisclosed family difficulties. Parents who were anxious due to concern about the unexplained change in the young person were often considered to be contributing to their illness. Hence many who attended the clinic had experienced unsatisfying encounters with the medical profession.

The reported symptoms were very consistent among the young people attending. The presence of post-exertional malaise (PEM), unrefreshing sleep, cognitive difficulties, persistent fatigue and pain (headache, muscle, abdominal) were all almost universally reported. Sore throats and lymph nodes, feeling hot and cold and symptoms later recognised as associated with orthostatic intolerance were very common. These symptoms were consistently reported even though at the time there was no access to this information in the public arena.

**5**

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

Although the intravenous immunoglobulin trial in young people appeared a promising treatment [22], trials in adults were inconclusive [23–25], and approval was not granted for its use. Thus options for treatment reverted to general management strategies for chronic illness. We relied on feedback from young people to inform us regarding what was helpful in their management. The service has since expanded to several paediatricians and access to a 4-week self-management program run by the Victorian Paediatric Rehabilitation Service at the hospital.

A diagnosis of CFS is made following an extensive history, to confirm the presence of key symptoms, examination and routine investigations to exclude alternative diagnoses. These symptoms include PEM, unrefreshing sleep and cognitive symptoms as well as additional somatic symptoms [15]. Other conditions including school refusal, somatisation disorder, eating disorders, isolated significant depression or anxiety, connective tissue disorders, coeliac disease or endocrine disorders are specifically checked. An adolescent psychosocial (HEADSS) screen is also conducted where appropriate [26]. Passive standing test was not routinely performed initially. However, upon recognition of the association of orthostatic intolerance

Routine screening investigations included coeliac screen, thyroid function and antinuclear antibody. Serology for EBV or cytomegalovirus (CMV) is routinely assessed or if there was any likelihood of overseas or tropical infections or if the young person had been in areas where Ross River Virus, Q fever (Coxiella burnetti),

Following diagnosis, the young person is asked to: rate the most troublesome symptom/s that he/she would like help with; outline his/her aspirations prior to illness; describe current school attendance, interests, and previous participation in sport, the family situation and supports including parental work schedule, and means of transport to school or activities. The young person is provided with a brief explanation of our current knowledge, a plan for managing the most severe symptoms, and an outline of a management plan that the young person would devise.

The rationale for the management plan is to minimise the impact of chronic illness while accommodating the specific issues associated with CFS. As CFS affects the educational, physical, social and emotional aspects of their life, it is considered important to not neglect any of these areas. This should include some proactive social contact, academic input, physical activity and a commitment to attend something enjoyable outside of home on a regular basis. None of these activities is to be neglected but the proportion does not have to be equal. The plan needs to be sustainable for at least a month before it is reviewed. For example, some physical activity is required to prevent becoming so de-conditioned that they are unsure whether they are weak and fatigued because they are unwell or because muscles are not being used. Social contact is important to ensure that the social learning that occurs during adolescence (how to respond in different situations, what behaviour is acceptable and how to interpret different social situations and how to understand

Barmah forest virus were endemic, serology for exposure is also checked.

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

with ME/CFS this assessment was included [1].

*2.3.2 Management plan designed by the young person*

**2.2 Diagnosis**

**2.3 Management**

*2.3.1 Initial appointment*

Although the intravenous immunoglobulin trial in young people appeared a promising treatment [22], trials in adults were inconclusive [23–25], and approval was not granted for its use. Thus options for treatment reverted to general management strategies for chronic illness. We relied on feedback from young people to inform us regarding what was helpful in their management. The service has since expanded to several paediatricians and access to a 4-week self-management program run by the Victorian Paediatric Rehabilitation Service at the hospital.

## **2.2 Diagnosis**

*Topics in Primary Care Medicine*

for referral.

**2. Outpatient management**

developmental changes. In those that report recovery, the duration of illness has mean of 5 years and range 1–16 years [10]. With long-term follow-up, there is a significant proportion that does not report recovery [10, 12, 13]. There is disruption to their educational, social and physical activities, which create huge challenges for the young people and their families [14, 15]. It is the commonest cause of reduced time at school [16, 17], and has a significant impact on educational functioning [18]. Hence, in addition to managing symptoms, strategies for coping with this chronic illness and its impact on the young person and the family have been central to its management in this clinic [10]. Although there are other chronic illnesses during childhood and adolescence that have physical, emotional, cognitive or educational impacts [19–23], this illness does affect all these areas. Neglecting these aspects can compound the effect of the illness, and impact on the developmental tasks of adolescence or the transition to or from adolescence. Parents have a role in helping navigate these tasks, as well as trying to manage a child who is unwell [19, 20]. This chapter will outline the management strategies that have been employed in an outpatient setting that have been guided by feedback from young people over a period of more than 25 years; a description of the development since 2012 of an intensive self-management program for those who need additional assistance; and observations about characteristics of participants in the program and their reasons

**2.1 Chronic fatigue syndrome outpatient clinic at the Royal Children's Hospital**

The Royal Children's Hospital is a specialised secondary and tertiary referral paediatric and adolescent hospital that services metropolitan Melbourne and all rural areas for the state of Victoria including bordering areas in neighbouring states. Furthest distances require 4–5 h of car travel. Referrals are received from family doctors or from specialist paediatricians. Victoria has a population of 6.3 million and is multicultural. There is a universal health system that ensures citizens can access health care free of charge to the family. There is also a private health system

The CFS clinic has been functioning since 1989. In the early years of the clinic

However, acceptance of the diagnosis in young people was uncommon in the medical fraternity. It was well recognised that Epstein Barr Virus (EBV) infection (or glandular fever) could run a prolonged course during adolescence. Irrespective of whether EBV was confirmed, it was assumed in some cases, that this was the cause of these symptoms. Alternative explanations that were entertained were depression, stress, school refusal or somatisation disorder or the possibility of undisclosed family difficulties. Parents who were anxious due to concern about the unexplained change in the young person were often considered to be contributing to their illness. Hence many who attended the clinic had experienced unsatisfying encounters with

The reported symptoms were very consistent among the young people attending. The presence of post-exertional malaise (PEM), unrefreshing sleep, cognitive difficulties, persistent fatigue and pain (headache, muscle, abdominal) were all almost universally reported. Sore throats and lymph nodes, feeling hot and cold and symptoms later recognised as associated with orthostatic intolerance were very common. These symptoms were consistently reported even though at the time there

the Holmes definition and Fukuda criteria for CFS were available [2, 3, 21].

that can provide partially subsidised health and allied health care.

was no access to this information in the public arena.

**4**

the medical profession.

A diagnosis of CFS is made following an extensive history, to confirm the presence of key symptoms, examination and routine investigations to exclude alternative diagnoses. These symptoms include PEM, unrefreshing sleep and cognitive symptoms as well as additional somatic symptoms [15]. Other conditions including school refusal, somatisation disorder, eating disorders, isolated significant depression or anxiety, connective tissue disorders, coeliac disease or endocrine disorders are specifically checked. An adolescent psychosocial (HEADSS) screen is also conducted where appropriate [26]. Passive standing test was not routinely performed initially. However, upon recognition of the association of orthostatic intolerance with ME/CFS this assessment was included [1].

Routine screening investigations included coeliac screen, thyroid function and antinuclear antibody. Serology for EBV or cytomegalovirus (CMV) is routinely assessed or if there was any likelihood of overseas or tropical infections or if the young person had been in areas where Ross River Virus, Q fever (Coxiella burnetti), Barmah forest virus were endemic, serology for exposure is also checked.

#### **2.3 Management**

#### *2.3.1 Initial appointment*

Following diagnosis, the young person is asked to: rate the most troublesome symptom/s that he/she would like help with; outline his/her aspirations prior to illness; describe current school attendance, interests, and previous participation in sport, the family situation and supports including parental work schedule, and means of transport to school or activities. The young person is provided with a brief explanation of our current knowledge, a plan for managing the most severe symptoms, and an outline of a management plan that the young person would devise.

#### *2.3.2 Management plan designed by the young person*

The rationale for the management plan is to minimise the impact of chronic illness while accommodating the specific issues associated with CFS. As CFS affects the educational, physical, social and emotional aspects of their life, it is considered important to not neglect any of these areas. This should include some proactive social contact, academic input, physical activity and a commitment to attend something enjoyable outside of home on a regular basis. None of these activities is to be neglected but the proportion does not have to be equal. The plan needs to be sustainable for at least a month before it is reviewed. For example, some physical activity is required to prevent becoming so de-conditioned that they are unsure whether they are weak and fatigued because they are unwell or because muscles are not being used. Social contact is important to ensure that the social learning that occurs during adolescence (how to respond in different situations, what behaviour is acceptable and how to interpret different social situations and how to understand one's peers) is not neglected. It can be very daunting later when it is expected that these skills have been acquired. Academic engagement is important so that they feel that their life chances have not been destroyed. The regular enjoyable activity outside of home is something that they have chosen to attend because it is 'worth it' and will not result in a prolonged recovery. It removes any prevarication regarding whether they feel well enough, whether they would cope or whether it would be easier not to go. Only if they are unable to move out of bed do they not attend. This hopefully prevents the reluctance to make decisions, to be adventurous or to be reliable.

In addition, young people generally have not had to learn to prioritise their activities during their teenage years but it is needed as developing adults. It is explained that they need to learn this much earlier than most and it is a very useful skill to acquire. Some activities, for example, attending school for an enjoyable subject could fulfil social, academic and enjoyable activities and also require some physical activity. If their important social network was outside of school then there needed to be an effort to engage with that group for a period of time that was manageable. If some young people felt that 'life was not worth living' if they could not play sport, as this was their main social connection, then adjustments could be made. They could be part of the team by 'coming off the bench' for a few minutes or not being required to actively train. They could be moved to a team position that did not require a lot of stamina. On the other hand, for some, physical activity may be a few activities of daily living spaced over the day, or once they are able to do some activity and have increased their strength, they often chose a variety of activities that they enjoy.

Their aspirations (prior to becoming unwell) play a key role in the decisions regarding their education. Attending school for set hours, rather than for specific subjects is difficult to sustain. Reduction in the school subject load to include subjects and teachers they liked, as well as subjects that are pre-requisites for what they want to do as a career is crucial. Trying to keep up with all subjects when only given minimal information is a source of unnecessary stress, and this rarely succeeds. A planned timetable ensures that the arrangements provide some consistency and predictability for the family (and for the teaching staff) and be manageable for the young person. If the symptoms are severe, the extent of 'academic input' may be reduced to reading about a hobby or reading a story that they are already familiar with.

It is explained to the young person that these consequences of illness can be more damaging than the illness itself and can occur with any chronic illness. Neglecting these areas creates significant hurdles to recovery such as: navigating social anxiety and social learning; entering the workforce without a potentially enjoyable, satisfying or more lucrative, less physically demanding job; needing to increase strength, or not having the confidence or resilience to know how they are able to manage their life. The young person is asked to estimate how they can balance these tasks within the bounds of the amount of energy available over the period of a week. The young people make those decisions over the subsequent few weeks and discuss their plan with their parents.

#### *2.3.3 Symptom management*

Only the most severe one or two symptoms are treated initially. Often treating one symptom such as sleep disturbance, and allowing them to take control of their life with the management plan reduces the severity of some of the other troublesome symptoms. Despite the prominent fatigue, malaise and concentration difficulties, the complaints of headache and sleep disturbance or dizziness and nausea due to orthostatic intolerance, can often be managed effectively.

**7**

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

Difficulties with sleep initiation, sleep phase shift, frequent waking and disturbing nightmares are actively managed with sleep hygiene techniques and melatonin or low dose tricyclic medications such as dothiepin or amitriptyline. Simple migraine prophylactic medications such as pizotifen or periactin are anecdotally effective in reducing the severity of headache. Simple measures such as increasing salt and fluid intake, including electrolyte drinks, and encouraging lower limb exercises and gentle exercise can assist with orthostatic intolerance. Similarly, muscle pain and fibromyalgia can be helped by reducing sleep disturbance and encouraging

Residual difficulties with concentration, recognition of depression, persistent severe dysmenorrhoea associated with exacerbation of CFS symptoms, ongoing nausea, abdominal discomfort or persistent orthostatic symptoms are usually addressed after review and the implementation of the management plan.

A 6-week follow up appointment is usually scheduled for review of their plan and whether the logistics are sustainable. Residual symptoms are checked including whether the symptom management is appropriate. Any further queries from the young person are addressed. Once a decision had been made regarding the schedule for education, appropriate explanation, documentation, advocacy, extra support, special provision or special consideration is provided or requested. A specific education program to ensure maximum possible opportunity to participate is therefore implemented. Sometimes this requires a combination of Distance Education and school attendance for 1–2 subjects, or attendance for a few classes with visiting teacher assistance. If necessary, the minimum requirements are negotiated to ensure the year level is passed so that they can progress with their peers. Additional details regarding educational strategies used by the Visiting Teacher Service have been documented [27]. If adjustments to sport schedules are required, these are provided and coaches and staff are usually very accommodating once they understand the reasons for the requests. Generally 3-monthly reviews are arranged to assess progress, educational issues, symptom management and review of goals. Young people are seen more frequently if necessary. Occasionally young people are followed up by a local paediatrician. In addition, parents often need help navigating the difficult adolescent period and uncertainties regarding assisting with the tasks of adolescent development in the context a chronic illness that is generally not well understood. The developmental tasks (19) of adolescence may fail to progress during the illness and may need to be addressed during management, or time allowed for some catch up when the young person is well enough. Such tasks can be difficult for any parent to navigate but even more difficult when the young person is clearly unwell and not able to

These tasks include increasing sense of independence and responsibility for their actions, peer relationships, sexual identity and development, assessment of risk, sense of self-worth and hope for the future. Persistent dependence, uncertainty about what is required, social anxiety and withdrawal, extreme caution in making decisions, poor self-esteem and depression regarding the future can be the consequence of the limitations imposed by chronic illness. Parents are not sure if they should be defending, protecting and trusting the young person's judgement or cajoling, setting limits and allowing the young person to make mistakes. Many parents put their life 'on hold' to care for the young person with the attendant complications for the whole family, and this often adds significant stressors. For many young people, doing some small chores that do not require much effort is important

in order to be part of the family and reduce tensions with siblings.

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

gentle exercise or physical therapy.

manage some simple activities of daily living.

*2.3.4 Review appointments*

#### *Self-Management of Chronic Fatigue Syndrome in Adolescents DOI: http://dx.doi.org/10.5772/intechopen.91413*

Difficulties with sleep initiation, sleep phase shift, frequent waking and disturbing nightmares are actively managed with sleep hygiene techniques and melatonin or low dose tricyclic medications such as dothiepin or amitriptyline. Simple migraine prophylactic medications such as pizotifen or periactin are anecdotally effective in reducing the severity of headache. Simple measures such as increasing salt and fluid intake, including electrolyte drinks, and encouraging lower limb exercises and gentle exercise can assist with orthostatic intolerance. Similarly, muscle pain and fibromyalgia can be helped by reducing sleep disturbance and encouraging gentle exercise or physical therapy.

Residual difficulties with concentration, recognition of depression, persistent severe dysmenorrhoea associated with exacerbation of CFS symptoms, ongoing nausea, abdominal discomfort or persistent orthostatic symptoms are usually addressed after review and the implementation of the management plan.

#### *2.3.4 Review appointments*

*Topics in Primary Care Medicine*

be reliable.

that they enjoy.

with their parents.

*2.3.3 Symptom management*

one's peers) is not neglected. It can be very daunting later when it is expected that these skills have been acquired. Academic engagement is important so that they feel that their life chances have not been destroyed. The regular enjoyable activity outside of home is something that they have chosen to attend because it is 'worth it' and will not result in a prolonged recovery. It removes any prevarication regarding whether they feel well enough, whether they would cope or whether it would be easier not to go. Only if they are unable to move out of bed do they not attend. This hopefully prevents the reluctance to make decisions, to be adventurous or to

In addition, young people generally have not had to learn to prioritise their activities during their teenage years but it is needed as developing adults. It is explained that they need to learn this much earlier than most and it is a very useful skill to acquire. Some activities, for example, attending school for an enjoyable subject could fulfil social, academic and enjoyable activities and also require some physical activity. If their important social network was outside of school then there needed to be an effort to engage with that group for a period of time that was manageable. If some young people felt that 'life was not worth living' if they could not play sport, as this was their main social connection, then adjustments could be made. They could be part of the team by 'coming off the bench' for a few minutes or not being required to actively train. They could be moved to a team position that did not require a lot of stamina. On the other hand, for some, physical activity may be a few activities of daily living spaced over the day, or once they are able to do some activity and have increased their strength, they often chose a variety of activities

Their aspirations (prior to becoming unwell) play a key role in the decisions regarding their education. Attending school for set hours, rather than for specific subjects is difficult to sustain. Reduction in the school subject load to include subjects and teachers they liked, as well as subjects that are pre-requisites for what they want to do as a career is crucial. Trying to keep up with all subjects when only given minimal information is a source of unnecessary stress, and this rarely succeeds. A planned timetable ensures that the arrangements provide some consistency and predictability for the family (and for the teaching staff) and be manageable for the young person. If the symptoms are severe, the extent of 'academic input' may be reduced to reading

It is explained to the young person that these consequences of illness can be more damaging than the illness itself and can occur with any chronic illness. Neglecting these areas creates significant hurdles to recovery such as: navigating social anxiety and social learning; entering the workforce without a potentially enjoyable, satisfying or more lucrative, less physically demanding job; needing to increase strength, or not having the confidence or resilience to know how they are able to manage their life. The young person is asked to estimate how they can balance these tasks within the bounds of the amount of energy available over the period of a week. The young people make those decisions over the subsequent few weeks and discuss their plan

Only the most severe one or two symptoms are treated initially. Often treating one symptom such as sleep disturbance, and allowing them to take control of their life with the management plan reduces the severity of some of the other troublesome symptoms. Despite the prominent fatigue, malaise and concentration difficulties, the complaints of headache and sleep disturbance or dizziness and nausea due

about a hobby or reading a story that they are already familiar with.

to orthostatic intolerance, can often be managed effectively.

**6**

A 6-week follow up appointment is usually scheduled for review of their plan and whether the logistics are sustainable. Residual symptoms are checked including whether the symptom management is appropriate. Any further queries from the young person are addressed. Once a decision had been made regarding the schedule for education, appropriate explanation, documentation, advocacy, extra support, special provision or special consideration is provided or requested. A specific education program to ensure maximum possible opportunity to participate is therefore implemented. Sometimes this requires a combination of Distance Education and school attendance for 1–2 subjects, or attendance for a few classes with visiting teacher assistance. If necessary, the minimum requirements are negotiated to ensure the year level is passed so that they can progress with their peers. Additional details regarding educational strategies used by the Visiting Teacher Service have been documented [27]. If adjustments to sport schedules are required, these are provided and coaches and staff are usually very accommodating once they understand the reasons for the requests.

Generally 3-monthly reviews are arranged to assess progress, educational issues, symptom management and review of goals. Young people are seen more frequently if necessary. Occasionally young people are followed up by a local paediatrician.

In addition, parents often need help navigating the difficult adolescent period and uncertainties regarding assisting with the tasks of adolescent development in the context a chronic illness that is generally not well understood. The developmental tasks (19) of adolescence may fail to progress during the illness and may need to be addressed during management, or time allowed for some catch up when the young person is well enough. Such tasks can be difficult for any parent to navigate but even more difficult when the young person is clearly unwell and not able to manage some simple activities of daily living.

These tasks include increasing sense of independence and responsibility for their actions, peer relationships, sexual identity and development, assessment of risk, sense of self-worth and hope for the future. Persistent dependence, uncertainty about what is required, social anxiety and withdrawal, extreme caution in making decisions, poor self-esteem and depression regarding the future can be the consequence of the limitations imposed by chronic illness. Parents are not sure if they should be defending, protecting and trusting the young person's judgement or cajoling, setting limits and allowing the young person to make mistakes. Many parents put their life 'on hold' to care for the young person with the attendant complications for the whole family, and this often adds significant stressors. For many young people, doing some small chores that do not require much effort is important in order to be part of the family and reduce tensions with siblings.

For younger patients, there are concerns regarding persistent dependence on parents, and anxiety regarding the illness, such as concerns about what was actually wrong and whether there would be recovery. They worry about managing at school, as well as social anxiety when they are absent from their social network for some time. There may also be depression and a sense of helplessness and powerlessness, especially if some family members, the medical profession or teachers do not understand. In addition, the transition into adolescence and secondary school is exacerbated when they are not able to attend frequently enough to engage socially.

#### **2.4 Feedback from young people**

Feedback from young people regarding their management was sought on many occasions over the years and has been reported in detail [28]. This feedback modified management. Feedback affirmed that being believed by the clinician, family and school staff and feeling as if they had an advocate to help them navigate the education system were central to their overall ability to cope and their general wellbeing. Having a management framework within which they could organise their priorities was seen as key to feeling as if they could have some control over their life again. Of note, assistance with being able to continue with education was valued as important as their medical management. Continuing social engagement as part of their self-management was crucial for continuing social learning. For those where outpatient support has not been sufficient, there is now access to a 4-week intensive self-management program.

#### **3. The intensive self-management program**

#### **3.1 Background**

In 2012, the Victorian Paediatric Rehabilitation Service (VPRS) at the RCH in Melbourne commenced multidisciplinary management of adolescents with CFS. This followed a state government review of services available for young people with CFS, and the recognition that outpatient services required additional support and a more coordinated approach. A systematic review by Knight et al. [29], of the limited literature available on paediatric interventions, indicated some support for cognitive behaviour therapy (CBT) and limited support for multidisciplinary intervention. However, the quality of these studies, did not allow firm conclusions to be drawn.

Thus it was decided that the new program would have a CBT framework, be goal-focused and strongly encourage self-management. Following ongoing evaluation and feedback, it was noted that some aspects continued to work well, while others needed modification. With the implication that there is no known 'cure', there needed to be a change in approach from the typical rehabilitation aim of assisting with the reduction of suffering as the sole focus. Feedback from families and participants found this approach to be disempowering. This ensured that, rather than being viewed as an illness to be endured it could be a more hopeful, dynamic and positive process. Recovery was possible and at the very least, there could be an improvement in functioning and some participation in important stages of adolescent development.

In the early years of the program, there was minimal involvement of families in program sessions, with the focus solely on the young person and engaging them in self-management. There was some inflexibility and a more rigid approach where all participants were encouraged to engage in activity on non-program days with little individualization of the program. Often participants were too exhausted at the end

**9**

**3.3 Assessment**

*3.3.1 Inclusion criteria*

Clinic is as follows:

well beyond the four-week program.

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

medical management alongside the CFS medical team.

of relatively long therapy days to convey to parents what they were keen to practise and how they needed to be supported at home. This resulted in confusion within families about plans and expectations on non-program days, repetition of the same information to multiple people and reduced understanding by parents of the clinical reasoning behind the program. This was an unfortunate approach and much was learnt from patients and families at this time. More flexible, individualised guidance in setting up a management plan was preferred. It allowed for flexibility, review and adjustment when progress occurred. It was noted that family involvement was required to improve participant engagement and successful carryover of

In addition, increasing recognition of the association of postural orthostatic tachycardia syndrome (POTS) in the referrals required a change in the focus of exercise therapy within the program. Cardiologists became an important part of the

The aim is to encourage ongoing, self-directed learning and management of the illness, so that participants and families have the strategies and confidence to reduce the chaos, uncertainty and loss that underpins living with CFS during adolescence. They are encouraged to re-engage in key areas of life that have been neglected or

The VPRS CFS Self-Management Program runs for 3 days per week, for a 4-week

A typical day is runs from 9.30 am to 3 pm. Each participant identifies his or her own goals and these are used to establish a framework to work within over the 4

The program is structured around individual and group sessions. The structure of the sessions allows for key content to be explored and built on over the weeks. During the non-program days (two weekdays and the weekend) they are encouraged to practise and to implement what they have learned. Participants are encouraged to be open-minded and to consider new ways of looking at and living their life. For many participants and families it is an enormous undertaking to attend the program. It varies how feasible it is to practise new skills on non-program days. For most, the opportunity to try out new activities and routines in a considered, modified way is attainable. For some, however, the goal is to engage during program days, learn the theory and skills within the three-day structure and have quiet days in between. Much of the practising then occurs post-program when they can spread their energy availability over a week at a less intense pace. This approach is flexible, individualised and sustainable as they learn self-management tools that continue

Participant inclusion criteria used by referring doctors from the CFS Outpatient

period and is located in an outpatient setting within the hospital. Four staff, an occupational therapist, a physiotherapist, an education consultant and a clinical psychologist provide interdisciplinary care. Each therapist covers 2 days of the 3-day program. They also meet weekly with referring doctors to discuss participant

weeks. They continue to work with this framework after the program.

**3.2 Overview of the current 4-week intensive self-management program** 

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

effects after the program.

**at RCH**

problematic.

progress.

#### *Self-Management of Chronic Fatigue Syndrome in Adolescents DOI: http://dx.doi.org/10.5772/intechopen.91413*

*Topics in Primary Care Medicine*

**2.4 Feedback from young people**

self-management program.

of adolescent development.

**3.1 Background**

**3. The intensive self-management program**

For younger patients, there are concerns regarding persistent dependence on parents, and anxiety regarding the illness, such as concerns about what was actually wrong and whether there would be recovery. They worry about managing at school, as well as social anxiety when they are absent from their social network for some time. There may also be depression and a sense of helplessness and powerlessness, especially if some family members, the medical profession or teachers do not understand. In addition, the transition into adolescence and secondary school is exacerbated when they are not able to attend frequently enough to engage socially.

Feedback from young people regarding their management was sought on many occasions over the years and has been reported in detail [28]. This feedback modified management. Feedback affirmed that being believed by the clinician, family and school staff and feeling as if they had an advocate to help them navigate the education system were central to their overall ability to cope and their general wellbeing. Having a management framework within which they could organise their priorities was seen as key to feeling as if they could have some control over their life again. Of note, assistance with being able to continue with education was valued as important as their medical management. Continuing social engagement as part of their self-management was crucial for continuing social learning. For those where outpatient support has not been sufficient, there is now access to a 4-week intensive

In 2012, the Victorian Paediatric Rehabilitation Service (VPRS) at the RCH in Melbourne commenced multidisciplinary management of adolescents with CFS. This followed a state government review of services available for young people with CFS, and the recognition that outpatient services required additional support and a more coordinated approach. A systematic review by Knight et al. [29], of the limited literature available on paediatric interventions, indicated some support for cognitive behaviour therapy (CBT) and limited support for multidisciplinary intervention. However, the quality of these studies, did not allow firm conclusions to be drawn. Thus it was decided that the new program would have a CBT framework, be goal-focused and strongly encourage self-management. Following ongoing evaluation and feedback, it was noted that some aspects continued to work well, while others needed modification. With the implication that there is no known 'cure', there needed to be a change in approach from the typical rehabilitation aim of assisting with the reduction of suffering as the sole focus. Feedback from families and participants found this approach to be disempowering. This ensured that, rather than being viewed as an illness to be endured it could be a more hopeful, dynamic and positive process. Recovery was possible and at the very least, there could be an improvement in functioning and some participation in important stages

In the early years of the program, there was minimal involvement of families in program sessions, with the focus solely on the young person and engaging them in self-management. There was some inflexibility and a more rigid approach where all participants were encouraged to engage in activity on non-program days with little individualization of the program. Often participants were too exhausted at the end

**8**

of relatively long therapy days to convey to parents what they were keen to practise and how they needed to be supported at home. This resulted in confusion within families about plans and expectations on non-program days, repetition of the same information to multiple people and reduced understanding by parents of the clinical reasoning behind the program. This was an unfortunate approach and much was learnt from patients and families at this time. More flexible, individualised guidance in setting up a management plan was preferred. It allowed for flexibility, review and adjustment when progress occurred. It was noted that family involvement was required to improve participant engagement and successful carryover of effects after the program.

In addition, increasing recognition of the association of postural orthostatic tachycardia syndrome (POTS) in the referrals required a change in the focus of exercise therapy within the program. Cardiologists became an important part of the medical management alongside the CFS medical team.

## **3.2 Overview of the current 4-week intensive self-management program at RCH**

The aim is to encourage ongoing, self-directed learning and management of the illness, so that participants and families have the strategies and confidence to reduce the chaos, uncertainty and loss that underpins living with CFS during adolescence. They are encouraged to re-engage in key areas of life that have been neglected or problematic.

The VPRS CFS Self-Management Program runs for 3 days per week, for a 4-week period and is located in an outpatient setting within the hospital. Four staff, an occupational therapist, a physiotherapist, an education consultant and a clinical psychologist provide interdisciplinary care. Each therapist covers 2 days of the 3-day program. They also meet weekly with referring doctors to discuss participant progress.

A typical day is runs from 9.30 am to 3 pm. Each participant identifies his or her own goals and these are used to establish a framework to work within over the 4 weeks. They continue to work with this framework after the program.

The program is structured around individual and group sessions. The structure of the sessions allows for key content to be explored and built on over the weeks. During the non-program days (two weekdays and the weekend) they are encouraged to practise and to implement what they have learned. Participants are encouraged to be open-minded and to consider new ways of looking at and living their life.

For many participants and families it is an enormous undertaking to attend the program. It varies how feasible it is to practise new skills on non-program days. For most, the opportunity to try out new activities and routines in a considered, modified way is attainable. For some, however, the goal is to engage during program days, learn the theory and skills within the three-day structure and have quiet days in between. Much of the practising then occurs post-program when they can spread their energy availability over a week at a less intense pace. This approach is flexible, individualised and sustainable as they learn self-management tools that continue well beyond the four-week program.

#### **3.3 Assessment**

## *3.3.1 Inclusion criteria*

Participant inclusion criteria used by referring doctors from the CFS Outpatient Clinic is as follows:

## 10–18 years of age.

CFS is the primary diagnosis and the patient accepts this. Display motivation to engage in the intensive nature of the program. Enrolment in education. Physically able to manage 3 days per week of engagement for 4 weeks without significantly worsening their symptoms as a typical program day requires participants to walk approximately 700 m to access the treatment areas from

the hospital entrance.

Tried doctor-led outpatient guidance in the first instance.

Stable mental health

This assessment consists of a 45-min psychology assessment, 45-min education assessment and a combined 90-min occupational therapy and physiotherapy assessment. The patient attends the assessment with at least one parent or guardian present. In addition to detailed assessment about CFS, there is exploration of the young person's motivation to participate in a group program setting and their attitudes and beliefs about CFS are recorded. This is to ensure a group program is a suitable 'fit' for the young person. The philosophy and structure of the intervention is explained and goal setting is completed.

We have also noted that if any of the above criteria are not met, the likelihood of positive engagement is poor. In particular, where motivation to participate is parent rather than patient led or if CFS is not the primary diagnosis, the group dynamic is affected.

It is clear that the intensive program is not suitable for all young people with CFS. Those who are unable to attend the program in person for all the required days without significant worsening of symptoms are not appropriate. These patients are encouraged to continue with the doctor-led outpatient guidance in conjunction with a physical therapist that can provide therapy in time frames and intensities that are a better fit for the patient.

Currently the program is moving towards offering pre-program conditioning and guidance to streamline the process of starting a program so that many months are not spent with the young person in limbo.

## *3.3.2 Baseline and outcome measures*

Outcome measures are completed at initial assessment, 6 weeks post-program and 6 months post-program. The current outcome measures are:


From 2012 to 2018, the psychological measure was the Beck Youth Inventories measure [32].

#### *3.3.3 Assessment decision*

The VPRS therapy team meet post-assessment to discuss findings. Provided the patient meets inclusion criteria and the family are keen to participate, an offer is

**11**

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

made to participate in an upcoming program. The wait list is usually 2–4 months. If either the family or the VPRS therapists do not feel the 4-week intensive program is an appropriate match for the family, alternatives in the community are explored. We have found that these alternative options are particularly appropriate in cases where families find it too difficult to be at the hospital for the required time due to

In addition, as several participants are in each program, every effort is made to match participants based on age, educational stage and likely group dynamic and,

Program information is emailed to families soon after an offer is made. This information includes logistics as well as a proposed timetable so that families can forward plan. A blank activity record is also sent to be completed the week prior to the program so that the therapy team have a current record of how the participant is

To give participants the smoothest transition to the program and ultimately an effective intervention, a VPRS therapist via telephone, or in person, conducts a pre-program readiness interview, in the 2 weeks prior to the program. The previously identified program goals are clarified and changed if requested. It has been noted that without adequate time to prepare mentally and physically for the program, it takes longer for participants to settle in and co-operate with the program's agreed expectations.

Participants work as a group to learn and implement core functional activities of daily living into their weekly schedules. Topics covered include sleep hygiene, balancing activity, leisure, memory and concentration, diet, pacing and energy conservation and setback planning. Participants learn to formulate a weekly planner, where they plan a balanced week of both 'need to do' activities and 'want to do' activities. This is to ensure that they plan a manageable week in line with their current baselines of their CFS physical and mental capabilities. During the program, participants embark on an outing as a group in order to practise these concepts and

Goal setting sets the framework for the program. Goals are revisited regularly and progress tracked. Weekly individual goal review and progression sessions occur with the Physiotherapist and Occupational Therapist. Weekend planning and weekend review sessions, help to build skills of incorporating structure into to daily routines. These are group sessions and peer feedback is encouraged. In the planning sessions participants generate ideas and suggestions of what is helpful to include in weekends. A key feature of weekend planning is to include leisure activities that the young person has previously enjoyed or is keen to participate in. Weekends are also used for practising independence, perhaps in driving lessons with a parent, taking public transport or helping cook a meal. They are also important opportunities for achieving sleep routine consistency and pacing activity. They also provide an opportunity to practise challenging thoughts and to practise mindfulness and clear

spending each day with regard to sleep, activity, social contact and study.

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

work, sibling needs or their own health issues.

to a lesser extent, current function and engagement in life.

*3.3.4 Pre-program information and program readiness*

*3.4.1 Pacing and energy conservation, sleep, leisure*

communication with family and friends.

strategies, as also planning and cooking a meal to do the same.

**3.4 Program content**

*3.4.2 Goal setting*

#### *Self-Management of Chronic Fatigue Syndrome in Adolescents DOI: http://dx.doi.org/10.5772/intechopen.91413*

made to participate in an upcoming program. The wait list is usually 2–4 months. If either the family or the VPRS therapists do not feel the 4-week intensive program is an appropriate match for the family, alternatives in the community are explored. We have found that these alternative options are particularly appropriate in cases where families find it too difficult to be at the hospital for the required time due to work, sibling needs or their own health issues.

In addition, as several participants are in each program, every effort is made to match participants based on age, educational stage and likely group dynamic and, to a lesser extent, current function and engagement in life.

### *3.3.4 Pre-program information and program readiness*

Program information is emailed to families soon after an offer is made. This information includes logistics as well as a proposed timetable so that families can forward plan. A blank activity record is also sent to be completed the week prior to the program so that the therapy team have a current record of how the participant is spending each day with regard to sleep, activity, social contact and study.

To give participants the smoothest transition to the program and ultimately an effective intervention, a VPRS therapist via telephone, or in person, conducts a pre-program readiness interview, in the 2 weeks prior to the program. The previously identified program goals are clarified and changed if requested. It has been noted that without adequate time to prepare mentally and physically for the program, it takes longer for participants to settle in and co-operate with the program's agreed expectations.

## **3.4 Program content**

*Topics in Primary Care Medicine*

10–18 years of age.

Enrolment in education.

the hospital entrance.

Stable mental health

and goal setting is completed.

that are a better fit for the patient.

*3.3.2 Baseline and outcome measures*

• School attendance

*3.3.3 Assessment decision*

measure [32].

are not spent with the young person in limbo.

affected.

CFS is the primary diagnosis and the patient accepts this.

Tried doctor-led outpatient guidance in the first instance.

Display motivation to engage in the intensive nature of the program.

Physically able to manage 3 days per week of engagement for 4 weeks without significantly worsening their symptoms as a typical program day requires participants to walk approximately 700 m to access the treatment areas from

This assessment consists of a 45-min psychology assessment, 45-min education assessment and a combined 90-min occupational therapy and physiotherapy assessment. The patient attends the assessment with at least one parent or guardian present. In addition to detailed assessment about CFS, there is exploration of the young person's motivation to participate in a group program setting and their attitudes and beliefs about CFS are recorded. This is to ensure a group program is a suitable 'fit' for the young person. The philosophy and structure of the intervention is explained

We have also noted that if any of the above criteria are not met, the likelihood of positive engagement is poor. In particular, where motivation to participate is parent rather than patient led or if CFS is not the primary diagnosis, the group dynamic is

It is clear that the intensive program is not suitable for all young people with CFS. Those who are unable to attend the program in person for all the required days without significant worsening of symptoms are not appropriate. These patients are encouraged to continue with the doctor-led outpatient guidance in conjunction with a physical therapist that can provide therapy in time frames and intensities

Currently the program is moving towards offering pre-program conditioning and guidance to streamline the process of starting a program so that many months

Outcome measures are completed at initial assessment, 6 weeks post-program

and 6 months post-program. The current outcome measures are:

• Depression Anxiety Stress Scales (DASS) [31]

• Canadian Occupational Performance Measure (COPM) [30]

• Physical measures—Day 1 sub maximal treadmill test and plank hold

From 2012 to 2018, the psychological measure was the Beck Youth Inventories

The VPRS therapy team meet post-assessment to discuss findings. Provided the patient meets inclusion criteria and the family are keen to participate, an offer is

**10**

## *3.4.1 Pacing and energy conservation, sleep, leisure*

Participants work as a group to learn and implement core functional activities of daily living into their weekly schedules. Topics covered include sleep hygiene, balancing activity, leisure, memory and concentration, diet, pacing and energy conservation and setback planning. Participants learn to formulate a weekly planner, where they plan a balanced week of both 'need to do' activities and 'want to do' activities. This is to ensure that they plan a manageable week in line with their current baselines of their CFS physical and mental capabilities. During the program, participants embark on an outing as a group in order to practise these concepts and strategies, as also planning and cooking a meal to do the same.

## *3.4.2 Goal setting*

Goal setting sets the framework for the program. Goals are revisited regularly and progress tracked. Weekly individual goal review and progression sessions occur with the Physiotherapist and Occupational Therapist. Weekend planning and weekend review sessions, help to build skills of incorporating structure into to daily routines. These are group sessions and peer feedback is encouraged. In the planning sessions participants generate ideas and suggestions of what is helpful to include in weekends. A key feature of weekend planning is to include leisure activities that the young person has previously enjoyed or is keen to participate in. Weekends are also used for practising independence, perhaps in driving lessons with a parent, taking public transport or helping cook a meal. They are also important opportunities for achieving sleep routine consistency and pacing activity. They also provide an opportunity to practise challenging thoughts and to practise mindfulness and clear communication with family and friends.

#### *3.4.3 Education*

Educational engagement is once again identified as the most significant part of life affected by CFS. The effects in a young person's life when school attendance is limited or absent are devastating, affecting self-esteem and mood from social isolation and compromised learning outcomes. Prior to the program the education consultant liaises with participants' school contacts to establish communication. It has been noted that the variability in school engagement prior to the program improves afterwards with schools taking a much greater interest in learning about CFS and how they can assist the young person to engage in school.

During the 4-week program, eight supervised group-learning sessions occur in the Education Institute Learning Space at the hospital where participants undertake private study and complete activities set by their school. They also apply memory and concentration techniques learnt during the program to assist with concentration, pacing, homework and study management. Four individual consultations provide strategies and recommendations for support upon returning to school. These are discussed with the student, family and school personnel. The education consultant continues to support participants and schools well beyond the program to assist with challenges that inevitably arise.

#### *3.4.4 Psychology*

The participants receive group psychology sessions weekly wherein they learn the following: (1) understanding how CBT can help; (2) monitoring and challenging thoughts; (3) understanding emotions, stress, anxiety and mood; (4) relaxation strategies for stress and anxiety; (5) coping strategies for low mood; (6) building motivation and (7) engaging in assertive communication skills and family conflict management. In addition to this, they receive individual psychological reviews each week. This builds on the group session work and focuses on assisting with interventions for the interaction between CFS symptoms and mental health.

#### *3.4.5 Physical therapy*

The physical therapy component of the program consists of individualised goal setting and program planning based on the initial assessment. It is refined and revised as the program progresses. There is a group theory component as part of some sessions, covering topics such as chronic pain, Postural Orthostatic Tachycardia Syndrome (POTS) and progressing movement and exercise safely in order to minimise the likelihood of post-exertional malaise.

Post-exertional malaise (exhaustion and malaise after activities, either physical or mental, that previously were tolerated well) is a hallmark feature of CFS. It greatly reduces young people's ability to participate in physical activity as previously enjoyed.

Early in the program, participants begin an individualised movement program, delivered in either an individual or small group setting. This starts with gentle stretching and strengthening and for those where it is appropriate, short duration cardio activity. Participants and families are actively involved in all decisions regarding types of reconditioning and pathways of progression.

Participants are given a choice of a range of approaches to movement and reconditioning. They are encouraged to choose activities they have previously enjoyed and would like to incorporate such as shooting goals in basketball outside for a set time with another participant, or completing movements on the pilates reformer

**13**

recovery rates.

standing.

progress.

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

machine. Movement tasks are incorporated into weekly plans and are aimed at being meaningful in the young person's life such as walking 5 min to the local shops to buy ingredients to bake or taking the family pet for a walk around the block. Some participants much prefer this approach while others are more aligned with an athlete rehabilitation approach with more conventional exercise. Careful consider-

In recent years, a high number of participants have a diagnosis of POTS alongside CFS. These patients need very specific management in physical therapy sessions. POTS symptoms come on with standing and are relieved when becoming supine. Heart rate increases by 40 beats per minute or more and there can be a blood pressure change. Associated autonomic symptoms include sweating and blueness/swelling in the feet. There are often palpitations, fatigue, exercise intolerance, nausea, near syncope, syncope, 'brain fog' and chronic pain. Doctors may prescribe

a.**Lower limb and core strengthening.** Lower limb muscles act as a secondary pump to augment venous return. Those patients who are significantly symptomatic start in a reclined sitting position or even in supine position to strengthen all large muscle groups. Exercise therabands are often used for resistance. As symptoms improve, strengthening is completed in standing and

progressed with increasing the number of repetitions and resistance.

b.**Cardiovascular reconditioning.** For the most debilitated patients cardiovascular reconditioning starts in a reclined position, usually with pedalling a light set of pedals. The progression is to sit more upright with feet out in front on the pedals and then on to a recumbent exercise bike followed by an upright exercise bike as able. Patients do walk short distances for functional purposes but most of the reconditioning is done in sitting position to reduce the orthostatic load. Sessions are initially short duration and low intensity before progressing in both these areas. Intensity is increased slowly with short duration interval work. Significant consideration and respect is given to fatigue levels and

c.**Standing tolerance drills.** While lower limb and core strengthening and cardiovascular conditioning are developed, some time is devoted, when tolerated, it to starting some exercises in standing position. These include heel raises; squats and wall push ups to challenge the body's ability to exercise while

d.**Additional management.** This includes electrolyte drinks, salt tablets, the wearing of lower body compression garments, raising the bed 10° with the head end higher, and encouraging sitting up with feet flat on the ground rather than lying down during the day. Many patients require medication support to enable the patient to be able to tolerate re-conditioning exercise. When patients present with a POTS diagnosis or have significant orthostatic symptoms, the approach outlined above has been effective. Progression does, however, require a multimodal approach with multidisciplinary input helpful to achieving

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

ation and monitoring is applied to all patients.

*3.4.6 Postural Orthostatic Tachycardia Syndrome (POTS)*

medications and the exercise component of treatment is critical. The physical therapy for these patients has four components:

Educational engagement is once again identified as the most significant part of life affected by CFS. The effects in a young person's life when school attendance is limited or absent are devastating, affecting self-esteem and mood from social isolation and compromised learning outcomes. Prior to the program the education consultant liaises with participants' school contacts to establish communication. It has been noted that the variability in school engagement prior to the program improves afterwards with schools taking a much greater interest in learning about

During the 4-week program, eight supervised group-learning sessions occur in the Education Institute Learning Space at the hospital where participants undertake private study and complete activities set by their school. They also apply memory and concentration techniques learnt during the program to assist with concentration, pacing, homework and study management. Four individual consultations provide strategies and recommendations for support upon returning to school. These are discussed with the student, family and school personnel. The education consultant continues to support participants and schools well beyond the program

The participants receive group psychology sessions weekly wherein they learn the following: (1) understanding how CBT can help; (2) monitoring and challenging thoughts; (3) understanding emotions, stress, anxiety and mood; (4) relaxation strategies for stress and anxiety; (5) coping strategies for low mood; (6) building motivation and (7) engaging in assertive communication skills and family conflict management. In addition to this, they receive individual psychological reviews each week. This builds on the group session work and focuses on assisting with interven-

The physical therapy component of the program consists of individualised goal setting and program planning based on the initial assessment. It is refined and revised as the program progresses. There is a group theory component as part of some sessions, covering topics such as chronic pain, Postural Orthostatic Tachycardia Syndrome (POTS) and progressing movement and exercise safely in

Post-exertional malaise (exhaustion and malaise after activities, either physical or mental, that previously were tolerated well) is a hallmark feature of CFS. It greatly reduces young people's ability to participate in physical activity as previously

Early in the program, participants begin an individualised movement program,

Participants are given a choice of a range of approaches to movement and reconditioning. They are encouraged to choose activities they have previously enjoyed and would like to incorporate such as shooting goals in basketball outside for a set time with another participant, or completing movements on the pilates reformer

delivered in either an individual or small group setting. This starts with gentle stretching and strengthening and for those where it is appropriate, short duration cardio activity. Participants and families are actively involved in all decisions

CFS and how they can assist the young person to engage in school.

tions for the interaction between CFS symptoms and mental health.

order to minimise the likelihood of post-exertional malaise.

regarding types of reconditioning and pathways of progression.

to assist with challenges that inevitably arise.

*3.4.3 Education*

*3.4.4 Psychology*

*3.4.5 Physical therapy*

**12**

enjoyed.

machine. Movement tasks are incorporated into weekly plans and are aimed at being meaningful in the young person's life such as walking 5 min to the local shops to buy ingredients to bake or taking the family pet for a walk around the block. Some participants much prefer this approach while others are more aligned with an athlete rehabilitation approach with more conventional exercise. Careful consideration and monitoring is applied to all patients.

## *3.4.6 Postural Orthostatic Tachycardia Syndrome (POTS)*

In recent years, a high number of participants have a diagnosis of POTS alongside CFS. These patients need very specific management in physical therapy sessions. POTS symptoms come on with standing and are relieved when becoming supine. Heart rate increases by 40 beats per minute or more and there can be a blood pressure change. Associated autonomic symptoms include sweating and blueness/swelling in the feet. There are often palpitations, fatigue, exercise intolerance, nausea, near syncope, syncope, 'brain fog' and chronic pain. Doctors may prescribe medications and the exercise component of treatment is critical.

The physical therapy for these patients has four components:


Psychology support in POTS patients appears to be very helpful, in particular assisting patients coping with the significant heart rate increases and adrenaline released on upright standing. These physical symptoms mimicking anxiety can be confusing for patients, particularly those where anxiety has not previously been present.

#### *3.4.7 Pain*

Pain is a common symptom in CFS. This can be headaches, joint pain or abdominal pain. Very often these pains do not respond to medication. Sometimes pain is present due to long periods of physical inactivity. For other patients the protective function of pain is no longer serving that purpose and patients may develop a central sensitisation.

The approach taken in the program in the first instance is to ascertain a patient's concept of pain. Once this has been established, using questioning and simple quizzes, a pain curriculum is developed. While some initial pain theory is covered in the group setting, further exploration of possible contributing factors to the young person's pain is explored on an individual basis in both physiotherapy and clinical psychology sessions. The treatment approach is based on the work of Lorimer Moseley and David Butler of the Neuro Orthopaedic Institute Australasia [33]. Its focus is on understanding chronic pain as one of many outputs of the brain in response to a range of inputs. It seeks to establish the interactions between the mind, the body and the environment and the complex interaction with the nervous system that occurs.

#### **3.5 Follow-up**

Patients are reviewed at 6 weeks and 6 months post-program. There is weekly email or telephone contact in the first 6 weeks post-program with a face-to-face review at 6 weeks. Patients and families are able to access ongoing support from the team for advice and direction. There is limited scope to offer therapist face to face sessions beyond the program outside of the scheduled reviews. All patients return to the care of their referring paediatrician post-program.

#### **3.6 Patient feedback**

Feedback is regularly sought from participants—both informally during the program and at follow-up reviews as well as written. More formal feedback has been obtained intermittently. While patients describe learning about pacing, thought challenging and educational tips as being helpful, they overwhelmingly describe meeting other young people in a similar position and feeling like they belong and are supported, as being the most valued part of the program. This often results in participants forming close bonds with each other and many friendships have continued over the years.

#### **4. Review of referrals**

As the program is resource intense, and many young people are successfully managed in outpatients, it has been important to attempt to identify which ones need the more concentrated input and access to the multidisciplinary team and when the ideal time is to refer. Approximately 25 complete the program each year. It has been noted that the proportion of males (26%) to females referred to the

**15**

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

program reflects the proportion noted over many years of close to 1:3 [10, 15]. However, there was a higher proportion than expected from rural areas. In Victoria, 23% of the population live in the non-metropolitan area, but 42% of participants came from non-metropolitan areas (chi-square 9.19, p < 0.005). Rural regions have less access to local paediatricians, additional educational services such as visiting teachers and specialised allied health support is scarce. There were higher proportions of young people participating in the program during year 9 (28%) and year 11 (24%) compared with the other years between grade 6 and year 12. The year 11 students are in their penultimate year of school prior to university entrance exams and year 9 is recognised as a turbulent year in adolescent social development, and the year after which some decisions on subject choices for future careers need to be

made. Hence educational issues were a significant stimulus for the referral.

Of note, 44% admitted to >4 h of screen time (phone, computer, television) per day. This would generally be considered excessive but did reflect those who had been unable to increase their school attendance and who had become more socially isolated. It did also become an increasing problem when gaming was involved as this tended to occur late at night and contribute to day/night reversal of sleep cycle and increasing loss of time from school. A higher proportion of males than females

POTS was diagnosed in 78% [1, 15] either coinciding with the onset of CFS following an infection, occurring associated with hyperflexibility and having associated CFS symptoms, or apparently developing after the prolonged bed rest or limited activity associated with their CFS. During recent years this has become better recognised, documented and managed but its management has occupied an increasing proportion of referrals. It has generally been poorly recognised by paediatricians and many allied health providers are unfamiliar with how to help

From outpatients, it was noted that early referrals to the program were often not appropriate. Young people and their families needed time to understand the illness, develop some confidence that they could plan an appropriate schedule and sustain it, and have an opportunity to improve some of the more troublesome symptoms, such as sleep disturbance and headache. Frequently simple measures for managing POTS or if these were not sufficient, referral to an appropriate cardiologist was important to improve control. Crucially, having a sustainable school program with understanding from school staff and their peers was central to management. Families also needed time to adjust their schedules to a more balanced and sustain-

Hence, those who, although they were attending school, struggled with their weekly schedule and balancing their daily activities such as exercise, sleep, school work and social activities needed additional help. Occasionally the family social circumstances made it difficult to attend school regularly. Teachers who were unsympathetic or peers who did not understand contributed to difficulties at school. Those who were not attending or managing school work, were often very anxious and increasing screen time contributed to further reduction in school attendance. Many found adjusting to avoiding a boom/bust cycle where they would do too much and then take a long time to recover and be very despondent or angry at these restrictions was a significant problem. They felt they needed more support

Only a small proportion of the patients seen in the outpatient clinic are referred to the program. As per the feedback over many years, ability to construct a selfmanagement program and guidance to adapt and sustain progress was highly valued. In addition, assistance with planning sustainable education with school liaison was cited as helpful in allowing them to remain socially engaged and hope

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

saw this as their only social outlet.

able form to assist the young person.

in planning and adapting.

especially in the context of the limited stamina of CFS.

#### *Self-Management of Chronic Fatigue Syndrome in Adolescents DOI: http://dx.doi.org/10.5772/intechopen.91413*

*Topics in Primary Care Medicine*

present.

*3.4.7 Pain*

central sensitisation.

system that occurs.

**3.6 Patient feedback**

continued over the years.

**4. Review of referrals**

**3.5 Follow-up**

Psychology support in POTS patients appears to be very helpful, in particular assisting patients coping with the significant heart rate increases and adrenaline released on upright standing. These physical symptoms mimicking anxiety can be confusing for patients, particularly those where anxiety has not previously been

Pain is a common symptom in CFS. This can be headaches, joint pain or abdominal pain. Very often these pains do not respond to medication. Sometimes pain is present due to long periods of physical inactivity. For other patients the protective function of pain is no longer serving that purpose and patients may develop a

The approach taken in the program in the first instance is to ascertain a patient's

Patients are reviewed at 6 weeks and 6 months post-program. There is weekly email or telephone contact in the first 6 weeks post-program with a face-to-face review at 6 weeks. Patients and families are able to access ongoing support from the team for advice and direction. There is limited scope to offer therapist face to face sessions beyond the program outside of the scheduled reviews. All patients return

Feedback is regularly sought from participants—both informally during the program and at follow-up reviews as well as written. More formal feedback has been obtained intermittently. While patients describe learning about pacing, thought challenging and educational tips as being helpful, they overwhelmingly describe meeting other young people in a similar position and feeling like they belong and are supported, as being the most valued part of the program. This often results in participants forming close bonds with each other and many friendships have

As the program is resource intense, and many young people are successfully managed in outpatients, it has been important to attempt to identify which ones need the more concentrated input and access to the multidisciplinary team and when the ideal time is to refer. Approximately 25 complete the program each year. It has been noted that the proportion of males (26%) to females referred to the

to the care of their referring paediatrician post-program.

concept of pain. Once this has been established, using questioning and simple quizzes, a pain curriculum is developed. While some initial pain theory is covered in the group setting, further exploration of possible contributing factors to the young person's pain is explored on an individual basis in both physiotherapy and clinical psychology sessions. The treatment approach is based on the work of Lorimer Moseley and David Butler of the Neuro Orthopaedic Institute Australasia [33]. Its focus is on understanding chronic pain as one of many outputs of the brain in response to a range of inputs. It seeks to establish the interactions between the mind, the body and the environment and the complex interaction with the nervous

**14**

program reflects the proportion noted over many years of close to 1:3 [10, 15]. However, there was a higher proportion than expected from rural areas. In Victoria, 23% of the population live in the non-metropolitan area, but 42% of participants came from non-metropolitan areas (chi-square 9.19, p < 0.005). Rural regions have less access to local paediatricians, additional educational services such as visiting teachers and specialised allied health support is scarce. There were higher proportions of young people participating in the program during year 9 (28%) and year 11 (24%) compared with the other years between grade 6 and year 12. The year 11 students are in their penultimate year of school prior to university entrance exams and year 9 is recognised as a turbulent year in adolescent social development, and the year after which some decisions on subject choices for future careers need to be made. Hence educational issues were a significant stimulus for the referral.

Of note, 44% admitted to >4 h of screen time (phone, computer, television) per day. This would generally be considered excessive but did reflect those who had been unable to increase their school attendance and who had become more socially isolated. It did also become an increasing problem when gaming was involved as this tended to occur late at night and contribute to day/night reversal of sleep cycle and increasing loss of time from school. A higher proportion of males than females saw this as their only social outlet.

POTS was diagnosed in 78% [1, 15] either coinciding with the onset of CFS following an infection, occurring associated with hyperflexibility and having associated CFS symptoms, or apparently developing after the prolonged bed rest or limited activity associated with their CFS. During recent years this has become better recognised, documented and managed but its management has occupied an increasing proportion of referrals. It has generally been poorly recognised by paediatricians and many allied health providers are unfamiliar with how to help especially in the context of the limited stamina of CFS.

From outpatients, it was noted that early referrals to the program were often not appropriate. Young people and their families needed time to understand the illness, develop some confidence that they could plan an appropriate schedule and sustain it, and have an opportunity to improve some of the more troublesome symptoms, such as sleep disturbance and headache. Frequently simple measures for managing POTS or if these were not sufficient, referral to an appropriate cardiologist was important to improve control. Crucially, having a sustainable school program with understanding from school staff and their peers was central to management. Families also needed time to adjust their schedules to a more balanced and sustainable form to assist the young person.

Hence, those who, although they were attending school, struggled with their weekly schedule and balancing their daily activities such as exercise, sleep, school work and social activities needed additional help. Occasionally the family social circumstances made it difficult to attend school regularly. Teachers who were unsympathetic or peers who did not understand contributed to difficulties at school.

Those who were not attending or managing school work, were often very anxious and increasing screen time contributed to further reduction in school attendance. Many found adjusting to avoiding a boom/bust cycle where they would do too much and then take a long time to recover and be very despondent or angry at these restrictions was a significant problem. They felt they needed more support in planning and adapting.

Only a small proportion of the patients seen in the outpatient clinic are referred to the program. As per the feedback over many years, ability to construct a selfmanagement program and guidance to adapt and sustain progress was highly valued. In addition, assistance with planning sustainable education with school liaison was cited as helpful in allowing them to remain socially engaged and hope

that their aspirations were achievable. In essence those referred and reporting benefit from the program where those who needed more support in planning their self-management, more intensive assistance for their POTS but most importantly assistance with their education.

It is clear that as the staff have become more familiar with the illness, and have received feedback that they have incorporated into the program, that the key features that are valued are identical to the feedback the outpatient program has received over the years [10, 28]. Access to physiotherapy especially for the specific management of POTS would make outpatient management easier. An education consultant to liaise with schools is often more acceptable for the school than being approached by a paediatrician, although usually medical documentation and recommendations are required by educational authorities. In addition, the input from a psychologist who has an understanding of the illness and the feelings of anxiety that occurs with POTS as well as the impact chronic illness and disrupted education has on the social and emotional development of a young person can be very helpful. Crucially it is the feeling that they are understood and believed and that they are not the only ones with the illness. Regaining some control over their lives by how they can manage the illness is highly valued.

### **5. Conclusion**

The majority of young people can be managed in an outpatient setting and availability of some of the expertise such as physiotherapy and an educational consultant would greatly assist in management in that setting. This would then free the more intensive self-management program for young people who could not access allied health, needed more guidance for planning or who needed help for family understanding, cooperation with school or help to understand the mental health issues that may accompany chronic illness and social isolation. The acceptance and linking with other young people with an illness that is poorly understood and accepted, has been invaluable.

The program at RCH will continue in its current form of individualised patient plans within a group setting. Involvement of families in key sessions alongside participants has shown to be the most effective way to encourage carryover of improved engagement in life post-program.

Ongoing feedback from young people and their families as well as research findings continue to inform both the outpatient management and the intensive VPRS program. Increasing interest and understanding from paediatricians and allied health staff can only help by reducing the frustration, delay, misunderstanding and access to services for these young people. Assisting them with symptom management, guidance in devising and implementing a self-management plan and assistance in navigating the education system has reportedly been highly valued. Having the added assistance of a multidisciplinary team and intensive program when aspects of this management were not sufficient has been highly valued.

#### **Acknowledgements**

The frank feedback from the young people regarding their management has been greatly appreciated. The input and support from the team members in the VPRS and the support of A/Prof Adam Scheinberg in setting up and maintaining the program is gratefully acknowledged. There was no external funding for this report.

**17**

**Author details**

Katherine Rowe1

Australia

\*, Amanda Apple2

\*Address all correspondence to: kathy@roweresearch.com

provided the original work is properly cited.

and Fiona McDonald1

1 Department of General Medicine, Royal Children's Hospital, Melbourne, Australia

2 Victorian Paediatric Rehabilitation Service, Royal Children's Hospital, Melbourne,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

The authors declare no conflict of interest.

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

**Conflict of interest**

*Self-Management of Chronic Fatigue Syndrome in Adolescents DOI: http://dx.doi.org/10.5772/intechopen.91413*

## **Conflict of interest**

*Topics in Primary Care Medicine*

assistance with their education.

can manage the illness is highly valued.

improved engagement in life post-program.

**5. Conclusion**

been invaluable.

**Acknowledgements**

that their aspirations were achievable. In essence those referred and reporting benefit from the program where those who needed more support in planning their self-management, more intensive assistance for their POTS but most importantly

received feedback that they have incorporated into the program, that the key features that are valued are identical to the feedback the outpatient program has received over the years [10, 28]. Access to physiotherapy especially for the specific management of POTS would make outpatient management easier. An education consultant to liaise with schools is often more acceptable for the school than being approached by a paediatrician, although usually medical documentation and recommendations are required by educational authorities. In addition, the input from a psychologist who has an understanding of the illness and the feelings of anxiety that occurs with POTS as well as the impact chronic illness and disrupted education has on the social and emotional development of a young person can be very helpful. Crucially it is the feeling that they are understood and believed and that they are not the only ones with the illness. Regaining some control over their lives by how they

It is clear that as the staff have become more familiar with the illness, and have

The majority of young people can be managed in an outpatient setting and availability of some of the expertise such as physiotherapy and an educational consultant would greatly assist in management in that setting. This would then free the more intensive self-management program for young people who could not access allied health, needed more guidance for planning or who needed help for family understanding, cooperation with school or help to understand the mental health issues that may accompany chronic illness and social isolation. The acceptance and linking with other young people with an illness that is poorly understood and accepted, has

The program at RCH will continue in its current form of individualised patient plans within a group setting. Involvement of families in key sessions alongside participants has shown to be the most effective way to encourage carryover of

Ongoing feedback from young people and their families as well as research findings continue to inform both the outpatient management and the intensive VPRS program. Increasing interest and understanding from paediatricians and allied health staff can only help by reducing the frustration, delay, misunderstanding and access to services for these young people. Assisting them with symptom management, guidance in devising and implementing a self-management plan and assistance in navigating the education system has reportedly been highly valued. Having the added assistance of a multidisciplinary team and intensive program when aspects of this management were not sufficient has been highly valued.

The frank feedback from the young people regarding their management has been greatly appreciated. The input and support from the team members in the VPRS and the support of A/Prof Adam Scheinberg in setting up and maintaining the program is gratefully acknowledged. There was no external funding for this

**16**

report.

The authors declare no conflict of interest.

## **Author details**

Katherine Rowe1 \*, Amanda Apple2 and Fiona McDonald1

1 Department of General Medicine, Royal Children's Hospital, Melbourne, Australia

2 Victorian Paediatric Rehabilitation Service, Royal Children's Hospital, Melbourne, Australia

\*Address all correspondence to: kathy@roweresearch.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Rowe PC. Orthostatic intolerance and chronic fatigue syndrome: New light on an old problem. Journal of Pediatrics. 2002;**140**(4):387-389

[2] Holmes GP, Kaplan JE, Gantz NM, et al. Chronic fatigue syndrome: A working case definition. Annals of Internal Medicine. 1988;**108**:387-389

[3] Fukuda K, Strauss S, Hickie I, et al. The chronic fatigue syndrome: A comprehensive approach to its definition and study. Annals of Internal Medicine. 1994;**121**:953-959

[4] Carruthers BM, van de Sande MI, De Meirleir KL, Klimas N, Broderick GG, et al. Myalgic Encephalomyelitis: International Consensus Criteria. 2011. DOI: 10.1111/j.1365-2796.2011.02428.x

[5] Institute of Medicine; Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press; 2015. DOI: 10.17226/19012

[6] Jason LA, Bell DS, Rowe K, Van Hoof ELS, Jordan KR, Lapp C, et al. A pediatric case definition for myalgic encephalomyelitis and chronic fatigue syndrome. Journal of Chronic Fatigue Syndrome. 2006;**13**:1-44. DOI: 10.1300/ J092v13n02\_01

[7] Jason LA, Barker A, Brown A. Pediatric myalgic encephalomyelitis/ chronic fatigue syndrome. Reviews in Health Care. 2012;**3**(4):257-270

[8] Rowe KS, Rowe KJ. Symptom patterns of children and adolescents with chronic fatigue syndrome. In: Singh NN, Ollendick TH, Singh AN, editors. International Perspectives on Child and Adolescent Mental Health.

Vol. 2. New York: Elsevier Science; 2002. pp. 395-415

[9] Rowe KS, Rowe KJ. Symptom patterns and psychological features of adolescents with chronic fatigue syndrome. Journal of Paediatrics & Child Health. 2005;**41**(8):S9 August [Paediatrics and Child Health Division The Royal Australasian College of Physicians: Paediatric Abstracts presented at the Annual Scientific Meeting, May 2005: Paediatrics & Child Health Divisional Abstracts and Posters: 2005]

[10] Rowe KS. Long term follow up of young people with chronic fatigue syndrome attending a pediatric outpatient service. Frontiers in Pediatrics. 2019;**7**:21. DOI: 10.3389/ fped.2019.00021

[11] Friedman KJ. Advances in ME/CFS: Past, present, and future. Frontiers in Pediatrics. 2019. DOI: 10.3389/ fped.2019.00131

[12] Bell DS, Jordan K, Robinson M. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics. 2001;**107**(5):994-998

[13] Rowe KS. 5-year follow-up of young people with chronic fatigue syndrome following the double-blind randomised controlled intravenous gammaglobulin trial. Journal of Chronic Fatigue Syndrome. 1999;**5**(3/4):97-107

[14] Rowe KS. Chronic fatigue syndrome. In: Kang M, Skinner SR, Sanci LA, Sawyer SM, editors. Youth Health and Adolescent Medicine. East Hawthorn, Vic: IP Communications; 2013. pp. 343-360

[15] Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS, et al. Myalgic encephalomyelitis/chronic

**19**

*Self-Management of Chronic Fatigue Syndrome in Adolescents*

[23] Lloyd A, Hickie I, Wakefield D, Boughton C, Dwyer J. A double-blind placebo-controlled trial of intravenous immunoglobulin therapy in patients with the chronic fatigue syndrome. The American Journal of Medicine.

[24] Peterson PK, Shepard J, Macres M, et al. A controlled trial of intravenous immunoglobulin G in chronic fatigue syndrome. The American Journal of

Wakefield D, Dwyer J, et al. Intravenous immunoglobulin is ineffective in the treatment of patients with chronic fatigue syndrome. The American Journal of Medicine. 1997;**103**(1):38-43

H.E.A.D.S.S.—Getting into adolescent heads. Contemporary Pediatrics.

[27] Rowe KS, Fitzgerald P. Educational strategies for chronically ill students: Chronic fatigue syndrome. The Australian

[28] Rowe KS. Paediatric patients with myalgic encephalomyelitis/chronic fatigue syndrome value understanding and help to move on with their lives. Acta Paediatr. 18 December 2019. DOI: 10.1111/apa.15054. [Epub ahead of print]

Harvey AR. Interventions in pediatric chronic fatigue syndrome/myalgic encephalomyelitis: A systematic review. Journal of Adolescent Health. 2013;**53**(2):154-165. DOI: 10.1016/j.

[30] Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian occupational performance measure: An outcome measure for occupational therapy. Canadian Journal

Educational and Developmental Psychologist. 1999;**16**(2):5-21

[29] Knight SJ, Scheinberg A,

jadohealth.2013.03.009

Medicine. 1990;**89**:554-560

[25] Vollmer-Conna U, Hickie I, Hadzi-Pavlovic D, Tymms K,

[26] Goldenring JM, Cohen E.

1998;**5**:75-90

1990;**89**:561-568

*DOI: http://dx.doi.org/10.5772/intechopen.91413*

management in young people: A primer. Frontiers in Pediatrics. 2017;**5**:121. DOI:

[16] Crawley E, Sterne JA. Association between school absence and physical function in paediatric chronic fatigue syndrome/myalgic encephalopathy. Archives of Disease in Childhood. 2009;**94**:752-756. DOI: 10.1136/

fatigue syndrome diagnosis and

[17] Crawley EM, Emond AM,

bmjopen-2011-000252

fped.2018.00302

2003;**6**(1):13-22

[21] Lloyd AR, Wakefield D, Boughton C, Dwyer J. What is myalgic encephalomyelitis? Lancet.

[22] Rowe KS. Double blind placebo controlled trial to assess the efficacy of intravenous gammaglobulin for the management of chronic fatigue syndrome in adolescents. Journal of Psychiatric Research.

1988;**1**(8597):1286-1287

1997;**31**(1):133-147

Sterne JAC. Unidentified chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a major cause of school absence: Surveillance outcomes from school-based clinics. BMJ Open 2011;**1**:e000252. DOI: 10.1136/

[18] Knight SJ, Politis J, Garnham C, Scheinberg A, Tollit MA. School functioning in adolescents with chronic fatigue syndrome. Frontiers in Pediatrics. 2018. DOI: 10.3389/

[19] Suris J-C, Michaud P-A, Viner R. The adolescent with a chronic condition. Part I: Developmental issues. Archives of Disease in Childhood. 2004;**89**:938- 942. DOI: 10.1136/adc.2003.045369

[20] Holmes AM, Deb P. The effect of chronic illness on the psychological health of family members. The Journal of Mental Health Policy and Economics.

10.3389/fped.2017.00121

adc.2008.143537

*Self-Management of Chronic Fatigue Syndrome in Adolescents DOI: http://dx.doi.org/10.5772/intechopen.91413*

fatigue syndrome diagnosis and management in young people: A primer. Frontiers in Pediatrics. 2017;**5**:121. DOI: 10.3389/fped.2017.00121

[16] Crawley E, Sterne JA. Association between school absence and physical function in paediatric chronic fatigue syndrome/myalgic encephalopathy. Archives of Disease in Childhood. 2009;**94**:752-756. DOI: 10.1136/ adc.2008.143537

[17] Crawley EM, Emond AM, Sterne JAC. Unidentified chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a major cause of school absence: Surveillance outcomes from school-based clinics. BMJ Open 2011;**1**:e000252. DOI: 10.1136/ bmjopen-2011-000252

[18] Knight SJ, Politis J, Garnham C, Scheinberg A, Tollit MA. School functioning in adolescents with chronic fatigue syndrome. Frontiers in Pediatrics. 2018. DOI: 10.3389/ fped.2018.00302

[19] Suris J-C, Michaud P-A, Viner R. The adolescent with a chronic condition. Part I: Developmental issues. Archives of Disease in Childhood. 2004;**89**:938- 942. DOI: 10.1136/adc.2003.045369

[20] Holmes AM, Deb P. The effect of chronic illness on the psychological health of family members. The Journal of Mental Health Policy and Economics. 2003;**6**(1):13-22

[21] Lloyd AR, Wakefield D, Boughton C, Dwyer J. What is myalgic encephalomyelitis? Lancet. 1988;**1**(8597):1286-1287

[22] Rowe KS. Double blind placebo controlled trial to assess the efficacy of intravenous gammaglobulin for the management of chronic fatigue syndrome in adolescents. Journal of Psychiatric Research. 1997;**31**(1):133-147

[23] Lloyd A, Hickie I, Wakefield D, Boughton C, Dwyer J. A double-blind placebo-controlled trial of intravenous immunoglobulin therapy in patients with the chronic fatigue syndrome. The American Journal of Medicine. 1990;**89**:561-568

[24] Peterson PK, Shepard J, Macres M, et al. A controlled trial of intravenous immunoglobulin G in chronic fatigue syndrome. The American Journal of Medicine. 1990;**89**:554-560

[25] Vollmer-Conna U, Hickie I, Hadzi-Pavlovic D, Tymms K, Wakefield D, Dwyer J, et al. Intravenous immunoglobulin is ineffective in the treatment of patients with chronic fatigue syndrome. The American Journal of Medicine. 1997;**103**(1):38-43

[26] Goldenring JM, Cohen E. H.E.A.D.S.S.—Getting into adolescent heads. Contemporary Pediatrics. 1998;**5**:75-90

[27] Rowe KS, Fitzgerald P. Educational strategies for chronically ill students: Chronic fatigue syndrome. The Australian Educational and Developmental Psychologist. 1999;**16**(2):5-21

[28] Rowe KS. Paediatric patients with myalgic encephalomyelitis/chronic fatigue syndrome value understanding and help to move on with their lives. Acta Paediatr. 18 December 2019. DOI: 10.1111/apa.15054. [Epub ahead of print]

[29] Knight SJ, Scheinberg A, Harvey AR. Interventions in pediatric chronic fatigue syndrome/myalgic encephalomyelitis: A systematic review. Journal of Adolescent Health. 2013;**53**(2):154-165. DOI: 10.1016/j. jadohealth.2013.03.009

[30] Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian occupational performance measure: An outcome measure for occupational therapy. Canadian Journal

**18**

*Topics in Primary Care Medicine*

2002;**140**(4):387-389

**References**

[1] Rowe PC. Orthostatic intolerance and chronic fatigue syndrome: New light on an old problem. Journal of Pediatrics.

Vol. 2. New York: Elsevier Science; 2002.

[9] Rowe KS, Rowe KJ. Symptom patterns and psychological features of adolescents with chronic fatigue syndrome. Journal of Paediatrics & Child Health. 2005;**41**(8):S9 August [Paediatrics and Child Health Division The Royal Australasian College of Physicians: Paediatric Abstracts presented at the Annual Scientific Meeting, May 2005: Paediatrics & Child Health Divisional Abstracts and Posters:

[10] Rowe KS. Long term follow up of young people with chronic fatigue syndrome attending a pediatric outpatient service. Frontiers in Pediatrics. 2019;**7**:21. DOI: 10.3389/

[11] Friedman KJ. Advances in ME/CFS: Past, present, and future. Frontiers in Pediatrics. 2019. DOI: 10.3389/

[12] Bell DS, Jordan K, Robinson M. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics.

[13] Rowe KS. 5-year follow-up of young people with chronic fatigue syndrome following the double-blind randomised controlled intravenous gammaglobulin trial. Journal of Chronic Fatigue Syndrome. 1999;**5**(3/4):97-107

[15] Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS, et al. Myalgic encephalomyelitis/chronic

[14] Rowe KS. Chronic fatigue syndrome. In: Kang M, Skinner SR, Sanci LA, Sawyer SM, editors. Youth Health and Adolescent Medicine. East Hawthorn, Vic: IP Communications;

2013. pp. 343-360

pp. 395-415

2005]

fped.2019.00021

fped.2019.00131

2001;**107**(5):994-998

[2] Holmes GP, Kaplan JE, Gantz NM, et al. Chronic fatigue syndrome: A working case definition. Annals of Internal Medicine. 1988;**108**:387-389

[3] Fukuda K, Strauss S, Hickie I, et al. The chronic fatigue syndrome: A comprehensive approach to its definition and study. Annals of Internal

[4] Carruthers BM, van de Sande MI, De Meirleir KL, Klimas N, Broderick GG, et al. Myalgic Encephalomyelitis: International Consensus Criteria. 2011. DOI: 10.1111/j.1365-2796.2011.02428.x

[5] Institute of Medicine; Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press; 2015. DOI:

[6] Jason LA, Bell DS, Rowe K, Van Hoof ELS, Jordan KR, Lapp C, et al. A pediatric case definition for myalgic encephalomyelitis and chronic fatigue syndrome. Journal of Chronic Fatigue Syndrome. 2006;**13**:1-44. DOI: 10.1300/

[7] Jason LA, Barker A, Brown A. Pediatric myalgic encephalomyelitis/ chronic fatigue syndrome. Reviews in Health Care. 2012;**3**(4):257-270

[8] Rowe KS, Rowe KJ. Symptom patterns of children and adolescents with chronic fatigue syndrome. In: Singh NN, Ollendick TH, Singh AN, editors. International Perspectives on Child and Adolescent Mental Health.

Medicine. 1994;**121**:953-959

10.17226/19012

J092v13n02\_01

of Occupational Therapy. 1990;**57**(2): 82-87. DOI: 10.1177/000841749005700207

[31] Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney, NSW: The Psychology Foundation of Australia; 1995

[32] Beck JS, Beck AT, Jolly JB. Beck Youth Inventories—Second Edition (BYI–2). Toronto, Ontario: Psychology Corporation; 2005

[33] Butler DS, Moseley GL. Explain Pain: (Revised and Updated). 2nd ed. Adelaide: Noigroup Publications; 2013

**21**

**Chapter 2**

**Abstract**

**1. Introduction**

This room (**Figure 1**) must include:

nated procedures (e.g. abscesses).

standing and sitting.

procedures.

Minor Surgery in Primary Care

Minor surgical procedures are defined as a set of procedures in which short surgical techniques are applied on superficial tissues, usually with local anesthesia, and minimal complications, that usually do not require postoperative resuscitation and need minimal equipment, many of which are used on a daily basis, and can be easily and safely performed in a short amount of time during clinic visit. General practitioners should have an optimal infrastructure and medical furniture in a minor surgery operating room. It is important to manage the instruments and materials involved for basic and advanced surgery. Also, for a good clinical practice in minor surgery, it is necessary that general practitioners handle anesthesia techniques (local anesthetic infiltration and regional blocks) and have knowledge of the body areas of risk in minor surgery and the topographic anatomy of the skin for the right performance of surgical procedure. The patients should be informed about the procedure and its technical details before asking them to sign the informed consent form.

**Keywords:** ambulatory surgical procedures, sutures, minor surgical procedures,

This chapter will try and help general practitioners master minor surgical

in minor surgical procedures has become a critical part of medical training.

General practitioners require these procedures for diagnostic or therapeutical reasons, in the outpatient setting as well in the emergency (excision of skin lesions or wound suturing for example). For that reason, the training of the general doctors in minor surgery is an additional tool for good medical practice and acquiring skills

Minor surgical procedures do not involve very sophisticated devices. However, some basic requirements in terms of infrastructure and equipment must be met [1, 2]. It is recommended that each facility has a specific room for these procedures.

*Surgical room*: a well-ventilated room, with a suitable temperature, it is imperative that is clean, but it does not require sterile isolation. The surgical room should be cleaned properly at the end of the surgical session, particularly after contami-

*Operating table*: It should be easily accessible from all sides, Height-adjustable and articulated tables. It is essential that allows the doctor to work in comfort, both

electrocoagulation, anesthetics, local, lipoma, keratosis, actinic

*Jose Maria Arribas Blanco, Wafa Elgeadi Saleh,* 

*Belén Chavero Méndez and* 

*María Alvargonzalez Arrancudiaga*

## **Chapter 2**

*Topics in Primary Care Medicine*

Foundation of Australia; 1995

Corporation; 2005

[32] Beck JS, Beck AT, Jolly JB. Beck Youth Inventories—Second Edition (BYI–2). Toronto, Ontario: Psychology

[33] Butler DS, Moseley GL. Explain Pain: (Revised and Updated). 2nd ed. Adelaide: Noigroup Publications; 2013

of Occupational Therapy. 1990;**57**(2): 82-87. DOI: 10.1177/000841749005700207

[31] Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney, NSW: The Psychology

**20**

## Minor Surgery in Primary Care

*Jose Maria Arribas Blanco, Wafa Elgeadi Saleh, Belén Chavero Méndez and María Alvargonzalez Arrancudiaga*

## **Abstract**

Minor surgical procedures are defined as a set of procedures in which short surgical techniques are applied on superficial tissues, usually with local anesthesia, and minimal complications, that usually do not require postoperative resuscitation and need minimal equipment, many of which are used on a daily basis, and can be easily and safely performed in a short amount of time during clinic visit. General practitioners should have an optimal infrastructure and medical furniture in a minor surgery operating room. It is important to manage the instruments and materials involved for basic and advanced surgery. Also, for a good clinical practice in minor surgery, it is necessary that general practitioners handle anesthesia techniques (local anesthetic infiltration and regional blocks) and have knowledge of the body areas of risk in minor surgery and the topographic anatomy of the skin for the right performance of surgical procedure. The patients should be informed about the procedure and its technical details before asking them to sign the informed consent form.

**Keywords:** ambulatory surgical procedures, sutures, minor surgical procedures, electrocoagulation, anesthetics, local, lipoma, keratosis, actinic

### **1. Introduction**

This chapter will try and help general practitioners master minor surgical procedures.

General practitioners require these procedures for diagnostic or therapeutical reasons, in the outpatient setting as well in the emergency (excision of skin lesions or wound suturing for example). For that reason, the training of the general doctors in minor surgery is an additional tool for good medical practice and acquiring skills in minor surgical procedures has become a critical part of medical training.

Minor surgical procedures do not involve very sophisticated devices. However, some basic requirements in terms of infrastructure and equipment must be met [1, 2].

It is recommended that each facility has a specific room for these procedures. This room (**Figure 1**) must include:

*Surgical room*: a well-ventilated room, with a suitable temperature, it is imperative that is clean, but it does not require sterile isolation. The surgical room should be cleaned properly at the end of the surgical session, particularly after contaminated procedures (e.g. abscesses).

*Operating table*: It should be easily accessible from all sides, Height-adjustable and articulated tables. It is essential that allows the doctor to work in comfort, both standing and sitting.

**Figure 1.** *Well-equipped room of minor surgery.*

*Doctor's stool*: A height-adjustable stool on wheels.

*Side table*: it is used to place the surgical instruments and material used during the surgery.

*Lamp*: It is necessary to have a directional light source, and it must provide adequate lighting with, at least, 45,000 lux of illuminance. It is advisable to have another auxiliary lamp with a magnifying glass.

*Showcase and containers*: For storing consumables and surgical instruments. There should also be properly marked containers for bio contaminated material, and a disposal system in accordance with current health legislation.

*Resuscitation equipment*: Including material for vascular access, airway intubation, saline, drugs for resuscitation (e.g. epinephrine, atropine, bicarbonate) and a defibrillator.

## **2. Sterilization system**

## **2.1 Physician's preparation for minor surgery**

Performing minor surgical procedures carries some risk of transmission of infectious diseases (such as HCV and HIV), both from patient to doctor and vice versa. To minimize this risk, all physicians performing invasive procedures should adopt and apply universal precautions, which include:

*Surgical attire*: surgical shirts and trousers ("scrubs") or gowns and sterile gloves. Surgical masks and eye goggles is considered highly desirable but not essential. Disposable gowns are very useful.

*Hand washing*: Hygienic scrubbing is suitable for minor surgery and involves using a normal soap solution (no brush) and washing thoroughly all skin folds for at least 20 seconds. Time span from scrubbing to glove placement should never exceed 10 minutes.

*Sterile glove placement*: Outer surface of the glove should be sterile, therefore they cannot be touched with the hands, only with the other glove; nonetheless, the inner or powdered part of the glove can be touched.

**23**

**Figure 2.**

*Correct way of managing of the scalpel.*

*Minor Surgery in Primary Care*

therefore, an important issue [1].

blunt dissection.

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

**3.1 Surgical instruments for minor surgery**

with the tip open, then cutting the tissue.

(12–15 cm). Long needle holders are not recommended.

retractor or dissecting forceps, opposing the pressure of the needle.

**3. Surgical instruments (handling) and suture material**

The quality, condition and type of instruments used in any procedure can affect

*Scalpel*: A number 3 handle with leaves number 15 for dissection and 11 for incisions and withdrawal of points. The scalpel blade is installed on the handle in a unique position, matching the blade guide with the handle guide. The scalpel is handled with the dominant hand like a pencil (**Figure 2**), allowing small and precise incisions. To increase precision, hand should be partially supported on the working surface. Skin should be tightened perpendicularly to the direction of the incision using the contralateral hand, cutting the skin perpendicularly. In hairy areas (eyebrows or scalp), to avoid damaging the follicles, the incision should be parallel to the hairshafts.

*Scissors*: The scissors allows us both the cutting dissection of the tissues and the

A 14 cm long curved blunt May scissors (cutting scissors) and an 11.5 cm curved

Scissors are handled by inserting the distal phalange of the thumb and fourth finger into the rings, then supporting the second finger on the branches of the scissors. Usually scissors are inserted with the tip closed and are then opened, separating the tissues in the anatomical layers, except for sharp dissection they are inserted

*Needle-holder*: needle-holders are meant to hold curved needles while stitching. The needle is held 2/3 of the way back from its point. A small or medium

Like other instruments with rings, the needle support is handled equally. To facilitate the passage of the needle through the tissues, the needle holder should describe a prono-supination movement, and for a proper edge eversion of the wound the angle of entry of the needle should be 90°. The non-dominant hand holds the skin with a

*Dissecting forceps*: Use of a 12 cm-long Adson forceps with teeth to handle the skin, plus a toothless Adson forceps for suture removal or two standard forceps, one with and one without teeth. It is important not to manipulate the skin using non-toothed forceps.

blunt Metzenbaum scissors (dissecting scissors) should be available.

its outcome. Choosing the right instruments for each surgical intervention is,

*Doctor's stool*: A height-adjustable stool on wheels.

another auxiliary lamp with a magnifying glass.

**2.1 Physician's preparation for minor surgery**

tial. Disposable gowns are very useful.

adopt and apply universal precautions, which include:

inner or powdered part of the glove can be touched.

*Side table*: it is used to place the surgical instruments and material used during

*Lamp*: It is necessary to have a directional light source, and it must provide adequate lighting with, at least, 45,000 lux of illuminance. It is advisable to have

*Showcase and containers*: For storing consumables and surgical instruments. There should also be properly marked containers for bio contaminated material,

*Resuscitation equipment*: Including material for vascular access, airway intubation, saline, drugs for resuscitation (e.g. epinephrine, atropine, bicarbonate) and a

Performing minor surgical procedures carries some risk of transmission of infectious diseases (such as HCV and HIV), both from patient to doctor and vice versa. To minimize this risk, all physicians performing invasive procedures should

*Surgical attire*: surgical shirts and trousers ("scrubs") or gowns and sterile gloves. Surgical masks and eye goggles is considered highly desirable but not essen-

*Hand washing*: Hygienic scrubbing is suitable for minor surgery and involves using a normal soap solution (no brush) and washing thoroughly all skin folds for at least 20 seconds. Time span from scrubbing to glove placement should never exceed

*Sterile glove placement*: Outer surface of the glove should be sterile, therefore they cannot be touched with the hands, only with the other glove; nonetheless, the

and a disposal system in accordance with current health legislation.

**22**

10 minutes.

the surgery.

**Figure 1.**

defibrillator.

**2. Sterilization system**

*Well-equipped room of minor surgery.*

## **3. Surgical instruments (handling) and suture material**

## **3.1 Surgical instruments for minor surgery**

The quality, condition and type of instruments used in any procedure can affect its outcome. Choosing the right instruments for each surgical intervention is, therefore, an important issue [1].

*Scalpel*: A number 3 handle with leaves number 15 for dissection and 11 for incisions and withdrawal of points. The scalpel blade is installed on the handle in a unique position, matching the blade guide with the handle guide. The scalpel is handled with the dominant hand like a pencil (**Figure 2**), allowing small and precise incisions. To increase precision, hand should be partially supported on the working surface. Skin should be tightened perpendicularly to the direction of the incision using the contralateral hand, cutting the skin perpendicularly. In hairy areas (eyebrows or scalp), to avoid damaging the follicles, the incision should be parallel to the hairshafts.

*Scissors*: The scissors allows us both the cutting dissection of the tissues and the blunt dissection.

A 14 cm long curved blunt May scissors (cutting scissors) and an 11.5 cm curved blunt Metzenbaum scissors (dissecting scissors) should be available.

Scissors are handled by inserting the distal phalange of the thumb and fourth finger into the rings, then supporting the second finger on the branches of the scissors. Usually scissors are inserted with the tip closed and are then opened, separating the tissues in the anatomical layers, except for sharp dissection they are inserted with the tip open, then cutting the tissue.

*Needle-holder*: needle-holders are meant to hold curved needles while stitching. The needle is held 2/3 of the way back from its point. A small or medium (12–15 cm). Long needle holders are not recommended.

Like other instruments with rings, the needle support is handled equally. To facilitate the passage of the needle through the tissues, the needle holder should describe a prono-supination movement, and for a proper edge eversion of the wound the angle of entry of the needle should be 90°. The non-dominant hand holds the skin with a retractor or dissecting forceps, opposing the pressure of the needle.

*Dissecting forceps*: Use of a 12 cm-long Adson forceps with teeth to handle the skin, plus a toothless Adson forceps for suture removal or two standard forceps, one with and one without teeth. It is important not to manipulate the skin using non-toothed forceps.

**Figure 2.** *Correct way of managing of the scalpel.*

#### **Figure 3.**

*Basic set of instruments of minor surgery: Scalpel (handle of the number 3 for scalpel number 15), scissors of May, Adson forceps with teeth, needle-holders and mosquito forceps.*

They used with the non dominant hand, between the first, second and third fingers. They allow the surgeon to expose the tissues to manipulate them.

*Homeostats*: homeostats are used to pull tissue, for homeostasis and, in some cases, for blunt dissection in absence of small scissors. Usually with 12 cm curved non-toothed Mosquito forceps.

For most minor surgical interventions, a basic set of surgical instruments is enough (**Figure 3**). But some surgical procedures require the use of special instruments or equipment, such as:

*Biopsy punch*: it is an instrument consisting of a handle and a cylindrical cutting edge (trephine) for obtaining tissue biopsies. It allows the surgeon to obtain fullthickness samples of the skin.

The most useful in minor surgery is the 4 mm punch but they are manufactured in different diameters. They are handled with the dominant hand, performing rotational movements of the instrument to cut the skin and obtain the sample [3].

*Curette*: it allows scraping of lesions on the skin Surface with a simple surgical technique that involves "scraping" or enucleating different types of superficial, hyperkeratotic or raised partial-thickness skin lesions.

*Cryosurgical equipment*: these are devices that spray a cryogen, which is usually liquid nitrogen that uses extremely cold temperatures to treat benign and malignant skin lesions (solar lentigines, common warts, myxoid cysts, actinic keratosis, etc.).

It is available, cost-effective, and rapid treatment that rarely requires anesthesia [4].

*Electrocautery*: it applies an electric current with ability to coagulate and cut through different tissues. There are different terminals depending on the type of procedure that is to be performed [5].

#### **3.2 Suture materials**

Different types of suture materials are available: threads, staples, adhesive sutures and tissue adhesives.

Depending on the material used for the suture, the operation time will be modified and will require anesthesia or not.

Conventional sutures require the use of anesthesia, operating time is increased, and tissue is traumatized, but provide a secure wound closure and minimal wounddehiscence rate compared to other types of closure [6].

#### *3.2.1 Sutures*

They are classified according to their origin (natural, such as silk, or synthetic polymers that produce less tissue reaction), their configuration (monofilament or

**25**

*3.2.1.2 Stitch removal*

*3.2.2 Suturing needles*

suture thickness.

*Minor Surgery in Primary Care*

from 2/0 to 4/0 or 5/0.

**Figure 4.**

*3.2.1.1 Features of main sutures*

to handle and tie.

maintain constant tension.

the type of wound and on the patient's features.

*(12) indexes of the manufacturer, (13) indicator of sterile packing.*

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

multifilament), and their size (the thickness of the suture is measured using a zeroscale [USP system] (**Figure 4**). The most commonly used in minor surgery range

*Information on suture: (1) caliber of the thread (system USP and metric), (2) trade name of the suture, (3) composition and physical structure of the thread, (4) length of the thread, (5) color of the thread, (6) model of needle (every manufacturer uses different references), (7) I draw from the needle to scale 1:1, (8) circumference of the needle (expressed in parts of circle), (9) section of the needle, (10) length of the needle, (11) expiry date,* 

The size and type of suture will be selected depending on the anatomical site,

• *Nonabsorbable sutures*: They are not degraded by the body and they are used for skin wounds in which stitches that are to be removed or for internal structures that must maintain a constant tension (like tendons and ligaments),

1.Silk: Suitable for skin suture and for removable sutures in general, it is easy

2.Nylon: Indicated for precise skin sutures and internal structures that must

3.Polypropylene: Indicated in continuous intradermal skin closure. It is a very soft suture with high package memory and, therefore, it requires more knots for secure tying, and it is more expensive than Nylon.

The period of time (in days) recommended for the extraction of points, together

Needle selection depends on the type of tissue to be sutured, its accessibility and

with an indication of the type of suture is described in **Table 1**.

• *Absorbable sutures*: A suture is considered absorbable if, when placed under the skin surface, it loses most of its tensile strength in 60 days. It has low tissue reactivity, high tensile strength. They are use in dermal suturing, subcutaneous tissue, deep suturing and ligatures of small vessels. The most commonly used, are the synthetic sutures (polyglactin 910 [Vicryl], polyglycolic acid [Dexon]…).

Polypropylene and Nylon, causes minimal tissue reaction.

#### **Figure 4.**

*Topics in Primary Care Medicine*

non-toothed Mosquito forceps.

**Figure 3.**

ments or equipment, such as:

thickness samples of the skin.

procedure that is to be performed [5].

fied and will require anesthesia or not.

**3.2 Suture materials**

sutures and tissue adhesives.

They used with the non dominant hand, between the first, second and third fingers.

*Homeostats*: homeostats are used to pull tissue, for homeostasis and, in some cases, for blunt dissection in absence of small scissors. Usually with 12 cm curved

*Basic set of instruments of minor surgery: Scalpel (handle of the number 3 for scalpel number 15), scissors of* 

For most minor surgical interventions, a basic set of surgical instruments is enough (**Figure 3**). But some surgical procedures require the use of special instru-

*Biopsy punch*: it is an instrument consisting of a handle and a cylindrical cutting edge (trephine) for obtaining tissue biopsies. It allows the surgeon to obtain full-

The most useful in minor surgery is the 4 mm punch but they are manufactured

*Cryosurgical equipment*: these are devices that spray a cryogen, which is usually liquid nitrogen that uses extremely cold temperatures to treat benign and malignant skin lesions (solar lentigines, common warts, myxoid cysts, actinic keratosis, etc.). It is available, cost-effective, and rapid treatment that rarely requires anesthesia [4]. *Electrocautery*: it applies an electric current with ability to coagulate and cut through different tissues. There are different terminals depending on the type of

Different types of suture materials are available: threads, staples, adhesive

Depending on the material used for the suture, the operation time will be modi-

Conventional sutures require the use of anesthesia, operating time is increased, and tissue is traumatized, but provide a secure wound closure and minimal wound-

They are classified according to their origin (natural, such as silk, or synthetic polymers that produce less tissue reaction), their configuration (monofilament or

in different diameters. They are handled with the dominant hand, performing rotational movements of the instrument to cut the skin and obtain the sample [3]. *Curette*: it allows scraping of lesions on the skin Surface with a simple surgical technique that involves "scraping" or enucleating different types of superficial,

hyperkeratotic or raised partial-thickness skin lesions.

*May, Adson forceps with teeth, needle-holders and mosquito forceps.*

dehiscence rate compared to other types of closure [6].

They allow the surgeon to expose the tissues to manipulate them.

**24**

*3.2.1 Sutures*

*Information on suture: (1) caliber of the thread (system USP and metric), (2) trade name of the suture, (3) composition and physical structure of the thread, (4) length of the thread, (5) color of the thread, (6) model of needle (every manufacturer uses different references), (7) I draw from the needle to scale 1:1, (8) circumference of the needle (expressed in parts of circle), (9) section of the needle, (10) length of the needle, (11) expiry date, (12) indexes of the manufacturer, (13) indicator of sterile packing.*

multifilament), and their size (the thickness of the suture is measured using a zeroscale [USP system] (**Figure 4**). The most commonly used in minor surgery range from 2/0 to 4/0 or 5/0.

The size and type of suture will be selected depending on the anatomical site, the type of wound and on the patient's features.

## *3.2.1.1 Features of main sutures*

	- 1.Silk: Suitable for skin suture and for removable sutures in general, it is easy to handle and tie.
	- 2.Nylon: Indicated for precise skin sutures and internal structures that must maintain constant tension.
	- 3.Polypropylene: Indicated in continuous intradermal skin closure. It is a very soft suture with high package memory and, therefore, it requires more knots for secure tying, and it is more expensive than Nylon.

## *3.2.1.2 Stitch removal*

The period of time (in days) recommended for the extraction of points, together with an indication of the type of suture is described in **Table 1**.

## *3.2.2 Suturing needles*

Needle selection depends on the type of tissue to be sutured, its accessibility and suture thickness.


#### **Table 1.**

*Indications of types of sutures and time for stitch removal.*

Needles are classified as triangular, spatulate or conical, according to their section. Triangular needles are considered the first choice in minor surgery, as they have sharp edges that allow suturing through highly-resistant tissues such as subcutaneous tissue, skin or fascia.

Curved needles are used with the needle holder, that is designed to hold needles atraumatically and safely. Short needle holders are preferred in minor surgery; however, they should be selected in accordance with the size of the needle and the surgical area.

#### *3.2.3 Staples*

Staples are applied by disposable staplers and they are available in different widths (R: normal staples, W: Wide staples). Staplers are preloaded with a variable number of staples. It has certain advantages such as the speed with which the suture is performed, low resistance and no tissue reaction.

They are applied with the dominant hand, while the non dominant hand everts the skin edges using dissecting forceps with teeth. Staple removal is performed using a staple extractor.

*Indications*: In linear wounds on the scalp, trunk and limbs, and for temporary closure of wounds in patients to be transferred or with other serious injuries.

*Contraindications*: Wounds on face and hands and regions that are going to be studied through CT or MRI.

#### *3.2.4 Adhesive sutures*

It consists of adhesive tapes made of porous paper and capable of approximating the edges of a wound or incision. They are available in various widths and lengths, and it can be cut.

**27**

patient.

*Minor Surgery in Primary Care*

*3.2.5 Tissue adhesives (glues)*

stratum corneum are shed along.

sutures in the subcutaneous plane.

needlesticks are avoided [1, 7].

will disappear after 7–10 days.

*3.2.5.2 Warnings for correct use*

**4.1 Basic surgical maneuvers**

*3.2.5.1 Application technique*

joint surfaces.

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

wound and then the other and along the wound.

reinforcement after stitch removal.

due to the risk of tape detachment.

and fingertips. They are also a good choice for elderly patients and to wound-

should be free of blood or secretions and dry. The suture tape is applied to the wound using dissecting forceps without teeth or fingers, first on one edge of the

Time for adhesive suture removal parallels time for conventional suture.

These products (cyanoacrylates) act as an adhesive, producing an epidermal plane closure, so they bind the most superficial epithelial layer (stratum corneum) and hold together the wound edges for 7–14 days. After this time, adhesive and

Adhesive can be used in deeper wounds or with great tension, associated at

It have advantages when compared with sutures: More rapid repair time, less painful procedure, better acceptance by patients, no need for suture removal or follow-up, good cosmetically results. Finally they are safer than sutures because

After cleanliness and hemostasis of the wound, tissue adhesive will be applied:

• Using fingers or dissecting forceps to approximate the wound edges, apply the adhesive on the outer surface of the skin. Then Keep the edges in contact for

• The wound does not require dressings but should be kept dry 5 days. The glue

If adhesive contact the eyes, use of a generous amounts of ophthalmic antibiotic

ointment should be placed within the eye and on the eyelid to break down the adhesive and reopening of eyelids with a gentle manual traction. If adhesive reach

**4. Surgical procedures and techniques of anesthesia in minor surgery**

The practice of any surgical procedure, however minimal, is not without risks. The possibility of complications during and after surgery must always be kept in mind. The results of surgical treatment are not always predictable, and depend on many factors, involving not only the physician's skills, but also the

30–60 seconds. The process can be repeated 3 times.

the cornea, it should be assessed for corneal abrasion.

Any wound closed with adhesive suture should not be wet for the first few days,

*Contraindications*: irregular wounds, on the scalp and hairy areas, skin folds and

Application and removal of adhesive sutures: For a good application the wound

*Indications*: linear and superficial wounds with little tension. The regions where they are used most are: the face, chest, non-articular surfaces of the limbs

#### *Minor Surgery in Primary Care DOI: http://dx.doi.org/10.5772/intechopen.88811*

*Topics in Primary Care Medicine*

Face, neck, nose, forehead

Ears 4/0–5/0 monofilament

subcutaneous tissue, skin or fascia.

*Indications of types of sutures and time for stitch removal.*

is performed, low resistance and no tissue reaction.

surgical area.

**Table 1.**

*3.2.3 Staples*

using a staple extractor.

studied through CT or MRI.

*3.2.4 Adhesive sutures*

and it can be cut.

Needles are classified as triangular, spatulate or conical, according to their section. Triangular needles are considered the first choice in minor surgery, as they have sharp edges that allow suturing through highly-resistant tissues such as

**Anatomical region Skin suturing Subcutaneous suturing** 

or silk

Scalp Staples 2/0 silk 3/0 7–9 6–8 Eyelids 6/0 monofilament or silk — 3–5 3–5

Lips 4/0 monofilament or silk 4/0 4–6 4–5 Trunk/abdomen 3/0–4/0 monofilament 3/0 7–12 7–9 Back 12–14 14 Lower extremity 3/0 monofilament 3/0 8–12 7–10 Penis 4/0 monofilament 3/0 7–10 6–8 Foot and pulp of fingers 10–12 8–10 Upper limb/hand 8–10 7–9 Mouth and tongue 3/0 Vicryl® — — —

**(Vicryl® or Dexon®)**

4/0 monofilament or silk 4/0 4–6 3–5

**Stitch removal Adults children**

— 4–5 3–5

atraumatically and safely. Short needle holders are preferred in minor surgery; however, they should be selected in accordance with the size of the needle and the

Staples are applied by disposable staplers and they are available in different widths (R: normal staples, W: Wide staples). Staplers are preloaded with a variable number of staples. It has certain advantages such as the speed with which the suture

They are applied with the dominant hand, while the non dominant hand everts the skin edges using dissecting forceps with teeth. Staple removal is performed

*Indications*: In linear wounds on the scalp, trunk and limbs, and for temporary

*Contraindications*: Wounds on face and hands and regions that are going to be

It consists of adhesive tapes made of porous paper and capable of approximating the edges of a wound or incision. They are available in various widths and lengths,

*Indications*: linear and superficial wounds with little tension. The regions where they are used most are: the face, chest, non-articular surfaces of the limbs

closure of wounds in patients to be transferred or with other serious injuries.

Curved needles are used with the needle holder, that is designed to hold needles

**26**

and fingertips. They are also a good choice for elderly patients and to woundreinforcement after stitch removal.

Any wound closed with adhesive suture should not be wet for the first few days, due to the risk of tape detachment.

*Contraindications*: irregular wounds, on the scalp and hairy areas, skin folds and joint surfaces.

Application and removal of adhesive sutures: For a good application the wound should be free of blood or secretions and dry. The suture tape is applied to the wound using dissecting forceps without teeth or fingers, first on one edge of the wound and then the other and along the wound.

Time for adhesive suture removal parallels time for conventional suture.

#### *3.2.5 Tissue adhesives (glues)*

These products (cyanoacrylates) act as an adhesive, producing an epidermal plane closure, so they bind the most superficial epithelial layer (stratum corneum) and hold together the wound edges for 7–14 days. After this time, adhesive and stratum corneum are shed along.

Adhesive can be used in deeper wounds or with great tension, associated at sutures in the subcutaneous plane.

It have advantages when compared with sutures: More rapid repair time, less painful procedure, better acceptance by patients, no need for suture removal or follow-up, good cosmetically results. Finally they are safer than sutures because needlesticks are avoided [1, 7].

#### *3.2.5.1 Application technique*

After cleanliness and hemostasis of the wound, tissue adhesive will be applied:


#### *3.2.5.2 Warnings for correct use*

If adhesive contact the eyes, use of a generous amounts of ophthalmic antibiotic ointment should be placed within the eye and on the eyelid to break down the adhesive and reopening of eyelids with a gentle manual traction. If adhesive reach the cornea, it should be assessed for corneal abrasion.

#### **4. Surgical procedures and techniques of anesthesia in minor surgery**

#### **4.1 Basic surgical maneuvers**

The practice of any surgical procedure, however minimal, is not without risks. The possibility of complications during and after surgery must always be kept in mind. The results of surgical treatment are not always predictable, and depend on many factors, involving not only the physician's skills, but also the patient.

## *4.1.1 Surgical incision and dissection*

There are two ways to dissect tissue: with a blunt dissection, separating the tissue, using Metzenbaum scissors or mosquito forceps, or cutting dissection, with a scalpel or scissors.

#### *4.1.1.1 Incisions shape in minor surgery*

Incisions must parallel the minimal tension lines, which match skin relaxation lines and facial expression. Thus, they result in an acceptable scar, both functionally and cosmetically. There are diagrams of the relaxed skin tension lines, for correct incision planning before surgery.

The incision can be marked prior to skin antiseptic preparation or a previously sterilized marking pen can be used in the surgical field after skin preparation and draping.

For excisional biopsies, it is necessary to leave an adequate margin (1–2 mm) of healthy skin both around the lesion and in depth, depending on each lesion.

#### *4.1.1.2 Types of incisions for minor surgery*

*Incision:* Used for drainage of abscesses or surgical exposure of deeper tissues (e.g., epidermal cysts, lipomas, lymph node biopsies). Depending of surgery or the anatomic area, Incisions can be angled, curved or straight.

*Elliptical excision*: Its should be oriented along the lines of minimal tension.

Usually the length of the ellipse should be 3 times its width and the ends form a 30° angle. Its used to remove skin lesions with a margin of healthy skin in depth and around lesion, and include all skin layers plus some subcutaneous fat (**Figure 5**). This technique allows diagnosis, treatment and facilitates closure producing good cosmetic results.

It is the ideal technique to remove the majority of skin lesions [8–10]. The procedure involves the following steps:

**29**

*Minor Surgery in Primary Care*

1.Design of the incision

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

2.Preparation of the surgical field

dermis to prevent jagged edges.

6.Hemostasis of the surgical area.

8.Cleaning the surgical area and dressing placement

9.After 48 hours the wound can be washed gently

intention. Tangential excision also called "skin shave".

and the patient informed of the results and prognosis.

7.Wound closure by layers

4.Superficial skin incision along the marked ellipse, going through the entire

5.Using the nondominant hand the deep wedge-shaped incision is made (always under direct vision), until fat is reached and the lesion is, thus, removed en

*Tangential excision*: it is the technique of choice to remove very superficial lesions using scalpel or scissors, eliminating only the most superficial layers of the skin and for which diagnosis is certain. The defect created is allowed to heal by secondary

No surgical procedure is complete until the pathology report has been received

Most episodes of bleeding in minor surgery can be controlled with pressure with a gauze or a surgical towel. It is recommended to apply a compressive bandage on the wound in the immediate postoperative period to reduce hematoma or

Tourniquet: Its allows the exploration of the wound and reduces the surgical time. Its use is limited to distal areas (the fingers nail surgery, etc.) and should not

• *The hemostats*: The surgeon holds bleeding vessel with the tip of a hemostat without teeth and controls the bleeding. To avoid damaging important structures (for example, tendons or nerves) it is necessary to identify the bleeding

• *The ligatures*: they are threads that tied around a blood vessel, occlude their light and prevent bleeding. After that, vessel should be fixed with a hemostat. The ligature should pass under the clamp and several knots must

• In the hemostasis by electrocoagulation, the Bovie is used in coagulation mode.

3.Local anesthetic injection.

bloc.

*4.1.2 Hemostasis*

*4.1.2.1 Types of hemostasis*

exceed 15 minutes.

vessel.

be tied.

seroma.

**Figure 5.** *Characteristics of the elliptical excision.*

1.Design of the incision

*Topics in Primary Care Medicine*

scalpel or scissors.

draping.

cosmetic results.

*4.1.1 Surgical incision and dissection*

*4.1.1.1 Incisions shape in minor surgery*

incision planning before surgery.

*4.1.1.2 Types of incisions for minor surgery*

anatomic area, Incisions can be angled, curved or straight.

The procedure involves the following steps:

There are two ways to dissect tissue: with a blunt dissection, separating the tissue, using Metzenbaum scissors or mosquito forceps, or cutting dissection, with a

Incisions must parallel the minimal tension lines, which match skin relaxation lines and facial expression. Thus, they result in an acceptable scar, both functionally and cosmetically. There are diagrams of the relaxed skin tension lines, for correct

The incision can be marked prior to skin antiseptic preparation or a previously sterilized marking pen can be used in the surgical field after skin preparation and

For excisional biopsies, it is necessary to leave an adequate margin (1–2 mm) of

*Incision:* Used for drainage of abscesses or surgical exposure of deeper tissues (e.g., epidermal cysts, lipomas, lymph node biopsies). Depending of surgery or the

*Elliptical excision*: Its should be oriented along the lines of minimal tension. Usually the length of the ellipse should be 3 times its width and the ends form a 30° angle. Its used to remove skin lesions with a margin of healthy skin in depth and around lesion, and include all skin layers plus some subcutaneous fat (**Figure 5**). This technique allows diagnosis, treatment and facilitates closure producing good

It is the ideal technique to remove the majority of skin lesions [8–10].

healthy skin both around the lesion and in depth, depending on each lesion.

**28**

**Figure 5.**

*Characteristics of the elliptical excision.*


*Tangential excision*: it is the technique of choice to remove very superficial lesions using scalpel or scissors, eliminating only the most superficial layers of the skin and for which diagnosis is certain. The defect created is allowed to heal by secondary intention. Tangential excision also called "skin shave".

No surgical procedure is complete until the pathology report has been received and the patient informed of the results and prognosis.

## *4.1.2 Hemostasis*

Most episodes of bleeding in minor surgery can be controlled with pressure with a gauze or a surgical towel. It is recommended to apply a compressive bandage on the wound in the immediate postoperative period to reduce hematoma or seroma.

## *4.1.2.1 Types of hemostasis*

Tourniquet: Its allows the exploration of the wound and reduces the surgical time. Its use is limited to distal areas (the fingers nail surgery, etc.) and should not exceed 15 minutes.


## *4.1.3 Suture techniques*

## *4.1.3.1 Interrupted sutures*

This is the most appropriate for minor surgery, as it helps to distribute stress, and promotes the drainage of the wound. The number of sutures needed varies according to the length, shape and location of the laceration. In general, the sutures are placed away from each other so that no space appears on the edges of the wound.

*Simple stitch (percutaneous)*: It is used alone or in combination with buried stitches in deeper wounds and it is considered the technique of choice.

*Simple stitch with buried knot*: Used to reduce tension within the wound and approximate the deep planes, before skin suturing. Absorbable material is used, the knot leaving in the depth of the wound, and is cut flush.

*Mattress stitch or "U" stitch*: It is useful in areas of loose skin (e.g., elbow, back of the hand), where the wound edges tend to invaginate. In addition this suture provides good obliteration of dead space, avoiding the need for buried sutures in shallow wounds.


## *4.1.3.2 Running sutures*

They are contraindicated if an infection is suspected and in very contaminated wounds.

*Simple running suture:* is a sequence of points with an initial knot and a final knot. It takes a short time to do it, but it makes it difficult to adjust the tension of the skin. It is rarely used in minor surgery*.*

*Continuous intradermal suture (subcuticular):* this type of suture allows the wound to be sutured without breaking the skin, avoids the "cross-hatching" and provides an optimal esthetic result. Non-absorbable monofilament suture material or absorbable material can be used. Intradermal sutures are used in wounds where it will be necessary to maintain the suture for more than 15 days. In minor surgery its usefulness is limited.

### *4.1.3.3 Knot-tying*

When a multifilament yarn is knotted (for example, Silk), three loops are usually sufficient (first a double loop plus two simple loops). When knotting a monofilament yarn (e.g., Nylon, polypropylene), an additional loop must be added to increase knot security. The knots should be placed on one side of the wound, rather than placed on top of the incision. This will allow a better visualization of the wound and will interfere less with the healing and facilitate the removal of points.

#### **4.2 Local anesthesia in minor surgery**

Local anesthetics block the transmission of nerve impulses and they causing, the absence of sensation in a specific part of the body, also other local senses may be affected.

**31**

**Table 2.**

*Minor Surgery in Primary Care*

micrograms/kg in children [11].

*4.2.1 Available presentations*

*4.2.2 Use of vasoconstrictors*

*4.2.3.1 Topical anesthesia*

*4.2.3.2 Infiltration anesthesia*

polyhedral figure.

1–3 ml applied directly on wound for 15–30 minutes

1–2 g of cream should be applied for each 10 cm2 of intact skin and occluded. Maximum dose is 10 g

LET® (4% lidocaine, 0.1% epinephrine 1:2000, 0.5% tetracaine)

EMLA® lidocaine 25 mg/ ml plus prilocaine 25 mg/ml,

*4.2.3 Basic techniques of local anesthesia*

And their characteristics are shown in the **Table 2**.

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

Local anesthetics can be classified into two groups: esters and amides (lidocaine,

mepivacaine, bupivacaine, prilocaine, etidocaine and ropivacaine). For their remarkable safety and efficacy we will only use amides. The association of vasoconstrictors allows better visualization of the surgical field. The most widely used is adrenaline and the maximum dose must not exceed 250 micrograms in adults or 10

The concentration of the anesthetic is expressed in %. We must know that a concentration of 1% means that 100 ml of the solution contain 1 g of anesthetic. Therefore a 2 ml ampoule of 2% mepivacaine, its contain 40 mg (**Table 2**).

Due to the risk of necrosis and other alteration like delayed healing, adrenaline should not be used in acral areas (e.g., toes), or in traumatized and devitalized skin.

It is use in an intact skin and for lacerations and mucosae, especially in children.

1.*Angular infiltration*: From the point of entry, the anesthetic is infiltrated in

2.*Perilesional infiltration*: Starting from each point of entry the anesthetic is infiltrated in a single direction. The different points of entry will be forming a

**Anesthetic Mode of use characteristics Indications Complications Not indicated**

Can be effective in children for face and scalp lacerations and less effective in limbs

Admitted for procedures on intact skin: scraping and shaving, cryosurgery, electrosurgery, laser hair removal, preanesthesia for infiltration

No important adverse effects reported

Local mild irritation, contact dermatitis. There have been reports of Methemoglobinemia in children aged <6 months

For mucosae and acral areas

For wounds or deep tissues

three or more different directions, like a fan (**Figure 6**).

Onset 20–30 minutes after application.

Onset 60–120 minutes after application. Duration of effect is 30–120 minutes. Not useful on palms of hands and soles of feet

*Topical anesthetics used in minor surgical procedures and their characteristics.*

### *Minor Surgery in Primary Care DOI: http://dx.doi.org/10.5772/intechopen.88811*

Local anesthetics can be classified into two groups: esters and amides (lidocaine, mepivacaine, bupivacaine, prilocaine, etidocaine and ropivacaine). For their remarkable safety and efficacy we will only use amides. The association of vasoconstrictors allows better visualization of the surgical field. The most widely used is adrenaline and the maximum dose must not exceed 250 micrograms in adults or 10 micrograms/kg in children [11].

## *4.2.1 Available presentations*

*Topics in Primary Care Medicine*

*4.1.3 Suture techniques*

shallow wounds.

*4.1.3.2 Running sutures*

usefulness is limited.

*4.1.3.3 Knot-tying*

removal of points.

**4.2 Local anesthesia in minor surgery**

wounds.

*4.1.3.1 Interrupted sutures*

This is the most appropriate for minor surgery, as it helps to distribute stress, and promotes the drainage of the wound. The number of sutures needed varies according to the length, shape and location of the laceration. In general, the sutures are placed away from each other so that no space appears on the edges of the wound. *Simple stitch (percutaneous)*: It is used alone or in combination with buried

*Simple stitch with buried knot*: Used to reduce tension within the wound and approximate the deep planes, before skin suturing. Absorbable material is used, the

*Mattress stitch or "U" stitch*: It is useful in areas of loose skin (e.g., elbow, back of the hand), where the wound edges tend to invaginate. In addition this suture provides good obliteration of dead space, avoiding the need for buried sutures in

• Horizontal mattress stitch: provides a good eversion of wound edges, especially

• Half-buried horizontal mattress stitch: is used to suture wound angles or surgi-

They are contraindicated if an infection is suspected and in very contaminated

*Simple running suture:* is a sequence of points with an initial knot and a final knot. It takes a short time to do it, but it makes it difficult to adjust the tension of

*Continuous intradermal suture (subcuticular):* this type of suture allows the wound to be sutured without breaking the skin, avoids the "cross-hatching" and provides an optimal esthetic result. Non-absorbable monofilament suture material or absorbable material can be used. Intradermal sutures are used in wounds where it will be necessary to maintain the suture for more than 15 days. In minor surgery its

When a multifilament yarn is knotted (for example, Silk), three loops are usually sufficient (first a double loop plus two simple loops). When knotting a monofilament yarn (e.g., Nylon, polypropylene), an additional loop must be added to increase knot security. The knots should be placed on one side of the wound, rather than placed on top of the incision. This will allow a better visualization of the wound and will interfere less with the healing and facilitate the

Local anesthetics block the transmission of nerve impulses and they causing, the absence of sensation in a specific part of the body, also other local senses may be

stitches in deeper wounds and it is considered the technique of choice.

in areas where the dermis is thick or with high tension [6]

knot leaving in the depth of the wound, and is cut flush.

cal edges of uneven thickness.

the skin. It is rarely used in minor surgery*.*

**30**

affected.

The concentration of the anesthetic is expressed in %. We must know that a concentration of 1% means that 100 ml of the solution contain 1 g of anesthetic. Therefore a 2 ml ampoule of 2% mepivacaine, its contain 40 mg (**Table 2**).

## *4.2.2 Use of vasoconstrictors*

Due to the risk of necrosis and other alteration like delayed healing, adrenaline should not be used in acral areas (e.g., toes), or in traumatized and devitalized skin.

## *4.2.3 Basic techniques of local anesthesia*

## *4.2.3.1 Topical anesthesia*

It is use in an intact skin and for lacerations and mucosae, especially in children. And their characteristics are shown in the **Table 2**.

## *4.2.3.2 Infiltration anesthesia*



#### **Table 2.**

*Topical anesthetics used in minor surgical procedures and their characteristics.*

**Figure 6.** *Anesthetic angular infiltration: it infiltrates following three or more different directions, like a fan.*

3.*Linear infiltration*: If the lesion to be operated on is a skin laceration, the anesthetic should be directly infiltrated into the wound edges in a linear fashion. If the wound is bruised and has irregular edges, it is preferable to use a perilesional technique from the uninjured area, and follow along the margins of the wound to avoid introducing microbial contamination.

### *4.2.3.3 Loco-regional block*

The needle is inserted at the base of the proximal phalanx in a dorsal and lateral location, in the collateral palmar digital nerve, and then local anesthetic is injected (maximum 4 ml). The needle is removed and after aspiration proceeds to infiltrate again the subcutaneous plane.

The surgeon must wait 10–15 minutes to obtain a complete effect of the blockage.

## **5. Preoperative considerations**

## **5.1 Diagnostic criteria for the most common lesions in minor surgery**

It is important that general practitioners have an extensive knowledge of the lesions most frequently treated by minor surgery [12].

The following paragraphs contain an overview of the most important diagnostic consideration in lesions usually treated with minor surgery.

#### *5.1.1 Seborrheic keratoses*

These lesions are easily treated with curettage, electrosurgery or cryosurgery. In case of doubt, an incisional biopsy should be sent for histopathological analysis.

**33**

*Minor Surgery in Primary Care*

*5.1.2 Epidermal cysts*

*5.1.3 Warts*

*5.1.4 Molluscum*

*5.1.5 Lipoma*

*5.1.6 Fibroma pendulum, skin tags*

utes to the induction of these lesions.

*5.1.7 Melanocytic nevi*

*5.1.8 Actinic keratosis*

squamous cell carcinoma.

*5.1.9 Basal cell carcinoma*

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

They are also known as epithelial cysts, epidermoid cysts, or improperly, "sebaceous cysts." The cyst wall consists of normal stratified squamous epithelium derived from the follicular infundibulum. Queratin is the main component inside the cyst. Their treatment is surgical removal for cosmetic reasons or due to recurrent infections.

They are a form of benign epithelial hyperplasia induced by the human papillomavirus (HPV). Clinical presentations of cutaneous HPV infection include: Verruca Vulgaris or plantar wart: you can use liquid nitrogen or salicylic acid.

It is presents as pearly white papules of 1–5 mm (sometimes even bigger) with central dimpling. They may appear isolated or in groups in the neck, trunk, anogenital area or eyelids. Their first choice treatment is cryosurgery, curettage.

Lipomas are slow-growing benign tumors of mature adipose tissue. They appear as soft, elastic, smooth or multilobulated tumors of variable size, with ill-defined borders, and not adherent to deep planes. The diagnosis is usually made clinically. But ultrasound can be helpful to distinguish a lipoma from an epidermoid cyst or a ganglion cyst [13].

They are not malignant and their treatment is justified for cosmetic reasons.

They are acquired lesions in the form of macules or papules or small nodules (<1 cm) and are constituted by groups of melanocytes located in the epidermis, dermis or both areas and rarely in the subcutaneous tissue. Sun exposure contrib-

It is located in sun-exposed areas such as bald scalp, the face, shoulders, ears, neck and the back of the hands. It is caused by damage from exposure to ultraviolet

Actinic keratosis is considered a precancer. 13–25% it could develop into a

If lesions are scarce and localized, they may be treated with liquid nitrogen.

It is the most common skin malignancy. Approximately 70% of basal cell carcinoma occurs on the face, and 15% presents on the trunk [14]. Exposure to ultraviolet (UV) radiation in sunlight, especially during childhood, is the most important

radiation. Actinic keratoses are more prevalent in males of middle-aged.

factors that contribute to the development of Basal cell carcinoma.

They are generally asymptomatic and they are treated by surgical removal [2].

## *5.1.2 Epidermal cysts*

They are also known as epithelial cysts, epidermoid cysts, or improperly, "sebaceous cysts." The cyst wall consists of normal stratified squamous epithelium derived from the follicular infundibulum. Queratin is the main component inside the cyst. Their treatment is surgical removal for cosmetic reasons or due to recurrent infections.

## *5.1.3 Warts*

*Topics in Primary Care Medicine*

*4.2.3.3 Loco-regional block*

**Figure 6.**

again the subcutaneous plane.

*5.1.1 Seborrheic keratoses*

**5. Preoperative considerations**

3.*Linear infiltration*: If the lesion to be operated on is a skin laceration, the anesthetic should be directly infiltrated into the wound edges in a linear fashion. If the wound is bruised and has irregular edges, it is preferable to use a perilesional technique from the uninjured area, and follow along the margins of the

*Anesthetic angular infiltration: it infiltrates following three or more different directions, like a fan.*

The needle is inserted at the base of the proximal phalanx in a dorsal and lateral location, in the collateral palmar digital nerve, and then local anesthetic is injected (maximum 4 ml). The needle is removed and after aspiration proceeds to infiltrate

The surgeon must wait 10–15 minutes to obtain a complete effect of the blockage.

It is important that general practitioners have an extensive knowledge of the

The following paragraphs contain an overview of the most important diagnostic

These lesions are easily treated with curettage, electrosurgery or cryosurgery. In case of doubt, an incisional biopsy should be sent for histopathological analysis.

**5.1 Diagnostic criteria for the most common lesions in minor surgery**

lesions most frequently treated by minor surgery [12].

consideration in lesions usually treated with minor surgery.

wound to avoid introducing microbial contamination.

**32**

They are a form of benign epithelial hyperplasia induced by the human papillomavirus (HPV). Clinical presentations of cutaneous HPV infection include: Verruca Vulgaris or plantar wart: you can use liquid nitrogen or salicylic acid.

## *5.1.4 Molluscum*

It is presents as pearly white papules of 1–5 mm (sometimes even bigger) with central dimpling. They may appear isolated or in groups in the neck, trunk, anogenital area or eyelids. Their first choice treatment is cryosurgery, curettage.

## *5.1.5 Lipoma*

Lipomas are slow-growing benign tumors of mature adipose tissue. They appear as soft, elastic, smooth or multilobulated tumors of variable size, with ill-defined borders, and not adherent to deep planes. The diagnosis is usually made clinically. But ultrasound can be helpful to distinguish a lipoma from an epidermoid cyst or a ganglion cyst [13]. They are generally asymptomatic and they are treated by surgical removal [2].

## *5.1.6 Fibroma pendulum, skin tags*

They are not malignant and their treatment is justified for cosmetic reasons.

### *5.1.7 Melanocytic nevi*

They are acquired lesions in the form of macules or papules or small nodules (<1 cm) and are constituted by groups of melanocytes located in the epidermis, dermis or both areas and rarely in the subcutaneous tissue. Sun exposure contributes to the induction of these lesions.

### *5.1.8 Actinic keratosis*

It is located in sun-exposed areas such as bald scalp, the face, shoulders, ears, neck and the back of the hands. It is caused by damage from exposure to ultraviolet radiation. Actinic keratoses are more prevalent in males of middle-aged.

Actinic keratosis is considered a precancer. 13–25% it could develop into a squamous cell carcinoma.

If lesions are scarce and localized, they may be treated with liquid nitrogen.

### *5.1.9 Basal cell carcinoma*

It is the most common skin malignancy. Approximately 70% of basal cell carcinoma occurs on the face, and 15% presents on the trunk [14]. Exposure to ultraviolet (UV) radiation in sunlight, especially during childhood, is the most important factors that contribute to the development of Basal cell carcinoma.

## *5.1.10 Squamous cell carcinoma*

This is a malignant tumor that usually appears on a previous premalignant lesion and requires a multidisciplinary therapeutical approach involving dermatologists, surgeons, radiotherapists, and chemotherapists [14].

## *5.1.11 Melanoma*

Of all skin malignancies, melanoma has the worst prognosis, Five-year survival rates for people with melanoma depend on the stage of the disease at the time of diagnosis.

## **5.2 Body areas of risk in minor surgery**

High-risk areas for minor surgery include the facial and cervical regions, axillary and supraclavicular regions, wrists, hands and fingers, the groin, the popliteal fossa and the feet.

We must consider those regions with a greater tendency to develop pathological scars (e.g., shoulder, sternal and interscapular region). Also the skin of black patients and children are especially prone.

## **6. Good clinical practice in minor surgery**

## **6.1 Preoperative**

For most basic minor surgical procedures, no preoperative work-up is needed. **Table 3** summarizes the precautions of minor surgery in primary care.

In patients with increased anxiety, 5–10 mg oral or sublingual diazepam, or 1–5 mg sublingual lorazepam can be administered 30 minutes before surgery.

*Contraindications for minor surgery:* Malignant skin lesion, allergy to local anesthetics, pregnancy (surgery should be deferred until the end of pregnancy, if malignancy is suspected, the patient should be referred to a specialist), an acute illness, doubt about patient's motivations, patients with psychiatric disorders or




**35**

*Minor Surgery in Primary Care*

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

**6.2 Intraoperative complications**

**6.3 Postoperative complications**

intention.

**Conflict of interest**

cation for any minor surgery procedure or technique.

young men. Even some patients lose consciousness.

• Hypertrophic scar and keloid scarring.

The authors declare no conflict of interest.

spontaneously over a period of seconds to a few minutes.

biopsy) generally considered to confer a low risk of bleeding [15].

uncooperative patients or refusal to sign the informed consent form is a contraindi-

Vasovagal syncope is the most frequent complication and is more common in

Treatment consists in administering oxygen and iv. fluids if needed and, in severe cases use atropine (0.5–1 mg sc or iv). Generally, most of patients recover

• Infection can occur in up to 1% of minor surgical patients, symptoms such as fever and/or chills are only rarely seen. Infections are treated by removing some of the stitches, plus daily cleaning and disinfection of the wound and allowing the wound to close by secondary intention. If necessary an oral antibiotic regimen may be initiated and inserted drain into the wound.

• *Hematoma-seroma*: is paramount suturing the wound in layers with no gaps

• *Wound dehiscence*: After wound dehiscence, repairs will take place by secondary

and, applying a compressive bandage to prevent their formation.

*Direct oral anticoagulants [DOACs] (Dabigatran, Rivaroxaban, Apixaban, Edoxaban):* If a moderate or high bleeding risk surgery, it can be omitted for approximately 2–3 days before a procedure, and resume 24 hours after surgery. However, cutaneous procedures (e.g., skin biopsy, tumor excision, bone marrow


<sup>-</sup>In patients with chronic use of corticosteroids.

Protocol for minor surgery in anticoagulated patients

<sup>- 3</sup> Day Suspend Sintrom ®

<sup>- 2</sup> Day Suspend Sintrom ® and add subcutaneous LMWH

LMWH single subcutaneous dose. Patient will take the usual dose of Sintrom ® (the same as before the suspension).

<sup>+3</sup> Day LMWH single subcutaneous dose. Usual dose of Sintrom ®

<sup>+4</sup> Day usual dose of Sintrom ®

INR will be obtained on day +10 (seven days after surgery)

### *Minor Surgery in Primary Care DOI: http://dx.doi.org/10.5772/intechopen.88811*

*Topics in Primary Care Medicine*

*5.1.10 Squamous cell carcinoma*

*5.1.11 Melanoma*

diagnosis.

and the feet.

**6.1 Preoperative**

surgeons, radiotherapists, and chemotherapists [14].

**5.2 Body areas of risk in minor surgery**

patients and children are especially prone.

not add vasoconstrictor to local anesthetic




+1 Day LMWH single subcutaneous dose usual dose of Sintrom ®

+3 Day LMWH single subcutaneous dose. Usual dose of Sintrom ®

INR will be obtained on day +10 (seven days after surgery)


suspension).


+2 Day usual dose of Sintrom ®

+4 Day usual dose of Sintrom ®

*Precautions of minor surgery.*

**6. Good clinical practice in minor surgery**

This is a malignant tumor that usually appears on a previous premalignant lesion and requires a multidisciplinary therapeutical approach involving dermatologists,

Of all skin malignancies, melanoma has the worst prognosis, Five-year survival rates for people with melanoma depend on the stage of the disease at the time of

High-risk areas for minor surgery include the facial and cervical regions, axillary and supraclavicular regions, wrists, hands and fingers, the groin, the popliteal fossa

We must consider those regions with a greater tendency to develop pathological scars (e.g., shoulder, sternal and interscapular region). Also the skin of black

For most basic minor surgical procedures, no preoperative work-up is needed.

In patients with increased anxiety, 5–10 mg oral or sublingual diazepam, or 1–5 mg sublingual lorazepam can be administered 30 minutes before surgery. *Contraindications for minor surgery:* Malignant skin lesion, allergy to local anesthetics, pregnancy (surgery should be deferred until the end of pregnancy, if malignancy is suspected, the patient should be referred to a specialist), an acute illness, doubt about patient's motivations, patients with psychiatric disorders or


LMWH single subcutaneous dose. Patient will take the usual dose of Sintrom ® (the same as before the

**Table 3** summarizes the precautions of minor surgery in primary care.

**34**

**Table 3.**

uncooperative patients or refusal to sign the informed consent form is a contraindication for any minor surgery procedure or technique.

*Direct oral anticoagulants [DOACs] (Dabigatran, Rivaroxaban, Apixaban, Edoxaban):* If a moderate or high bleeding risk surgery, it can be omitted for approximately 2–3 days before a procedure, and resume 24 hours after surgery. However, cutaneous procedures (e.g., skin biopsy, tumor excision, bone marrow biopsy) generally considered to confer a low risk of bleeding [15].

## **6.2 Intraoperative complications**

Vasovagal syncope is the most frequent complication and is more common in young men. Even some patients lose consciousness.

Treatment consists in administering oxygen and iv. fluids if needed and, in severe cases use atropine (0.5–1 mg sc or iv). Generally, most of patients recover spontaneously over a period of seconds to a few minutes.

## **6.3 Postoperative complications**


## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Jose Maria Arribas Blanco1 \*, Wafa Elgeadi Saleh<sup>2</sup> , Belén Chavero Méndez2 and María Alvargonzalez Arrancudiaga2

1 Professor of Medicine Department, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), Specialist in Family and Community Medicine, Madrid, Spain

2 Specialist in Family and Community Medicine, Servicio Madrileño de Salud (SERMAS), Madrid, Spain

\*Address all correspondence to: jarribasb@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**37**

*Minor Surgery in Primary Care*

[1] Arribas JM. Cirugía menor y procedimientos en medicina de familia. 2nd ed. Madrid: Jarpyo

[3] Zuber TJ. Punch biopsy of the skin. American Family Physician. 2002;**65**(6):1155-1158, 1161-1162, 1164

[4] Freiman A, Bouganim N. History of cryotherapy. Dermatology Online

[5] Hainer BL. Electrosurgery for the skin. American Family Physician.

[6] Kudur MH, Pai SB, Sripathi H, Prabhu S. Sutures and suturing techniques in skin closure. Indian Journal of Dermatology, Venereology and Leprology. 2009;**75**(4):425-434

[7] Singer AJ, Quinn JV, Hollander JE.

[8] Hussain W, Mortimer NJ, Salmon PJ. Optimizing technique in elliptical excisional surgery: Some pearls for practice. The British Journal of Dermatology. 2009;**161**(3):697-698.

[9] Czarnowski C, Ponka D, Rughani R, Geoffrion P. Elliptical excision: Minor surgery video series. Canadian Family

The cyanoacrylate topical skin adhesives. The American Journal of Emergency Medicine.

2008;**26**(4):490-496

Epub 2009 Jun 25

Physician. 2008;**54**(8):1144

2006;**35**(7):492-496

[10] Wu T. Plastic surgery made easy—Simple techniques for closing skin defects and improving cosmetic results. Australian Family Physician.

**References**

Editores; 2006

Surgeon. 2019;**17**:186

Journal. 2005;**11**(2):9

2002;**66**(7):1259-1266

*DOI: http://dx.doi.org/10.5772/intechopen.88811*

[11] Achar S, Kundu S. Principles of office anesthesia: Part I. Infiltrative anesthesia. American Family Physician.

[12] Wolff K, Johnson RA. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York: El McGraw-Hill Companies, Inc; 2009

Bergin D. The diagnostic accuracy of ultrasonography for soft tissue lipomas: A systematic review. Acta Radiologica Open. 2017;**6**:2058460117716704

[14] Wang YJ, Tang TY, Wang JY, et al. Genital basal cell carcinoma, a different pathogenesis from sun-exposed basal cell carcinoma? A case-control study of 30 cases. Journal of Cutaneous

[15] Beyer-Westendorf J, Gelbricht V, Förster K, et al. Peri-interventional

anticoagulants in daily care: Results from the prospective Dresden NOAC registry. European Heart Journal.

management of novel oral

[13] Rahmani G, McCarthy P,

2002;**66**(1):91-94

Pathology. 2018

2014;**35**:1888

[2] Murphy R, Hague A, Srinivasan J. A review of forehead lipomas: Important tips for the training surgeon. The

## **References**

*Topics in Primary Care Medicine*

**36**

**Author details**

Jose Maria Arribas Blanco1

(SERMAS), Madrid, Spain

and María Alvargonzalez Arrancudiaga2

provided the original work is properly cited.

\*Address all correspondence to: jarribasb@gmail.com

\*, Wafa Elgeadi Saleh<sup>2</sup>

1 Professor of Medicine Department, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), Specialist in Family and Community Medicine, Madrid, Spain

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Specialist in Family and Community Medicine, Servicio Madrileño de Salud

, Belén Chavero Méndez2

[1] Arribas JM. Cirugía menor y procedimientos en medicina de familia. 2nd ed. Madrid: Jarpyo Editores; 2006

[2] Murphy R, Hague A, Srinivasan J. A review of forehead lipomas: Important tips for the training surgeon. The Surgeon. 2019;**17**:186

[3] Zuber TJ. Punch biopsy of the skin. American Family Physician. 2002;**65**(6):1155-1158, 1161-1162, 1164

[4] Freiman A, Bouganim N. History of cryotherapy. Dermatology Online Journal. 2005;**11**(2):9

[5] Hainer BL. Electrosurgery for the skin. American Family Physician. 2002;**66**(7):1259-1266

[6] Kudur MH, Pai SB, Sripathi H, Prabhu S. Sutures and suturing techniques in skin closure. Indian Journal of Dermatology, Venereology and Leprology. 2009;**75**(4):425-434

[7] Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. The American Journal of Emergency Medicine. 2008;**26**(4):490-496

[8] Hussain W, Mortimer NJ, Salmon PJ. Optimizing technique in elliptical excisional surgery: Some pearls for practice. The British Journal of Dermatology. 2009;**161**(3):697-698. Epub 2009 Jun 25

[9] Czarnowski C, Ponka D, Rughani R, Geoffrion P. Elliptical excision: Minor surgery video series. Canadian Family Physician. 2008;**54**(8):1144

[10] Wu T. Plastic surgery made easy—Simple techniques for closing skin defects and improving cosmetic results. Australian Family Physician. 2006;**35**(7):492-496

[11] Achar S, Kundu S. Principles of office anesthesia: Part I. Infiltrative anesthesia. American Family Physician. 2002;**66**(1):91-94

[12] Wolff K, Johnson RA. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York: El McGraw-Hill Companies, Inc; 2009

[13] Rahmani G, McCarthy P, Bergin D. The diagnostic accuracy of ultrasonography for soft tissue lipomas: A systematic review. Acta Radiologica Open. 2017;**6**:2058460117716704

[14] Wang YJ, Tang TY, Wang JY, et al. Genital basal cell carcinoma, a different pathogenesis from sun-exposed basal cell carcinoma? A case-control study of 30 cases. Journal of Cutaneous Pathology. 2018

[15] Beyer-Westendorf J, Gelbricht V, Förster K, et al. Peri-interventional management of novel oral anticoagulants in daily care: Results from the prospective Dresden NOAC registry. European Heart Journal. 2014;**35**:1888

**39**

**Chapter 3**

in Spain

**Abstract**

agents like omalizumab.

**1. Introduction**

Approach to Chronic Urticaria

Emergency Services: Case Reports

Urticaria is a common process. The true incidence is not known; it is believed that between 15 and 25% of the population may suffer at some point in his life. Acute urticaria has a prevalence of 20% and the chronic form 0.5–1%. Urticaria is a disease that affects the skin and mucosa, characterized by the presence of hives. It occurs as a localized intracutaneous edema circled and an area of redness (erythema), which is typically itchy. There are histaminergic foods and drugs that worsen the prognosis of the disease*.* Foods which rely on aging to taste nice are always presumed to be high in histamine (chocolate, yogurt, seafood, strawberries, etc.) and drugs like nonsteroidal anti-inflammatory drugs. For diagnosis we have several tools (urticarial activity score, chronic urticaria quality-of-life questionnaire (CU-Q2oL), urticaria control test, etc., among which the most useful, simple, and cost-effective is the clinic history). The treatment of choice are antihistamines, from a daily tablet up to four tablets as maximum dose. Corticosteroids are excluded to exacerbations and must be prescribed in short guideline (maximum 10 days) without progressive decrease. Severe forms of urticaria resistant to treatment with antihistamines are treated with biological

from Primary Care and

*Luis Geniz Rubio, Macarena Ávila Pérez,* 

*José Ángel López Díaz and Sara Alcántara Luna*

**Keywords:** urticaria, hives, itching, angioedema, antihistamines

urticaria as prevalent and its high morbidity.

The current version of the EAACI/GA2

2018 contains new aspects about diagnosis and treatment.

The interest in making this chapter was to explain the pathology of chronic

We often see this problem in our primary care consultations and emergency

At the end of the chapter, we show a series of cases treated in our practice (observed in a Juan Ramon Jimenez's dermatology room in Huelva, Spain), expos-

LEN/EDF/WAO urticaria guideline from

services, so we consider its important to make a chapter about urticaria.

ing results obtained with the different forms of treatment (**Figure 1**).

## **Chapter 3**
