"I feel exhausted all the time !"
Tiredness is common to all of us - but exhaustion every day for months and years is debilitating and often these sufferers have few outward signs and indeed few if any abnormal routine blood tests. So you can imagine how quickly the Prozac prescription gets handed out!
CFS has fatigue as the key problem but many CFS sufferers have multiple symptoms involving many organ systems. Hence the difficulty they face when trying to get recognition and help. Also called ME (Myalgic encephalomyelitis) because of the brain and muscle involvement.
Tiredness is a very common complaint with multiple causes. Here we will confine the page to the spectrum of CFS and FMS. Throughout the world there are various classification systems with criteria, for example:
CDC (Center for Diseases Control and Prevention) - Fukuda et al 1994
- chronic fatigue (CF) for 6 months or more excluding other diseases
- plus 4 of more of the following that have been present for previous 6 months:
- impaired memory or concentration
- sore throat
- tender lymph nodes
- muscle tenderness (myalgia)
- joint pain without swelling
- headaches of a new type or pattern
- unrefreshing sleep - loss of deep 'slow wave' sleep stages 3 and 4
- fatigue after exertion lasting 24 hours or more
Further symptoms and signs from Holmes and Canadian criteria:
- mild fever or chills
- neuropsychiatric symptoms - light sensitive, visual disturbances, irritability, confusion, mind fog, depression, sleep disturbances, confusion, disorientation.
- muscle fasciculations (twitching)
- pharyngitis
- enlarged lymph nodes
- Low blood pressure standing, delayed postural hypotension
- postural tachycardia, palpitations, shortness of breath
- lightheaded
- pale, nausea, irritable bowel, bladder frequency
Symptoms according to systems:
Central Nervous System (CNS)
- fatigue, irritability, depression, apathy, listlessness, impaired memory and concentration, anxiety, insomnia, waking from pain.
Musculoskeletal system:
- Pain and morning stiffness in muscles-tendons-ligaments in areas: neck and shoulders, upper and lower back, hips, inner and outer elbows, inner knees, wrists and chest. Can get actual joint pains sometimes- various arthritis types can coexist.
Intestinal System:
- Irritable bowel syndrome (spastic colon etc), nausea waves, spasms, pain, bloating, gas, erratic bowel function.
Genitourinary System:
- frequency, bladder spasms, burning, interstitial cystitis, vaginal pain syndrome, intercourse pain, PMS. Fibromyalgia is usually worse PM.
Skin:
- Various rashes, hives, blisters. Sensations like burning, cold/hot, tingling, electric vibrations, prickling, crawling and flushing.
Other:
- headaches, dizziness, vertigo, spinning sensation, numbness, tingling, weight gain, fluid retention, sensitivity to light or noise even tastes and smells, restless legs
CFS can have other names where there are overlapping symptoms: FMS, ME (myalgic encephalomyelitis), neurasthenia, multiple chemical sensitivities (MCS), chronic glandular fever (EBV), post-viral syndrome.
Other conditions with tiredness as a feature:
These need to be excluded, some examples:
- hypothyroidism
- adrenal disorder
- sleep apnoea and narcolepsy
- depression, bipolar disorder
- cancer
- autoimmune disorders
- infection
- toxic exposure
- substance abuse
- medication side-effects
Cause of CFS
No one cause has been found. Currently there are multiple theories and its likely that many factors produce CF such as altered immune status, toxin exposure and reduced detoxification process, exposure to certain infections, exposure to vaccinations, genetic predisposition, stress exposure, endocrine (hormone) status, age and sex, dietary health and micronutritional state (vitamins, minerals, trace elements and essential fatty acids).
It appears that a central disruption to cell functioning occurs triggered by a toxin or stress to the system.
For a more indepth discussion of CFS cause theory click here >>>
Workup Flow for CFS patients
Various levels of investigations are possible - availability and cost determines how thorough it can be done. Logic and commonsense indicates one should start with basic testing for commoner causes and then proceed to the more obscure. Here is the sequence, the details are on separate pages for patient access. Refer to right side-bar.
- Medical History General Health Questionnaire
- CFS Criteria Questionnaire
- Physical Examination
- Investigations: Workup - Level 1 - 2 - 3
Treatment
- Strict correction of diet and optimisation of intestinal tract - eliminate toxins, microbial infection, correct dysbiosis, remove food allergens or intolerance's. Refer to GIT-Liver Detox >>>
- Identify possible hypoglycaemia - common in CFS - symptoms of hypoglycaemia >>>
- Detox or chelate out heavy metals.
- Identify and correct oral-dental amalgam issues, root infections.
- Treat any identified or suspected infection - maybe long term, with probiotic cover.
- Correct any endocrine imbalance especially thyroid. Refer to the thyroid resistance theory.
- Correct sleep disorders
- Consider series of intravenous ascorbic acid infusions
- Target intra-cellular mitochondria with specific energy enhancing agents.
- General nutrient support, herbal tonics
- Massage, Far infrared saunas to detox.
- Careful exercise programs.
- CBT may be appropriate for some (cognitive behavioural therapy)
- Antidepressants - I am not an advocate for drug treatment. If major depression is not responding to natural neurotransmitter enhancing agents then AD's may have a place. For example amitryptiline may help some sufferers with pain and sleep disturbance.
Patients wishing to investigate CFS refer to right side-bar topics and questionnaires.
Full treatment protocols (members only) read more >>>
Fibromyalgia Syndrome - FMS
Fibromyalgia can be considered as the other end of the fatigue spectrum but with muscle pain as the prominent symptom - both upper and lower body areas.
FMS is very common - but there are some diagnosed with it but dont really fit all the criteria; they still have tiredness and sore muscles but again like the CFS situation there are many other medical conditions presenting with tiredness and pain.
Three predominant findings:
- Multiple tender muscle (myofascial) points (must have 11 out of 18 trigger points)
- Disturbed sleep pattern (chicken or egg - does bad sleep produce fatigue and pain or FMS produce poor sleep?)
- Fatigue
Many of the symptoms of CFS above may also occur with FMS, hence the overlapping of these two syndromes.
Causes are unknown but we follow the same workup as for CFS. Certain issues are important in FMS:
- Some workers consider Thyroid dysfunction to be the single most important factor - others disagree. It certainly needs to be looked into thoroughly in every patient.
- Sleep deprivation appears very important. Any normal person consistantly deprived of proper restorative sleep (non-REM) may also become fatigued and develop muscle pains.
- Growth Hormone deficiency is noted often. This hormone is important for sleep-time muscle repair and regrowth.
- Brain neurotransmitter metabolism also may be impaired - serotonin and tryptophan. Its already known that when there is a drop in serotonin, sleep disturbances (non-REM) occur, depression may result, increased body complaints follow as does increased perception of pain.
- Substance P, is altered in FMS and not CFS. This chemical influences pain thresholds and so the tender muscle points in FMS may be just exaggerated 'normal' tender muscle points. This is one theory.
It is possible that in the CFS-FMS spectrum, FMS patients have a worse response in terms of muscle pain activation, hence this becomes the dominant feature.
Workup
- Medical History and Timeline
- Physical Examination - specifically documenting Tender Points
- Mapping - a newer technique which by manually palpating all muscle groups one can map and record the tender bands of muscles. This can be more useful than the 18 tender points for monitoring response to treatments.
Refer to the CFS workup in the right side-bar.
In addition to the CFS treatment guidelines, further emphasis is placed on the following:
| FMS and Cell Energy | Cells dont function properly. Mitochondria are the organelles inside each cell which provide energy; they are impaired. FMS patients have 'tired cells'! |
Certain supplements can target mitochondria, increasing their energy output |
| FMS and low adrenal function | Chronic stress can deplete adrenal cortisol, aldosterone and other mineralocorticosteroids - low blood pressure | This has to be checked and can be corrected |
| FMS and low Thyroid function | Critical to body energy production | Relatively easy to check and treat. |
| FMS and low Growth Hormone | Not uncommon especially in females-leads to muscle pain and fatigue. | Meaured as IGF-1 Easily treated but expensive, as injections. Oral forms of no proven benefit. |
| FMS and nutrient imbalances | Though rarely a cause, may contribute to severity | Blood tests and hair analysis |
| FMS and toxins | As FMS is a multisystem disorder, toxin/chemical sensitivity is common | Follow liver detox protocols |
| FMS and digestive disorders | Same as with CFS | Full workup required and dietary corrections |
| FMS and sleep | Abnormal rhythms of sleep patterns occur. Melatonin and serotonin are important and can be measured. | Melatonin is very useful in some, whereas low dose tricyclic drug can be very useful in other FMS patients |
| FMS and allergies | Food and inhalant allergy can trigger inflammation | |
| FMS and infections | Increased susceptibility | Antimicrobials may be required |