Coming next - chronic fatigue and fibromyalgia
Chronic Fatigue Syndrome
The Centers for Disease Control and Prevention have provided the following definition of Chronic Fatigue Syndrome or CFS.
Definition
A great deal of debate has surrounded the issue of how best to define CFS. In an effort to resolve these issues, an international panel of CFS research experts convened in 1994 to draft a definition of CFS that would be useful both to researchers studying the illness and to clinicians diagnosing it. In essence, in order to receive a diagnosis of chronic fatigue syndrome, a patient must satisfy two criteria:
1. Have severe chronic fatigue of six months or longer duration with other known medical conditions excluded by clinical diagnosis; and
2. Concurrently have four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours.
The symptoms must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue.
The 1988 chronic fatigue syndrome (CFS) working case definition (Holmes, et al) did not effectively distinguish CFS from other types of unexplained fatigue. For this reason, it was decided during a 1993 meeting of CFS investigators to develop a logical revision of that definition. The ensuing effort led to the 1994 definition.
The most recognized symptoms reported by patients and documented by researches in the field include:
Symptoms
Chronic fatigue syndrome shares symptoms with many other disorders. Fatigue, for instance, is found in hundreds of illnesses, and 10% to 25% of all patients who visit general practitioners complain of prolonged fatigue. The nature of the symptoms, however, can help clinicians differentiate CFS from other illnesses.
Primary Symptoms
As the name chronic fatigue syndrome suggests, this illness is accompanied by fatigue. However, it's not the kind of fatigue patients experience after a particularly busy day or week, after a sleepless night or after a stressful event. It's a severe, incapacitating fatigue that isn't improved by bed rest and that may be exacerbated by physical or mental activity. It's an all-encompassing fatigue that results in a dramatic decline in both activity level and stamina.
People with CFS function at a significantly lower level of activity than they were capable of prior to becoming ill. The illness results in a substantial reduction in occupational, personal, social or educational activities.
A CFS diagnosis should be considered in patients who present with six months or more of unexplained fatigue accompanied by other characteristic symptoms. These symptoms include:
• cognitive dysfunction, including impaired memory or concentration
• postexertional malaise lasting more than 24 hours (exhaustion and increased symptoms) following physical or mental exercise
• unrefreshing sleep
• joint pain (without redness or swelling)
• persistent muscle pain
• headaches of a new type or severity
• tender cervical or axillary lymph nodes
• sore throat
Other Common Symptoms
In addition to the eight primary defining symptoms of CFS, a number of other symptoms have been reported by some CFS patients. The frequency of occurrence of these symptoms varies among patients. These symptoms include:
• irritable bowel, abdominal pain, nausea, diarrhea or bloating
• chills and night sweats
• brain fog
• chest pain
• shortness of breath
• chronic cough
• visual disturbances (blurring, sensitivity to light, eye pain or dry eyes)
• allergies or sensitivities to foods, alcohol, odors, chemicals, medications or noise
• difficulty maintaining upright position (orthostatic instability, irregular heartbeat, dizziness, balance problems or fainting)
• psychological problems (depression, irritability, mood swings, anxiety, panic attacks)
• jaw pain
• weight loss or gain
Clinicians will need to consider whether such symptoms relate to a comorbid or an exclusionary condition; they should not be considered as part of CFS other than they can contribute to impaired functioning.
Clinical Course
The severity of CFS varies from patient to patient, with some people able to maintain fairly active lives. By definiton, however, CFS significantly limits work, school and family activities.
While symptoms vary from person to person in number, type and severity, all CFS patients are functionally impaired to some degree. CDC studies show that CFS can be as disabling as multiple sclerosis, lupus, rheumatoid arthritis, heart disease, end-stage renal disease, chronic obstructive pulmonary disease (COPD) and similar chronic conditions.
CFS often follows a cyclical course, alternating between periods of illness and relative well-being. Some patients experience partial or complete remission of symptoms during the course of the illness, but symptoms often reoccur. This pattern of remission and relapse makes CFS especially hard for patients and their health care professionals to manage. Patients who are in remission may be tempted to overdo activities when they're feeling better, which can exacerbate symptoms and fatigue and cause a relapse. In fact, postexertional malaise is a hallmark of the illness.
The percentage of CFS patients who recover is unknown, but there is some evidence to indicate that the sooner symptom management begins, the better the chance of a positive therapeutic outcome. This means early detection and treatment are of utmost importance. CDC research indicates that delays in diagnosis and treatment may complicate and prolong the clinical course of the illness.
CFS is seen more commonly in women than in men, in patients as they enter middle age, and may run in some families suggesting a genetic link:
Who's at Risk?
More than one million Americans have CFS. This illness strikes more people in the United States than multiple sclerosis, lupus, lung cancer or ovarian cancer.
Researchers continue to explore possible causes and risk factors for CFS. Many questions remain, but there are some characteristics that may help indicate who is most at risk for CFS:
• CFS occurs four times more frequently in women than in men, although people of either gender can develop the disease.
• The illness occurs most often in people in their 40s and 50s, but people of all ages can get CFS.
• CFS is less common in children than in adults. Studies suggest that CFS is more prevalent in adolescents than in younger children.
• CFS occurs in all ethnic and racial groups, and in countries around the world. Research indicates that CFS is at least as common among African Americans and Hispanics as it is among Caucasians.
• People of all income levels can develop CFS .
• CFS is sometimes seen in members of the same family, but there's no evidence that it's contagious. Instead, there may be a familial or genetic link. Further research is needed to explore this.
Possible Causes
The cause or causes of CFS remain unknown, despite a vigorous search. While a single cause for CFS may yet be identified, another possibility is that CFS represents a common endpoint of disease resulting from multiple precipitating causes. As such, it should not be assumed that any of the possible causes listed below has been formally excluded, or that these largely unrelated possible causes are mutually exclusive. Conditions that have been proposed to trigger the development of CFS include virus infection or other transient traumatic conditions, stress, and toxins.
Infectious Agents
Due in part to its similarity to acute or chronic infections, CFS was initially thought to be caused by a virus infection (i.e., Epstein-Barr (EBV) mononucleosis). It now seems clear that CFS is not caused exclusively by any single recognized infectious disease agent. CDC's four-city surveillance study found no association between CFS and infection by a wide variety of human pathogens, including EBV, human retroviruses, human herpesvirus 6, enteroviruses, rubella, Candida albicans, and more recently bornaviruses and Mycoplasma. Taken together, these studies suggest that among identified human pathogens, there appears to be no causal relationship for CFS as a whole. However, the possibility remains that CFS may have multiple causes leading to a common endpoint, in which case some viruses or other infectious agents might have a contributory role for a subset of CFS cases. Recently published research suggests that infection with Epstein-Barr virus, Ross River virus and Coxiella burnetti will lead to a post-infective condition that meets the criteria for CFS in approximately 12% of cases. The severity of the acute illness was the only factor found to predict which individuals would have persistent symptoms characteristic of CFS at the six-month and one-year period following infection.
Immunology
It has been proposed that CFS may be caused by an immunologic dysfunction, for example inappropriate production of cytokines, such as interleukin-1, or altered capacity of certain immune functions. One thing is certain at this juncture: there are no immune disorders in CFS patients on the scale traditionally associated with disease. Some investigators have observed anti-self antibodies and immune complexes in many CFS patients, both of which are hallmarks of autoimmune disease. However, no associated tissue damage typical of autoimmune disease has been described in patients with CFS. The opportunistic infections or increased risk for cancer observed in persons with immunodeficiency diseases or in immunosuppressed individuals is also not observed in CFS. Several investigators have reported lower numbers of natural killer cells or decreased natural killer cell activity among CFS patients compared with healthy controls, but others have found no differences between patients and controls.
T-cell activation markers have also been reported to have differential expression in groups of CFS patients compared with controls, but again, not all investigators have consistently observed these differences. One intriguing hypothesis is that various triggering events, such as stress or a viral infection, may lead to the chronic expression of cytokines and then to CFS. Administration of some cytokines in therapeutic doses is known to cause fatigue, but no characteristic pattern of chronic cytokine secretion has ever been identified in CFS patients. In addition, some investigators have noted clinical improvement in patients with continued high levels of circulating cytokines; if a causal relationship exists between cytokines and CFS, it is likely to be complex. Finally, several studies have shown that CFS patients are more likely to have a history of allergies than are healthy controls. Allergy could be one predisposing factor for CFS, but it cannot be the only one, since not all CFS patients have it.
Hypothalamic-Pituitary Adrenal (HPA) Axis
Multiple laboratory studies have suggested that the central nervous system may have an important role in CFS. Physical or emotional stress, which is commonly reported as a pre-onset condition in CFS patients, activates the hypothalamic-pituitary-adrenal axis, or HPA axis, leading to increased release of cortisol and other hormones. Cortisol and corticotrophin-releasing hormone (CRH), which are also produced during the activation of the HPA axis, influence the immune system and many other body systems. They may also affect several aspects of behavior. Recent studies revealed that CFS patients often produce lower levels of cortisol than do healthy controls. Similar hormonal abnormalities have been observed by others in CFS patients and in persons with related disorders like fibromyalgia. Cortisol suppresses inflammation and cellular immune activation, and reduced levels might relax constraints on inflammatory processes and immune cell activation. As with the immunologic data, the altered cortisol levels noted in CFS cases fall within the accepted range of normal, and only the average between cases and controls allows the distinction to be made. Therefore, cortisol levels cannot be used as a diagnostic marker for an individual with CFS. A placebo-controlled trial, in which 70 CFS patients were randomized to receive either just enough hydrocortisone each day to restore their cortisol levels to normal or placebo pills for 12 weeks, concluded that low levels of cortisol itself are not directly responsible for symptoms of CFS, and that hormonal replacement is not an effective treatment. However, additional research into other aspects of neuroendocrine correlates of CFS is necessary to fully define this important, and largely unexplored, field.
Neurally Mediated Hypotension
Rowe and coworkers conducted studies to determine whether disturbances in the autonomic regulation of blood pressure and pulse (neurally mediated hypotension, or NMH) were common in CFS patients. The investigators were alerted to this possibility when they noticed an overlap between their patients with CFS and those who had NMH. NMH can be induced by using tilt table testing, which involves laying the patient horizontally on a table and then tilting the table upright to 70 degrees for 45 minutes while monitoring blood pressure and heart rate. Persons with NMH will develop lowered blood pressure under these conditions, as well as other characteristic symptoms, such as lightheadedness, visual dimming, or a slow response to verbal stimuli. Many CFS patients experience lightheadedness or worsened fatigue when they stand for prolonged periods or when in warm places, such as in a hot shower. These conditions are also known to trigger NMH. One study observed that 96% of adults with a clinical diagnosis of CFS developed hypotension during tilt table testing, compared with 29% of healthy controls. Tilt table testing also provoked characteristic CFS symptoms in the patients. A study (not placebo-controlled) was conducted to determine whether medications effective for the treatment of NMH would benefit CFS patients. A subset of CFS patients reported a striking improvement in symptoms, but not all patients improved. A placebo-controlled trial of NMH medications for CFS patients is now in progress.
Nutritional Deficiency
There is no published scientific evidence that CFS is caused by a nutritional deficiency. Many patients do report intolerances for certain substances that may be found in foods or over-the-counter medications, such as alcohol or the artificial sweetener aspartame. While evidence is currently lacking for nutritional defects in CFS patients, it should also be added that a balanced diet can be conducive to better health in general and would be expected to have beneficial effects in any chronic illness.
Treatment
Managing chronic fatigue syndrome can be as complex as the illness itself. There is no cure yet, no prescription drugs have been developed specifically for CFS, and symptoms vary considerably over time. These factors complicate the treatment picture and require you and your health care team to constantly monitor and frequently revise treatment strategies.
It may take some time to find a combination of traditional and alternative therapies that works for you, but it’s important not to delay symptom management. For instance, untreated sleep problems can actually make other symptoms—like pain and memory problems—worse.
One key to managing CFS is working with your doctor and other health care practitioners to create an individualized treatment program for you. This program should be based on a combination of therapies that address coping techniques, symptoms and activity management.
Recommended Treatment at CHM
At CHM we recommend that you continue to consult with and work with your primary care physician but that you also get alternative care in the form of naturopathic, naprapathic, acupuncture, herbal medicine, and professional counseling.
The naturopathic approach to CFS is like farming. The naturopath will attempt to restore the bodies natural healing, restorative and reparative processes through the fundamental processes that built health and restores cells and organ systems to their normal vital state of function.
Deep breathing and muscle relaxation techniques, massage and healing touch, and movement therapies like stretching, yoga and tai chi can be beneficial for CFS patients in reducing anxiety and stress (major recognized contributors to CFS) and promoting a sense of well-being.