Chronic Fatigue Syndrome and Fibromyalgia have been very difficult to diagnose and treat in the past due to its complexity in pathology and symptom picture. In my experience, it is never only one variable that is causing the suffering. Variables can include the following:
- endocrine imbalance (Hormone secreting glands including the adrenals, thyroid, pancreas, and Hypothalamic-Pituitary Axis)
- environmental toxins
- psychological trauma or stress
- malnutrition and malabsorption of critical nutrients
- physical undiagnosed injuries or impeding masses
- genetic predisposition
- autoimmune conditions
- mitochondrial abnormalities
- chronic viral infection
It is ideal that a patient diagnosed or suffering from symptoms that resemble Chronic Fatigue Syndrome and Fibromyalgia have thorough laboratory testing completed to rule out concomitant conditions. To view a comprehensive list of laboratory testing please read here.
Potential Treatment Strategies for Chronic Fatigue Syndrome and Fibromyalgia
Lifestyle, dietary nutrition, nutritional supplementation, parenteral therapies, physical medicine, traditional Chinese medicine, homeopathy, psychological counseling, limiting environmental toxins and pharmaceutical medications are all effective ways of managing chronic fatigue syndrome (CFS) and fibromyalgia (FM). It is important to keep in mind that these are NOT cures but ways to manage and lift symptoms. Thorough investigation to the underlying causes will aid in the path to healing.
It is frequently observed that prior to the onset of CFS and FM, patients have very busy and highly functioning lives. A hypothesis for energy deprivation is the inability to pace and have adequate rest periods throughout the day. This can contribute to the “burn out” and complete exhaustion experienced in this patient population (Bested and Logan, 2008).
Adequate rest periods and restorative practices such as yoga, meditation and moderate exercise and activities can help with energy conservation (Bested and Logan, 2008). Exercise is important in maintaining muscle strength and healthy circulation, however over-training can predispose patients to CFS and FM-like symptoms. A study by Kingsbury et al. (1998) shows athletes with “Over-training Syndrome” to have decreased plasma glutamine which can increase susceptibility for infections and chronic fatigue.
Sleep is crucial to healing the mind and body. The insomnia experienced by patients with CFS and FM can further exacerbates the fatigue, brain fog, migraines, and myalgia symptoms. For optimal health and healing, proper sleep hygiene is critical:
- bedroom kept as dark as possible
- utilizing the bedroom for sleep only
- creating a quiet and clutter-free environment
- keeping to a regular bed time schedule every day of the week
- avoid going to bed too exhausted
- avoid stimuli prior to bedtime (ie. caffeine, exercise, TV, computer use)
- moderate daily physical activity
- avoiding large meals late at night
- utilizing relaxation techniques in the evenings (ie. meditation, deep breathing, baths, calming teas)
- using comfortable and supportive mattress and pillow (Bested and Logan, 2008).
Nutritional modifications are often very beneficial to the overall wellbeing of people living with CFS and FM. As with many conditions, improvements to a balanced diet high in vegetables and limited animal protein and simple carbohydrates supports healthy body function. A mostly raw vegetarian or vegan diet has been shown to have overall symptom improvements in patients with Fibromyalgia (Donalson et al., 2001; Gaby, 2011, Prousky, 2008). Other helpful diet modifications can be:
- eating small frequent meals
- avoiding sensitive and allergic foods
- avoiding foods that have been processed and preservatives
- avoiding glutamate additives (like MSG)
- limiting refined sugars
- drinking 8-10 glasses of filtered and re-mineralized water
A trial period of a hypoallergenic or oligo-antigenic diet to identify food sensitivities and intolerances is often helpful in decreasing inflammation and dysfunction in the CFS and FM population (Bested and Logan, 2008).
Periodic nutritional supplementation is typically indicated for CFS and FM patients to regain and maintain healthy cellular homeostasis. The following common supplementation treatments are well researched in aiding CFS and FM symptoms.
Please contact your Naturopathic Doctor if you are considering taking any of these supplements. There are potentially severe interactions and may not be best indicated for your particular situation. Dosing and duration of treatment is very critical in healthy healing without complications or aggravation of your condition. If you need references for Naturopathic Doctors in your area please email me at info@DrAlisonChen.com.
5-Hydroxytryptophan (5-HTP)– 5-HTP is a precursor to serotonin which can significantly improve symptoms of anxiety, pain intensity and distribution, sleep quality, and fatigue in FM patients. Side effects are rare but can cause sleep disturbances and gastrointestinal discomfort. 5-HTP can also interact with certain medications that function on the CYP 3A4 pathway, especially in antidepressants medications (ie. SSRI, amitriptyline and monoamine oxidase inhibitors) (Prousky, 2008; Gaby, 2011).
Acetyl-L-Carnitine (ALC)– mitochondrial dysfunction has been related to decreased L-carnitine due to its role as a fatty acid shuttle into the mitochondria to be utilized for energy production. L-carnitine is a neurotransmitter that passes the blood-brain barrier to increase blood flow and enhance enzyme activations to help treat depression and musculoskeletal pain (Gaby, 2011; Prousky, 2008).
Alpha-Lipoic Acid (ALA)– Intracellular GSH is found to be increased with supplementation of ALA and can delay muscular fatigue during exercise (Prousky, 2008).
Cobalamine (Vitamin B12)– Vitamin B12 has a wide range of benefits in the human body. It is especially useful in the treatment of fatigue, myalgia and neurological symptoms. It can aid in regulating red blood cell shape (RBC) and stiffness, which can impair capillary blood flow in tissues. Nutritional insufficiencies due to poor dietary intake or dysfunctional nutritional absorption can be corrected with sublingual, oral, or intramuscular injections of different forms of vitamin B12 (Prousky, 2008).
CoEnzyme Q10– CoQ10 is essential in ATP synthesis in the mitochondria by being an electron carrier (Prousky, 2008).
Evening Primrose Oil (EPO)– EPO induces prostaglandin E1 and helps increase the fluidity of the lipid bilayer of red blood cells to improve it’s flexibility. EPO and vitamin B12 has shown to effectively work together to improve RBC health (Prousky, 2008).
Glutathione (GSH)– low GSH is associated with increased permeability of the blood-brain barrier and can contribute to the cause of CFS. Intramuscular injections have shown improvements in fatigue, memory, concentration and pain tolerance (Prousky, 2008).
Magnesium malate– Mg malate has shown efficacy for musculoskeletal pain management in patients with chronic fatigue syndrome and fibromyalgia. Magnesium is an essential cofactor in energy production and to support the health of the central nervous system (Bested and Logan, 2008; Gaby, 2011).
Melatonin– Insomnia and sleep difficulties can contribute to furthur decline in the health of CFS and FM patients. Melatonin is a safe supplement to assist in regulating the normal circadian rhythms of the body and mind (Bested and Logan, 2008).
N-Acetylcysteine (NAC)– NAC indirectly increases GSH synthesis (Prousky, 2008).
NADH– Nicontinamide adenine dinucleotide (NADH) supports mitochondrial production of ATP and has been found to improve symptoms of fatigue and cognitive dysfunction (Prousky, 2008). Clinical experience indicates combining NADH with anti-oxidants is most useful to reduce CFS and FM symptoms (Bested and Logan, 2008).
Omega-3 fatty acids– Omega-3 fatty acids especially high in EPA have been found to decrease inflammation, cardiovascular conditions and cognitive decline in various illnesses. Chronic fatigue and fibromyalgia patients have seen a significant improvement in pain management, fatigue, sleep, mood, mobility, and depression (Bested and Logan, 2008).
Probiotics (Tuzen, Culturelle)– Irritable Bowel Syndrome (IBS) is a condition often experienced by people with CFS and FM. Probiotics can help to regulate TH1 and TH2 immune function but can be often too intense for sensitive patients. Tuzen and Culturelle are 2 brands that are specifically beneficial and safe for this population (Bested, 2008).
Ribose– An altered ATP synthesis mechanism is observed in CFS and FM patients with ribose being a key component in adenine nucleotide synthesis (Gaby, 2011).
Thiamine (Vitamin B1)– Thiamine status has been found to be lower in patients with fibromyalgia and normal in patients with chronic pain due to other causes. This impairment may be partially due to a magnesium deficiency due to its requirements with thiamine conversion to thiamine pyrophosphate, the biologically active form of vitamin B1 (Gaby, 2011).
Vitamin D– Vitamin D is often deficient in the CFS and FM population. This deficiency is confounded by for people living in Canada (due to its geographical location in relation to the sun), advancing age, obesity, malabsorption, malnutrition or chronic renal failure. Musculoskeletal pain is a common manifestation of vitamin D deficiency (Gaby, 2011).
Parenteral IV therapies
Dr. Alan Gaby re-evaluated Dr. John Myers’ intravenous (IV) treatment of vitamins and minerals and found them to be very effective in treating migraines, chronic fatigue, fibromyalgia, depression, athletic performance and other conditions (Gaby, 2002). His basic Myers’ Cocktail is shown in Table 1, however modifications are often made depending on the patient’s presentation and sensitivities. Some side effects of the Myers’ Cocktail can be a sensation of heat and decreased blood pressure, especially if the solution is injected to rapidly, and is often resolved after 10-30 seconds once the treatment is discontinued. Patients with kidney dysfunction should not be given this treatment or closely monitored depending on their condition. Patients taking potassium depleting diuretics, beta-agonists, or glucocorticoids should have their potassium levels corrected before IV magnesium therapy is considered. In rare cases, anaphylactic reaction to IV thiamine is possible and if the patient has a known vitamin B1 sensitivity should be made aware to their health practitioner and lab technician. All allergies and sensitivities must be reported along with recent normal creatinine laboratory results prior to IV treatment (Gaby, 2002).
Table 1: Nutrients in Myers’ Cocktail
|Nutrient||Amount (common protocol)|
|Magnesium chloride hexahydrate 20% (magnesium)||2-5 ml (4ml)|
|Calcium gluconate 10% (calcium)||1-3 ml (2ml)|
|Hydroxocobalamin 1000mcg/ml (B12)||1 ml|
|Pyridoxine hydrochloride 100mg/ml (B6)||1 ml|
|Dexpanthenol 250mg/ml (B5)||1 ml|
|B complex 100||1 ml|
|Vitamin C 222mg/ml||4-20 ml (6ml)|
|Sterile water||(8 ml)|
Traditional Chinese Medicine
A case report by Mears (2005) identified a successful acupuncture protocol for post-viral fatigue syndrome, utilizing electro-stimulation at Large Intestine-11, Large Intestine-4, Liver-3, and Stomach-36. The Acupuncture Desk Reference identified the following acupuncture points for the treatment of fibromyalgia; Liver-3, Large Intestine-4, Pericardium-6, San Jiao-5, Large Intestine-15, Gall Bladder-21, Stomach-36, Spleen-6, Urinary Bladder-20 and Ren-4 (Kuoch, 2011). A constitutional Traditional Chinese Medicine intake in combination with the common CFS and FM points would provide a more individualized treatment protocol.
Homeopathy is able to help limit acute symptoms of CFS and FM, but is most effective with a constitutional diagnosis of the individualized patient. For example, a common acute remedy for body aches and pain is Arnica montana given at a lower potency more frequently (Morrison, 1993). A possible constitutional homeopathic remedy could be Calcarea carbonica which is indicated for an individual who is hard-working, with a strong sense of responsibility, has anxiety and fear about their security (finances, health), has a sense of over-whelm, has a strong fear of mice/rats and of heights to the point of a phobia, and may portray an unreasoning despair or depression in their life (Morrison, 1993).
Psychological counseling and Cognitive Behavioural Therapy
Alda et al. (2011) classifies Fibromyalgia Syndrome patients with catastrophism congnition, in which they are exclusively focused on pain and the belief that the worst possible outcome is going to occur, concentrating on negative vision (magnification), continuous rumination, and helplessness. There is a consistent relationship between catastrophizing and distress reactions to painful stimulations in patients with FM (Alda et al., 2011). Potential consequences associated with pain catastrophizing are heightened pain behaviors, increased pain intensity, greater analgesic consumption, reduced daily activity involvement, occupational disability and suicidal ideation (Alda et al., 2011). Cognitive Behavioral Therapy helps patients cope with pain and catastrophising responses by aiming to alter a person’s attitude towards pain and self-management (Thiere et al., 2006). Please also see my post on Fibromyalgia and CBT treatment for more details.
There are various environmental aggravators that typically worsen CFS and FM symptoms. Avoiding these triggers can support health and limit further functional decline (Prousky, 2011; Bested and Logan, 2008):
- viral infections
- change in sleep schedule
- cold exposure
- overexertion (physical or mental)
- sensory and information overload
- excessive stress
- prolonged driving
- air travel
- specific food agents and sensitivities (ie. glutamate/ MSG, aspartame)
- heavy metal exposure (mercury amalgums, aluminum)
- household cleaning agents
- personal hygiene products (ie. Sodium Lauryl Sulfate containing ingredients)
- synthetic hair dyes
- perfumes and creams (especially people with multiple chemical sensitivities)
- poor air quality, ventilation and filtration (toxins, pollution, allergens, mold)
- water and food quality
As a Naturopathic Doctor, prescribing the pharmaceuticals below are not in our jurisdiction. However, we are very familiar with the actions, interactions and side effects of these medical drugs. Pharmaceuticals can be great aiders when used appropriately for the patient’s particular condition and for the proper dose and duration. Most patients are unaware that they may potentially be able to come off some (if not all) of their medications under careful monitoring by their MD and ND. Please speak with your health practitioners when you are starting or stopping any medications and if you notice unwarranted adverse effects. Common pharmaceutical medications utilized by medical doctors for the treatment of chronic fatigue syndrome and fibromyaligia are discussed below (Bested and Logan, 2008):
Sleep disturbances– Dimenhydrinate/ Gravol, Tryptophan/ Tryptan, Zopiclone/ Imovane, Clonazepan/ Rivotril, Doxepin/ Sinequan, Amitriptyline/ Elavil, Trazodone/ Desyrel, Cyclobenzaprine/ Flexeril, Mirtazapine/ Remeron, Bromazepam/ Lectopam, Zolpidem/ Ambien
Pain management– Aspirin, Tylenol, Advil, Lakota, non-steroidal anti-inflammatory drugs (ie. Ibuprofen, Naproxen), muscle relaxants (ie. Flexeril, Baclofen), analgesics (ie. acetaminophen), narcotics (ie. codeine, oxycodone, tramadol hydrochloride, morphine, fentanyl)
Anti–Epileptics– Neurontin/ Gabapentin, Lyrica/ Pregabalin
Antidepressants– Tricyclic antidepressants (ie. Amitriptyline, Doxepin), selective Serotonin reuptake inhibiors (ie. Paxil, Zoloft), dual reuptake inhibitors (ie. Effexor/ Venlafaxine)
Again, please contact your Naturopathic and Medical Doctor if you are considering making any changes to your supplement or pharmaceutical regiment. There are potentially severe interactions and may not be best indicated for your particular situation. If you need references for Naturopathic Doctors in your area or have any questions, please email me at info@DrAlisonChen.com.
Keep up-to-date on the latest research for Fibromyalgia and Chronic Fatigue Syndrome by read other related topics:
- Fatigue: What is FM and CFS?
- Etiology and Lab Testings for FM and CFS
- FM and Cognitive Behavioral Therapy
- How much sleep do I need?
- Fibromyalgia and CFS References
- Toronto Star FM Case Study: Sandy Bolyki
- Guaifenesin Protocol with Dr. St. Amand
Here are my FM/CFS book recommendations from fellow medical colleagues:
- Hope and Help for Chronic Fatigue Syndrome and Fibromyalgia, 2e – Dr. Alison Bested, MD and Dr. Alan Logan, ND
- The Complete Fibromyalgia Health, Diet Guide and Cookbook– Dr. Louise McCrindle, ND