Understanding and Treating Chronic Fatigue and Fibromyalgia (Part 2)

In order to assist in understanding modern naturopathic holistic health care, I propose to use as models in this series a number of health problems such as Chronic Fatigue Syndrome, also known as Myalgic Encephalomyelitis (CFS/M.E.) as well as the widespread muscle pain problem currently defined as fibromyalgia, or Fibromyalgia Syndrome (FMS). In this article there will be a brief overview of these two conditions, and as the series develops we will examine the common threads in causation, the differences, as well as ‘what works’ in therapeutic terms based on research to date.


I have chosen these two conditions specifically because each contains within it’s possible aetiology a cluster of causative and potentiating factors and conditions which are remarkably similar. FMS and CFS(ME) also have a wide range of identical symptoms ranging from fatigue through impaired cognitive and memory functions, to muscular pain, digestive disturbances, headaches and sleep disturbance.1,2,3


By virtue of their ill-defined natures these conditions have become a refuge, one could say a dumping ground, for a host of undiagnosed and apparently undiagnosable health problems.
The majority of medical practitioners seem either to be unaware of the reality of the causes, nature and appropriate care of such problems or are openly disbelieving as to their very existence. These are often patients dubbed ‘heart sink’ because of their emotional effect on the doctor, as the patient enters the room, yet again clutching a list of symptoms and requests for help.


All too often classified as ‘neurotic’ with their symptoms ascribed to ‘depression’, this is a truly miserable population of people, who often feel profoundly misunderstood by those around them (sympathy is finite and six months into such conditions it is often in scant supply from friends and family) as well as let down by the medical profession who is either disinterested, dismissive or perfunctory in its prescribing of antidepressant medication.


To have to endure this sort of emotional and social isolation as well, as the cluster of demoralising symptoms with which they are burdened, is clearly enough to depress anyone, and it is the experience of most practitioners and therapists involved in working with such patients that any apparent depression is usually a result, rather than a cause, of their problems.
In the alternative and complementary health field a veritable industry has emerged which treats such problems with varying degrees of success using a range of approaches and methods – sometimes suitable and sometimes not. All too often what is on offer addresses such patient’s needs only partially, with predictably disappointing results.


There are no simple answers to conditions where causes lie in a mix of nutritional deficiencies, acquired toxicities, bowel dysbiosis, inadequate stress coping abilities, sensitivities and allergies, inappropriate or excessive medication, inadequate sugar control mechanisms, hormonal imbalances, poor posture and breathing dysfunction, current or past viral, parasitic, yeast or bacterial infections, impaired organs of digestion and elimination, emotional distress….. and more. There are certainly no magic bullets which can remedy a situation which may have taken many years to evolve.


These are a growing army of these walking wounded, the ‘vertically ill’ who are too sick to function adequately but are commonly not quite sick enough to become ‘horizontally ill’, actually bed bound, although this is all too often an outcome in severe examples.


Unless there is an underlying awareness of the true nature and causes of such conditions, and until there is a real understanding of the ways in which it is possible to offer encouragement for an abused and over-stretched immune system to begin to restore health, many forms of proffered help (orthodox or alternative) will succeed only in either masking or, at best, moderating the patient’s symptoms.


Understanding Homeostasis: Self-Healing

It is absolutely vital for anyone afflicted with a chronic illness to hold onto the fact that their body is a self-healing mechanism, that since broken bones mend and cuts usually heal, and that since most health disturbances, from infections to digestive disturbances, get better with or without treatment (often faster without !) that, in a healthy state, there must be in operation a constant tendency towards normalisation and balanced function. This is called homeostasis.


Homeostatic functions (which include the immune system) can be overwhelmed by too many tasks and demands, because of (perhaps) any or all of a selection of negative impacts including nutritional deficiencies, accumulated toxic material (environmental pollution, either as food or inhaled, in medication, previous or current use of drugs etc), emotional stress, recurrent or current infections, allergies, modified functional ability due to age or inborn factors or acquired habits involving poor posture, breathing imbalances and/or sleep disturbances and so on and on …


At a certain point in time the adaptive homeostatic mechanisms break down and frank illness, disease, appears and as homeostasis breaks down, a state of heterostasis emerges.4
At this time the body needs help, treatment, and this can take the form of either:


  • a: Reducing the load which is impacting the body by taking away as many of the undesirable factors as possible, by avoiding allergens, improving posture and breathing, learning stress coping tactics, improving diet, using supplements if called for, helping normalise sleep and circulatory function, introducing a detoxification programme, dealing with infections, and generally trying to keep the pressure off the defence mechanisms while it focuses on the current chronic repair needs.


  • b: Enhancing, improving, modulating defence and repair processes by a variety of means, mainly non-specific (described as constitutional methods, which will be explained further in later articles in this series)


  • c: Treating the symptoms: while making sure that what is being done does not add further to the burden of the defence and repair mechanisms.
    Meet Fibromyalgia


Fibromyalgia (FMS) used to be called fibrositis (among many other names) and even now when the word ‘fibromyalgia’ is used in medical writing it is often accompanied by the word ‘fibrositis’.
The similarities between Fibromyalgia syndrome, Chronic Fatigue Syndrome and Irritable Bowel Syndrome are listed below.5,6


In Fibromyalgia, Chronic fatigue Syndrome and Irritable Bowel Syndrome the following similarities are found:










AgeYoung Adult
Primary SexFemale
PrevalenceCommon
CauseUnknown
ChronicYes
Laboratory StudiesUsually Normal
PathologyNone
DisablingFrequently

In addition to these similar, indeed identical, factors, all these conditions are also frequently characterised by pain, fatigue, headaches, disturbed sleep patterns, anxiety, depression, numbness and tingling in the arms, hands or feet, bowel disturbances (diarrhoea and/or constipation on their own or alternating) all frequently affected by the weather, by activity and by stress and there are usually many painful and sensitive areas to be found on palpation in all of them. Irritable bowel problems will usually also be associated with palpable painful areas in the abdomen.


The Official Definition of/Criteria for FMS7

The most commonly accepted definition (devised by the American College of Rheumatology in 1990) is that the person affected needs to show:


  • History of Widespread Pain

    Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist and pain below the waist. In addition there should be pain in the spine or the neck or front of the chest, or thoracic spine or low back.


  • Pain in 11 of 18 Tender Point Sites on Finger Pressure

    There should be pain on pressure (around 4kg of pressure maximum) on not less than 11 of the following sites:

    • Either side of the base of the skull where the subocciptal muscles insert.


    • Either side of the side of the neck between the 5th and 7th cervical vertebra, technically described as between the ‘anterior aspects of inter-transverse spaces’.


    • Either side of the body on the midpoint of the muscle which runs from the neck to the shoulder (upper trapezius)


    • Either side of the body on the origin of the supraspinatus muscle which runs along the upper border of the shoulder blade.


    • Either side, on the upper surface of the rib, where the second rib meets the breast bone, in the pectoral muscle.


    • On the outer aspect of either elbow just below the prominence (epicondyle)


    • In the large buttock muscles, either side, on the upper outer aspect in the fold in front of the muscle (gluteus medius)


    • Just behind the large prominence of either hip joint in the muscular insertion of piriformis muscle.


    • On either knee in the fatty pad just above the inner aspect of the joint.
      Children with FMS


Many children are also now being diagnosed with FMS, often starting with flu-like symptoms and then becoming chronic with sleep disturbance a major feature. Some children also display Attention Deficit Disorder (ADD) symptoms, fatigue, school and behaviour problems and commonly a tendency to allergies. Some FMS experts also find that such children frequently have very loose (hypermobile) joints.


How Many People are Affected by FMS?

Muscular pain which goes on and on for months or years is now very common, often causing sufficient disability to prevent people from working or functioning normally, in fact Fibromyalgia Syndrome (FMS) is now the commonest disorder seen by rheumatologists, after osteoarthritis and rheumatoid arthritis.


Dr.Don Goldberg, Chief of Rheumatology at Newton-Wellesley Hospital and Professor of Medicine at Tufts University School of Medicine, estimates that there are between three and six million Americans affected by fibromyalgia, mainly between the ages of 26 and 35 with the vast majority being women (86% females against 14% males according to many surveys).


Based on population size and surveys we can therefore estimate that between 750,000 and a 1.5 million people in Britain also have fibromyalgia.


In total it is estimated, by Professor Bruce Rothschild of Northeast Ohio Universities College of Medicine, that nearly 25% of patients seen at rheumatology clinics are actually suffering from fibromyalgia.8


How Disabling is Fibromyalgia (FMS)?

100 out of 394 patients (that is 25.3%) with FMS (all female) and 12 out of 44 males (27) were shown in a recent survey to be sufficiently badly affected by the condition as to be unable to work; they were effectively disabled.9


Almost all the others surveyed claimed that their FMS affected their job performance very badly. In Canada a single insurance company, London Life, reported in 1989 that it was issuing monthly long-term disability payments to over 630 people with a diagnosis of fibromyalgia, involving a total of around a million dollars a month.


Historical Confusion of ‘Names’

Just as ‘fibrositis’ has become fibromyalgia, so has Chronic Fatigue Syndrome now replaced the former terms ‘chronic mononucleosis’ and ‘chronic Epstein-Barr syndrome’ of the recent past, and ‘neurasthenia’ and ‘nervous exhaustion’ of Victorian times.


There is still disagreement amongst experts as to whether CFS is the same as Myalgic encephalomyelitis (ME) or not, and it seems likely that this argument will run for some time. In these articles, wherever chronic fatigue is not related to a known disease processes such as diabetes or clinical depression, or simply to over tiredness through natural causes (e.g. overwork), the two names will be bracketed together as CFS(ME).


Some doctors insist that the psychological aspects of these conditions is the most important cause and they use the terms ‘masked depression’ and ‘somatoform disorder’ to describe such conditions. This is strongly resented by those afflicted by CFS(ME) or FMS who see the psychological and emotional symptoms as being the result of their fatigue, pain and general ill-health and not as causes.
CFS(ME) and FMS: are they the same?

There is also disagreement amongst experts as to whether or not ‘fibromyalgia syndrome’ and ‘chronic fatigue syndrome’ are not in fact the same condition.


Both CFS(ME) and FMS often seem to begin after an infection or a severe shock (physical or emotional) , and the symptoms are very similar. The only obvious difference seems to be that for some people the fatigue element is the most dominant while for others the muscular pain symptoms are greatest.


In other words for many people the diagnosis CFS(ME) and FMS are interchangeable terms, although there are certain symptoms (fever, swollen glands for example) which are found in a higher percentage of CFS(ME) patients than those with FMS, which sometimes make such a comparison less precise.


Symptoms Compared

One of the most interesting list of symptoms associated with FMS/CFS(ME) was that given to a conference on the subject by a leading San Francisco physician Carol Jessop MD in 1990.10
The number of patients she has seen and studied (over a thousand) makes this a comprehensive selection of associated symptoms, and is even more impressive since many of her patients are referred to her by other physicians thus making the diagnosis more likely to be accurate that is to say that both she and the referring doctor have agreed that these people ARE suffering from FMS or CFS(ME).


Common Symptoms Found in Dr Jessop’s Patients














Chronic Fatigue100%
Cold Extremities100%
Impaired Memory100%
Frequent Urination95%
Depression94%*
Sleep Disorder94%
Balance Problems89%
Muscle Twitching80%
Dry Mouth68%
Muscle Aches68%
Headache68%
Sore Throat20%

* Dr Jessop stated that this was a ’reactive depression’ not a ‘clinical depression’ and that only 8% of her depressed patients had required prior medical attention for this before the symptoms of CFS or FMS emerged


Physical and laboratory findings

Dr Jessop reported the following symptoms and findings as well amongst her 1324 patients, average age 39, 75% of whom were female.














Elevated temperature10%
Normal temperature25%
Subnormal temperature65%#
Low blood pressure86%
Yeast infections
(tongue or mouth)
87%
Tender thyroid40%
White spots on nails85%*
Tender neck muscles91%
FMS tender spots86%
Abdominal tenderness80%
Swollen lymph nodes18%

# Possibly indicating under active thyroid function

* These white flecks are thought to relate to zinc deficiency


  • 82% of 880 patients specifically tested had yeast cultured from purged stool samples.
  • 30% had parasites in their purged stool samples.
  • 38% were found to be deficient in magnesium using a three day loading test and two 24 hour urine samples.
  • 32% had low zinc levels using blood tests (she believes sweat analysis is more accurate but this is not easy to use in an office practice)


Dr.Jessop stated that her patients reported that a number of classical disturbances and symptoms existed well before the onset of their CFS/FMS symptoms.


For example:


  • 89% had irritable bowel symptoms before their FMS/CFS
  • 80% had ‘constant gas’ or bloating before their FMS/CFS
  • 58% had constipation before their FMS/CFS
  • 40% reported heartburn before their FMS/CFS
  • 89% reported recurrent childhood ear,nose, throat infections
  • 40% had a history of recurrent sinusitis
  • 30% recurrent bronchitis
  • 20% recurrent bladder infections
  • 90% of the females had premenstrual symptoms prior to onset of current illness
  • 65% reported endometriosis before their FMS/CFS
  • 30% had dysmenorrhoea before their FMS/CFS
  • 22% had generalised anxiety disorders prior to their illness


Sleep problems were present in just 1% of her patients before CFS/FMS and over 90% after its onset.


As will be shown in subsequent articles, sleep is a key feature of this condition and restoration of normal sleep is vital in recovery.

References

1. Yunus M. Fibromyalgia and other functional syndromes’ Journal of Rheumatology 16(sup 19)69 1989


2. Moldofsky H. Fibromyalgia, sleep disorder and chronic fatigue syndrome Ciba Foundation Symposium 173 Chronic Fatigue Syndrome p 262-270 1993


3. Goldenberg D. Fibromyalgia, chronic fatigue syndrome and myofascial pain syndrome. Current Opinion in Rheumatology 5:199-208 1993


4. Hans Selye The Stress of Life – McGraw Hill 1980).


5. Block S. ‘Fibromyalgia and the Rheumatisms’ Controversies in Clinical Rheumatology 19(1)p68 1993;


6. Goldenberg D. ‘Fibromyalgia and its relationship to chronic fatigue syndrome, viral illness and immune abnormalities’. Journal of Rheumatology 16(sup 19)92 1989


7. George Duna and William Wilke Diagnosis, etiology and therapy of fibromyalgia Comprehensive Therapy 19(2)60-63;1993


8. Bruce Rothschild Fibromyalgia : An explanation for the aches and pains of the nineties Comprehensive Therapy 17(6):9-14 1991


9. Goldenberg D Presentation to the 1994 American College of Rheumatology meeting


10. Fibromyalgia Network Newsletters : October ‘90 thru January ‘92 Compendium #2, January 1993, May 1993 Compendium, January 1994, July 1994.
Available from Fibromyalgia Network 5700 Stockdale Hwy, Suite 100,Bakersfield, CA 93309-2554 USA

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