Symptoms and Causes of Chronic Fatigue Syndrome:
Chronic Fatigue Syndrome (CFS) is a controversial condition, the existence of which is hotly debated within the medical profession. The term itself was first used in 1988 but the syndrome has existed for much longer. It has previously been known as neurasthenia and myalgic encephalomyelitis (ME). The term CFS has been adopted to define a sufficiently homogeneous group of patients to allow research into etiology, pathogenesis, natural history and management. As the word syndrome suggests, CFS is not recognized as a distinct disease process.
A number of definitions of CFS have been proposed. All include the concept of fatigue that interferes with activities of daily living and is of at least six months duration. The Center for Disease Control (CDC) in Atlanta has defined CFS as the presence of:
- Clinically evaluated, unexplained, persistent or relapsing fatigue that is of new or definite onset; is not the result of ongoing exertion; is not alleviated by rest; and results in a substantial reduction of previous levels of occupational, educational, social or personal activities.
- Four or more of the following symptoms that persist or recur during six or more consecutive months of illness and that do not predate the fatigue:
- Self-reported impairment in short-term memory or concentration
- Sore throat
- Tender cervical or axillary nodes
- Muscle pain
- Multi -joint pain without redness or swelling
- Headaches of a new pattern or severity
- Un-refreshing sleep
- Post-Exertional malaise of at least 24 hours
The most prominent symptom of CFS is usually overwhelming fatigue, especially after exercise.
- Other common symptoms include headaches, sore throat, enlarged lymph nodes, muscles pain especially after exercise, un-refreshing sleep, chest and abdominal pains.
- The diagnosis of CFS is difficult to confirm in the absence of any definitive sign or test.
- It is often a diagnosis of exclusion.
- The other problem with the diagnosis of CFS is that there are a number of conditions whose symptoms overlap with those of CFS.
- The two most significant are fibromyalgia and depression.
- The major presenting symptom in fibromyalgia is usually widespread muscle and joint pain but fatigue is nearly always present.
- Fibromyalgia is characterized by the presence of multiple tender points in the muscles.
- Trigger points are also frequently seen in patients with CFS and form an important part of the treatment.
- Fatigue is often the primary presenting symptom in patients with depression and many of the symptoms described in CFS are found in depressive patients.
Management of the patient with CFS (or fibromyalgia and depression) is a considerable challenge for the practitioner. The natural history of CFS is of a very gradual improvement over a period of months and sometimes years.
- Treatment should be oriented towards psychological support and symptom relief.
- It is essential that the treating practitioner acknowledges that the patient has a real problem and is prepared to give the patient a diagnosis.
- It is important to give the patient plenty of time and both the patient and those close to her (or him) will have many questions.
- We recommend seeing the patient at least weekly in the initial treatment phase and later on a less frequent but still regular basis.
- Exercise is the cornerstone of treatment of chronic fatigue.
- This may seem strange when one considers that post-exercise fatigue and muscle pain are two of the most significant features of the disease but a slow, graduated increase in activity is an essential part of management.
- The exercise program may have to commence at a ‘ridiculously’ low level considering the history of some athletes.
- But it should commence at a level that the patient can achieve comfortably with minimal or no adverse effects in the 24-48 hours post-exercise.
- The increase in activity should be very gradual and if adverse symptoms develop, the patient should return to the previous level of activity and build up even more slowly.
- In a six-month randomized blinded prospective trial in individuals with CFS, it was found that a graded exercise program significantly improved both health perceptions and the sense of fatigue whereas the use of an antidepressant (fluoxetine) improved depression only.
- Another study of 66 patients with CFS also demonstrated a positive effect with graded aerobic exercise.
- Many drug treatments have been advocated but with little evidence of their efficacy.
- Simple analgesics may be helpful and we recommend the use of a tri- cyclic antidepressant (e.g. amitryptiline 10-25 mg) in a single nocte dose.
- This drug seems to improve sleep quality and patients will usually wake up more refreshed as a result.
- Many nutritional supplements have also been advocated but again there is no evidence of their efficacy we have found the treatment of muscle trigger points with dry needling to be helpful in reducing muscle pains and headaches in a number of patients with CFS.
Other Causes of Tiredness
A number of psychological problems are associated with a feeling of excessive tiredness. The two most common states are anxiety and depression. These problems may be related to the athletes sporting endeavors or, alternatively, may be quite unrelated.
- The presence of eating disorders such as anorexia, nervosa and bulimia should also be considered.
- Hypothyroidism is more common than most realize, occurring in 1% of adults, with subclinical disease in Solo. The condition can affect any organ system.
- Hypothyroidism is characterized by a general slowing of body processes and can present as chronic fatigue, cold intolerance, weight gain and, in women, menorrhagia.
- It is often associated with high cholesterol levels.
- An elevated serum thyroid stimulating hormone level is a sensitive indicator and patients with this condition generally respond well to treatment with levothyroxine.
- Diabetes, neuromuscular disorders and cardiac problems are all associated with excessive tiredness.
- Exercise induced as the major symptom rather than the more typical cough, chest tightness or shortness of breath post exercise.
- A number of medications may cause excessive tiredness.
- These include beta-blockers, antihistamines, diuretics, anticonvulsants, sedatives and muscle relaxants.