Comprehensive Treatment For Chronic Fatigue, Fibromyalgia &
Fibromyalgia (FM), Chronic Fatigue Syndrome (CFS) and Autoimmune
disease are treatable conditions. The most effective treatment protocols
address six areas that have been shown to directly influence chronic
fatigue and pain: sleep quality, hormone deficiency, opportunistic
infections, nutritional deficiency, exercise, and stress level.
By treating these areas concomitantly we hope to achieve improvement
in a short period of time, however, patients should not expect immediate
relief and it is realistic to anticipate 3 - 6 months of treatment
before significant remission occurs. We endorse the treatment approach
used by Dr. Jacob Teitelbaum (author of From Fatigued To Fantastic).
The following is a brief introduction to treating sleep, hormones,
infections, nutrition, exercise and stress:
Stress: Reducing stress has undeniable long-term health benefits,
especially for FM patients who experience flare ups with increased
stress. Brain imaging research indicates that pain signals can be
processed in different portions of the brain. Fibromyalgia patients
tend to process pain in areas that are different from controls (PMID
16933135). When pain is processed in centers associated with having
little control, the pain is more intense than it is when processing
pain in a area associated with feelings of control. This means one’s
pain will hurt more if they feel like they have little control over
it. For more information on this relationship, go to Medline and
index PMID 16082231. We work with John Leonard, Ph.D. who teaches
people a simple and enjoyable technique to modulate pain signals,
giving people power and control over their pain. For more about
Dr. Leonard go to http://www.neurobehavioralprograms.com.
He generally sees patients just a few times and most patients are
delighted with the results.
2.) Hormones: “Dysregulation” of the hypothalamic-pituitary
adrenal and thyroid axis is not a small problem. Our study of the
alterations in pituitary function lead us to believe that the pituitary
changes are physiologically adapted for survival and can be triggered
by infection. This is not a random dysregulation, but a pattern
of changes that can be compensated for and reversed to some degree.
Many patients report improved cognitive function and decreased pain
when their hormone levels are normalized with supplemental thyroid
T3, oxytocin, and androgen cream as indicated by their blood work.
Normalizing the rT3/fT3 ratio can have a profound effect on neurotransmitter
synthesis, mitochondrial function, pituitary function and immune
function. Improving endogenous nitric oxide production with hormones
and nutrition helps to reduce musculoskeletal pain and improve circulation.
Naltrexone (PMID 11862370) and angiotensin receptor blockers (PMID
17514587) have been shown to normalize HPA axis function at low
3.) Infections: Opportunistic infections are those
that capitalize on any opportunity to infect. Genetic mutations
in methylation enzymes will diminish immune function, and give infections
a green light. The infections we most commonly encounter in our
patients are those that have been documented by CFS/FM researchers
(Stratton, Nicolson, Peterson, Montoya, etc.). It appears that it
is rarely a single organism and usually a combination of opportunistic
infections that produce chronic illness. These infections all have
the capacity to live inside of a white blood cell (WBC), which is
an impressive feat. Once inside the host’s WBC’s, these
infections modulate cellular metabolism and create an environment
that that favors additional infection. Impaired WBC and mitochondrial
function provides an opportunity for infectious agents to multiply.
Bacterial signals, such as endotoxin and heat shock protein, disrupt
metabolism leading to a depletion of Vitamin D receptors, and an
increased clearance of essential nutrients needed to fight infection.
There are infection opposing nutrients that we want to insure our
patients are taking regularly. Antimicrobial medication can be helpful,
but our preference is begin with daily infrared sauna (fever), infection
opposing nutrients, low dose naltrexone, methylation support and
more because the die-off from these measures alone can be significant.
Once the patient is feeling stronger, antimicrobial agents can be
introduced if the blood work and clinical setting supports it the
need for it. Below is a brief synopsis of infections that we feel
are worth investigating and treating:
Viral Infections: Human Herpes Virus 6 & 7 (HHV 6, HHV 7).
Herpes virus infections are common (chicken pox, Ebstein-Barr Virus,
Cytomegaly virus) and once infected, humans carry these viruses
in a dormant form for the rest of their lives. Most people are infected
with HHV 6 and HHV 7 as children and it is one of the many flu-like
illnesses that children endure. When these infections come out of
dormancy in an adult it can cause chronic fatigue, flu-like symptoms
and fever. Antibody tests are not a great measure of relapse, but
Dr. Montoya at Stanford has found that patients with the highest
titers tend to respond best to antiviral medication. PCR tests (which
amplify DNA) are positive when the virus is actively replicating
in the blood, but these do not appear to be very sensitive. HHV-6A
is the strain of HHV-6 that is most associated with chronic fatigue
and there is preliminary evidence that 12 infusions of Vistide can
induce remission. A draw back to this approach is that Vistide costs
$900 per infusion and relapses are frequent. Another approach is
to use oral antiviral medication. Valtrex costs approximately $300
per month and works for many patients who require approximately
5 months of treatment. Dr. Montoya has been using Valcyte, which
costs $2,500 per month and has a worrisome side effect profile that
requires careful monitoring.
Bacterial Infections: There is a growing number of studies finding
Mycoplasma and Chlamydia pneumoniae antibodies and DNA in the blood
of patients with FM, CFS, Gulf War Syndrome, MS, Asthma, Chronic
Bronchitis, Chronic Sinusitis and RA. Chlamydia pneumoniae appears
to contribute to atherosclerosis, interstitial cystitis and scaring
skin lesions known as pyoderma gangrenosa. Dr. Stratton at Vanderbilt
Medical Center has published a variety of articles linking Chlamydia
pneumoniae to a variety of chronic diseases. It is interesting that
he has documented the presence of Chlamydia pneumoniae DNA in 14/17
bladder biopsies from persons suffering from interstitial cystitis
and other FM researchers (Clauw et. al. 1997) have confirmed a link
between FM and interstitial cystitis. Chlamydia pneumoniae is commonly
encountered and is a resilient opportunist with 3 forms in its life
cycle allowing it to evade single agent antibiotic regimens. Treatment
for Chlamydia pneumoniae requires months of treatment (similar to
TB). Learn more about Chlamydia pneumoniae at: Cpnhelp.org
Staying ahead on the clearing of the endotoxin released when
bacteria are killed by using endotoxin lowering agents is very helpful.
Fungal/Mold Colonization: This a controversial field of study
in medicine and a complex topic. In brief, researchers at Mayo Clinic
devised a new fungal culture technique and found that essentially
all people, healthy and ill, have 2-3 different strains of mold
living in their sinuses. Colonization may involve other mucosal
surfaces, such as the lungs and intestines. Symptoms can develop
when eosinophils (one of our white blood cells) are activated against
mold. The allergic reactions can take a number of different forms
from the classic type I reaction (runny nose, scratchy eyes, asthma),
to type III hypersensitivity reactions which causes immune complex
formation (a source of autoimmune reactions such as vasculitis)
and serum sickness. The serum sickness reaction can develop 10 -
20 hours after ingesting food that contains mold proteins if the
person is sensitized to that mold. For example chocolate, bread
malts, and sodas all contain Aspergillus mold protein, but it is
difficult for most people to link these foods to their “flare-ups”
because the type 3 hypersensitivity reaction may take half a day
to occur. Mold colonization and sensitization can be addressed by
treating the sinuses with antifungal sprays, and treating the intestines
with antifungal pills that are not absorbed into the blood stream.
Minimizing dietary exposure to mold spores is often helpful. Insuring
that one’s home environment is not a source mold is important.
Mold counts are highest during the rainy season and many illnesses
flare during this time. If your symptoms are worse in these months,
try to recall if you were ever exposed to high levels of mold in
a water-damaged home, or work environment. The syndrome referred
to as Allergic Fungal Sinusitis links the development of allergies
to foods, pollens and chemicals with fungal colonization of the
sinus. These allergies lessen when fungal colonization is treated.
Blood testing for IgG levels to mold and foods are helpful and Mayo
Clinic has the only reliable fungal culture technique available.
Another useful test is the serum eosinophil cationic protein (ECP)
level, which increases as eosinophils are activated by mold and
parasites. ECP levels can be followed as treatment proceeds to document
response and influence the doses of antifungal medication.
Parasites: Stool culture using Great Smokies Lab is the best
way to document a parasitic infection. Local hospital labs are generally
not as sensitive and false negative results are common.
Nutritional deficiencies are common in people with chronic stress
and illness. One of our immediate goals is to normalize nitric oxide
metabolism, which dramatically reduces pain because nitric oxide
has analgesic properties and because nitric oxide improves blood
flow to muscle and the nervous system. See the end of the Fibromyalgia
Handbook (the first book in our curriculum) which lists all of Dr.
Teitelbaum’s treatments. His Energy Powder contains most of
the nutrients people need to replenish their precursors to nitric
oxide in a single scoop of powder. There are many helpful supplements
available, but the following are ideal to begin with:
3 oils: We recommend two brands, Nordic Naturals or Eskimo 3.
Taking high doses can diminish depression, reduce swelling and decrease
pain. Start with the flavored pills and graduate to the flavored
liquid if you would like to try higher doses. There are two major
components of omega 3 oils, DHA and EPA. DHA facilitates brain function
and is mildly stimulating, while EPA reduces swelling and has a
calming effect. Increasing one’s dose too rapidly can be associated
with diarrhea. The ability to tolerate omega 3 oils increases with
time. Therapeutic dose is between 3 - 5 grams daily and maximum
response for rheumatoid arthritis comes at 3 months, while cognitive
benefits can be seen within a few days.
The acetyl form provides the most rapid response. Acetyl-L-carnitine
is expensive, but it is associated with weight loss by improving
fat metabolism and increases exercise endurance. Take 500 mg twice
daily for the first few months. You can find inexpensive carnitine
Q10: Can improve brain and cardiac function at doses of 200
mg daily. Patients with methylation mutations will have difficulty
manufacturing adequate CoQ10.
Vit B12: Sublingual forms and injected B12 can be very helpful.
Depending on the presence or absence of methylation mutations, some
patients will do better with hydroxycobalamine or methylcobalamine
rather than the standard cyanocobalamine.
Oral magnesium can cause diarrhea in some people. If tolerated,
try 400 - 800 mg daily. Magnesium is essential for ATP formation
and nerve function. It is depleted with stress.
Exercise: mpact exercise has been proven to decrease symptoms
when patients are able to exercise. Walking, stretching, yoga, Tai
chi, water aerobics and other sports are perfect and medicinal.
An exercise and stretching video can be obtained from the Oregon
Fibromyalgia Foundation. The number of physiological and immunological
benefits associated with exercise are too numerous to list. As soon
as your pain scores decrease and you can tolerate exercise, start
with 20 minute sessions of low impact exercise 3 times per week.
Sauna for 30-60 minutes a day (start with 10 minutes) can burn more
calories than strenuous exercise and may serve as a substitute for
exercise until you are feeling able to return to regular activities.
Dr. Lawrence Wilson’s book Sauna Therapy is excellent and
worth reading if you are considering sauna therapy.
Sleep: Shallow, non-restorative sleep is a hallmark of CFS,
FM & PTSD. Shallow sleep offers a survival advantage for people
sleeping in a dangerous environment by allowing them to arouse quickly
if danger should approach. The trouble is that this PTSD-related
arousal circuit can be difficult to turn off once it is set in motion
and chronic insomnia can arise. The hyperarousal will often resolve
when a person feels safe, but we know from war veterans suffering
from PTSD that the memories can perpetuate the trauma reaction.
A good night’s sleep is essential to improved function, so
it is imperative that we find a way to reestablish stage 3 and 4
sleep for our patients. We have a long list of sleep enhancing medications
and herbs for you to try. It may take time to find the medication
that works best for you because everyone is different and what works
perfectly well for one patient can have the opposite effect on another.
Some people have such a high stress level that it is difficult to
resolve their insomnia with a pill and it is stress reduction and
counseling that restores their deep restorative sleep. If sleep
apnea (periods of airway obstruction while sleeping) is not addressed,
recovery is unlikely. A sleep study is necessary to make the diagnosis
of sleep apnea. It is not uncommon for the hyperarousal state to
abate as infections are treated. The mechanism for this reaction
is unclear, but the response is sometimes dramatic.
Chronic Fatigue Syndrome and autoimmune disease are not psychogenic
diseases processes (they are not in one’s head). There is
a growing body of research that confirms significant physiological
abnormalities including increased serum TNF-alpha, IL-8, and IL-10,
increased muscle glycation products and NFkB, reduced mitochondrial
membrane permeability, abnormal unmyelinated axons in the skin,
reduced mu-opioid receptors, increased spinal fluid substance P
levels, imbalanced autonomic nervous system, disrupted sleep architecture,
chronic respiratory infections, low vitamin D levels, reduced cerebral
blood flow and abnormal pain processing. We believe these disruptions
of normal physiology are related to infections that exploit genetic
predisposition. We offer our patients a comprehensive approach to
treatment by assessing and treating infection, insomnia, hormone
imbalances, nutritional deficiencies and helping patients reduce
stress. While treating infections there can be a “die off
reaction” called a Herxheimer reaction which causes a temporary
worsening of symptoms as the organisms are dying. It is a good idea
to take a short break from treatment when this occurs and that means
patients must be patient. The rewards are worth the trouble. Dr.
Teitelbaum finds that approximately 80% of his patients improve
after 8 to 12 months of treatment. We are constantly looking for
ways to accelerate the recovery process. Most of our patients respond
within 2-3 months of treatment, are significantly better at 6 months
and the majority of our patients are asymptomatic within 12 months.
Many of our recovered FM & CFS patients have offered to discuss
their recovery process with new patients who find it hard to believe
that coming out of FM is possible. Their contact information is
available upon request.
Medical Visits: We usually meet every couple of weeks for
the first 3 visits to insure that patients are responding to treatment
and showing steady improvement. Frequent visits are helpful in the
beginning because there is a great deal of information to process,
and the medications we use require some monitoring. Once the right
combination of medications is determined, visits are much less frequent.