We've finally made it to the best part: treatment strategies!
As you may recall from Part 1 (read here), many patients who meet the diagnostic criteria for CFS/ME have a component of pain that meets the criteria for FM. They are co-morbid syndromes often occurring together with major overlapping in symptoms, so for that reason, I'm coupling the treatment approach together. In practice, my treatment plans are patient-centred depending on individual obstacles to health, bothersome symptoms, etc. but this post gives an overview of my approach using Naturopathic Medicine.
Before diving in, I want to make one point clear: Generally, a multi-disciplinary approach to treatment works best. I am not anti-medication. Some patients get a lot of relief from certain medications and that's great! Naturopathic Medicine can address symptoms that aren't being addressed with medication and/or can help reduce side effects.
Prognosis - "Will I ever get better?"
A review of 14 studies (from 2005) looked at ME/CFS patients and found that:
5% - recovered
40% - improved during follow-up
8-30% - returned to work
5-20% - had worsening of symptoms
Most patients aren't able to return to their pre-illness level of functioning. But take the above stats with a grain of salt - each of those studies had different inclusion criteria for patients studied, used different questionnaires to determine recovery, and patients were receiving different treatments.
When looking at those CFS/ME patients with a decreased likelihood of improvement, they found the following risk factors:
-Severity of illness at time of onset
-Lack of early management (overexertion in the early stages are more likely to lead to deterioration) *see below on pacing*
-Having a mother with the illness
-Co-morbid diagnosis of fibromyalgia
Fundamentals to Treatment
1. Pacing = most important for CFS/ME patients
Pacing is conserving energy by taking breaks in between activities to avoid 'crashes' from over-exertion. These breaks can involve lying down, meditating, deep breathing, or simply sitting down. This can be extremely difficult for patients to do because of pressure (put on themselves or by others) to maintain normal functioning like keeping up with chores, cooking, looking after kids, going to work, etc. It's also difficult because prior to diagnosis, many CFS/ME patients were busy, high achieving, successful, multitaskers who could push through and accomplish anything thrown at them. Another challenge is maintaining pacing on days when patients feel better than usual - it's so tempting to push the boundaries slightly which can result in a crash. Accepting that energy reserves aren't what they used to be is the first step, followed by body awareness, discipline, and practice. Studies have found improvements in physical functioning and fatigue ratings in patients who don't exceed their 'energy envelopes' - so pacing is incredibly important!
A key aspect of pacing is educating others on the importance of pacing. This includes other healthcare providers you are seeing. If you receive treatment (ex. massage) that is too aggressive and triggers a crash - kindly educate on the importance of avoiding crashes and that way they can adjust their treatment accordingly. It's not personal - the focus should be on what's best for you, and that's avoiding crashes.
There is no single diet that works best for all patients. Ultimately, everyone can benefit from reducing processed foods and sugar and by consuming a rich, whole-food diet. Identifying and avoiding food triggers is important - some patients benefit from removing common triggers like dairy and gluten from the diet. Others have seen results from eliminating food from the nightshade family or by switching to organic produce. Determining food triggers can be done through elimination diets or by testing (this could be a whole topic in itself!) Proper nutrition is essential and can't be overlooked. I help patients find ways to incorporate nutritious, delicious food into their lives without spending hours in the kitchen.
3. Daily movement (within energy capabilities)
With regular pacing, patients can begin to determine their limits for activity. Slow, graded movement can then be introduced based on interests - walking, stretching, yoga, etc. Notice how I didn't say exercise? Avoiding high intensity aerobic exercise that exceeds energetic reserves is key.
Depending on a patient's baseline ability to carry out activities, they may need to first wait for some symptomatic improvement before proceeding with movement. By improving diet, nutrition, sleep, stress, and managing symptoms with techniques described above, patients start to feel a little bit better and it becomes more realistic.
4. Nutritional Supplements
Many patients benefit from specific nutrients such as Vitamin B12, Probiotics, L-Glutamine, Vitamin D, Magnesium, Omega 3 Fish oil, Zinc, CoQ10, D-Ribose, etc.
I choose supplements based on presenting symptoms, if there are any depletions from medications that need to be corrected, deficiencies based on blood work, and by looking at their entire symptom picture. Many patients have gastrointestinal dysfunction which impairs absorption, so strengthening the gut is an important starting point. Brand and dose of supplements are very important - lower quality products may have binders and fillers that patients react to, may contain a lower dose than what's on the label, and be present in low-absorbable forms.
5. Herbal Support
Similar to nutritional supplements, herbs provide another means to target specific symptoms (ex. stress support) and to strengthen the body overall. I recommend daily consumption of herbal teas to most of my patients because they're an affordable, easy, and effective habit to incorporate.
6. Body Work
Acupuncture is a great adjunctive treatment. I use it to decrease central pain sensitization via it's ability to modulate pain pathways in the brain and to increase endorphin release (our body's anti-pain modulators.) Points can also be added to address specific bothersome symptoms, such as constipation. Some patients aren't able to tolerate acupuncture - and that's ok, it's not one treatment suits all.
Cupping is another great adjunctive treatment. The negative pressure created by the suction can desensitize sensory nerve endings in the skin and can loosen tight fascia that's 'stuck' on muscles contributing to pain. It also improves local circulation, allowing nutrients to reach muscles and for waste products to clear. I find cupping especially effective for patients with FM. Cupping can be performed gently with minimal suction and moved slowly along muscles. With this technique, it will not leave the characteristic cupping marks and should not cause pain.
7. Stress Support
Patients with ME/CFS have HPA dysfunction, which is the hormonal system in our brain that regulates our response to stress and affects our mood. Unmanaged long term stress can cause a myriad of health effects and low mood is not only a pre-disposition, but a consequence of suffering from a chronic illness. Herbal/nutritional support and body work can be very helpful.
8. Sleep Support
If you recall in Part 2 (read here), sleep architecture is pretty thrown off in ME/CFS patients. I discuss sleep hygiene practices with patients to remove obstacles that interfere with melatonin release (for example - limiting exposure to blue light from screens prior to bed!) Herbal and nutritional support here can be very helpful.
I use a combination of the modalities discussed above to achieve symptomatic improvement in my patients with FM or CFS/ME. Treatment plans are individualized, so they vary from person to person.
Interested in learning more? You can book a free 15min consultation to ask any remaining questions that you may have. If you're ready to dive in and get started, book an appointment here.
Bested AC, Marshall LM. Review of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: an evidence-based approach to diagnosis and management by clinicians. Reviews on environmental health. 2015 Dec 1;30(4):223-49.
Cairns R, Hotopf M. A systematic review describing the prognosis of chronic fatigue syndrome. Occupational medicine. 2005 Jan 1;55(1):20-31.