Chronic Fatigue and Pain Syndrome
by Dr. Mo Lerner

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So many times, we doctors have to sit in judgment of our patients. Just like judges who adjudicate, we must decide, based on the weight of evidence before us, whether those we see are telling the truth or not. When there is potential secondary gain involved, such as time off work or a monetary settlement, we cannot help but look suspiciously at our patients. I would like to think I can see through most facades, but even after all these years I am still uncertain in some situations. That is because, despite all the fancy scientific diagnostic capabilities, pain and fatigue are still subjective sensations. The pain of a burn or serious wound is obvious, but what about the muscle aches and fatigue ascribed to The Yuppie Flu and Fibromyalgia?

These two conditions have come into vogue in the past decade as diagnoses of exclusion. When doctors cannot find any anatomical or pathological evidence of infection or disease in a situation where so many people complain of similar symptoms, they usually describe these phenomena as Syndromes of Unknown Origin. Although Fibromyalgia ("fibro," as in muscle fibers and "algia" meaning pain) and Chronic Fatigue Syndrome (aka CFS, "Yuppie Flu," EB "Virus-Like" Disease) are not necessarily related entities, I will deal with them in this column because they share many similarities.

Epidemic of the Boomers
Generalized fatigue lasting at least six months that just does not seem to respond to rest is one of the main symptoms of CFS. When so many people began showing up at their doctors with this picture, scientists began to believe that the culprit must have been a virus. Many viruses, such as the initially suspect Epstein Barr virus (EBV), can lie dormant in the body for months or years because they hide inconspicuously in a variety of tissues and even inside the genetic make-up of the bodys own cells. They are then often reactivated in times of stress, as many of you with cold sores (Herpes virus) will attest to. In CFS, the onset of the illness is usually insidious but it can (and often does) follow an acute flu-like illness. Reactivation of a virus can occur in certain tissues such as the throat. As the immune system of the body tries to fight off this renewed invasion, soldier cells muster and multiply in the lymphatic system, causing swollen and often tender lumps to form in the neck and other areas of the body. The Epstein-Barr virus, best known for causing painful lumps and bumps in the neck, armpits, and what was colloquially referred to as the "kissing disease" (Mononucleosis), is a good example of an organism displaying this characteristic. A battle ensues with the enemy viruses, in which little chemical bombs explode all over the body. These chemicals cause fatigue, aches, pains, fever, and stiffness. This chemical warfare is even known to be responsible, in some circumstances, for changes in mood and thinking skills (cognition).

It just so happens that in CFS, victims complain of generalized fatigue, insomnia, sore, aching muscles, sore throat, enlarged lymph glands, and mood swings. Anxiety, depression, memory loss, and the inability to concentrate trouble many patients. Although the onset is usually gradual, it often follows an acute infection or stressful time. It is no wonder scientists have suspected viruses as the offenders in CFS.

After years of extensive research, however, no one has ever definitively found the cause. We do know that CFS mostly, but not exclusively, affects attached/married women in their twenties to forties who are intelligent achieversoften professionals in fairly high stress jobs. The symptoms can stick around for years.

Fibromyalgia
Ninety percent of people with Fibromyalgia also complain of chronic fatigue, not relieved by adequate sleep.

In order to differentiate this problem from a variety of other conditions and also to lend it some legitimacy, researchers have indicated that in order to make a true diagnosis of Fibromyalgia one must have a very specific and fairly complex group of symptoms.

If the body is divided into four quadrants (picture a line drawn vertically from the center of your nose through the belly button and distally, crossed by a vertical line through the stomach area) one must have pain in all quadrants for at least three months. Also of interest are the actual points of pain/tenderness that must occur in at least eleven of eighteen specific places in the body. These include the back of the base of the head, sides of the neck, in the shoulder blades, the breast bone, back of the elbows, hips, top of the buttocks, and behind the knees.

The pain is of an achy nature, aggravated, of course, by local prodding. One of the reasons the pain has often been dismissed as malingering is that it seems to get worse with physical activity. Interestingly, it also gets worse with complete inactivity (like morning stiffness) or exposure to cold weather and high humidity. There is often the numb sensation of pins and needles and a subjective feeling of swelling in extremities. There may also be objective evidence of Raynauds Syndrome, also known as "cold hands" disease, for obvious reasons. Migraine-like headaches, associated with classic sensitivity to bright lights, are a common complaint. Irritable bowels, painful menstruation, and a weak bladder round out the symptomatology.

Just as with CFS, the cause is a mystery, but it is suspected that infection or some traumatic emotional or physical event precipitates the most severe form of the illness. More commonly, it follows a gradual course, increasing in intensity over time. The person profile is similar to CFS with females affected somewhat more than males.

Tests
Since the cause of both of these problems is unknown, no tests exist that specifically point in their direction. Nonetheless, it is important to rule out other problems such as cancer, Human Immunodeficiency Virus (HIV) and slow metabolism (Thyroid malfunction) or a variety of arthritic or psychiatric disorders. For this reason, doctors should order basic laboratory, radiological and possibly psychiatric examinations, looking for organic/psychogenic pathology that can be corrected.

Treatment
One of the biggest problems for those who truly suffer from these disorders is that their doctors, faced with normal tests and non-specific signs, often dismiss their patients as suffering from depression or anxiety. Prescribing sedatives such as Benzodiazepines (e.g. valium) can be deleterious, amplifying the symptoms. Telling a patient that "its all in his/her head" causes further deterioration if he/she gets no relief with standard doses of antidepressants or regular Psychotherapy. "Doctor shopping" and a sense of hopelessness are inevitable. This is not to suggest that all psychotherapy is contraindicated. Remember that emotional and physical problems can precipitate these diseases and the underlying antecedent should be treated.

The good news is that creating even a modest change in lifestyle pattern often improves the picture considerably. Classic anti-inflammatory medications geared towards arthritis or overt muscle strains may not work unless in combination with other modalities.

Biofeedback and cognitive therapy make use of conditioning techniques that seem to override the pain and suffering parts of the brain in favor of those concerned with relaxation and contentment. Classic physiotherapy in isolation for sore muscles and bones almost universally fails. However, graded exercise (people with Fibromyalgia usually feel better when they are moving like the proverbial tortoise, slowly but surely) and, in particular, aqua-sizing (pool exercise) are the keys to surmounting these syndromes. As the body continues to increase movement, muscles and joints become lubricated and more relaxed.

Avoidance of opiates (Codeine, Morphine,) or other addictive medication, unless necessary, is a good idea. Frequent smaller meals, regular sleep hygiene, and a distinctively low dose of certain antidepressants (Amitryptyline or Cyclobenzaprine) taken a few hours before bedtime may help. Joining a support group of people in a similar situation invariably improves the quality of life.

Real Illness?
Over the years, physicians have often dismissed these problems as simple aches and pains of life or as indicative of job avoidance. After all, the economic implications of Fibromyalgia are astounding. In the workplace, employers claim that those afflicted with this syndrome only attain forty percent of the productivity of normal workers. Nearly one half require some assistance with activities of daily living (lifting, cleaning etc.) and almost one quarter of those diagnosed are on permanent disability payments.

There are undoubtedly in society some who abuse the system, feigning illness and injury. One can understand the skepticism concerning CFS and Fibromyalgia. Not only are they similar in presentation, they both have a broad spectrum of non-specific symptoms that cannot be proven or tested for, and cause a tremendous strain economically and on productivity by virtue of absenteeism. I have seen many "slackers" in my career and admit that every time I come across a body building Adonis who is on sick leave because of a sore finger or questionable headache.

In fairness, there now seems to be scientific acceptance of the fact that one in twenty people may suffer from Fibromyalgia and thousands from Chronic Fatigue Syndrome. If you are one of those, seek help from an unbiased and caring health care professional or contact The American College of Rheumatology or your local Arthritis Society office. Most importantly reduce stress in your life, get out, and enjoy.





Heretic Physician