By John Messmer
Penn State Family and Community Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Fatigue is one of the more common complaints patients bring to primary-care doctors. It is a challenging problem for the patient and the physician. Being "tired all the time" is frustrating for the person who can not manage a full day of work or school or stay awake for a normal day's activities. For physicians, it means sorting through all the possible causes of fatigue to find and, hopefully, fix the problem.
Almost everyone has experienced fatigue from working too hard or studying too long or from transient difficulty staying or falling asleep. Usually the problem passes and life gets back to normal. For some, however, it lasts for months and is severe enough to interfere with work, school or home obligations. When it is that severe, it may be more than simple fatigue.
Chronic fatigue syndrome or CFS combines the hallmark symptom of fatigue with impaired concentration and memory, and may include sore muscles and joints, headaches and swollen lymph nodes. If symptoms like these last more than six months and sleep is not refreshing and if work, educational, social or personal activities are impaired, it could be CFS.
Fibromyalgia is similar to CFS but the fatigue is less and pain and stiffness are greater. People with fibromyalgia have chronic pain in the muscles and tissues that surround and move joints, particularly the neck, spine, shoulders and back. Sleep is also impaired and poor sleep may be the inciting problem. People with either condition can experience bloating, dry mouth and eyes, irregular heart rhythms, irritability and depression, tingling and numbness, difficulty breathing, diarrhea, and abdominal pain.
People with CFS or fibromyalgia not only face the problem of having these illnesses, but because there are no blood tests or X-rays to diagnose them, some physicians and patients' families do not believe they have a true illness. Many other illnesses, including psychiatric problems, have similar symptoms and sorting them out can be frustrating. Hypothyroidism, sleep apnea, narcolepsy, depression, schizophrenia, autoimmune disorders, various cancers, hormonal disorders, infections, alcohol and substance abuse and adverse drug reactions all overlap symptoms and physical findings of CFS and fibromyalgia.
Faced with the nonspecific nature of these problems, patients and physicians have searched for a diagnostic test to explain the conditions and prove it's not "all in their heads." Tests for various viruses including Epstein-Barr, herpes virus, retroviruses and intestinal viruses have not proven helpful. Various assays of impaired immune function have been inconsistent and should not be used to diagnose CFS or fibromyalgia. CT scans, MRIs, nuclear medicine imaging all are useless diagnostic tests except to rule out other diseases that have similar symptoms. The only recommended lab tests are a blood count, chemistry profile, thyroid level, urinalysis and a test for inflammation called a sedimentation rate.
So far, there is no specific treatment for CFS or fibromyalgia. Each person's treatment must be specifically tailored, although some facets of care are universally recommended. Education for the patient and family is essential as in all chronic illnesses. Understanding the problem fosters a positive attitude and effective communication while reducing the impact the problem has on family dynamics.
Exercise is essential for everyone, including CFS and fibromyalgia patients. It might seem counterintuitive to ask someone experiencing fatigue to exercise, but a gentle and gradually progressive exercise program prevents deconditioning from lack of activity and begins to restore tolerance of exertion. Exercise helps improve mood and encourages restful sleep. Physical therapy, massage, hypnosis, acupuncture, yoga, chiropractic and aquatic exercises have shown benefits in many cases.
Some medications can be helpful. Anti-inflammatory medications relieve pain although chronic use might irritate the stomach or affect the kidneys. The patient's doctor can advise the person about the relative safety for their particular case. Antidepressants, particularly a group of older ones called tricyclic antidepressants, in doses far lower than are used for depression, have been very helpful for pain relief and restoring restful sleep. Stimulants may have a role in treating fatigue, particularly a newer agent, modafinil, which is approved for narcolepsy. Occasionally, medications to control heart rate or low blood pressure are used in specific circumstances.
Unfortunately, since there is no sure-fire cure, CFS and fibromyalgia patients desperate for treatment have tried unproven therapies and even treatments shown to be ineffective. Immune system stimulants, steroids, DHEA, gamma globulin, enemas, extracts of various animal organs and surgical treatments have not proven effective. Mineral supplements, amino acids, coenzyme Q-10, herbal supplements and dietary supplements have yet to show any benefit.
Approximately 15 of every 100,000 people have CFS and about one in 50 have fibromyalgia. Although they are not fatal, they are chronic and can be debilitating. Treatment is not simple and it requires effort by the patient, but improvement is possible for most people.
For information on CFS go to http://www.cdc.gov/ncidod/diseases/cfs/index.htm and for fibromyalgia go to: http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm on the Web.