Chronic Fatigue

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Therapeutic Protocol for Chronic Fatigue Syndrome or Myalgic Encephalomyelitis

A comprehensive approach is absolutely necessary in the treatment of this difficult health syndrome termed Chronic Fatigue Syndrome (ME/CFS). At present, pharmaceutical medicine plays a minor role in standard therapy, with management of the disease, which results in more than half of diagnosed patients worldwide unable to work, limited to cognitive behavioral therapy and graded exercise and pacing. The world health community has stressed that a number of health problems should be examined in these cases, including allergic disorders, hormonal imbalances, adrenal stress, liver dysfunction, lipid imbalances, constipation, acid imbalances, fungal and yeast overgrowths, and essential fatty acid imbalances and nutritional deficiencies. Since most health authorities agree that ME/CFS is multifactorial and highly varied in underlying causes, triggers and symptom manifestation, but is most likely tied to chronic low-grade infections and the reactions to these infections, with immune dysfunction, toxin overload and widespread mitochondrial dysfunction, a persistent and comprehensive approach to therapy is evidently needed. This holistic protocol should include clearing of any lingering low-grade infections, aiding detoxification, and restoring mitochondrial health in the central nervous system. CIM/TCM may provide a host of restorative therapies and therapeutic approaches, combined in a single treatment session.

This step-by-step comprehensive approach is often overlooked in the field of modern medicine, where doctor's visits are kept short. The TCM physician, or Licensed Acupuncturist, is the perfect person to integrate into the protocol to make a thorough review of these potential problems and come up with a holistic and multi-dimensional approach to treatment. Only when the patient takes a pro-active approach and shows a persistence and determination, working with a knowledgeable and competent physician of Complementary Medicine will the problem be solved. Acupuncture, nutrient medicine, herbal medicine and physiotherapy have all been proven to have some beneficial effect, and used together as a comprehensive treatment, the chance of success is greatly enhanced.

The therapeutic protocol needs to be individually tailored due to the variety of symptoms and stages of disease in chronic fatigue. An acute or subacute case of Epstein-Barr virus mononucleosis could call for both specific antiviral herbs, and herbs to stimulate a stronger immune complement response. Viscum alba is an herb that stimulates a strong interferon response, for example, but does have a dose dependent mild toxicity, and thus should only be used with prescription and monitoring by a Licensed herbalist. In chronic cases, antiviral herbs may be of limited benefit, but therapy to increase immune health and response could benefit dramatically, and immunomodulatory herbs such as Cordyceps (Dong chong Xia cao) have now been proven to significantly inhibit expression of Epstein-Barr Virus and benefit the immune system responses dramatically, via a number of pathways, as well as Astragalus (Huang qi) to a lesser extent. Few herbal chemicals have been found to be specific to EBV, but European olive leaf tincture has been studied and found to inhibit certain amino acid processes in the viral membrane, making this herb a potential therapeutic that will be further studied. A variety of Chinese herbs have been found useful in study, including Ban lan gen (Isatis), Gan cao (licorice root), and Hu zhang (Bushy knotweed / Polygonum cuspidatum), the source of the now famous herbal chemical resveratrol. Echinacea is an herb found to have a variety of effects that potentially inhibit EBV indirectly, and indirect effects were also evident in studies of St. John's Wort tincture.

A variety of Chinese herbs have proven antiviral effects, and the ability of the Complementary and Integrative Medicine (CIM) physician to prescribe short courses of a variety of herbs in formula inexpensively provides the patient with a broad antiviral effect to counter the low grade deep viral infections associated with chronic fatigue syndromes. There is no safe and effective antiviral course of therapy in pharmaceutical medicine. This aspect of herbalism makes the integration of the Licensed Acupuncturist, who is the primary professional herbalist in the United States, if herbal specialty is part of their medical school training, an essential part of treatment with CFS/EM. Current research is identifying very specific antiviral effects for various herbs to help guide therapy. Many of these effects are immunomodulatory of the innate immune system, and this is important, because the herbal therapy will help restore your natural homeostatic mechanisms, and not result in a dependency on chronic drug use. Since dysfunction of the innate immune system is a central aspect of the underlying cause of many of these chronic fatique syndromes, restoration of the immune complement system and its regulation is essential.

Traditional Chinese Medicine (TCM) has long utilized combinations of herbs to simultaneously promote and modulate the innate immune responses and stimulate antiviral and antimicrobial effects. Often, these herbal formulas also contain herbs that stimulate increased circulation and benefit the nervous system or production of white blood cells and immunomodulating cells, or help to promote healthy membranes. The allopathic system in standard medicine will target just one aspect of the pathophysiology of systemic conditions such as CFS/EM, but TCM will provide a broad array of benefits. Studies cited below prove that common herbs utilized by professional herbalism have specific effects that inhibit the key immune cytokines driving dysfunction in encephalomyelitis and chronic fatigue. These herbs and herbal products must be of high quality, and the effects are dose-dependent, and for this reason, in a country that does not regulate the commercial herbal industry, utilizing a professional to prescribe is also essential.

Current research with Chronic Fatigue Syndrome and Complementary Therapies

Because Chronic Fatigue Syndrome / Myeloencephalopathy (CFS/ME) is such a complicated and systemic holistic health problem, an intelligent patient will quit looking for a simple treatment strategy, and instead look for a knowledgeable Complementary Medicine physician to utilize current research and devise a comprehensive treatment protocol. The combination of acupuncture, herbal and nutrient medicine, and even instruction in medical qigong practices, has been heavily researched, with promising results. This shows that the medical field has recognized the efficacy of these treatments. A single piece of the treatment protocol, though, may not be effective enough, and a more complex and thoughtful protocol is recommended. While complex treatment protocols are often avoided, a thoughtful patient realizes that incomplete treatment strategy may prolong the disease perpetually, while adoption of a more comprehensive strategy for a short time may result in less effort and money spent on care in the long run.

In 2014, a meta-review of all types of CIM/TCM therapies for the treatment of CFS/ME was conducted at the Beijing University of Chinese Medicine, Hebei University in Baoding, China and UiT The Arctic University of Norway, and concluded that: "TCM appears to be effective to alleviate the fatigue symptom for people with CFS. However, due to the high risk of bias of the included studies, larger, well-designed studies are needed to confirm the potential benefit in the future." The treatments studied in the 23 Randomized Controlled Human Clinical Trials (RCTs) found in 6 databases of medical research, which involved 1776 participants, included acupuncture, Chinese herbal medicine, Qi gong, moxibustion, and physiotherapy, and used the Cochrane risk of bias analysis (PMID: 25146068). The problem with this type of evidence, as outlined below, involves the study design in RCTs, which have been designed to evaluate single pharmaceutical chemicals, not the broader holistic effects in CIM/TCM, which do not adhere to the blinding of both patients and physicians to the selection of so-called placebo and actual treatment in these modalities, and thus involve "risk of bias". Obviously, this double blinding is easy for a pill with no taste, but is nearly impossible with manual therapies such as acupuncture and Qi gong, where not only the physical stimulation but interaction between the physician and patient is important, or to the use of herbal medicines, which have unique tastes, even in pill form. What is implied in this type of study is that the research is not valid, and that there is no strong evidence of benefit, which is untrue. This negative implication produces its own type of placebo effect, crating a negative perception of the treatments, and reducing the clinical effectiveness, as well as the utilization. Many scientific studies have measured many physiological benefits from this variety of treatments in integrative care of CFS/ME, and patients would be best advised to seek out treatments that combined these various modalities in the clinic, achieving a better synergistic and holistic set of effects. Short courses of frequent treatment and more prolonged courses of individualized herbal and nutrient medicine that used a goal-oriented step-by-step process would achieve the best outcomes. While there is no sudden miracle cure for many patients with chronic CFS/ME, these complementary therapies offer much benefit, and are most effective when the underlying disease processes that are responsible for CFS/ME are identified. The lack of a real diagnostic differentiation in standard medicine is of much concern, and should be the focus in future improvement of care. We cannot effectively treat that which we do not fully understand.

In complicated pathologies research identifying effective treatment strategies face enormous hurdles. The standard for modern research, the double-blinded placebo-controlled clinical human trial, is the end or the path of scientific study performed to judge safety and efficacy of new pharmaceutical chemicals. These new drugs are designed to perform one simple act to affect an allopathic effect on a specific disease mechanism. In chronic fatigue syndromes the patients may have numerous biological dysfunctions that need correction, and we still do not know whether the syndrome now termed Chronic Fatigue Syndrome / Myeloencephalopathy, or Myeloencephelitis (CFS/ME) is a single defined syndrome or a group of syndromes that are distinct. Using this type of research standard, the double-blinded placebo-controlled human clinical trial, to decide whether single treatments within the scope of a holistic treatment protocol in integrative Complementary Medicine is proven effective is perhaps irrelevant. Various treatments in Complementary Medicine should serve as adjuncts to care, to integrate with an allopathic medicine, and to improve the outcome or speed the cure. The problem in difficult and complex pathologies such as CFS/ME is that allopathic medicine has not found that single allopathic treatment protocol. There is no central modern treatment to integrate with. Obviously, the patients, in choosing their treatment protocol, and it is the patient that should choose in a free society, must look at other objective proof of treatment efficacy, and indeed, must look at a number of treatments that can be combined in an individualized protocol to best achieve realistic goals of restoration and relief from the chronic fatigue symptoms.

Utilizing acupuncture stimulation in the treatment protocol for CFS

Recent larger double-blinded placebo studies with acupuncture have yielded mixed results due to problems with the study design. A large Mayo Clinic trial with true placebo showed significant benefit in treating CFS with acupuncture, and little benefit from placebo, while subsequent trials have shown statistically equal positive effects from the acupuncture points selected compared to nearby points off the meridian, and points stimulated without a real needle. This presents confusing data to the patients as they read short study summaries and try to decide if acupuncture will help them. All of these clinical trials have demonstrated significant benefit from acupuncture, but the study design, using needle stimulation at points near the points being studied as a form of sham acupuncture, also demonstrated significant benefit, somewhat less than the primary points chosen, but not significantly different statistically. Other articles on this website, in the For Practitioners section, Research, for example, outline the problems with these double-blinded studies designed for assessment of pharmaceutical safety and efficacy. These problems have prompted the British Medical Service and the European Union to call for an end to the double-blind design for acupuncture and manual therapies, and instead use a therapy blinded only to the patient, with devices that conceal whether the patient has been penetrated with a needle. If the Chronic Fatigue patient looks carefully at the full study results of acupuncture efficacy in CFS, they will see a promisingly significant reduction in pain and fatigue, and improved sleep and quality of life measurement, from acupuncture therapy, even when performed with the constraints of study design that do not allow optimal point selection, needle manipulation, or the usual combination of therapies seen in actual holistic acupuncture practice. The scientific data shows that acupuncture holds much promise for these patients, yet the study authors, who are usually medical doctors with bias, often downplay the promise of acupuncture and the positive treatment results, usually stating that acupuncture did not statistically perform better than the treatment chosen as the sham or placebo acupuncture in the study design.

One example of acupuncture study in recent years elucidates the complexity of analyzing the true potential of a manual medical treatment in the treatment of complex pathologies such as Chronic Fatique Syndrome and Fibromyalgia. While acupuncture stimulates broad homeostatic modulating effects, these studies focus on just one or two outcomes, often designing the study to achieve negative analysis.

In a study published in the Annals of Internal Medicine, sham needling, involving acupuncture points not of study designation as the primary points, which the treating acupuncturist was unaware were not the studied points, showed a drop in pain intensity from an average of 7.2/10 to 4.8/10, and acupuncture using the chosen points showed a drop in pain intensity from about 7.8/10 to 5.4/10. Decreases in fatique intensity were similar. Both the so-called "sham" acupuncture points and the ones chosen as the primary points could be utilized clinically in the treatment of pain. The simulated acupuncture was performed on the chosen needle sites and involved use of a toothpick in a guide tube to stimulate the point and mimic therapy without actual metal needle insertion. In effect, the point was stimulated by a means of acupuncture used historically in China, where a number of types of the 9 classic needles did not penetrate the skin, but rather stimulated a surface trigger point. The point that must be considered is that acupuncture trigger point stimulation works by stimulating a response in the body and mind of the patient, not by a direct effect of the metal needle. The fine stainless steel needle was the product of the evolution of the technique, and before we had steel, acupuncture was successfully performed with needles of other design and make up, including shards of stone, bamboo, and cruder metals that could not be formed into fine filiform needles. Use of the early needles, even ones that stimulated the points without skin penetration, produced positive outcomes that sustained the practice of acupuncture over the thousands of years of its popular practice in medicine.

In these acupuncture studies with CFS/ME patients, manipulation of the needles was not allowed, although this is routinely performed in the clinic, and recent studies at Harvard have demonstrated the diverse effects of needle manipulations and differing sensations on even the central brain. Using needle manipulations complicate the variations in study and are usually not allowed in order to achieve uniform responses. Thus, the difference between the unmanipulated needle insertion and the so-called sham or placebo techniques is not a great difference. These simulated treatments also showed reduction in pain and fatique intensity, though, and improvement in sleep, and quality of life for the CFS/ME patients. Obviously, the so-called "simulated" or "sham" acupuncture stimulation had an actual effect. The research designers attribute the positive effects of treatment to placebo effect, and discounted the acupuncture benefits. Recent study of the placebo effect has shown that this effect is growing in efficacy over the years, and in fact, even in pharmaceutical studies, is now generally nearly as effective in therapy as the pharmaceuticals themselves. A placebo effect potentially achieves symptom relief, biological effect, and cure. Since acupuncture stimulation acts by stimulating normal homeostatic mechanisms in the body, the difference between an effective placebo response and an effective acpuncture stimulated response is a fine line.

Dismissal of acupuncture benefits as placebo effects does not diminish its efficacy. The question of study design in acupuncture, where the acupuncture and sham acupuncture both consistently generate significant benefit, has become more and more controversial. In the study of Chronic Fatique Syndrome, where the mechanisms of pathology are still unclear, but involve systemic factors and potential neurohormonal dysfunction, and standard pain medication has little positive effect, the patient welcomes improvement regardless of whether this is considered placebo effect or not. In addition, acupuncture in the clinical setting is most often combined with herbal and nutrient medicine, and sometimes with effective deep soft tissue pathology, providing a package of care that is greater than acupuncture alone. Acupuncture stimulation provides a potential for many positive effects for the CFS/ME patient, and is just one part of the treatment protocol, not the whole package. Complementary Medicine, and especially the treatments available in the specialty of Traditional Chinese Medicine offer many resources for the CFS/ME patient, and can be successfully integrated into the care from the M.D. or the Naturopathic physician.

In China, the study of specific acupuncture protocols in the treatment of CFS/ME continues to both show positive benefits and help guide the TCM physicians in point selection and needle manipulation techniques. Here are some examples.

Both manual stimulation and electroacupuncture have demonstrated benefits. A study in 2010 at Guangzhou University in China (PMID: 20862932) studied 90 patients that were randomly divided into groups receiving simple acupuncture at three points (DU20, DU16, and ST9), and patients receiving injection with a glucose and herbal solution at those points. A short course of therapy resulted in fatigue scores reduced from averages of 9.37 to 5.41 with the acupuncture stimulation, and 9.08 to 7.34 with the injections of either sugar and herbal solution, based on analysis of parameters of function in the brain as well as physical fatigue parameters. Both types of treatment showed significant improvement, and the acupuncture stimulation showed significantly better improvement than the herbal injections. The sophistication of the study, both in choice of comparative treatments, and in the measures of outcome, were much improved over earlier studies. Such studies provide excellent guidance for the TCM physician, and guide the use of various point selection groups and types of stimulation. Another study in 2010 at the Chengdu University in China (PMID: 20568438) studied the effects of specific electroacupuncture stimulation on restoration of the circadian rhythms in CFS/ME patients. This study analyzed P3a and P3b markers after stimulation with electroacupuncture at just two points (ST36 and UB23). The circadian rhythms of P3a and P3b latency were corrected by the treatments, and the cognitive scores of the patients improved. Links to these studies are available in the section of this article entitled Additional Information.

Many scientific studies of acupuncture related to the various known biological dysfunctions in Chronic Fatigue Syndrome have now been performed and meta-analysis of these various published studies have also been conducted. Much of this information is available to the public on the NIH scientific study database PubMed. A meta-analysis conducted by the China Academy of Chinese Medical Sciences in 2009 (PMID: 20209981) looked at 28 studies that met rigorous standards of modern medical research and concluded: "Acupuncture therapy is effective for CFS, but still needs to be confirmed by more high-quality studies." Both funding and the problems of study design and controversies in this realm have presented problems in the completion of large high-quality studies, but the research continues. Whether the political and economic hurdles that have stymied the end stage human clinical trials of acupuncture will soon be overcome, and standard medicine, and subsequently government guidelines, will finally fully endorse acupuncture as a prominent part of the therapy in Chronic Fatique Syndromes, is still in question. What is not in question is whether the efficacy of acupuncture has been established. The individual patient must decide whether they want to utilized this inexpensive and simple, practical and effective treatment within a broad protocol of treatment to overcome chronic fatigue and pain.

Nutrient and herbal medicine in the treatment of CFS/ME

Even standard medicine now supports nutritional and herbal medicine in the treatment of CFS/ME. Numerous prominent medical websites and universities support this therapy, although their support is very limited, and cautious not to list many types of therapy being studied and proven effective. Once again, the political and economic factors and industry bias, in an industry that makes up over a fifth of our total economy in the United States, is considerable. The individual patients often need to look even beyond these small endorsements of nutrient and herbal therapy to find effective proven strategies. Study of nutritional deficiencies common to patients with Chronic Fatique Syndrome, and listed on standard medical websites, include CoQ10, L-Tryptophan, zinc and Vitamin B12 (methyl or hydroxycobalamin), which have been noted as deficient in a high percentage of patients studied. The use of L-Carnitine, Omega 3 fatty acids, folic acid, magnesium, and NADH have all been studied and shown to be effective on a percentage of patients. A 2006 study at the Fibromyalgia and Fatique Centers in Dallas, Texas, found that the supplement D-ribose significantly reduced symptoms of pain, fatique, insomnia and reduced mental clarity. D-ribose is a sugar metabolite that stimulates a high production of ATP, the main cellular fuel. B2 riboflavin and B3 inositol hexcotinate, in a slow release form, has also been proven to benefit mitochondrial health and efficient production of ATP to reduce fatique. While these various medicines alone may not exert a significant quick improvement in all individual patients, the combination of these various studied nutrient medicines cannot hurt the patient, and will only contribute to greater overall health. They may all be combined with effective acupuncture and herbal protocols.

Research in 2011 at the University of South Australia School of Pharmacy and Medical Sciences (see study link below in additional information) revealed that chronic fatigue syndrome may be associated with altered carnitine homeostasis. Concentrations of oleyl-L-carnitine and linoleyl-L-carnitine, related to an imbalance of omega-3 and -6 fatty acids, were, on average, 30-40 percent lower in studies patients than in controls. An accumulation of omega-6 fatty acids, especially in the liver, was hypothesized as a contributor to the disease. Use of an omega-3 fatty acid supplement, such as krill oil, in combination with acetyl-l-carnitine and P5P was noted as potentially increasing carnitine palmitoyltransferase-1 activity improving symptoms of chronic fatigue over time. The use of an herbal formula to improve liver health and function, combined with a short course of acupuncture to help achieve this goal, may improve the effects of this part of the therapy greatly. You may access these studies in the section of this article entitled Additional Information.

Much attention has been focused on the use of treatment protocols to address gastroenteritis, functional gastrointestinal diseases, and parasitic diseases to relieve or resolve Chronic Fatigue Syndrome. Neuroimmunopsychology and other disciplines that interface between neuropsychiatry and gastroenterology, exploring the brain-gut interaction, have led to studies of a number of treatments to restore gastrointestinal health to relieve pathologies of neuroimmunobiology, such as encephalomyelitis. A study (cited in Additional Information) at Punjab University, Chandigarh, India, studied the effect of Lactobacillus acidophilus (probiotics) and alginate beads loaded with Lactobacillus acidophilus on animals with induced Chronic Fatigue Syndrome. These probiotic treatments significantly improved symptoms, and decreased TNF-alpha levels in blood, also showing improvement in splenic hypertrophy, hypotrophy of the thymus, and attenuated oxido-nitrosative stress in the CNS. Incorporation of a restorative protocol of the biota appears to be a potentially important part of the therapeutic protocol.

Study of herbal medicines in the treatment of chronic fatigue syndrome has been extensive in Asian countries, but studies published in Western medical journals have been limited. Benefit was seen with ginseng, echinacea, Siberian ginseng, St. Johns' Wort, Gingko biloba and bilberry extract in Western studies. These herbs are not the strongest herbs in the Materia Medica, though, and the professional herbalist looks to more effective herbs used over centuries in TCM medicine and studied in modern scientific research. This research confirmation of many herbs is now extensive, but still mainly from China, Japan, and Korea. The data from these studies is too extensive to list in this article, and the patient should consult with TCM physicians to understand the specific herbal medicines that that herbal specialist chooses. A 2009 meta-analysis from the University of Alberta, in Canada, found that the problems of applying pharmaceutical research standards in human clinical trials, namely the randomization of a double-blinding and placebo process, was still problematic, and that none of the herbal studies in 13 research databases concerning herbal efficacy in CFS met these rigid standards, although over 2400 studies were analyzed. The authors stated that "methodological limitations resulted in the exclusion of all studies". Randomly blinding both the treating physician and the patient to an herb with an obvious taste and appearance, and devising a placebo indistinguishable from the herb, is a design problem. Most of the Chinese studies still analyze the effects of specific herbal chemicals compared to no treatment. Since there are no pharmaceutical treatments, comparative studies are not performed in this regard. Since 2009, though, more rigorous studies in China have devised acceptable RCT studies, which have produced promising results. The main problem in these studies is that no specific Chinese herbal chemical is studied as a single medicine in the protocol. An array, or formulas, of chemicals will be utilized, and these formulas will contain hundreds of complement chemicals to achieve goals. Patients need to be aware of this difference between pharmaceutical medicines and holistic treatment protocols.

Often, professional herbalists need to look beyond these simple randomized controlled human clinical trials of herbal medicine to determine what protocols are proven to work in a holistic treatment protocol. For instance, in 2014, a multicenter research study of the main active chemical in the Chinese herb Cordyceps (Dong chong Xia cao), conducted at the Kyungpook National University School of Pharmacy, the Sungkyunkwan University Department of Genetic Engineering, the Catholic University of Korea College of Medicine, the Catholic Kwangdong University College of Medicine, Duksung Women's University College of Pharmacy, and the Korea Institute of Bioscience and Biotechnology, found that Cordycepin significantly suppresses Epstein-Barr Virus replication and transfer in many types of human tissues and cells. Since Epstein-Barr Virus (EBV) has been found to be a hallmark of many cases of Chronic Fatigue Syndrome, this novel therapeutic aid could be invaluable in the holistic treatment protocol. Cordyceps extract was also noted to possess antiviral, antimicrobial and anti-inflammatory effects against multiple viruses and chronic microbial infections (PMID: 25621301). Such research is quickly affirming that the standard treatment modalities in TCM for chronic fatigue have been very effective, even if none of them presents a miracle cure by themselves, and helps guide individualized design for holistic treatment protocols in the future that will be more and more effective as Complementary and Integrative Medicine (CIM) becomes more evidenced.

Herbal protocol is usually individualized to the patient and addresses a variety of concerns. In clinical practice the herbalist will prescribe formulas based on the individual's need and the goals of therapy. In Chronic Fatigue Syndrome (CFS/ME) these goals could include hormonal balance, neurochemical balance, antioxidant therapy, health of the gastrointestinal system, liver detoxification help, and other protocols. The patient should stick to a professionally guided herbal therapy for some time to judge results.

Instruction in various therapeutic activities, including external qigong therapy, can be very helpful to the fibromyalgia patient as well as the patient with chronic fatigue syndrome, which often overlap. Qigong therapy in this form can be taught by a competent acupuncturist that is trained, and involves a variety of techniques that are simple and enjoyable. Read the studies in the section of this article entitled Additional Information that proved benefit. Links to the studies and summaries are provided.