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Understanding chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is one of the conditions that is very poorly understood. Not only does the recovery tend to be complex but it is often misdiagnosed as well. According to CDC, over 90% of people who live with chronic fatigue syndrome  have not been diagnosed by a doctor. In this article, we will discuss the information sources available for CFS and also what treatment options you can consider if you are living with CFS.

What is chronic fatigue syndrome?

One of the difficulties with trying to define what CFS is is that there is no tests available to confirm if someone has CFS. It is pretty much a diagnosis of exclusion. In other words, if you experience chronic fatigue that cannot be explained by other diseases or conditions, it is assumed that you have CFS.

The hallmark characteristic of CFS is fatigue that is persistent for over six months. Sleep is often affected. However even with rest, the symptoms of fatigue do not seem to fully improve. The tricky part to fatigue is that many diseases and conditions have fatigue as a syndrome. How then do we separate fatigue that is due to CFS versus fatigue due to an underlying condition that is  yet-to-be diagnosed?

What are the symptoms of CFS?

chronic fatigue syndrome symptoms
A survey of 1055 participants in Australia on what it means to be living with MECFS

Symptoms of CFS include extreme exhaustion, poor cognitive capacity, muscle and joint pain. As a chiropractor, I work closely with clients with CFS to help them with their chronic pain and physical function. If you experience fatigue that is debilitating on a regular basis for a prolonged period of time, that doesn’t seem to improve even after a good night’s sleep, then CFS may potentially be a diagnosis you should consider.

Extreme exhaustion can be triggered by working, studying, exercise, etc. Often the tiredness is enough for the person to not be able to continue with their tasks. This means having to take long breaks and not having enough energy to participate in other daily activities (e.g., exercising, hobbies, etc).

How is CFS diagnosed?

The most important thing to note about diagnosis of chronic fatigue syndrome is that it is strictly a diagnosis by exclusion. In other words, there are no specific tests or assessments that can confirm that you definitely have CFS.

During the diagnostic process, you will see a doctor who will go through your history and to get an understanding of your fatigue. They may also order blood and urine tests to investigate other potential causes of your fatigue. Most of these tests should return normal for a CFS diagnosis to be considered.

In 2015, National Academy of Medicine (NAM) published the diagnostic guideline for CFS. While it is by no means the gold standard, most diagnostic criterias for CFS seem comparable. Needless to say, fatigue must be a key feature. For it to be considered chronic, the fatigue needs to last for at least six months. This is slightly different from chronic pain, where the symptoms only need to persist for more than three months.

There are also other feature (not exhaustive) to consider:

  • The fatigue must have a new onset (i.e., not life-long)
  • Must result in substantial reduction in ability to engage in activities such as work, hobbies, social life, etc
  • Fatigue is not the result of usual exertion (i.e., normal activities can also trigger the fatigue)
  • Fatigue is not significantly alleviated with rest

Last year, a new study reported a blood test that may potentially be useful for diagnosis of CFS. The test uses Raman spectroscopy that compares blood cells of people with CFS versus healthy individuals. The test was able to accurately identify CFS in 91% of the participants. It also could differentiate the extent of their condition (i.e., mild, moderate, severe). Due to the novelty of this technique, more research will be required before it can be formally recognised as a diagnostic tool for CFS.

What is post-exertional malaise?

post-exertional malaise triggers
Post exertional malaise is not a just a general sense of tiredness after strenuous activity Even the smallest of activity or event can sometimes be enough to trigger a PEM episode

In my clinical work with clients with CFS or suspected CFS, post-exertional malaise (PEM) is probably the most debilitating.

Malaise refers to a general feeling of discomfort or illness. This is something you may have experienced with infections such as COVID, dengue, etc. Post-exertional malaise refers to malaise that occurs after physical or mental exertion. For people with CFS, PEM could be triggered by very minor exertion that is very well tolerated previously.

The debilitating part to PEM is that the exertion could last days, weeks, or even months in some cases. During this period, CFS patients tend to feel constantly sick and there is nothing that could seem to alleviate their symptoms. It is common for them to not feel better even after a good night’s sleep.

Furthermore, the unpredictability of the condition means there is no way for a person to tell when their malaise will pass. In other words, you wake up day in, day out feeling sick, without knowing when you will get better. This is mentally exhausting and can be psychologically challenging.

As a result of this, it is common for people with CFS to actively avoid activities and mental exertion in hopes to prevent a post-exertional malaise episode.

Who are the right medical specialists to consult for CFS?

In Singapore, a rheumatologist will likely be a good place to start for further investigation. A rheumatologist will be able to determine what tests you should go for as well as help you coordinate your care.

The other name for CFS is “myalgic encephalomyelitis”. Myalgic refers to muscle pain while encephalomyelitis refers to inflammation of the brain or spinal cord. This is why the condition is often managed by rheumatologists.

Other specialists to consider include neurologists, sleep specialists, or pain specialists.

What are the treatment options for chronic fatigue syndrome?

By far, most experts agree that exercise and psychotherapy to be the most useful treatments for chronic fatigue syndrome. Exercise, especially at the beginning, can be difficult (because of PEM). It is best to work with an exercise professional with clinical training for best results.

Psychotherapy such as cognitive behavioural therapy (CBT) can help people with CFS to rethink their condition. Some of the areas that may be worked on include addressing dysfunctional thoughts, beliefs, or attitudes toward their own condition or their recovery. CBT can also help increase motivation, self-efficacy, and address fear-avoidance behaviour (i.e., avoiding activities due to PEM).

In Singapore, Traditional Chinese Medicine (TCM) also offers treatments for ME/CFS. According to Eu Yang Sang, ginseng could help with fatigue while cordyceps can improve energy levels. From their website, sliced ginseng is available from at $43.90 for 100g while cordyceps essence are $91.90 for six 20ml bottles.

Although (empirical, double-blinded) research supporting use of TCM is limited, the risk of adverse outcomes from consuming Chinese herbs is extremely low. While I personally and professionally do not recommend TCM herbs, many clients and personal friends have experienced great results with them.

How does exercise at Square One Active Recovery look like for CFS?

Exercise therapy is what we do offer at Square One Active Recovery for chronic fatigue syndrome. The first objective of exercise therapy in CFS is first to preserve function and physical strength. Through exercise, we aim to help people do more in their daily lives. Because physical activity can induce PEM, part of our work together will also include trying to ascertain the level of exercise you can do without triggering an episode of post-exertional malaise. Over time, we will slowly increase your capacity for exercise through graded exposure.

If your condition is severe, may start to look at loss regulation. This is when your condition is deteriorating and what we are looking at achieving is to minimise the loss of function, strength, energy level, etc that is associated with your condition.

The other benefits of exercise can include improving fatigue and mood. Exercise can also improve sleep. However, it is not entirely clear how exercise can directly with help with among CFS patients. The focus of exercise therapy is largely to preserve function and to gradually increase physical activity levels over time. In doing so, we aim to reduce the effects of CFS and ultimately help our clients help themselves achieve their recovery goals.

Is it possible to get long-term results with CFS?

If we want to look at longer term outcomes, we definitely have to adopt a ownself-help-ownself approach. There is no quick fix for CFS. Ultimately, there are four parts to a satisfactory recovery:

1. Ascertaining and understanding what is your current capacity (e.g., physical, cognitive, etc)

2. Identify current resources and what you can use to help yourself

3. Increasing your current capacity through graded exposure

4. Minimising disrupt to daily life by mitigating potential risk factors

Once you are able to achieve all four, you can surely, albeit slowly, work yourself towards your recovery goals.

Having said that, it’s not uncommon for people to have flare-ups and unexpected episodes in their recovery journey. What is most important, when they come our way, is to be able to effectively mitigate triggers while still able to slowly increase your capacity for daily functioning.

Using a solution focused approach for chronic fatigue syndrome

The uniqueness of using a solution-focused approach is that it allows us to shift the client’s attention away from what is the problem to what is their end goal. From there, we can work backwards to figure out the steps that is required to get there.

It sounds intuitive, but it is not. Most of us, perhaps subconsciously, tend to focus on the problem and find solutions to “fix” it. The issue with a problem-based approach is that it assumes that removal of a said problem brings you closer to your goal. Unfortunately, this is not true.

Take for example adopting cycling as an exercise. Using a problem-based approach you may focus on that you don’t yet have a bike and therefore need to purchase one. Having done so, you rode on a bike for a couple of days and weeks. Then what?

Falling off the wagon

You guess it. You stopped cycling.

What’s next?

You find the next problem you have to address, and you try to fix it. Again, removal of problems do not always guarantee success.

Using a solution focused approach keeps your end goal in focus: I want to cycle on a regular basis. The decisions you consider and make will always revert to the same question, does it take me closer to my goal?

Sure, you may reach the same solution in that buying a bike will bring you closer to your goal. But the difference is that a solution-focused approach makes you reflect on that. Is purchasing a bike really what is going to bring you closer any to your goal?

If so, sure. Why not. Go to your nearest Decathlon and purchase a bike.

If not, especially when past experiences tell you purchasing an equipment does not guarantee its consistent usage, it helps you relook into alternative solutions and find what truly matters in helping you get closer to your goal.

Chronic Fatigue Syndrome is a complex and often debilitating condition that requires understanding and compassion. While much about CFS remains unknown, increasing awareness can help reduce stigma and promote better care for those affected. If you or someone you know is experiencing symptoms of CFS, consider seeking advice from a healthcare professional who is knowledgeable about the condition. Together, we can work towards a greater understanding of CFS and support those who live with it every day.

BOOK A CHIROPRACTOR IN SINGAPORE

Based in Singapore, Square One Active Recovery offers treatments with a very big difference. With our evidence-based exercise approach, you can achieve your recovery goals in just 12 weeks. Not getting results from your chiropractor, TCM doctor or physiotherapist? Talk to us and find out how we can take your recovery to the next level.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.






    author avatar
    Dr. Jesse Cai
    Chiropractor

    Jesse, a chiropractor with a unique approach, believes in empowering his clients to lead functional and fulfilling lives. Jesse worked with high-level Australian athletes, including roles such as Head Sport Trainer for Forrestfield Football Club, board member of Sports Chiropractic Australia, and member of Sports Medicine Australia.

    author avatar
    Dr. Jesse Cai Chiropractor
    Jesse, a chiropractor with a unique approach, believes in empowering his clients to lead functional and fulfilling lives. Jesse worked with high-level Australian athletes, including roles such as Head Sport Trainer for Forrestfield Football Club, board member of Sports Chiropractic Australia, and member of Sports Medicine Australia.
    author avatar
    Dr. Jesse Cai Chiropractor
    Jesse, a chiropractor with a unique approach, believes in empowering his clients to lead functional and fulfilling lives. Jesse worked with high-level Australian athletes, including roles such as Head Sport Trainer for Forrestfield Football Club, board member of Sports Chiropractic Australia, and member of Sports Medicine Australia.