Naturopathic treatment for Chronic Fatigue Syndrome and Fibromyalgia

*Last updated February 2021 by Eric Chan

A large proportion of my naturopathic patients present with some form of fatigue and fibromyalgia type pain. In many cases, the fatigue may be a symptom of a coexisting condition. For example, fatigue is one of the many symptoms of diseases such as rheumatoid arthritis, anemia, hypothyroidism, congestive heart failure, and so forth. In fact, fatigue can be a symptom of many disease processes. This is why a conventional workup, including history, examination, and when necessary, laboratory investigation, is necessary to rule out other disease processes that may contribute to fatigue.

In these cases, the fatigue is secondary, and will likely improve when treatment for the primary condition has been successful.

But what about the patient, where fatigue persists and no conventional cause or diagnosis can be found?

The numbers are actually quite staggering, as the CDC states that up to 4 million Americans suffer from the disease that has been labelled chronic fatigue syndrome. When specific types of pain and sensitivity are present, then the diagnosis is chronic fatigue syndrome and fibromyalgia. Diagnosis can be a challenge because there are no consistent lab biomarkers that are specific for CFS that are readily available to test, patient's do not “look sick,” as mentioned above, fatigue is common to many other illnesses, and finally, chronic fatigue syndrome and fibromyalgia can tend to relapse and remit.

On this page:

• Diagnosing myalgic encephalitis / chronic fatigue syndrome

• Additional Naturopathic Work Up for chronic fatigue syndrome and fibromyalgia

• Treatment for chronic fatigue syndrome and fibromyalgia from a naturopathic perspective

• In cases where infections are thought to be a part of the patient’s picture, is ozone therapy superior to antibiotic therapy as a treatment for chronic fatigue syndrome and fibromyalgia?

• What does a course of ozone therapy for chronic fatigue syndrome entail?

• Chronic fatigue syndrome diet

• Chronic fatigue syndrome treatment vitamins

• What about chronic fatigue treatment medications?

• Summary: chronic fatigue syndrome treatment options

• References

Diagnosing myalgic encephalitis / chronic fatigue syndrome:

There are many diagnoses that are typically considered on the basis of other symptoms before considering a diagnosis of chronic fatigue syndrome. These could be relatively common, clear conditions such as overt hypothyroidism, diabetes, or anemia.

The use of different criteria below can often be helpful in considering a CFS diagnosis:

The Revised Canadian Consensus Criteria for myalgic encephalitis / chronic fatigue syndrome:

• Fatigue

• Post-exertional malaise and/or post-exertional fatigue

• Unrefreshing sleep or disturbance of sleep quantity or rhythm disturbance

• Pain (or discomfort) that is often widespread and migratory in nature

• Two or more neurological/ cognitive manifestations

• At least one symptom from

two of the three categories:

– autonomic manifestations

– neuroendocrine manifestations

– immune manifestations

• Persistent or recurring symptoms for ≥ 6 months but not lifelong

The Institute of Medicine has guidelines in 2015 that propose the following diagnostic criteria:

1.     A substantial reduction or impairment in the ability to engage in pre-illness levels of activity (occupational, educational, social or personal life) that:

1.          lasts for more than 6 months

2.     is accompanied by fatigue that is:

1.          often profound

2.          of new onset (not life-long)

3.     not the result of ongoing or unusual excessive exertion

4.     not substantially alleviated by rest

2. Post-exertional malaise (PEM)* – worsening of symptoms after physical, mental or emotional exertion that would not have caused a problem before the illness. PEM often puts the patient in relapse that may last days, weeks, or even longer.

3.     Unrefreshing sleep* – patients with ME/CFS may not feel better or less tired even after a full night of sleep despite the absence of specific objective sleep alterations.

At least one of the following two additional manifestations must be present:

1.     Cognitive impairment* – patients have problems with thinking, memory, executive function, and information processing, as well as attention deficit and impaired psychomotor functions. All can be exacerbated by exertion, effort, prolonged upright posture, stress, or time pressure, and may have serious consequences on a patient’s ability to maintain a job or attend school full time.

2.     Orthostatic intolerance – patients develop a worsening of symptoms upon assuming and maintaining upright posture as measured by objective heart rate and blood pressure abnormalities during standing, bedside orthostatic vital signs, or head-up tilt testing. Orthostatic symptoms including lightheadedness, fainting, increased fatigue, cognitive worsening, headaches, or nausea are worsened with quiet upright posture (either standing or sitting) during day-to-day life, and are improved (though not necessarily fully resolved) with lying down. Orthostatic intolerance is often the most bothersome manifestation of ME/CFS among adolescents.

*The frequency and severity of these symptoms need to be evaluated. The IOM committee specified that “The diagnosis of ME/CFS should be questioned if patients do not have these symptoms at lesuitaast half of the time with moderate, substantial, or severe intensity.”

Additional Naturopathic Work Up for chronic fatigue syndrome and fibromyalgia

Naturopathic medicine views a patient from a holistic perspective. It is not simply about using natural substitutes for drug products or surgery. A clear diagnosis such as that which comes from fitting the above criteria is important, and it is just as important to evaluate other factors which may contribute to the symptoms and intensity of CFS / fibromyalgia.

As an example, a naturopathic approach in depression might involve, depending on the detailed history, looking at subtle thyroid or adrenal hormone imbalances, toxicities that affect neurological function and communication, deficiencies or dependencies on nutrients that affect mood, or sometimes even infection or inflammatory disorders. It would not simply involve giving a natural substitute for the serotonin reuptake inhibitor drugs, although that could be a part of the whole plan.

In trying to investigate suitable naturopathic treatments for chronic fatigue syndrome, we might look at things such as hormone balance, tests for micronutrient deficiencies, toxins that may impair energy production within the cell, whether or not a specific chronic fatigue syndrome diet may be suitable for one person’s individual case, as examples.

Our work up for chronic fatigue syndrome and fibromyalgia for example may include the following tests depending on the case:

– hsCRP to assess for inflammation

– ESR to assess for inflammation

– ANA/RF to assess for any autoimmune tendencies, or autoimmune disease. While the numbers may not be overtly high suggesting autoimmune disease, we often see borderline elevations of both of these, even without for example joint pain suggestive of rheumatoid arthritis, which may indicate some immune dysregulation.

– CBC to rule out anemia but also to look for any white blood cell changes that may suggest inflammation or covert infection

– ferritin to rule out iron deficiency, but also to see if elevations may suggest an increased iron burden, or may suggest inflammation

– blood chemistry panel

– thyroid panel with TSH, free T3, free T4, reverse T3, TPO, thyroglobulin, anti-thyroglobulin antibodies to get an overall picture of thyroid hormone function and balance

– 4 point salivary cortisol levels in 24 hours to assess if there may be a component of adrenal fatigue (not Addison’s disease, but rather suboptimal levels or even chronically elevated levels). This can again be useful to assess adrenal hormone balance but also get an idea of stress levels as well as the patient’s adaptation to stress

– mold IgG and IgE panel, Mycotoxin panel as a consideration to see if mycotoxins may be affecting energy generation at the cellular level

– chronic infection tests such as lyme, bartonella, other viruses

– blood heavy metal levels and provoked urinary metals as a consideration to see if metal toxins may be affecting energy generation at the cellular level

– markers for abnormal biochemistry within the cell in energy generation pathways can be assess by tests such as an Organic Acids Test. This gives a variety of information on gut ecology and imbalances, neurotransmitter balance, possible deficiencies in micronutrients and certain vitamins, and blockades in energy generation pathways.

For example:

The organic acids test can give us information on the above energy cycle, including points at which succinate might be high, possibly indicating a toxicity condition. Alternatively, sometimes we will find that the Candida cycle is high, possibly indicating treatment or further investigation into the gut.

Some of these tests, such as the western blot for Lyme, ferritin, and the thyroid panel, are still looking for conventional diseases, but are additionally useful to see if more subtle changes might be affecting the patient. The rest may be positive in chronic fatigue syndrome and fibromyalgia patients, but are not specific for that disease only. In other words, they can be positive in other conditions as well. However, they may be able to help to guide the type, frequency and intensity of chronic fatigue syndrome treatment, as well as provide objective markers for health improvement to correlate with subjective improvement in fatigue.

Many physicians and naturopathic doctors have firmly held the belief that chronic fatigue syndrome and fibromyalgia may be associated with multiple, silent, persistent infections.

Multiple because it would be considered rare for a single infection to cause such profound and long-lasting weakness. This is even the case in cases where Lyme disease is involved. The Borrelia organism that causes lyme disease creates a distinct subset of disease. However, in patients who have reacted with the full chronic disease syndrome manifestations, Borrelia may be primary but coinfections with other organisms likely are associated with the longstanding persistence and debilitating nature of the disease.

Silent because it is rare to have the typical manifestations of infections. Thus it is rare to see a patient with a fever, an elevated white blood cell count, or very high CRP or ESR levels. Silent also because the immune system is unable or unmotivated to mount an effective response to the infection.

Persistent for obvious reasons. Most of the patients who have had chronic fatigue syndrome and fibromyalgia have tried multiple approaches, and multiple natural alternatives to drugs. It is important to note that persistent may also apply to the immunological and neurological changes that are triggered by infection, even when the infection is gone.

Treatment for chronic fatigue syndrome and fibromyalgia from a naturopathic perspective

The naturopathic treatment for chronic fatigue syndrome and fibromyalgia that I find useful in many such patients is ozone therapy and nutrient repletion. Nutrient repletion may be treated with a chronic fatigue syndrome diet and in some cases, vitamin and mineral infusions.   Treatments are individualized for each patient’s case specifics as some patients respond well to oral treatment, whereas in other patients, we may see persisting abnormalities in markers of mitochondrial production (cellular energy production) in tests such as the organic acids test, despite supplementation.

The ozone component of our naturopathic fibromyalgia and chronic fatigue syndrome treatment may be either ozone or ultraviolet blood irradiation. This is an older therapy which was used in American hospitals before interest was lost with the advent of the “cure” of infections with penicillin. Ultraviolet blood irradiation, with the addition of ozone, stimulates the immune system to address both acute, and in the case of chronic fatigue syndrome, multiple silent chronic infections. The mechanism involves oxidation and stimulation of cytokines that regulate the immune system. In my experience, I often find that ozone therapy alone can give similar results as ozone combined with ultraviolet blood irradiation.

Robert Rowen, MD, author of Second Opinion Newsletter, has written a very comprehensive article about the use of ultraviolet blood irradiation in American hospitals for serious acute infections. The article is called the “Cure that time forgot,” and is available here.

A more technical article, by the same name, is here.

There are a few theorized mechanisms of how such a ozone / ultraviolet blood irradiation may help addressing multiple, silent, persistent chronic infections. What we do know is that although the small amount of blood treated (100-200 mLs), the mechanism does not likely involve a simple direct killing of infections in the blood because it is only a small portion of the total blood supply that is treated.

One possible theorized mechanism is that the ozone or ultraviolet blood irradiation acts as an ‘autologous stimulation’ that the infections or toxins produced by the infection are present in the blood stream already. The combination of UV exposure and ozone acts to break down the germ or toxin, exposing new areas to the immune system when the blood is reinfused. The immune system then becomes activated, and over a few stimulations, these infections are no longer “silent” and they stimulate an appropriate response from the white blood cells.

A more recent mechanism that has been elucidated involves the stimulation of cytokine release by the white blood cells. When UV energy or ozone reacts with the white blood cells in the blood, the chemical messengers that stimulate activation of the immune system are released. These cytokines are then reinfused into the body as the blood is returned to the patient. Cytokines are the messengers of the immune system, and with a proper coordinated release of cytokines, the immune system becomes much more adept at clearing chronic persistent infections.

A good summary of the mechanisms in ozone therapy is published at: Curr Med Chem. 2016;23(4):304-14. Ozone: A Multifaceted Molecule with Unexpected Therapeutic Activity.

There is also the mechanism of increasing circulation, oxygen delivery, and energy generation that I have described in an article on oxidative medicine in general. This involves the effect of peroxides that are created by ozone and UV when they react with the blood. The short chain fatty peroxides oxidize cofactors in the energy generating systems of the cell, called the Kreb's cycle and oxidative phosphorylation in the mitochondria. Chemicals like 2,3 diphosphoglycerate increase (helping red cells to deliver oxygen,) intracellular antioxidants such as catalase and glutathione increase, and blood viscosity decreases.

In my experience, it depends. Unless lyme disease, or a similar intracellular pathogen (germ) is confirmed to be positive, it is difficult to find a drug that is active against the multiple infections present.

If there is a clear viral component, such as that described by Lerner et al with EBV and some CFS subsets of patients, then I do like the combination of an antiviral with ozone therapy.

In my opinion, it is generally better to actively involve and stimulate the immune system to clear the infection, so this ability to clear the infection lessens chances of recurrence. If only antibiotics are used, or antivirals, then on stopping the medicine, there is a chance of recurrence if exposure reoccurs, or if the latent infection becomes more active.

In most cases of chronic fatigue syndrome, the short course of  ozone treatments involves two to three treatments a week for 4-5 weeks. Follow up lab panel and treatment is given in 4 weeks.  Treatments may be then given as needed in the future.

While there is no one specific diet for chronic fatigue syndrome, optimizing the diet is a very important part of the supportive treatment. This typically involves ensuring that optimal nutritional needs are met from both a calorie as well as vitamin and mineral perspective is met. Very few people eat enough fruit and vegetables, and get enough fiber. This becomes even more important to make sure the body has the basic building blocks to produce energy.

In some patients, identification and removal of foods that may be contributing to fatigue is important. There are multiple mechanisms possible. Food sensitivities could be contributing immune activation and serving as a drain on energy. One study found marked improvement in a group of fibromyalgia patients when gluten sensitivities were addressed - they did not have celiac disease.

In other cases, treating the gut in general and ensuring that the diet is anti-inflammatory for gut health is the “chronic fatigue syndrome diet.” There is emerging evidence that the gut bacteria can have compounds that translocate across the gut bacteria, contributing to certain CFS pictures. Some of our patients have a clear gastrointestinal comorbidity and symptom complex in addition to their chronic fatigue, and in such cases we might use the anti-inflammatory diet and nutrients below as well as evaluate gut ecology.

Nutritional treatment is a core component of treating any patient, and is crucial in CFS and fibromyalgia. However, we also know that the diagnosis of CFS or FMS does not mean that one particular group of nutrients would be useful for all. In fact, a review article published in 2017 looked at patients who have these diagnoses, and did not find any consistent (except for vitamin E) deficiencies, nor did they find good evidence of any single nutrient consistently helping the patients.

Results: A total of 5 RCTs and 40 observational studies were included in the qualitative synthesis, of which 27 studies were included in the meta-analyses. Circulating concentrations of vitamin E were lower in patients compared to controls (pooled standardized mean difference (SMD): -1.57, 95%CI: -3.09, -0.05; p = .042). However, this difference was not present when restricting the analyses to the subgroup of studies with high quality scores. Poor study quality and a substantial heterogeneity in most studies was found. No vitamins or minerals have been repeatedly or consistently linked to clinical parameters. In addition, RCTs testing supplements containing these vitamins and/or minerals did not result in clinical improvements.

Discussion: Little evidence was found to support the hypothesis that vitamin and mineral deficiencies play a role in the pathophysiology of CFS and FMS, and that the use of supplements is effective in these patients.

Another review study found certain nutrients were helpful in this group of patients, but stopped short of recommendations due to needing more investigation:

Background: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is characterised by unexplained fatigue for at least 6 months accompanied by a diverse but consistent set of symptoms. Diet modification and nutritional supplements could be used to improve patient outcomes, such fatigue and quality of life. We reviewed and discussed the evidence for nutritional interventions that may assist in alleviating symptoms of CFS/ME.

Methods: Medline, Cinahl and Scopus were systematically searched from 1994 to May 2016. All studies on nutrition intervention were included where CFS/ME patients modified their diet or supplemented their habitual diet on patient-centred outcomes (fatigue, quality of life, physical activity and/or psychological wellbeing).

Results: Seventeen studies were included that meet the inclusion criteria. Of these, 14 different interventions were investigated on study outcomes. Many studies did not show therapeutic benefit on CFS/ME. Improvements in fatigue were observed for nicotinamide adenine dinucleotide hydride (NADH), probiotics, high cocoa polyphenol rich chocolate, and a combination of NADH and coenzyme Q10.

Conclusions: This review identified insufficient evidence for the use of nutritional supplements and elimination or modified diets to relieve CFS/ME symptoms. Studies were limited by the number of studies investigating the interventions, small sample sizes, study duration, variety of instruments used, and studies not reporting dietary intake method. Further research is warranted in homogeneous CFS/ME populations.

Our approach in considering chronic fatigue syndrome vitamins is to not automatically suggest certain nutrients (such as the NADH and CoQ10 above) based on the diagnosis of ME/CFS, but rather to consider that nutritional or supplemental therapy might be more likely to be useful in an individual patient if:

1. the diet appears to be lacking in overall quality

2. there are gastrointestinal signs that may suggest gut inflammation (compromising nutrient absorption as a possibility)

3. if energy pathway testing such as that done with organic acids assays suggest there are certain energy production pathways that are blocked (and are dependent on optimal vitamin or mineral levels)

In some patients, there is a clear option for treatment with medication to at least alleviate some symptoms. Such patients are usually somewhat more functional, and some prescription medications may be useful to help alleviate some of the fatigue symptoms. Prescription medications are often useful to help with more restorative sleep, although natural agents are often preferred at first.

Trials are very small when they are done, and many give conflicting results. Investigations have been done for drugs such as modafinil (a wakefulness promoting agent), amantadine (an antiviral as well as anti-fatigue agent often used in the fatigue of multiple sclerosis), and carnitine (a mitochondrial agent also available as a supplement). In my own patients, we discuss these symptomatic measures from a risk and possible benefit perspective, considering trials to see if they are useful.

The mainstay of conventional treatment is pacing, and living within the energy envelope available. This is a very important part of treatment and can help the patient to manage their lifestyle to fit the condition, allowing them the ability to cope and adjust to necessary activities of daily living.

In addition to this, our approach is to see if there is anything else supportive that can be done to hopefully expand this energy envelope.

If you would like to consider these options, please call our office to make an appointment with Dr Eric Chan, ND at 604 275 0163.

Ozone therapy safety (major autohemotherapy): A survey done in Germany of close to 5 million ozone treatments showed an accident rate of 7 serious incidents, all associated with direct IV injection of the gas (not done in our clinic).  There is a slight possibility of allergy to heparin, though this is a commonly used blood thinner. Some patients do not like the site of their own blood, but they quickly become accustomed to this.

In our experience, the most frequently seen (but still rare) side effect is dizziness/vasovagal/fainting reaction due not at all to the volume of the blood, but rather the needle experience as well as seeing the blood. Possible but extremely rare complications may include soft tissue infection (as with any injection / blood draw), or vein inflammation and clots.

One recent case study has been published on ozone therapy where a single patient with kidney failure had high blood potassium and subsequent arrhythmia. The authors had concluded that the ozone therapy (which looked to be done 9 days in a row) was to blame, but this is not at all clear. The authors did not think that red cell breakdown was responsible for the high blood potassium, but that is the only mechanism that would make sense if the ozone was done daily. Theoretically low grade red cell breakdown would release potassium, and if the treatment is overdone and the kidneys can not excrete this could accumulate.

Photoluminescence therapy (ultraviolet blood irradiation) was used extensively in the 30's to 40's before the advent of antibiotics and the vaccine for polio.  It has an extensive safety and efficacy record. For a great summary of this treatment, buy the book "Into the Light" at www.drdouglass.com.  An online article also available is “The Cure that time forgot” which summarizes much of the published experience.  Potential side effects of ultraviolet blood irradiation are similar to those mentioned above for ozone therapy/major autohemotherapy.

References: Myers’, Intravenous vitamin/mineral injections

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References: Ozone and Diabetes

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References: Ozone

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References: Ultraviolet Blood Irradiation

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 References: Acupuncture for Headaches, Pain

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