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Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) is a disorder of unknown etiology, which probably has an infectious basis. CFS is a state of chronic fatigue, which exists without other explanation, for a year or more, and is accompanied by cognitive difficulties.

Various unrelated infectious diseases (eg, pneumonia, Epstein-Barr virus [EBV] infection, diarrhea, and upper respiratory tract infections) appear to lead to a state of prolonged fatigue in some patients. If the condition is accompanied by cognitive difficulties, the disease is termed CFS.

While the cause of CFS is unknown, the disease probably is an infectious disease with immunological manifestations. CFS is not caused by EBV, one of the viruses that may lead to a state of chronic fatigue. EBV definitely has not been shown to cause CFS, and CFS is not synonymous with chronic EBV or chronic infectious mononucleosis.

One or more viruses have been implicated as the cause of CFS, excluding EBV, but no causal relationship between any virus and CFS has been proven. Some have suggested that Chlamydia pneumoniae is the infectious agent responsible for CFS, which may become activated following prior contact with another infectious disease agent.

CFS initially was termed “encephalomyalgia” because it was appreciated, particularly by British clinicians, that the essential clinical features of CFS included both an encephalitic component (as manifested by cognitive difficulties) and a skeletal muscle component (as manifested by chronic fatigue). Patients without cognitive dysfunction should not be considered to have CFS.

Pathophysiology: Because the immune system is up-regulated in CFS, antibody titers to various previously encountered antigens are increased. While increased titers do not indicate a causal relationship in CFS, nevertheless, the titers are useful as laboratory clues, which, when taken together, occur regularly in patients with CFS.

Hypoperfusion of frontoparietal areas of the brain is responsible for cognitive abnormalities in CFS.


* In the US: CFS affects tens of thousands of individuals.

* Internationally: CFS appears to be less common overseas but exists worldwide.

Sex: This condition occurs more commonly in females than in males.

* Patients with CFS often give a history of an antecedent infection that precipitated the prolonged state of fatigue and followed the initial illness. The patient may have a history of EBV infectious mononucleosis, cytomegalovirus (CMV) infectious mononucleosis, pneumonia, diarrhea, or upper respiratory tract infection. Patients with acute disease from these infections have fatigue during the acute illness, but the fatigue resolves as the patient recovers. In patients with CFS, the fatigue continues for a year or more after they have recovered from the acute infectious event.

* Patients usually are cardiac "A" intensive people from a personality standpoint. These patients are not malingerers, and they do not seek secondary gain. As a group, they want a fully functioning life restored, and they become frustrated by their inability to perform their work and home tasks because of their prolonged fatigue and cognitive dysfunction.

* Patients with CFS may be depressed secondarily because of their inability to perform normal duties at home and at work, but they are not depressive individuals per se. Depressive individuals give a history of being depressed for many years, and they lack the cognitive dysfunction characteristic of individuals with CFS.

* The typical complaint of patients with CFS is that they have problems with short-term memory but not long-term memory. Patients with CFS may complain of verbal dyslexia manifested by the inability to find or say a particular word during normal speech. The inability to find the word or delay in getting the word out is very disturbing to patients with CFS and may interfere with their occupation.

* Patients with CFS also typically complain of postexertional fatigue, being excessively tired after doing relatively normal tasks that they have done for years previous to their CFS without any particular problem. Patients also complain of fatigue even after prolonged periods of rest or sleep. Patients with CFS do not recharge or arise refreshed after sleeping. Patients with CFS do not complain of sore throats or fevers.

* The diagnosis of CFS depends on eliminating other causes of chronic persistent fatigue. Many patients have lifestyles that would make anyone feel fatigue on a long-term basis. This may be related to job, family, or home stress. Patients with malignancy should be excluded because fatigue often accompanies neoplastic disease.

* Many patients with fatigue but not CFS have a supratentorial component to the illness, and psychosomatic illness often is manifested as otherwise unexplained fatigue.

* If the above conditions can be excluded, then the diagnosis of CFS may be entertained.


* Patients with signs of adrenal or thyroid disorders also should be eliminated from consideration of CFS because they have an endocrinologic explanation for their fatigue.

* Similarly, patients with signs of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) also have a reason for chronic fatigue.

* CFS should be diagnosed only after other causes of fatigue are excluded and the fatigue has lasted for at least 1 year. CFS may be excluded as a diagnostic consideration from patients with prolonged fatigue if they do not have cognitive difficulties.

* The physical examination often reveals no abnormalities, but left axillary node involvement and/or crimson crescents are the most consistent findings during a physical examination.

* The lymph nodes in CFS are small, moveable, and not tender and most commonly involve the neck, axillary region, or inguinal region.

* In the oropharynx, purple/crimson discoloration of both anterior tonsillar pilars in the absence of pharyngitis is a frequent marker in patients with CFS. The cause of crimson crescents is not known, but they are observed frequently in patients with CFS. Patients with other disorders also may have crimson crescents.

* A single lymph node that is very large, tender, or immovable suggests a diagnosis other than CFS. Similarly, generalized adenopathy suggests a diagnosis other than CFS.

* Trigger points are not present in CFS. Trigger points indicate fibromyalgia but not CFS. CFS and fibromyalgia rarely coexist in the same patient.


* CFS probably is caused by an infection due to a virus and/or C pneumoniae infection.

* Many viruses have been studied as potential causal agents, including EBV, HHV-6, coxsackievirus B, spumaviruses, and even human T-cell leukemia virus strains.

* Patients with CFS often are referred to an infectious disease consultant because of elevated IgG VCA EBV titers. Increased IgG titers to the VCA of EBV are common in the general population, regardless of whether the patient is fatigued or not. An increased IgG VCA EBV titer indicates past exposure to EBV but does not indicate acute disease or explain the patient's chronic fatigue state. EBV often is the precipitating event that has triggered the patient's chronic fatigue state.

* Some investigators have suggested that C pneumoniae is the cause of CFS. Tests for C pneumoniae that are available in hospital or commercial laboratories are done by immunoglobulin M (IgM) and IgG enzyme-linked immunosorbent assay (ELISA) determinations. As with elevated EBV IgG VCA titers, many individuals in the healthy population have elevated IgG titers to C pneumoniae.

* Some patients with CFS have evidence of acute or recent infection by C pneumoniae, as evidenced by an elevated IgM C pneumoniae titer, and these patients are the most likely to respond to antichlamydial therapy.

* Investigators studying the potential role of C pneumoniae in CFS believe that serum tests are insensitive, and the only way to determine if some patients have CFS due to C pneumoniae is to diagnose the presence of the organism using sensitive tests, including polymerase chain reaction (PCR). PCR for C pneumoniae is a very sensitive technique but, unfortunately, is available only in research centers.

*Candida albicans or yeast infections do not cause CFS.

Other Problems to be Considered:

CFS must be differentiated from other disorders that have a fatigue component. CFS usually is easily differentiated from other causes of CFS by the presence of cognitive dysfunction, which is absent in almost all other fatigue-producing disorders. Possible differentials include the following:

Adrenal insufficiency
Human immunodeficiency virus (HIV)
Liver disease
Renal disease

Psychosomatic illness: Patients with psychosomatic disorders may have elevated IgG VCA EBV titers, which may mislead them and their physicians to believe they have CFS. As mentioned, EBV may precede CFS, but it does not cause CFS. Such patients do not manifest the physical findings or abnormal laboratory tests that are part of the diagnosis of CFS. Such patients also do not have the cognitive dysfunction that is typical for a patient with CFS.

Lyme disease: CFS may be readily differentiated from Lyme disease in various ways. Patients from endemic areas may have elevated IgG Lyme titers. Few of these patients have neuroborreliosis, which must be diagnosed by doing simultaneous cerebrospinal fluid (CSF) and serum IgM and IgG Lyme titers. If the CSF titers are higher than those simultaneously obtained from the serum, then the patient has neuroborreliosis. Most patients with acute Lyme disease have a neurologic component, but chronic neuroborreliosis is distinctly uncommon. Patients with chronic neuroborreliosis do not have the same cognitive defects as patients with CFS (see History), and fatigue usually is not present.

Medical Care:
* Because most cases of CFS may be based on a viral infection, no uniformly effective therapy exists for CFS.

* In patients with elevated C pneumoniae levels, particularly increased IgM titers, antichlamydial therapy may be effective.

* Infectious disease consultants should perform a history and physical examination on patients with possible CFS.

Quercetin- As directed on label. Protects against allergens and increases immunity.
Bromelain- As directed on label. Enhances the effectiveness of Quercetin
Bee Pollen- (some are allergic) As directed on label. Increases immunity and speeds up healing.
Flaxseed oil- As directed on label. Reduces pain and inflammation. Enhances all body functions.
Multi vitamin- As directed on label. To improve overall health and assure proper nutrition.
Beta-carotene- 15000 IU daily.
Vit. B complex- 75-100 mg. 3 times daily.
Vit B5- 100 mg. 3 times daily. Aids immune function.
Vit B6- 50 mg. 3 times daily. Increases immunity
Vit C- 3000- 10000 mg. divided doses. Increases immunity, aids in preventing infection and decreases mucous.
Vit E- 400- 1000 IU daily. Improves circulation and speeds healing.
Coenzyme Q10- 60 mg. Daily. Valuable immune system stimulant. Increases cellular oxygenation.
Dimethylsulfoxide- As directed on label. Relieves pain and strengthens the immune system.
Garlic- 2 capsules 3 times daily. An immune system stimulant that helps keep the infection in check.
Proteolytic enzymes- As directed on label take with meals and in between meals. Destroys free radicals and aids digestion of food.
Grape seed abstract- As directed on label. Powerful antioxidants. Reduce inflammation and the frequency of colds and flu. Neutralize allergic reactions.

Echinacea- boosts the immune system and fights viral infection.
Goldenseal -(Tea or alcohol free dropper full) 3 x daily. Not longer than 1 week taking daily.

Spinal Adjustments/ Mobilization:
Spinal hypomobile segments will likely be found at C1-C3, T1-T2, T8-T12 and maybe others after relaxing the tissues and adjusting the fixated we then apply mobilization spondylotherapy over segments T1-T2.

* Rest, as needed

* Moderate activity

* Avoid strenuous exercise.

* Most cases improve to some degree over time.

Patient Education:
* Exacerbations are precipitated by lack of sleep, stress, or exercise.