Tuesday, July 23, 2013


In this blog will briefly discuss the different symptoms of Chronic fatigue syndrome (CFS) its clinical diagnosis and different treatment options.

Chronic fatigue syndrome is a medical condition and its diagnosis is based on the clinical picture. CFS there is no specific blood test or any specific laboratory evaluation or imaging study that makes a diagnosis. It may help to understand and evaluate and to rule out other disease process. Example- to rule out anemia or thyroid dysfunction causing the symptoms. According to the Center of Disease control they have stated few criteria for the diagnosis of CFS:

(A) Person has severe fatigue lasting for 6 months or longer and is not relieved with rest and is not associated with other medical or mental illness. This is a key manifestation and in conjunction with other symptoms

(B)One may have 4 or more other symptoms listed below on top of above severe fatigue then person may have Chronic fatigue syndrome
  • Enlarged or tender neck or arm pit (axillaries) lymph nodes.
  • Frequent sore throat
  • Impaired short-term memory or concentration
  • Muscle pain
  • Multiple join pain but has no swelling or any redness
  • Headache new pattern
  • Unrefreshing sleep
  • Post-expressional fatigue lasting for more than 24 hours.

When above criteria is fulfilled one is considered to have the chronic fatigue syndrome.


There is no one specific treatment that works for all. It needs to be individualized treatment approach. So there are multimodality approach is used. Uses of pharmacological and non-pharmacological treatment options are use. Based on the view of the author integrative medical treatment approach works the best in this kind of situation. Which includes the standard medical approach for evaluation of the CFS and adding other alternative medical treatment modalities. Alternative treatment modalities like Ayurveda (Traditional Indian Medicine), Yoga, Pranayama, Herbs, dietary modification, relaxation, improvement of the sleep and life style may help to improve the symptoms. This is a big topic and will discuss in the blog separately.

ChronicFatigue Syndrome
The three key drugs that are FDA approached for the treatment of Fibromyalgia is Lyrica (pregabalin), Cymbalta (duloxetine) and Savella (milnacipran). It is helpful in controlling the symptoms but do have many side effects on long run, one needs to know about it. Medication may need to control the symptoms in many cased also. The dose needs to be adjusted periodically with clinically been monitored as one gets better. The goal should be to be on the least amount of dose or is off the drug at some point if possible. It may be possible in some patient and some not. As CFS is a chronic disease or condition and long-term efficacy and side effects of the drugs over 10-20 years is not known.

If you or loved one has CFS not all physicians are comfortable taking care of the disease. It is a complex disease. It will be good to talk to your primary care about it and see who would be best for this condition in your area or if chronic fatigue clinics are in your area. One needs to find a physician who can spend time and understand the on going disease process individually and help mange it. Patient also has to do his/her share to improve further. A long-term relationship needs to be developed with the healthcare provider. It takes many months to show improvement so be patiently waiting for a while the treatment is going on. This is specially if one has the symptoms more than 3-5 years.


Fatigue Causes
In this blog, we will look into the chronic sleep deprivation and its relationship to chronic fatigue syndrome, fibromyalgia, sleep problems and other health issues.

The normal sleep requirement is around 7-8 hours; generally around 10:00 pm to 6:00 am. If there is a problem getting sleep with either the person having no time to sleep or cannot fall asleep or maintain sleep, then over a period of months and years, he can develop other health issues.

Chronic fatigue syndrome or fibromyalgia can become worse if there are sleep problems. Good sleep may help to improve that to some extent as those are multi-faceted diseases. Good sleep is a key to keep the symptoms under control.

If a person has delayed sleep phase syndrome (more on that in coming blogs), meaning they tend to go to bed late and wake up late like teenagers, (loves going to bed around 1:00 am-5:00 am and waking up around 10:00 am-2:00 pm), then the biological sleep clock changes. He cannot function very well at other times and will be sleepy going to school, college or work. He cannot wake up early and cannot fall asleep early when he goes to bed, let’s say, around 11:00 pm or 12 midnight as they have to be up around 6:00-7:00 am. So, he has about 3 hours of sleep loss every day. This is a cumulative sleep loss for the body and one is causing a sleep debt to his body. Down the road, it may affect the health if not addressed. Just like good food is a key for health, so is sleep.

If one has a problem falling asleep or has insomnia of other causes, then also he will have lack of sleep. The underlying cause of the chronic sleep deprivation needs to be evaluated and if one is not getting better, then it is good to see his own physician, and especially a sleep specialist if possible, to understand the underlying cause of sleep problem(s).

Chronic sleep deprivation or lack of long term sleep will slowly lead to multiple medical problems. It may produce digestion problems like more gas or heart burn symptoms. Emotional problems like anxiety, depression, and addictions, like on-going smoking and alcohol use. It starts affecting the memory, especially the short term. Long term leads to cardiovascular problems, hormonal imbalances, and abnormal sugar level. If one has diabetes , then it may also get worse down the road.

Another important thing is the inability to lose weight, if one is overweight. Lack of adequate sleep will lead to abnormal fat metabolism and inability to lose weight. This may happen in spite of watching the diet and doing exercise.

Chronic sleep deprivation, if neglected, can slowly cause lots of health issues and difficulty for health care professional to diagnose, as it is the person who knows the sleep problem and is not reporting it. Also, the chronic sleep deprivation can lead to low pain threshold and increase in the pain if one has chronic pain syndrome, like chronic back pain, neck pain or body pain. Similarly, it also leads to increase irritability and emotional issues. It can more frequently create arguments in the house or in relationships than in persons who are fully rested with adequate sleep.

Generally, it is good to have the physician address this issue, if one has it, as there is a variable from person to person, but of the few things that may help one, it is the improvement of the sleep hygiene. (Refer to other sleep hygiene blogs for other details.) Slowly, one should get into the habit of going to bed at the same time and waking up at same time. Unless one has to mandatorily work after 10:00 pm, it is good then to retire for the day and to sleep and wake up around 6:00 am or a little earlier , if possible, and keep the same schedule. This schedule will have the biological clock synchronize with the sunrise and sunset cycle for most people with few exceptions, like those who are further away from the equator. Secondly, it also has relationship with the secretion of the cortisol level. Similar findings for good health are also discussed in Ayurveda literature.

If one has a problem, the use of non-pharmacological or cognitive behavioral therapy under professional guidance may help a lot. Some may have to use prescribed sleep medications, but the use should be as minimal as possible. Doing the Pranayama or the breathing exercise of Yoga or doing Yoga may slowly help to set the biological clock back to around 10:00 pm to 6:00 am schedule. The general rule is to go to bed one minute forward or backward in the clock. Let’s say, one is waking up at 9:00 am and wants to wake up at 6:00 am, then he can start waking up at 8:59 am, then 8:58 am, then 8:57 am and so forth and it may take 180 days or 6 months to get to the resynchronization of the biological clock. But still, one will have to be vigilant on that also, as the body clock has a tendency to move clockwise, so we love to wake up late and go to bed late, especially when there is a stimulus like TV, internet, etc.

Diet is equally important to keep this biological clock moving in right time and not to lag behind. A high fiber diet with lots of fruits and vegetables is a must. Smoking cessation is a key. If one has sleep problem, then one should not use alcohol, as it affects the sleep and creates the sleep maintenance difficulty, meaning it will not allow one to stay asleep. Even a small drink is sufficient to do it. Use of coffee be cut down and specially avoid it after lunch. Other this is the use of the chocolate be minimized to an extend as they affect the sleep and if possible be stoped completely. Chocolate may affect the sleep and it is very settle change and if after stoped after months one may find the difference.

If one can do some meditation or learn simple breath meditation, it may help also. If sleep problem is in relation to the different issues in life, like in relationships, with social issues, work issues, financial issues or control issues, one may need counseling, but if something cannot be changed, then it is better to accept it and move forward in life as can affect the sleep and the health.

Regularly doing the alternate nostril breathing and slow deep breathing exercises may help, especially when done in the morning and at bedtime. If one wakes up, then he may need to do it at that time, which may help to fall back to sleep slowly.

So, the longer the sleep problem has been, then it may take a longer time to improve and Pranayama may help. There may be some set backs while doing all the changes, but going back to the routine may further help.

Source Link:- http://fatiguecare.com/blog/chronic-sleep-deprivation-or-long-term-lack-of-sleep-and-its-relationship-with-chronic-fatigue-and-health/

Monday, July 22, 2013


Chronic fatigue syndrome (CFS) is a very complex disease with persistent low-grade energy not improving after adequate rest. The symptoms are there for months or years and do not improve. In this section, let us look at a different perspective away from modern medicine and look at Ayurveda to understand how CFS is manifested and what can be done to improve it. This will give us different in site. Ayurveda can always be integrated with a current medical treatment approach to benefits the patient’s treatment for chronic fatigue syndrome or fibromyalgia.

Patients with sleep apnea with chronic fatigue syndrome or fibromyalgia who are on CPAP or BiPAP and compliant with treatment may still have residual fatigue during the daytime or a low-energy level at the end of the day. Ayurveda can further help in such cases.

The word Ayurveda is Ayu, which means long healthy life and veda which means science, so Ayurveda is the science that explains the long healthy life or it is also called Indian medical science. It is one of the oldest medical systems in the world, which originated in India and documented to mankind. Books written hundreds and thousands of years ago in Sanskrit literature help this understanding. Very good information has been described in Ayurveda as it treats the patient uniquely on an individual basis and not as a group therapy. As no two people with chronic fatigue symptoms are the same genetically, so will the treatment be unique to them as well.

Chronic fatigue syndrome is not a new disease as Ayurveda has described chronic fatigue syndrome and it has been present for centuries. It discusses low-energy level or low bala in the body and how it should be addressed.

Ayurveda describes the body made of five key elements namely, fire, earth, water, air and space. Ayurveda also describes the basic three body types namely, vata, pitta and kapha. Vata is predominantly air, pitta is fire quality, and kapha is earthly quality. Its permutation and combination gives rise to the different body types and body tissues and different energy flow as a basic prakruti or genetics of the person.

A person with body type Kapha, will have chronic fatigue with lethargy, a more sluggish, heavy-set person, long sleeper with low metabolism and slow digestion.

A person with body type Pitta, may have more heat in the body and feels warm or hot, gets heartburn, may have lose bowel movements, skin rash, and generally an active personality with tendency to get angry if things do not happen the way they intended to happen. Fibromyalgia falls in this area, but the involvement is predominantly muscle. Fibromyalgia patients have chronic fatigue and are different than patienst with no fibromyalgia and CFS.

A person with body type Vata, may have irregular sleep habits, difficulty falling or maintaining sleep, constipation, dry skin, mild irritation, joint discomfort, etc. These are the general descriptions, but as all have all three qualities, different things can be seen in a person, but one or two types will be more predominant.

Usually, patients with chronic fatigue syndrome have the vata-pitta or pitta-vata type generally in most cases. This can be analyzed by the ayurvedic pulse diagnosis and other bodily features. If one has chronic fatigue then if one learns Ayurveda, it may help them and in the long run pay it back multiple times as it is a good way of understanding the body type and one can make modifications.

So if one has pitta-vata type and the chronic fatigue is in that subtype than the management would be to alleviate the vata and the pitta factors by improving the digestion, restful sleep and using the herbs that are specific for that body type. Generally, sleeping between 10:00 pm and 6:00 am on a regular basis and doing pranayama or breathing exercises of yoga may further help.

Drugs or foods that cause the heartburn or high acid in the body may need to be analyzed and reduced or eliminated based on a case-by-case basis. The goal should be to be on a low medication list including the vitamins, as they are not able to digest it. The diet should be high in fruits and vegetables and easily digested food. Relaxation and sound sleep is very important and initially the person may have to spend weeks to have increase in the hours to restore the sleep deprivation syndrome. Multiple other things need to be done but with the above few, one can get started.

Generally, it takes 1-2 years and at times 3 years for this to improve based on the medical condition of the person. Slow and steady may win the race to overcome fatigue if a systematic plan is followed. Ayurveda is the key for this understanding.

Source Link:- http://fatiguecare.com/blog/chronic-fatigue-syndrome-and-ayurveda-understanding-cfs-from-ayurvedic-perspective/

Monday, July 15, 2013


Poor sleep hygiene is becoming a global problem with our busy lifestyles, which affects the health and if it persists for a long time it leads to diseases such as chronic fatigue syndrome, fibromyalgia, recurring infection, etc.

Sleep hygiene is a key in management of chronic fatigue.  Usually, most patients with chronic fatigue syndrome have poor sleep hygiene.  There is sleep irregularity either in timing, duration of sleep or has sleep interruption.  After a period of time with ongoing chronic fatigue, they adapt to a different sleeping pattern and at times sleeping at irregular hours.  This in turn affects the health in the long run and is a vicious cycle that needs to be stopped.

The normal sleep onset should be around 9:00 pm to 10:00 pm and waking up around 5:00 am to 6:00 am.  Generally, waking up around 6:00 am will improve overall health, but itself in the long run improves the metabolism, digestion process, eliminating of excreta, decreasing anxiety, and sense of well being.

Most of the patients with chronic fatigue initially resist this kind of change as their sleeping pattern has changed.  The circadian rhythms in the brain are already changed or adapted to new time and needs to be changed where it is like re-programming a computer.  Once it is done slowly and adequately, there is gradual improvement.

Unless sleep hygiene is not improved until then, the improvement of having chronic fatigue syndrome symptoms will be less.  “The number of hours you sleep before midnight are the good hours” is an old English saying and it is true as “eating an apple a day keeps the doctor away.”

One needs to focus on improvement in sleep hygiene.  If it is gradually done after many months or a year or two, he/she may see a gradual improvement.  If irregular sleeping habits have been present for many months or years, it will take time to improve.

The sleep hygiene generally takes 6 to 12 months to improve and at times, 24 months or longer in some patients we have seen in our practice.  This needs to be first, mentally accepted by the person with poor sleep hygiene that it needs to be improved and then the person can work on that. We have seen in our practice that patients who resist these changes have persistence of chronic fatigue symptoms. It does become difficult for patients who are working night shift or rotating shift.

The improvement generally is very slow and gradual, and if it happens, it remains with the health for a long time unless it is interrupted by infection, stress, medications or other medical conditions.  If this happens then re-synchronizing sleep cycle may further help.  Doing regular pranayama or breathing exercises or yoga may further help the process gradually.  It may be beneficial if done in the morning and before bedtime to relax.

Tuesday, July 9, 2013


In patients with chronic fatigue syndrome (CFS), the sleep history is very important and sleep apnea needs to be ruled out as one of the causes of CFS.

Sleep apnea with increase in weight gain is a fairly common disorder now in USA and in the world. It is now more common than bronchial asthma. The screening for sleep apnea is more commonly performed by primary care physicians making a general public awareness of the disease.

The following are some important screening points for obstructive sleep apnea:

• History of snoring
• Excessive daytime sleepiness
• History of witnessed apnea (being told by someone that the person has stopped breathing while asleep)
• History of hypertension
• Neck size greater than 17 inches in males and 16 inches in females

If two or more criteria are present from above, one may have sleep apnea and it would be prudent to seek a medical evaluation.

With the treatment of sleep apnea, there should be improvement of the CFS but if it still persists, then other causes like restless leg syndrome, pain-related arousals, sleep interruption, constipation, etc., need to be looked into.

Monday, July 8, 2013


Chronic fatigue is a complex medical problem, which requires management with a multi-layer approach. A single modality of management may be less effective or not effective at all.

Chronic fatigue has multiple different causes and it needs to be addressed at multiple angles one step at a time.

Chronic Fatigue Syndrome Treatment

A few important causes of chronic fatigue are sleep problems, infection, digestive dysfunction, hormonal imbalances, anxiety or depression, and/or medication side effects to name a few.

In a patient more than one cause may be present but all needs to be addressed otherwise, the improvement of the fatigue is not seen.

Improvement in sleep is the key for improvement in the digestion, so there is gradual restoration of the energy.

Because of that, integrative methods by use of current medical science for correct medical diagnosis, Ayurveda, lifestyle changes, Yoga or Pranayama (breathing exercise of Yoga) may help.

A single approach is less helpful and using an integrative approach for chronic fatigue is helpful. This helps gradual improvement of the fatigue and restoration of energy at the mental and physical level over a period of time.

Expect a very slow recovery as most cases take months.