What is Chronic Fatigue Syndrome (CFS)?

Chronic Fatigue Syndrome (CFS), also known as myalgic encephalomyelitis (ME/CFS), is a complex condition characterized by severe, persistent fatigue that is not alleviated by rest. It is more common in women, particularly those over the age of 45, and is often underdiagnosed (Tinkle et al, 2017)

Symptoms of CFS

CFS is associated with a wide range of symptoms, including:

• Cognitive and memory impairments

• Muscle and joint pain

• Headaches

• Non-restorative sleep (waking up unrefreshed despite adequate sleep duration)

• Post-exertional malaise (worsening of symptoms after physical or mental exertion)

• Psychological issues such as anxiety or depression (Tinkle et al, 2017)

Causes and Contributing Factors

The causes of CFS are multifactorial and may include:

• Infectious agents and post-viral syndromes

• Immune system dysregulation

• Allergies

• Endocrine imbalances

• Nutritional deficiencies

• Cardiovascular abnormalities, such as low blood pressure, postural orthostatic tachycardia syndrome (POTS), and neurally mediated hypotension (NMH) (Tinkle et al, 2017)

Fatigue in conditions like CFS and hEDS is often the result of multiple, interrelated factors. For example, dysautonomia may exacerbate non-restorative sleep, ligamentous laxity in hEDS may lead to increased muscle tension and energy expenditure to maintain joint stability and balance.. A systematic approach is necessary to identify these interactions and address them effectively.

Fatigue in Hypermobile Ehlers-Danlos Syndrome (hEDS)

Fatigue is a frequent complaint among individuals with hypermobile Ehlers-Danlos syndrome (hEDS). It encompasses both physical and mental exhaustion that minimally improves with rest and often aligns with the diagnostic criteria for CFS (Tinkle et al, 2017). In a study of EDS patients, chronic fatigue, post-exertional malaise, and unrefreshing sleep were universal, while cognitive impairments, joint pain, and headaches were also prevalent (Tinkle et al, 2017).

Evaluation of Fatigue

Given its multifactorial nature, fatigue requires a comprehensive evaluation. Potential contributors to fatigue include:

• Sleep disorders such as sleep apnea or poor sleep hygiene

• Nutritional deficiencies (e.g., B12, folate, vitamin D, magnesium)

• Chronic illnesses affecting major organs (e.g., cardiac, pulmonary, liver, or kidney conditions)

• Hormonal imbalances, such as thyroid or adrenal dysfunction

• Post-viral syndromes or systemic triggers like mast cell activation or cytokine release (Francomano et al. 104-107)

Management Strategies

Managing fatigue involves identifying and addressing its underlying causes through a personalized treatment plan. Key strategies include:

• Pain Management: Medications, physical therapy, and coping strategies to reduce chronic pain.

• Sleep Hygiene: Optimizing sleep routines and treating disturbances with medications such as trazodone, gabapentin, or mirtazapine to improve sleep quality [Walsh, 2009].

• Psychological Support: Addressing anxiety and depression through therapy and relaxation techniques, as these conditions can worsen fatigue and pain perception dampening sympathetic arousal.

• Lifestyle Adjustments: Incorporating breathing exercises, stress management, and gradual physical activity tailored to the individual's capacity dampening sympathetic arousal. (Francomano et al. 104-107)

Conclusion

Fatigue in CFS and hEDS is a result of multiple overlapping factors, making it essential to identify and address as many contributors as possible in a comprehensive treatment plan. With careful evaluation and tailored interventions, it is possible to improve quality of life and reduce the burden of fatigue.

References

Tinkle B, Castori M, Berglund B, Cohen H, Grahame R, Kazkaz H, Levy H. Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history. Am J Med Genet C Semin Med Genet. 2017 Mar;175(1):48-69. doi: 10.1002/ajmg.c.31538. Epub 2017 Feb 1. PMID: 28145611.

Jacobs, J. W. G., et al., editors. Ehlers-Danlos Syndrome : A Multidisciplinary Approach. IOS Press, 2018, http://bibpurl.oclc.org/web/92086.

Francomano, Clair A, et al. Symptomatic : The Symptom-based Handbook for Ehlers-danlos Syndromes and Hypermobility Spectrum Disorders. San Diego: Elsevier, 2023.