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Excerpt from The CFIDS & Fibromyalgia Self-Help Book: Treatment Options for Fatigue, Pain and Sleep

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www.ProHealth.com • September 22, 2004


Excerpt from: The CFIDS & Fibromyalgia Self-Help Book By Bruce Campbell, Ph.D.

Chapter 4: Treatment Options for Fatigue, Pain and Sleep

Because there is so far no cure for either CFIDS or fibromyalgia, treatment focuses on controlling symptoms. This chapter outlines treatment options for three of the most common symptoms: fatigue, pain and sleep. The discussion can be summarized in two points: A symptom often has more than one cause. It may be helpful to use several coping strategies in response. You can manage fatigue, pain and sleep using a three-part strategy:
1. Address interactions among fatigue, pain and poor sleep.
2. Combat causes common to all three symptoms.
3. Pursue symptom-specific remedies.

FATIGUE
Fatigue is the central symptom in CFIDS and a significant problem for most people with fibromyalgia. The word fatigue may be a misleading way to refer to the physical and mental exhaustion that often permeates the lives of patients, making them listless and unable to complete normal activities. One cause of fatigue is the illness itself, which uses energy in attempting to heal. But fatigue can have many other causes, including the following factors:
Pain: Having ongoing physical discomfort intensifies fatigue. For example, tensing muscles in response to pain is tiring.
Poor Sleep: Rather than being refreshing, sleep is often non-restorative, compounding fatigue.
Activity: Overactivity intensifies symptoms, often leading to cycles of push and crash.
Stress: Stress leads to fatigue when healing energy is lost to worry and muscle tension. A higher level of fatigue, in turn, can increase worry, creating another vicious cycle in which symptoms and your response to them intensify one another.
Feelings: Strong emotions like worry, anger, grief and depression are a normal response to serious illness. These feelings can intensify fatigue. Depression, for example, brings listlessness. Worry and anger dissipate energy.
Inactivity: A lower activity level creates deconditioning. A lowered fitness level, in turn, makes you more likely to experience fatigue when you try to be active. In sum, a lower activity level creates deconditioning, which in turn intensifies fatigue.
Poor Nutrition: Poor quality food, insufficient quantity of food, digestive problems or food allergies can all contribute to fatigue.
Medications: Fatigue is a side effect of many medications
Because fatigue can have many causes, you may benefit from using several coping strategies. You’ll find a variety of strategies below, divided into three groups.
1) Reversing the Interactions of Fatigue, Pain and Poor Sleep
The three symptoms of fatigue pain and poor sleep intensify one another in a downward spiral. For example, pain is inherently tiring and also tends to produce muscle tension, which is fatiguing. Physical discomfort can also make it difficult to get to sleep or to sleep comfortably. Poor sleep, in turn, increases both fatigue and pain. Unrefreshing sleep leaves you as tired in the morning as you were before going to bed. Lack of good sleep also deepens the experience of pain. Lastly, fatigue affects both pain and sleep. Being tired makes pain worse. It may also lead to excessive rest and naps during the day, which can make sleep problems worse. You may be able to break this vicious cycle and create an upward spiral. An improvement in one symptom can have a positive effect on the other two. Probably the commonest symptom to attack first is poor sleep.
2) Combating Overactivity, Stress, Emotions and Inactivity
Several factors that cause fatigue also worsen pain and make sleep more difficult. These include overactivity, stress, emotions and inactivity. Measures you take in response can have an effect on all three symptoms. Because these measures are so helpful against a variety of symptoms, most of the book will be devoted to showing you how to apply them in your life. In this chapter, I’ll outline how they can help you.

Pacing Pacing, which means finding the right balance of activity and rest for your unique situation, is the primary strategy for combating the fatigue due to overactivity. Pacing means understanding your limits and then honoring them. You’ll learn how to determine your limits in Chapter 5, which discusses the concept of the energy envelope. Chapter 6 offers strategies you can use to honor your limits, including setting priorities, taking regular rests, having short activity periods, living by a schedule, and managing special events like vacations and holidays.

Stress Management Stress is pervasive in chronic illness and intensifies many symptoms. For example, if you are anxious, your worry can lead to muscle tension, which increases both pain and fatigue. Strategies for stress management are offered in Chapter 9. Other sources of stress include the expectations we have for our relationships and for ourselves. Chapter 10 explains how making mental adjustments can reduce stress. Chapter 12 discusses how to improve relationships.

Managing Emotions Powerful emotions are part of chronic illness, a response to the disruption of life, to losses and to uncertainty it brings. Emotional reactions may be intensified by CFIDS and fibromyalgia, which seem to make emotional reactions stronger. Chapter 11 describes how to manage depression, anxiety and anger. Chapter 13 offers resources to help you move beyond grief.

Exercise If being ill reduces your activity level and leads to deconditioning, you may be able to start a spiral in the other direction with exercise. Exercise produces a higher level of fitness, thus reducing fatigue. But it also helps combat pain, lessens stress and improves mood. Exercise is usually recommended for fibromyalgia patients and may also be helpful for CFIDS as well. For more, see the section on exercise later in this chapter. 3) Remedies for Poor Nutrition and Medication Side Effects Finally, here are some strategies you can use to combat fatigue-specific symptom causes, measures to take in response to poor nutrition and medication-related fatigue.

Good Nutrition CFIDS and fibromyalgia patients often experience several different kinds of problems getting good nutrition. First, because of energy limitations, lack of appetite or severity of symptoms, some people may not spend enough time to prepare and eat balanced meals. Eating well can provide energy and boost the immune system. Some possible solutions if you have difficulty eating a balanced diet include getting help with food preparation and freezing meals for use on days when symptoms are intense. Second, most patients experience an intolerance of alcohol and many are sensitive to caffeine and/or sweeteners. Cutting down or eliminating these substances may reduce symptoms and mood swings and also improve sleep. Lastly, about one third of CFIDS patients and some fibromyalgia patients experience sensitivities to various foods or have difficulty absorbing nutrients. Sensitivity may manifest as one or more of the following: changes in pulse, fatigue, heartburn, gas, nausea, diarrhea and constipation. Individual responses vary greatly. About two thirds of CFIDS patients and many fibromyalgia patients have no new food problems because of being sick, while others may react strongly to certain foods. Unfortunately, there is no common set of foods to which patients are sensitive. One person may respond badly to dairy while another must avoid wheat. The bottom line: if you think you are sensitive to food, you will have to experiment; there is no single “CFIDS diet” or “fibromyalgia diet.” Some common sources of food allergy include dairy products, eggs, soy, wheat, and corn. The classic way to test for food allergies is the elimination diet. To experiment in this way, first identify foods you think might cause problems. Second, eliminate them from your diet. Third, reintroduce them one by one. Because reactions can take one to several days to develop, you will need records of what foods you eat and what symptoms you experience for a several day period. You may find you cannot tolerate some types of food at all or that you can tolerate a food if you eat it only occasionally.

Medication Adjustments Many medications, including some anti-depressants and drugs prescribed for pain, have fatigue as a side effect. To combat this source of fatigue, ask your doctor about fatigue when reviewing medications. A change of medication or a lower dosage may help.

PAIN
Pain is usually the central symptom for fibromyalgia patients and often a problem for CFIDS patients as well. Like fatigue, pain can have a variety of causes and is best managed using a variety of strategies. Factors that make pain worse include: Fatigue: Being tired reduces resiliency and increases our perception of pain. Poor Sleep: Pain often makes getting good rest difficult. Poor sleep, in turn, makes pain worse. Activity: Ignoring the body’s signals to stop, we often push beyond our limits. Being too active or not balancing activity and rest worsens pain. Stress: Stress makes living with illness more difficult and worsens our perception of pain. Also, stress Feelings: Like stress, emotions Inactivity: Muscles deteriorate through inactivity. Weak muscles contribute to pain. Body Mechanics: Poor posture or staying too long in one position can make pain more intense. Environmental Factors: Feeling hot or cold, or changes in barometric pressure can deepen pain. I suggest you manage pain using the same three-part strategy outlined for controlling fatigue: address the interactions of pain, fatigue and sleep; combat causes common to all major symptoms; and pursue pain-specific strategies. First, explore how fatigue and poor sleep affect pain. For most people, fatigue deepens the perception of pain. When we feel tired, we experience pain more intensely. Reducing fatigue can also lessen pain. Similarly, poor sleep intensifies pain so improving sleep can help control pain. Second, factors that cause fatigue and poor sleep also make pain worse. These include overactivity, stress, emotions and inactivity. Strategies such as pacing, stress management, managing emotions and exercise can help reduce all three symptoms. Exercise, which is discussed in a separate section later in this chapter, can reduce pain by increasing flexibility, muscle tone and endurance. Each of the other three strategies is explored in a separate chapter. Here I’ll outline their benefits for controlling pain.

Pacing Finding the right balance of activity and rest can help you control your pain. The key is to know your activity limits and to stay within them using techniques like short activity periods, task switching and restbreaks. Taking regular, scheduled rests that we call pre-emptive rest, can be particularly helpful. Such rest is one of the most popular strategies used by people in our program. People who use pre-emptive rests often take one or two rests a day, ranging in length from 10 minutes to half an hour. Whatever the length, the secret is to rest on a schedule, regardless of how you feel, rather than waiting for symptoms to intensify. For more on rest, see Chapter 6.

Stress Reduction It is easy to respond to pain by tensing muscles, which intensifies pain. One way to reduce pain is by using relaxation, as described in Chapter 9. The pain management techniques you’ll find there have been shown to reduce pain as much as some medications, without the side effects.


Managing Emotions Since worry, frustration and other emotions create muscle tension, relaxation procedures that reduce pain through reducing stress can also help reduce the effects of negative emotions. Also, our subjective experience of pain is increased by emotions. Fear intensifies pain, so managing anxiety can help control pain. Another set of strategies for controlling pain through managing emotions has to do with changing how you think. An increase in symptoms may trigger negative thoughts like “I’m not getting anywhere,” “I’ll never get better,” or “It’s hopeless.” Such thoughts can then make you feel anxious, sad, angry and helpless. These feelings intensify pain and trigger another round of negative thoughts. Chapter 10 presents a system for recognizing and gradually changing habitual negative thoughts.

Pain-Specific Remedies Lastly, there are measures you can take specifically in response to pain. We’ll look at three: medications, physical treatments like heat, cold and massage, and body mechanics.

Medications For many CFIDS and fibromyalgia patients, pain relief through medications may be modest, achieved through the use of non-prescription products such as aspirin and other over-the-counter pain relievers. Others find some help through various prescription drugs, including sometimes narcotics. Prescription medications that improve sleep can have a beneficial effect on pain as well. Anti-depressants such as Elavil (Amitriptyline), Prozac and Paxil are often tried. Successful treatment of CFIDS and fibromyalgia is usually very individualized, depending on factors such as a person’s symptom pattern and her response to different medications. Experimentation is usually required to find medications that are effective. It is difficult to predict which treatment may be successful. Sometimes a medication will be effective for a time, and then lose effectiveness. Usually, patients are started on dosages that are a small fraction of normal dosage levels.

Physical Treatments Heat and cold can be used for temporary relief of pain. Heat is best utilized for reducing the pain that results from muscle tension and inactivity. The warmth increases blood flow and thereby produces some relaxation, reducing pain and stiffness. For localized pain, you might use a heating pad or hot packs. For overall relief, people often use warm baths, soaks in a hot tub or lying on an electric mattress pad. Cold treatments are helpful in decreasing inflammation by reducing blood flow to an area. They also may numb the areas that are sending pain signals. You might use gel packs, ice packs or even bags of frozen vegetables. With both heat and cold, you should not use the treatment for more than 15 or 20 minutes at a time. Massage of painful areas can also provide temporary relief from pain. Like heat, massage increases blood flow and can also relieve spasms. You can consider three different forms of massage: self-massage using your hands, massage using a handheld device, and professional massage.

Body Mechanics Experimentation with how you hold your body and how you move it can help you control pain. Try different postures, both standing and sitting, to find which ones minimize your pain. Also, note how long you can maintain a posture without creating problems. Many patients find that staying in one position for an extended period of time creates stiffness and intensifies pain. The solution is to move periodically. Check your body frequently for muscle tension. Areas that are often tense include the jaw, neck and shoulders. Movement, massage or telling yourself to relax can help. When working in the kitchen, consider placing one foot on a footstool to reduce the strain on your back. If tasks that involve repetitive motion, such as chopping, cause pain, experiment to find how long you can work without creating pain and how long you have to pause before returning to work. Then break up the task into several brief sessions. If you have problems standing, consider sitting on a stool.

SLEEP
Poor sleep is one of the most common problems for fibromyalgia patients and also very prevalent among people with CFIDS. With both illnesses, poor sleep is a major source of intensified symptoms. You may spend a night in bed, but awaken as tired as before going to bed. Other sleep problems are common as well, such as difficulty getting to sleep, waking in the middle of the night or early in the morning, and sleeping more than you want. It is widely believed that a major cause of sleep problems, especially for fibromyalgia patients, is abnormal patterns of brain waves. Our brains are active during sleep, moving among several different types of sleep, each with characteristic brain waves. The deepest and most restorative type of sleep is referred to as delta sleep. Patients with CFIDS and fibromyalgia often get less delta sleep than they need, and thus don’t feel refreshed when they get up in the morning. When healthy volunteers were deprived of delta sleep in an experiment, they developed symptoms of fibromyalgia in a few days. Like fatigue and pain, poor sleep can have more than one cause. Factors that make good sleep difficult include:
Fatigue: Feeling tired from poor sleep can lead to excessive daytime napping, which can make it more difficult to fall asleep at night. Also, fatigue is often associated with a “tired but wired” feeling that makes getting to sleep harder.
Pain: Pain makes getting food rest difficult.
Activity: Being too active can be over stimulating (feeling “wired”).
Stress & Worry: Stress often leads to muscle tension, which makes falling asleep more difficult. Preoccupation with problems can make getting to sleep harder.
Sleep Habits & Environment: Sleep can be disturbed by factors like irregular hours, a noisy environment, an uncomfortable bed or a noisy sleeping partner.
Food, Alcohol & Tobacco: Factors such as consuming too much caffeine, drinking alcohol
Medications: Some sleep medications that are effective when used occasionally can produce poor sleep if used frequently. Also, some drugs produce side effects like a feeling of grogginess in the morning. Medications taken for other problems may interfere with sleep if they contain, for example, antihistamines or caffeine.
Sleep is especially challenging because there is no standard remedy that has proven helpful in solving sleep problems for people with CFIDS and fibromyalgia, and because an approach that is effective for a while may become ineffective. For both these reasons, sleep is an area in which a flexible, experimental approach utilizing a variety of strategies can be useful. I suggest you address sleep using the same three-part approach outlined earlier for controlling fatigue and combating pain. First, look at the interactions among pain, fatigue and sleep to determine how the vicious cycle of the three symptoms intensifying one another can be interrupted and an upward spiral begun. For the interaction between fatigue and sleep, ask whether daytime napping might be interfering with your ability to fall asleep. Also, if your activity level leaves you feeling “wired,” pacing strategies may be helpful. Reducing pain before going to bed can help. Many patients find a hot bath or time in a hot tub helpful. Second, several factors that increase fatigue and worsen pain also make sleep more difficult. These include activity level, stress and worry. Measures you take in response can have an effect on all three symptoms. Because multi-symptom strategies such as pacing and stress management are so important, they are discussed at length in separate chapters later in the book. We’ll outline here their benefits for sleep. Pacing offers an answer to a sleep-related problem created by too much activity. Some patients find that, contrary to a healthy person’s experience of feeling relaxed after exertion, they are edgy and restless. By keeping your activity level within the limits imposed by your illness, you can avoid the tired-but-wired feeling. Relaxation methods help you ease tense muscles and thereby may make it easier to get good rest. Try relaxation procedures like those described in Chapter 9 or soak in a hot tub or bath before going to bed.

Sleep-Specific Remedies Last, there are measures you can take that address sleep problems specifically. You can try solving sleep problems by using medications, by experimenting with your sleep habits and environment, and by changing other personal habits.

Medications Medications can be useful for sleep problems but there is no single medication found helpful for all patients. As with the use of drugs to treat other symptoms of CFIDS and fibromyalgia, you will probably have to experiment to find what works for you. Also, you may develop a tolerance for a drug so that it becomes less effective over time. A sensible approach if you have poor sleep is to find a sympathetic physician who will work with you and to keep abreast of treatment developments by reading publications and visiting websites of leading fibromyalgia and CFIDS organizations. Medications commonly used to treat sleep problems include over the counter products like melatonin and valerian, antihistamines such as Benadryl, clonazepam (Klonopin), tricyclic antidepressants such as amitriptyline (Elavil), benzodiazepines such as Halcion, and the hypnotic drug Ambien. Often a combination of two drugs is prescribed, one to initiate sleep and another to maintain sleep.

Sleep Habits & Environment You may be able to improve your sleep by changing your sleep habits or your sleep environment.
1. Have a Comfortable Environment: Provide yourself with an environment conducive to good sleep by having a good mattress and by controlling light, noise and temperature.
2. Establish a Routine: You may fall asleep more easily if you have ‘going-to-bed’ rituals. You can prepare yourself for falling asleep by having a routine to go through each night. Things like brushing your teeth or doing light reading every night before retiring can help you wind down.
3. Get Up at the Same Time: Setting an alarm so that you get up at the same time each day can help you adjust gradually back to more normal hours. Usually you don’t need to compensate by changing your bedtime to an earlier hour. Your body will adjust itself.
4. Limit Daytime Napping: Often daytime napping interferes with nighttime sleep. If you find that you have trouble falling asleep at night when you nap during the day or your sleep is worse than usual, you might consider sleeping only at night. (On the other hand, if napping does not disturb your sleep, you may need more rest.)
5. Use Relaxation or Distraction to Fall Asleep: It may be easier to fall asleep if you listen to quiet music or distract yourself in some other way such as by counting or watching your breath. You might use relaxation techniques such as those in Chapter 9 to help you fall asleep.
6. Manage Worry: If you lie awake at night with thoughts running through your head, consider setting aside a “worry time” each night before going to bed. Take a half hour to write down all your worries and what you plan to do about them. If worries come up as you are trying to go to sleep, tell yourself “I’ve dealt with that. I don’t have to worry because I know what I’m going to do.”

Other Factors Affecting Sleep
1. Limit caffeine: Avoid products like coffee, tea and soft drinks for several hours before going to bed. They contain caffeine, which is a stimulant.
2. Limit alcohol: Be moderate in your use of alcohol and avoid it in the several hours before bedtime. Alcohol can create restless and uneven sleep. You may be able to fall asleep after drinking, but then awaken later and have trouble falling back asleep.
3. Eliminate smoking: Tobacco contains nicotine, which stimulates the nervous system, making it more difficult to fall asleep.

Other Sleep Problems Some patients have one or more additional sleeping problems besides insufficient delta sleep. Two of the most common are restless leg syndrome and sleep apnea. The former involves “twitchy limbs,” the experience of strong unpleasant sensations in the leg muscles that create an urge to move. The problem is often at its worst at night. Self-management techniques that may help include reducing consumption of caffeine and other stimulants, the use of exercise involving the legs, and taking supplements to counteract vitamin deficiencies. Medications may help on a short-term basis. Check with your doctor if you believe you might have this condition. Apnea meaning absence of breathing, occurs when a person’s airway becomes blocked during sleep. An episode can last from a few seconds to a few minutes. The person then awakens, gasps for air and falls asleep again. This can occur many times a night. A common remedy is the use of a CPAP (continuous positive airway pressure) machine to keep the airway open. The patient wears a mask through which a compressor delivers a continuous stream of air, keeping the airway open. Other treatments are also used for this condition. If you suspect you have this problem, consult a sleep specialist.

EXERCISE
The benefits of exercise are great. Exercise counteracts the fatigue that results from deconditioning. If we are less active, we become less fit and activity tires us more easily. Lower activity is likely to increase stiffness. Also, being less active can lead to worry, frustration and depression. If being ill reduces activity level, leading to deconditioning, greater fatigue, stiffness, anxiety and depression, a way to start a spiral in the other direction is with exercise. Exercise counteracts all these factors. It produces a higher level of fitness, it reduces stress, fatigue and stiffness, and it improves mood. As Edward Hallowell says: “Exercise is probably the best natural antianxiety, antiworry agent we have.... It is an antidepressant, it reduces tension, it drains off excess aggression and frustration, it enhances a sense of well-being, it improves sleep, it curbs the tendency to eat absentmindedly, it aids in concentration, and it reduces distractibility.” Exercise is recommended for most fibromyalgia patients and may be helpful for CFIDS patients as well. But there are some patients for whom exercise is not likely to be helpful and may even produce a setback. It may be inappropriate for people whose symptoms are particularly severe and is inadvisable when symptoms flare up dramatically. Before starting an exercise program, check with your doctor. He in turn may refer you to other professionals who specialize in exercise, such as physical or occupational therapists. A comprehensive fitness program includes three types of exercise. Flexibility exercises (stretching) reduce stiffness and keep joints and muscles flexible. Strengthening exercises maintain or increase muscle strength, thereby reducing pain. Endurance or aerobic exercises strengthen your heart and lungs. They help lessen fatigue by giving you more stamina, help improve sleep and mood, and aid weight control. (For detailed exercise programs in each of the three areas, see the Arthritis Helpbook.)

Exercise Guidelines In creating your exercise program, consider the following guidelines.
1. Remember: All Physical Activity is Exercise. Even if you don’t have a formal exercise program, you are already exercising if you clean house, do laundry, garden, cook or shop. For some people, a trip to the grocery store is a day’s exercise. When you are creating an exercise program, be sure to include your daily physical activity when calculating your total exertion.
2. Start Low. Begin by finding a safe level of exercise, one that does not intensify your symptoms. The goal is to have a sustainable level of effort that you can do several times a week. You might try a gentle aerobic form of exercise, like walking or exercising in a pool. To improve your flexibility, try stretching, yoga or Tai Chi. For strength training, use light weights or isometric and isotonic exercises. For some people, starting low may mean as little as one to two minutes of exercise per session.
3. Go Slow. It is usually advisable to keep the same duration goal for at least a week or two, and to increase the duration very gradually. Increases in duration should be only a few minutes at a time, typically only 10% or so. You may break down your total exercise times into a number of shorter sessions, aiming eventually for something like a half an hour a day. It may take six months to a year to build up to a 30-minute routine.
4. Monitor Yourself. The intensity of your exercise should be in the 3 to 4 range, where 1 is resting and 10 is the most effort you can imagine. A standard often used to determine whether you have an appropriate level of aerobic exercise is the talk test: you should be able to carry on a conversation while exercising. If you have pain that lasts several hours after you finish, experiment with the intensity and length of your program. You may be able to reduce pain by experimenting with heat or massage before exercise and cold after. Heat in the form of heat pads or warm water (shower or bath) increases blood flow; cold in the form of ice packs or bags of frozen vegetables reduces inflammation. To evaluate your program and troubleshoot problems, consider keeping a record of your exercise and the consequences. You might record the time and duration of exercise, its intensity and your symptom level before and after. You can note symptoms using a ten point scale or perhaps letters like L, M and H to note low, medium and high. A diary can help you see the effects of exercise, some of which may be delayed for hours or even days.

Sticking with it: Exercise for the Long Haul The benefits of exercise are greatest for those who exercise regularly, but it can be difficult to work out consistently. Here are some ideas for how to persevere with an exercise program.
1. Do exercise you enjoy. Your chances of sticking with an exercise program are much greater if you enjoy what you are doing, so find a form of exercise you like. Make your time more enjoyable by listening to music or distracting yourself in some other way.
2. Find the right setting. If you have trouble motivating yourself to exercise alone, exercise with a friend or in a class. Making a commitment and socializing while you exercise are two good ways to increase the odds that you will stick with an exercise program.
3. Keep records. Consider motivating yourself by keeping records. Setting goals and measuring progress often helps people stick with their program. Also, keeping an exercise diary is a way to hold yourself accountable.

REFERENCES:
Arthritis Foundation. The Arthritis Foundation’s Guide to Good Living with Fibromyalgia. Arthritis Foundation: Atlanta, 2001
Caudill, Margaret. Manage Pain Before It Manages You. New York: Guilford Press, 1995
Hauri, Peter and Shirley Linde. No More Sleepless Nights. New York: Wiley, 1991.
Lorig, Kate and James Fries. The Arthritis Helpbook. Cambridge, Mass: Perseus Books, 2000. (c) Bruce Campbell, Ph.D. All rights reserved. Reprinted with permission. For more information and to learn about the Internet CFIDS/Fibromyalgia Self-Help course, please visit: http://www.cfidsselfhelp.org/index.htm



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