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Suboptimal thyroid function is very common, and it is important to treat all chronic myalgia patients with thyroid hormone replacement if their free T4 blood levels are below even the 50th percentile of normal (Janet Travell – personal communication). Many CFS/FMS patients also have difficulty in converting T4, which is fairly inactive, to T3, the active hormone. Additionally, T3 receptor resistance may be present, requiring higher levels.8 In most CFS/FMS patients, I give an empiric trial of Armour thyroid, ½ to 2 grains every morning, adjusted to the dose that feels best to the patient as long as the free T4 is not above the upper limit of normal.
TSH testing is not reliable. Iodine support (I use Tri-Iodine 6.25 mg a day) can be helpful. Optimizing ferritin (iron) levels by keeping them over 60 is needed for proper conversion of T4 thyroid to active T3. Selenium 200 mcg can help in Hashimoto's, but otherwise I limit selenium to 55 mcg a day, as higher doses are associated with a modestly increased diabetes risk.
I find the most reliable indicator of the need for adrenal support to be sugar cravings associated with irritability when hungry.
An excellent glandular/herbal mix for adrenal support that is very safe and effective is Adrenal Stress End (from Integrative Therapeutics). I also consider bioidentical prescription Cortef, 5 to 12.5 mg a day if needed.
Low Estrogen and Testosterone
These have been discussed at length in other Townsend Letter articles, so I will simply note that bioidentical and herbal support when needed is very helpful.
I – Immune Dysfunction, Infections, Inflammation, and Impingement: Immune dysfunction is part of the FMS process. Opportunistic infections present in FMS/CFS include yeast/candida, chronic sinusitis, nasal–toxin producing Staph aureus infections, numerous bowel infections, and chronic, low-grade viral and antibiotic-sensitive infections (e.g., Lyme disease). These may need to be treated, especially candida, though many infections resolve on their own as immune function improves.
Inflammation also needs to be addressed, and natural remedies do so brilliantly. My favorites are below.
Treating Inflammation Naturally
My favorite natural anti-inflammatories are:
1. BCM95 highly absorbed curcumin
3. willow bark
4. omega-3 EFAs
These are contained in:
Curaphen (by EuroMedica): This mix of highly absorbed curcumin, boswellia, DLPA, and nattokinase has been a pain relief miracle – sometimes helping when morphine has not. It continues to build in effectiveness over 6 weeks, but is often effective in 30 minutes. For severe chronic pain, I give 2 tabs 3× day for 6 weeks, then lower the dose or give as needed.
Pain Formula (by Integrative Therapeutics): This mix of willow bark, boswellia, and cherry is especially helpful for arthritis and back pain. For severe chronic pain, I give 2 tabs 3× day for 6 weeks, then lower the dose or give as needed.
EurOmega 3 (by EuroMedica): This vectorized omega-3 is what I use for omega-3 support. One pill delivers the same effective level of omega-3s as 8 regular fish oil capsules, containing the EFAs but leaving out the unneeded triglycerides. So 1–2 a day are plenty, with lower cost, better compliance, no toxicity or rancidity, and no fish oil burps.
I combine all 3 of the above in those with pain and add them to any pain meds that the person is on. After 6 weeks, the pain meds can often be tapered down or stopped, and the dose of the herbals lowered (or taken as needed). In a head-on study, the components of Curaphen were much more effective than Celebrex for arthritis. At the beginning of the study, 79% of the people taking Celebrex were in moderate to severe pain, dropping to 50% after 12 weeks. In those who took Curaphen equivalent, these numbers were 86% and 21%, respectively. Basically, the medication resulted in major pain reduction in only 29% in the Celebrex group vs. 65% in the herbal group!9
Meanwhile, in another head-on study, willow bark was twice as effective as ibuprofen for back pain.10 Besides being more effective, the herbals result in "side benefits" instead of side effects!
N – Nutritional Deficiencies: FMS/CFS patients are often nutritionally deficient. B vitamins, magnesium, ribose, iron, coenzyme Q10, malic acid, and carnitine are essential for mitochondrial function. These nutrients are also critical for many other processes. Although blood testing is not reliable or necessary for most nutrients, I do recommend that you check B12 and ferritin levels.
I begin people with FMS/CFS on the following nutritional regimen:
1. A quality multivitamin suited for their needs. It should contain at least a 50 mg B complex, 150 mg of magnesium glycinate, 900 mg of malic acid, 2000 IU of vitamin D, 500 mg of vitamin C, zinc 15 mg, selenium 50 mcg, chromium 200 mcg, and amino acids. Because there are dozens of important nutrients, and patients got tired of taking handfuls of tablets each day, I now use a powdered multivitamin called the Daily Energy Enfusion (by Integrative Therapeutics) in almost all of my patients (even those without CFS) for overall nutritional support. It contains over 50 nutrients in a single drink, replacing over 35 tablets each day. This should be taken long term with 1 EurOmega 3 daily.
2. If the ferritin is under 60 mg/ml, supplement with iron (with added vitamin C for absorption and not within 2–6 hours of a thyroid dose).
3. If the B12 level is under 540 pg/ml, I recommend B12 injections, 3000 mcg IM three times a week times for 15 weeks, then as needed based on the patient's clinical response or 5000 mcg (5 mg) SL daily.
4. Coenzyme Q10: 200 mg a day.
5. Acetyl-L-carnitine: 500 mg twice daily for 4 months.
6. The person should avoid sugar and caffeine, and water intake should be increased.
7. An especially important nutrient? Ribose (Corvalen by Douglas Labs). This is one of the single most important nutrients for treating fibromyalgia, A study that we authored published in the Open Journal of Pain showed that ribose not only significantly decreased fibromyalgia pain but also increased energy an average of 61% at 3 weeks.11
It is also very effective for heart disease as well. I consider ribose the most important nutrient discovery of the decade!
A Few Final Points...
Topical Pain Relief
When dealing with localized pain, it is often neither needed nor desirable to soak all 200 pounds of a person to treat 3 ounces of painful tissue, and topical treatments can be excellent. A few of my favorites include:
1. Comfrey topical (Traumaplant by EuroPharma). This is an amazing and often quickly effective treatment for many kinds of pain, and a top priority for everyone's medicine cabinet. Try it and prepare to be amazed
2. Topical menthol creams (such as Tiger Balm) can help for tension headaches and other muscle pains
3. Compounded pain creams. For prescribing practitioners, this can be helpful for nerve and tendonitis pain.
A Few Specific Pain Conditions
Vitamin B6 (P5P)
300 mg 2×/day for 6–2 weeks (diabetic & other neuropathies)
1–2 g IV magnesium sulfate over 15 minutes gives immediate elimination of the migraine in 85%!12,13
Excedrin Migraine Amount
Butterbur (Petadolex).........You can give 100 mg every 3 hours to eliminate an acute migraine. Give 50 mg 3× per day for 1 month and then 50 mg 2× per day for prevention
Nutritional support and treating food sensitivities are very important
Vitamin B2 (riboflavin)
CoQ10 and Magnesium
400 mg/day (67% decrease)14
50 mg 2× per day
1000 mcg (43% decrease)
200 mg/day of each may also help
Effective treatment is available for almost all pain, just not from standard physicians. Although this article focuses on metabolic aspects of pain relief, applying structural therapies (e.g., chiropractic and osteopathic manipulation and numerous forms of body work), biophysics (e.g., acupuncture and frequency specific microcurrent), and other modalities can also be dramatically effective. People with pain do best, as do their practitioners, when practitioners speak with each other, cross-refer, and share information!
1. Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy Am J Med. 27 July 1998;105(1,Suppl 2):31S–38S.
2. Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis BMJ. 2011;342:c7086. Available at http://www.bmj.com/content/342/bmj.c7086.full.pdf.
3. Teitelbaum J, Bird B. Effective treatment of severe chronic fatigue: a report of a series of 64 patients. J Musculoskel Pain. 1995;3(4):91–110.
4. Teitelbaum JE, Bird B, Greenfield RM, et al. Effective treatment of CFS and FMS: a randomized, double-blind placebo controlled study. J Chronic Fatigue Syndr. 2001;8(2):3–24. The full text of the study can be found at www.Vitality101.com.
5. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug;13(8):715–724. Epub 2012 May 16. http://www.ncbi.nlm.nih.gov/pubmed/22607834 Accessed Sept. 19, 2013.
6. Demitrack MA, Dale K, Straus SE, et al. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab. December 1991;73(6):1223–1234.
7. Yunus MB, Aldag JC. Restless legs syndrome and leg cramps in fibromyalgia syndrome: a controlled study. Br Med J. 25 May 1996;312(7042):1339.
8. Lowe JC, Reichman AJ, Yellin J. The process of change during T3 treatment for euthyroid fibromyalgia: a double-blind, placebo-controlled, crossover study. Clin Bull Myofasc Ther. 1997;2(2/3):91–124
9. Antony B, Kizhakkedath R, Benny M, Kuruvilla B. Clinical evaluation of an herbal formulation in the management of knee osteoarthritis. Poster presentation. Presented at Osteoarthritis Research Symposium Internationale (OARSI) Annual World Congress on Osteoarthritis. September 15–18, 2011; San Diego, CA.
10. Chrubasik S et al. Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study. Am J Med. 2000 July;109(1):9–14.
11. Teitelbaum JE, Jandrain J, Mcgrew R. Treatment of chronic fatigue syndrome and fibromyalgia with D-ribose – an open-label, multicenter study. Open Pain J. 2012;5:32–37.
12. Demirkaya S, Vural O, Dora B, Topçuoğlu MA. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171–177.
13. Mauskop A, Altura BT, Cracco RQ, Altura BM. Intravenous magnesium sulfate rapidly alleviates headaches of various types. Headache. 1996 Mar;36(3):154–160.
14. Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology. 1998 February;50(2):466–470.
Jacob Teitelbaum, MD
Medical Director of the Practitioners Alliance Network (PAN)
Author of From Fatigued To Fantastic! and Pain Free 1-2-3: A Proven Program to Get YOU Pain Free Now! and senior author of the landmark study "Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia – a Placebo-Controlled Study."
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