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The GIST

The Blog

The GIST is at the bottom of the blog.

Exhaustion

The authors took the opportunity to address non-drug means to improve oxygen delivery, blood flows, and oxygen uptake by the tissues.

Studies often have a treatment section at the end of the paper, but I’ve never seen anything like the one that showed up at the end of a study Health Rising recently covered. The “Cardiopulmonary and metabolic responses during a 2-day CPET in myalgic encephalomyelitis/chronic fatigue syndrome: translating reduced oxygen consumption to impairment status to treatment considerations” was a landmark study that validated the results of the 2-day exercise tests in chronic fatigue syndrome (ME/CFS).

The study featured some familiar names: Betsy Keller, Staci Stevens (exercise physiologist) and Jared Stevens, Susan Levine and John Chia (ME/CFS experts), Dikomo Shungu and Maureen Hanson (researchers) and had a long treatment section (called “Treatment Considerations”) at the end of the paper.

Biggest 2-Day Exercise Study Ever Validates the Energy Problems in ME/CFS: Pt. I

That was intriguing given the rather stark news out of the study: short but intense periods of exercise one day dramatically affect the ability of people with ME/CFS to generate energy the next day. What to do about that unexpected reduction in energy production? The authors didn’t provide any magic bullets, but they outlined a series of possible non-drug interventions they believe can “positively influence… many, if not all symptoms” found in ME/CFS.

They all centered around the “Fick Principle”.

The Fick Principle

The Fick Principle formed the basis of the authors treatment suggestions.

The Fick Principle and ME/CFS

They grounded the interventions physiologically by referring to the “Fick Principle”, developed by a German mathematician/physicist named Adolph Eugene Fick, in 1870. The Fick Principle states, given that oxygen is our main source of energy, energy production is wholly dependent on three things: getting oxygen into the blood (via breathing), speeding the oxygen-rich blood to the tissues that need them, and then having those tissues extract oxygen from the blood.

Almost everything in the treatment review section flows from the Fick Principle in one way or another. Since both blood flows and oxygen extraction appear to be problematic in ME/CFS and long COVID, the question the authors grappled with was: what can be done – without drugs – to improve them?

Finding ways to improve autonomic nervous system functioning plays a major role in this process. During exercise, depleted tissues send signals to the brainstem, telling it they need more oxygen (blood). When that happens, the brainstem and autonomic nervous system usually work together seamlessly to increase breathing (oxygen uptake) and blood flows.

Not so much in diseases like ME/CFS and long COVID, though, where problems with both breathing (the ventilatory response) and blood flows (hemodynamics) impair the delivery and uptake of that mighty molecule – oxygen – into the tissues.

Cardiovascular system

The authors presented a variety of non-drug ways to improve oxygen intake via breathing and improved blood flows

No Drugs Required: Increasing Blood Flows, Oxygen Delivery, and Tissue Oxygenation in ME/CFS and Long COVID

Most of the interventions proposed are not new, but they’ve never been proposed in quite the context that they were here; i.e. exercise physiologists, ME/CFS doctors and researchers prescribing ways to improve oxygen uptake in the lungs and tissues, and blood flows.

Battling “Insufficient Venous Return”, or Preload Failure

Studies indicate that many people with ME/CFS exhibit “preload failure”; that is, they are unable to fully fill the veins that enter the heart with blood. That results in less blood being pumped out of the heart (reduced stroke volume, possibly small hearts) and reduced blood deliveries to the tissues.

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Treatment Approach – the authors recommend the use of compression garments (shorts, tights, stockings, shirt, sleeve), which athletes use to aid recovery by increasing blood flows. Massage is another technique that enhances relaxation and, therefore, blood flows, as well as improves mood.

Core Stability Exercises

Core stability exercises can support correct spinal alignment, improve core muscle coordination, and increase intra-abdominal pressure to improve circulation and oxygen delivery.

Both Dr. Rowe and physical therapists working with Dr. Lapp have noticed a tendency for pinched-in chests and rounded shoulders which can impair healthy breathing.

The authors recommended working with a physical therapist, athletic trainer, or strength/conditioning coach first to provide guidance and feedback. Note that local muscle sensitivity when exercising new muscle groups can be expected. Core stability exercises should be performed within the limitations of exertion tolerance, as well.

Vagus Nerve Stimulation (VNS)

While noting that studies suggest some efficacy of VNS in these diseases, the authors also reported that substantial evidence indicates that VNS can help to rebalance the cardiac nervous system to reduce heart rate.

The largest nerve in the body, the vagus nerve, transmits immune, sensory, and autonomic signals to the brain, regulates autonomic nervous system functioning, and impacts pain.

(We are hopefully on the verge of a breakthrough in this area. The NIH’s SPARC Effort is mapping out the vagus nerve in excruciating detail in order to understand how it works, and how to use it to improve health. Dysautonomia International has funded several successful VNS studies and a European manufacturer will reportedly soon apply to have its product sold in the U.S.)

SPARC-ing an Electroceutical Revolution – A Fibromyalgia and ME/CFS Perspective

Cryotherapy

Short, intense exposure to the cold can rebalance the autonomic nervous system. Fibromyalgia studies are underway.

Cryotherapy or Cold Therapy

Cold therapy is another approach athletes use to recover more quickly. The autonomic nervous system is again the main focus as cold exposure stimulates the autonomic nervous system to increase core temperatures.

The authors noted that a very brief, intensely cold whole-body exposure can re-regulate the ANS toward homeostasis – thus theoretically improving ME/CFS. Indeed, studies suggest that adding stretching to brief whole-body cryotherapy sessions reduces fatigue, and increases sleep and cognitive function. Several fibromyalgia studies are underway and the authors called cryotherapy a “promising approach”. A blog on cryotherapy is coming up.

Manual Lymphatic Drainage

The accumulation of toxins in the brain due to poor glymphatic drainage could, of course, be causing numerous symptoms. Interestingly, a dysregulated ANS could be playing a role here too as alterations in sympathetic nervous system activity could impair the lymphatic system from properly draining toxins from the brain. The authors referred to a study that found that the Perrin technique can be helpful in ME/CFS.

Toxic Brains, Frozen Spines and the Perrin Point: Ray Perrin, ME/CFS and Fibromyalgia

Red Light Therapy (photobiomodulation/low-level laser therapy)

Returning to sports medicine, the authors noted that athletes often use red light therapy to enhance their recovery. Red light therapy has been shown to relieve soreness, reduce inflammation, lactic acid, and oxidative stress, and support aerobic metabolism. This is a big topic and a blog is coming up on red light therapy.

Myofascial release therapy

Restrictions in the fascia – the thin connective tissue that supports our organs, muscles, bones, nerves, blood vessels – you name it and the fascia are likely there – could surely impact blood flows.

Peter Rowe has shown that restrictions in the fascia are often present in ME/CFS. Even simply putting a mild strain on the nerves and soft tissue can result in pain, problems concentrating, and other symptoms of PEM. Besides being painful, restricted fascia can reduce the ability of our muscles to produce force, increase inflammation, and interrupt blood flows.

It’s not clear why the fascia have become impacted in ME/CFS, but infections, prolonged sitting, or bed rest can cause the muscle/nerve system to become locked down or ‘frozen’. (The authors suggested that people who have experienced long periods of low mobility or immobility check out this option.) Once that happens, the nerves cannot elongate properly when we move, causing tension and pain.

Peter Rowe reported that in ME/CFS:

“The rib cage is often very tight, and rotational range of motion is markedly limited. Pressure on the rib cage can give rise to diverse symptoms including vision changes, lightheadedness (to the point of near-fainting), and other autonomic nervous system sensations.” 

What to do about it? Rowe states that myofascial release ‘in the direction of ease’, functional technique, and strain and counter-strain and craniosacral techniques, as well as practices like Tai Chi, yoga, and massage can help the body relax, allowing more movement, a reduction in problems standing, and increased functionality.

While these techniques – like those Ray Perrin uses to get the lymphatic system of the brain going again – can be subtle, Rowe noted that this kind of work is one treatment his patients always want to return to.

‘Strained’ – Are Neuromuscular Problems Causing Chronic Fatigue Syndrome?

The authors of this paper reported that “appropriate physical therapy, bodywork, breathing exercises, gentle stretches, stress reduction, acupuncture, foam rolling, FasciaBlaster®, a heating pad or hot water bottle, and/or nutritional support for fascia” may all help relieve pain and tension.

  • Check out a series of myofascial release videos from the husband of fibromyalgia doctor Ginerva Liptan. See one of them below:

Blood Flow Restriction Training (BFR)

THE GIST

  • A recent landmark study that validated the results of the 2-day exercise tests in chronic fatigue syndrome (ME/CFS) – also, surprise, surprise included an extensive treatment consideration section at the end of the paper. The treatment considerations were mostly focused on improving oxygen intake, blood flows, and oxygen uptake in the tissues via improving autonomic nervous system functioning.
  • The authors didn’t provide any magic bullets, but they outlined a series of non-drug interventions they believe can “positively influence… many, if not all symptoms” found in ME/CFS.
  • Studies indicate that many people with ME/CFS exhibit “preload failure”; that is, they are unable to fully fill the veins that enter the heart with blood. That results in less blood being pumped out of the heart (reduced stroke volume, possibly small hearts) and reduced blood deliveries to the tissues. The authors recommended using compression garments (shorts, tights, stockings, shirt, sleeve), and massage to improve blood flows.
  • Core stability exercises can support correct spinal alignment, improve core muscle coordination, and increase intra-abdominal pressure to improve circulation and oxygen delivery. Doctors have noticed a tendency for pinched-in chests and rounded shoulders which can impair healthy breathing in ME/CFS/FM. Note that local muscle sensitivity when exercising new muscle groups can be expected.
  • The authors reported that substantial evidence indicates that vagus nerve stimulation can help to rebalance the cardiac nervous system. The largest nerve in the body, the vagus nerve, transmits immune, sensory, and autonomic signals to the brain, regulates autonomic nervous system functioning, and impacts pain. With a great deal of study underway and a European company (hopefully) bringing a new vagus nerve stimulator to the market we should see progress in this intriguing area.
  • Cryotherapy / cold therapy – the authors noted that a very brief, intensely cold whole-body exposure can re-regulate the ANS toward homeostasis – thus theoretically improving ME/CFS. Fibromyalgia cryotherapy studies are underway.
  • Myofascial release therapy can release restrictions in the fascia – the thin connective tissue that supports our organs, muscles, bones, nerves, blood vessels, etc. Peter Rowe has shown that restrictions in the fascia are often present in ME/CFS.  Besides being painful, restricted fascia can reduce the ability of our muscles to produce force, increase inflammation, and interrupt blood flows. Appropriate physical therapy, bodywork, breathing exercises, gentle stretches, stress reduction, acupuncture, foam rolling, FasciaBlaster®, a heating pad or hot water bottle, and/or nutritional support for fascia” may all help relieve pain and tension. See the blog for some videos on myofascial stretching.
  • Manual lymphatic drainage (aka the Perrin technique) can help to relieve toxin buildup in the brain.
  • The authors stated, “Given the broad-reaching impact of improved breathing mechanics, this low-risk, low-cost, non-pharmacological approach to symptom mitigation should be a first-line approach.” Health Rising will cover breathing techniques in an upcoming blog.
  • Blood flow restriction training involves restricting the blood flow to trap the blood in specific muscles. BFR can increase strength and muscle size and improve blood vessel functioning. While work on BFR needs to be done in ME/CFS, the authors called BFR “a promising approach to reduce fatigue and improve muscle function”.
  • Noting that “effective pacing can reduce fatigue, psychological distress, depression, and improve overall physical function”, the authors supported using basic journaling of symptoms to understand when the symptoms of post-exertional malaise emerge. Various ways to determine an appropriate heart rate are discussed in the blog.
  • Mindfulness training can help rebalance the autonomic nervous system and help to move patients away from ‘sickness’ and towards ‘health’.
  • Noting that multi-symptom diseases like ME/CFS are often treated using multiple drugs, the authors asserted that many, if not all, symptoms can be “positively influenced” using these non-pharmacological approaches.
BFR involves restricting the blood flow to trap the blood in specific muscles. BFR can increase strength and muscle size and improve blood vessel functioning. While work on BFR needs to be done in ME/CFS, the authors called BFR “a promising approach to reduce fatigue and improve muscle function”.

Activity Pacing

Noting that “effective pacing can reduce fatigue, psychological distress, depression, and improve overall physical function”, the authors supported using basic journaling of symptoms to understand when the symptoms of post-exertional malaise emerge.

An exercise study can help determine at what heart rate things start to go south physiologically for people with these diseases. A heart rate monitor with an alarm set to 10 beats per minute below the indicated heart rate can then be used to avoid PEM. (Check out the Workwell Foundation if you would like to have these exercise tests done.)

For people who have not had an exercise test done, a Rating of Perceived Exertion (RPE) scale can help. An upper exertion limit RPE of 10–12 (for the Borg scale) or an RPE of 2–3 (for the modified Borg Scale) is recommended to start with.

This kind of exertion runs from non-taxing and very gentle in which you can easily maintain a conversation to “comfortable” in which you can maintain a conversation without getting out of breath.

Using journal entries, you can assess if the activity is causing increased symptoms or is helping to reduce them.

Another way to pace is to add 15 bpm to your resting heart rate (RHR + 15), and stay below that. Resting heart rate should be measured after 5 min of seated or supine rest in a quiet environment.

Another metric to look at is heart rate variability. (I use the Oura ring to determine resting heart rate, activity levels, sleep, HRV, and others). A decrease in HRV indicates the sympathetic nervous system has been activated (fight/flight) and more pacing is needed.

Pacing is not a panacea – it will not cure these diseases – but the authors reported that “Effectively pacing over time may allow for a very gradual escalation of physical and cognitive activities“.

breathe

The authors asserted that focusing on breathing should be a “first-line” approach to mitigating symptoms. Many different breathing techniques are available and Health Rising will cover some in a future blog.

Breathing

“Given the broad reaching impact of improved breathing mechanics, this low-risk, low-cost, non-pharmacological approach to symptom mitigation should be a first-line approach.”

Breathing was the next to last non-pharmacological approach addressed, but it was not the least. In fact, the authors believe that everyone with these diseases should give breathing techniques a try. Why? Because “impaired respiratory function is universal in ME/CFS”. In order to get oxygen to the brain and tissues, breathing must be addressed – but increasing oxygen levels aren”t the only reason to address breathing.

Voluntary slow or diaphragmatic breathing can quickly improve heart rate variability (which is low in ME/CFS), improve respiratory function, reduce stress, anxiety, constipation, migraine, and other autonomic nervous system maladies, help with postural stability, elimination and metabolic balance (!).

Many different breathing techniques are available and Health Rising will cover some in a future blog.

Mindfulness Training

The authors even brought in a little mindfulness training at the end – not a lot, but some. They asserted that understanding the role the autonomic nervous system (ANS) plays in the “fight or flight” response, pain, infection, and stress is at the core of integrative approaches that seek to move patients away from ‘sickness’ and toward ‘health’. (The focus on the ANS is reminiscent of Dan Neuffer’s approach in “CFS Unraveled“.)

Noting that increasing evidence indicates these approaches can be helpful in “many diseases”, they cited a study showing that meditation can increase resilience to the coronavirus.

Conclusion

Noting that multi-symptom diseases like ME/CFS are often treated using multiple drugs, the authors asserted that many, if not all, symptoms can be “positively influenced” using these non-pharmacological approaches.

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