By Marcello Cherchi, MD PhD
For patients
The cause of chronic fatigue syndrome (CFS) is not known. Some people with CFS feel something is wrong with their balance, but since the cause of this is not known, it is unclear how to treat it.
For clinicians
Overview
The etiology of chronic fatigue syndrome (CFS) is unknown. Some patients with CFS complain of disequilibrium, but the mechanism of this symptom is unclear. The usual proposals include “central vestibular” deficits and autonomic abnormalities. On rotatory chair testing, these patients may show low gain on slow harmonic oscillation, and high gain on optokinetic testing. On computerized dynamic posturography, CFS patients may show low composite scores, visual dependence and hip dominance. Most studies interpret these non-specific findings to reflect central vestibular dysfunction, rather than peripheral vestibular disease. Most, though not all, studies report autonomic abnormalities in CFS patients.
Introduction
Chronic fatigue syndrome (CFS) is also referred to in some literature as myalgic encephalomyelitis. The underlying etiology of chronic fatigue syndrome is unknown (Prins, van der Meer, Bleijenberg 2006).
Pathophysiological mechanism of disease
Since the etiology of CFS is not understood, the mechanism by which CFS might cause audio-vestibular dysfunction is unknown. The usual proposals include autonomic dysfunction, and some sort of central vestibular dysfunction.
Clinical presentation
Furman commented that, “Patients with chronic fatigue syndrome (CFS) often complain of disequilibrium that is nonspecific” (Furman 1991). This matches our clinical experience of CFS patients who complain of a disturbance of equilibrium but have difficulty articulating a coherent description of this symptom.
Ocular motor examination
A case report described spontaneous nystagmus in one CFS patient (Palaniappan and Sirimanna 2002).
Testing: vestibular
Ash-Bernal and colleagues (Ash-Bernal et al. 1995) performed a vestibular battery (caloric testing, rotatory chair testing and computerized dynamic posturography) on 11 CFS patients and found “no predominant pattern of abnormalities,” though observed that:
- Rotatory chair test findings:
- “Three [patients] had abnormally low earth vertical axis rotation (EVA) gains at the higher frequencies tested,” and “As a group, the average EVA was significantly lower than normal in the 0.1 – 1.0 Hz range.”
- “In horizontal axis rotation, the CVS group had a higher than normal bias value for… optokinetic [responses],” and “Five of the 11 subjects had an abnormal OKN bias build up over the course of the run, equal to or actually exceeding the 60 degrees/s target velocity by as much as 14 degrees/s.”
- “Patients typically performed below average in dynamic posturography.”
- “One patient had abnormal caloric testing.”
Ash-Bernal and colleagues concluded that, “Altogether, these results are more suggestive of central nervous system deficits than of peripheral vestibular disfunction” (Ash-Bernal et al. 1995).
Furman (Furman 1991) studied three patients and reported:
“None had abnormalities that suggested peripheral vestibular deficits, in that caloric responses were normal in each patient. However, all three patients had abnormal results on testing with dynamic posturography — one patient’s results suggested disease of the vestibular system, and the others’ results indicated nonspecific abnormalities more suggestive of CNS deficits. Additionally, one individual had positional nystagmus and evidenced asymmetry on rotation; both abnormalities of the vestibular system are nonspecific and nonlocalizing. Data from this small sample of patients suggests that… The abnormalities seen to date are more suggestive of CNS deficits than of peripheral vestibular deficits” (Furman 1991).
Palaniappan and Sirimanna (Palaniappan and Sirimanna 2002) studied one CFS patient and reported spontaneous nystagmus and an asymmetrical vestibulo-ocular reflex.
Serrador and colleagues (Serrador et al. 2018) compared computerized dynamic posturography results in 27 CFS patients and 22 matched controls. They reported that:
- “CFS patients had lower SOT [sensory organization testing] composite scores than healthy controls… indicating that they had worse overall balance.”
- “Subjects with CRS had poorer scores on the SOT visual score. Low scores on this visual assessment indicate that CFS patients were unable to use visual information accurately.”
- “CFS subjects had a lower strategy score (i.e., more non-ankle movement) than did the [healthy control] subjects (i.e., relatively more movement about the ankles).”
In short, CFS patients have poorer overall balance; they inappropriately rely on incorrect visual information; and they use a hip-dominant strategy.
Testing: other
Some investigators have explored autonomic function in CFS patients. Most of these studies identify autonomic abnormalities, including hypotension (Rowe and Calkins 1998). For example:
- Bou-Holaigah and colleagues (Bou-Holaigah et al. 1995) studied tilt table testing in 23 CFS patients and 14 controls, and reported abnormal tilt table responses in 22 out of 23 CFS patients (96%) but only 4 out of 14 controls (29%).
- Freeman and Komaroff studied autonomic function in 23 CFS patients and concluded that, “Patients with CFS show alterations in measures of sympathetic and parasympathetic nervous system function” (Freeman and Komaroff 1997), including on measures of heart rate on standing and tilting, expiratory/inspiratory ratio of heart rate, Valsalva and tilt table testing.
- De Becker and colleagues studied 21 CFS patients and 13 matched controls and found that, “There was a trend toward an increased heart rate during the cold pressor test” (De Becker et al. 1998).
- Stewart and colleagues studied heart rate variability in head-upright tilt testing in 16 CFS patients (age 11 – 19 years) compared to 26 non-CFS patients being evaluated for syncope and 13 healthy control subjects. They concluded that, “CFS is associated with NMH [neurally-mediated hypotension] during HUT [head upright tilt] in children. All indices of HRV [heart rate variability] are markedly depressed in CVS patients” (Stewart et al. 1998).
Not all studies reach these conclusions. For example, Soetekouw and colleagues conducted autonomic testing on 37 CFS patients and 38 control subjects and concluded, “The findings of the study suggest that there are no gross alterations in cardiovascular autonomic function in patients with CFS” (Soetekouw et al. 1999).
Treatment
There is no proven treatment for CFS. CFS frequently presents with symptoms involving multiple organ systems, manifesting with sleep disturbances, musculoskeletal symptoms, mood disorders and cognitive deficits. Frequently the care of a CFS patient is overseen by a rheumatologist; depending on a particular patient’s symptoms, consultation with a sleep physician or a psychiatrist may be appropriate.
Regarding the vestibular symptoms of CFS, since some studies identify autonomic abnormalities (including hypotension), a number of trials have been undertaken to explore whether fludrocortisone may be helpful, but none of these studies demonstrated superiority of fludrocortisone over placebo (Blockmans et al. 2003; Peterson et al. 1998; Rowe et al. 2001).
References
Ash-Bernal R, Wall C, 3rd, Komaroff AL, Bell D, Oas JG, Payman RN, Fagioli LR (1995) Vestibular function test anomalies in patients with chronic fatigue syndrome. Acta Otolaryngol 115: 9-17. doi: 10.3109/00016489509133339
Blockmans D, Persoons P, Van Houdenhove B, Lejeune M, Bobbaers H (2003) Combination therapy with hydrocortisone and fludrocortisone does not improve symptoms in chronic fatigue syndrome: a randomized, placebo-controlled, double-blind, crossover study. Am J Med 114: 736-41. doi: 10.1016/s0002-9343(03)00182-7
Bou-Holaigah I, Rowe PC, Kan J, Calkins H (1995) The Relationship Between Neurally Mediated Hypotension and the Chronic Fatigue Syndrome. JAMA 274: 961-967. doi: 10.1001/jama.1995.03530120053041
De Becker P, Dendale P, De Meirleir K, Campine I, Vandenborne K, Hagers Y (1998) Autonomic testing in patients with chronic fatigue syndrome. Am J Med 105: 22S-26S. doi: 10.1016/s0002-9343(98)00168-5
Freeman R, Komaroff AL (1997) Does the chronic fatigue syndrome involve the autonomic nervous system? Am J Med 102: 357-64. doi: 10.1016/s0002-9343(97)00087-9
Furman JM (1991) Testing of vestibular function: an adjunct in the assessment of chronic fatigue syndrome. Rev Infect Dis 13 Suppl 1: S109-11. doi: 10.1093/clinids/13.supplement_1.s109
Palaniappan R, Sirimanna T (2002) Peripheral vestibular dysfunction in chronic fatigue syndrome. Int J Pediatr Otorhinolaryngol 64: 69-72. doi: 10.1016/s0165-5876(02)00039-3
Peterson PK, Pheley A, Schroeppel J, Schenck C, Marshall P, Kind A, Haugland JM, Lambrecht LJ, Swan S, Goldsmith S (1998) A preliminary placebo-controlled crossover trial of fludrocortisone for chronic fatigue syndrome. Arch Intern Med 158: 908-14. doi: 10.1001/archinte.158.8.908
Prins JB, van der Meer JW, Bleijenberg G (2006) Chronic fatigue syndrome. Lancet 367: 346-55. doi: 10.1016/S0140-6736(06)68073-2
Rowe PC, Calkins H (1998) Neurally mediated hypotension and chronic fatigue syndrome. Am J Med 105: 15S-21S. doi: 10.1016/s0002-9343(98)00167-3
Rowe PC, Calkins H, DeBusk K, McKenzie R, Anand R, Sharma G, Cuccherini BA, Soto N, Hohman P, Snader S, Lucas KE, Wolff M, Straus SE (2001) Fludrocortisone acetate to treat neurally mediated hypotension in chronic fatigue syndrome: a randomized controlled trial. JAMA 285: 52-9. doi: 10.1001/jama.285.1.52
Serrador JM, Quigley KS, Zhao C, Findley T, Natelson BH (2018) Balance deficits in Chronic Fatigue Syndrome with and without fibromyalgia. NeuroRehabilitation 42: 235-246. doi: 10.3233/NRE-172245
Soetekouw PM, Lenders JW, Bleijenberg G, Thien T, van der Meer JW (1999) Autonomic function in patients with chronic fatigue syndrome. Clin Auton Res 9: 334-40. doi: 10.1007/BF02318380
Stewart J, Weldon A, Arlievsky N, Li K, Munoz J (1998) Neurally mediated hypotension and autonomic dysfunction measured by heart rate variability during head-up tilt testing in children with chronic fatigue syndrome. Clin Auton Res 8: 221-30. doi: 10.1007/BF02267785
