SUBMITTED BY: Sharlene Bennett, Naturopath & Medical Herbalist (BHSc, AdvDip Nat, AdvDip Med Herb)
PATIENT: 35-year-old female
INITIAL PRESENTATION:
Chronic Fatigue Syndrome (CFS) for years on and off after a long history of Epstein-Barr virus and depression. Signs of fibromyalgia (FM) present with pain, sore muscles and extreme fatigue symptoms, where she can spend days in bed after a day of exertion, work or physical activity. FM flares with stress or when run-down. A family history of depression, which is commonly seen in FM and CFS, and is often noted as an early factor in the development of pain-like conditions. She takes antidepressants and finds this helps with depression and long-term management of mood. Otherwise feels really low and struggles to cope. A history of gut issues, presenting with IBD and suspected Colitis when stressed or run down.
HERBAL TREATMENT
General Herbal Formula (200mL):
Withania 1:2 60ml
Astragalus 1:2 60ml
American Ginseng 1:2 50ml
Lomatium 1:2 30ml
Liquorice 1:1 10ml
Dosage: 100ml (weekly), 7.5ml 2 - 3 x daily
Pain Herbal Formula (100ml):
Corydalis 30ml
California Poppy 30ml
Lemon Balm 30ml
Ginger 10ml
Dosage: 2.5mls as required, for pain and discomfort and settling digestion.
FOLLOW-UP:
First follow-up consult after two weeks, she feels better on the first dose of herbs in the morning, but still struggles in the afternoon. Much better after using herbs for pain as required for muscle pain and digestion discomfort.
Second follow-up consult four weeks later, she has started to feel better and increased energy in the mornings but later in the afternoon still struggling. Digestion discomfort is reduced and the general pain score 1-10 is now under a five. Additional supplementation was added, including the use of MitoQ for mitochondrial support for energy. Also, an active B vitamin complex at a high dose for extra nervous system and energy support in the mornings after the first dose of the herbs. Magnesium and malic acid powder for muscle tension and pain support in the afternoons.
Third follow-up consult six weeks later, she is coping with improved energy in mornings and afternoons, where getting out of bed feels easier, but still tires easily. Herbal Formula altered by adding 10mL of Korean ginseng and replaced Lomatium with 20mL Rehmania.