Pain Relaxation Meditation/mindfulness Manual methods (e.g., physiotherapy, acupuncture, and acupressure) Sleep Sleep hygiene Relaxation strategies Autonomic dysfunction, e.g., POTS Stockings Increase in water intake (>2 litres/day) or rehydration solutions, drinking frequently Increase in salt intake Sleep with feet in higher position (a few centimetres higher, increasing very slowly each night, up to what is tolerated) Diet Healthy and balanced diet Anti-inflammatory diet Reduce ingestion of simple carbohydrates Adequate fluid intake Adequate ingestion of protein Increase unsaturated fatty acids and omega-3 fatty acids May try exclusion diets with support from dietician, especially for food with reported intolerances by the patient. It may be worth trying to avoid gluten, lactose, or fructose during a few weeks to test if there is any improvement in symptoms [71]. Support measures “Pacing” and activity management to work with the “energy envelope” [72] Supporting therapies that could help with coping and adapting to changes in life due to symptoms, within the “energy envelope”, and counselling or psychotherapy Occupational therapy provided by professionals with experience in ME/CFS patients Social workers who could help with social welfare Educational needs: welfare and educational sectors should be involved in the planning and care for affected patients, particularly children, adolescents, and young adults

A professional view on symptom management and relief

“Periods of rest and “pacing” are important components of all management strategies for ME/CFS patients. Physicians should advise people with ME/CFS on the role of adequate rest, how to introduce breaks into their daily routine, and their frequency and length which may be appropriate for each patient. Excessive rest may be counterproductive, except in the initial stages of disease, in the very severe cases, or in cases of acute exacerbation; so it is important to introduce ‘low level’ physical and cognitive activities within the patient’s capacity, according to the severity of symptoms. Sleep management is tailored to the individual, the role and effect of disordered sleep is explained, common changes in sleep dysfunction that may exacerbate fatigue symptoms are identified; common manifestations include insomnia, hypersomnia, sleep reversal, altered sleep-awake cycle and non-refreshing sleep. The professional provides general advice on good sleep hygiene and encourages gradual changes in sleep pattern, though of course there is no implication that poor sleep hygiene is the cause of non-refreshing sleep. Relaxation techniques appropriate for ME/CFS should be offered for the management of pain, sleep problems and comorbid stress or anxiety. Examples include guided visualisation and breathing techniques, which can be incorporated into daily routines and rest periods”, while mindfulness ma be of value as a sympathetic nervous system modulator. Although exclusion diets are not generally recommended for managing ME/CFS, many people find them helpful for some symptoms, including bowel symptoms. The patient may attempt an exclusion diet or dietary manipulation under professional guidance and supervision, e.g., from a dietitian. For those with nausea, advice includes eating small portions and snacking on dry starchy food and sipping fluids. The use of anti-emetic drugs should be considered if the nausea is severe.” Dr. L. Lorusso (personal communication)