a multimodal treatment is supported by results of multiple RCTs, and the aggregated findings are supported by meta-analyses. There is no strong evidence supporting epidural injections for back pain, but there has been a single RCT on relief of leg pain. Neither is there strong evidence to support intrathecal drug therapies for neuropathic pain or minimally invasive spinal procedures for vertebral compression fractures (American Society of Anesthesiologists Task Force on Chronic Pain Management and American Society of Regional Anesthesia and Pain Medicine, 2010).

A growing body of evidence demonstrates that acupuncture can be useful for chronic pain (Lee et al., 2012; Manheimer et al., 2005; Vickers, 2012). The strongest evidence supports its use in treatment for headache, but it may be effective for other forms of chronic pain, such as low back pain and osteoarthritis. Therefore, acupuncture should be considered for use in customizing pain treatment of patients who have CMI.

CHRONIC FATIGUE SYNDROME

Chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis, affects an estimated 4 million people in the United States, according to the Centers for Disease Control and Prevention (CDC), with prevalence estimates ranging from 0.2% to 2.54% (Maquet et al., 2006; Reeves et al., 2007). CFS is more common and more severe in women and people who have Latino and African-American backgrounds, and its prognosis worsens with age (Jason et al., 2011). People who have CFS often have other comorbid conditions, such as obesity and metabolic disorders, depression, irritable bowel syndrome (IBS), fibromyalgia, and multiple chemical sensitivity. Multiple symptoms of each of those conditions can overlap substantially with CMI, including fatigue, nonrestorative sleep, tenderness on palpation, and some mild cognitive dysfunction (CDC, 1994). Definitions of CFS vary, but the diagnosis is the result of careful review of patient history, physical health and mental health examinations, clinical laboratory testing, and indicated imaging studies to rule out other medical and psychologic diagnoses that may explain the symptoms of CFS. Definitions of CFS used by CDC and UK National Health Service are included in Box 5-1.

Chronic Fatigue Syndrome and Chronic Multisymptom Illness

Much research on CFS has targeted infectious triggers associated with low-grade fever, adenopathy, and influenza symptoms. Regardless, no consistent viral agents (such as human herpesvirus 6 and Epstein-Barr virus) have been definitively identified (Glaser and Kiecolt-Glaser, 1998). Fever, adenopathy, and infection-like symptoms tend to decrease over time, and fatigue and other somatic symptoms common in CMI become more prominent



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