ME/CFS & Covid-19: information for you & your doctor

COVID-19 Information and Resources – Bateman Horne Center, March 2020


Dr Lucinda Bateman

The Bateman Horne Center works for the medical advancement and treatment of  Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS)and Fibromyalgia in Salt Lake City, Utah, USA.

In addition to the resources for patients and doctors on ME/CFS they have produced some briefing papers on Covid-19 and ME/CFS, many of which are helpful people from anywhere in the world.

Dr Suzanne Vernon



Medical Director: Dr Lucinda Bateman

Researcher: Dr Suzanne Vernon



Medical Considerations Letter — In the event you become acutely ill, the Medical Care Considerations Letter serves as a guiding resource for outside medical care intervention. The intent of this letter is to provide care professionals with further information about your illness of ME/CFS and/or severe FM to assist them with their medical intervention decisions.

“you should assume they have a serious, chronic, multisystem illness that may negatively impact their prognosis”

“Based on current evidence the underlying pathology of ME/CFS involves energy metabolism, the nervous system, and the immune system.”

COVID-19 and ME/CFS/FM Frequently Asked Questions: Drs. Bateman and Yellman answer specific questions about COVID-19 as it relates to ME/CFS/FM.

e.g. Are people with ME/CFS/FM at a higher risk than the general public of dying from COVID-19 if contracted? … The immune dysregulation of ME/CFS/FM may reduce ability to fight viral infections. Additionally, the presence of chronic inflammation, allergies, asthma, mast-cell activation may pose additional risks.

Suzanne D. Vernon, PhD, addresses: SARS, CoV-2, and COVID-19: A scientific overview of COVID-19, infection/transmission, testing, and treatments on the horizon.

Advance Care Planning: The Advance Care Planning document provides guidance for establishing advanced-care-directives and POLST documents.

Personal Guidance and Decision Making

e.g. Advance Directives: Everyone, not just those with ME/CFS, should document end-of-life wishes on paper regarding aggressive medical care in a life-threatening situation. Discuss with family and medical professionals as needed.



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ME, Covid-19 & self-isolating

What do people with ME need to know about Covid-19 and self-isolating?              updated 10 April 2020


The Health Minister for Wales has confirmed that people over 70 and people with a range of health conditions, including  neurological conditions, should self-isolate. People with a cough and/or high temperature are asked to self isolate for 7 days. Those who have had contact with someone with confirmed Covid-19 should self-isolate for 14 days. Everybody should stay at home except for essential shopping, short daily exercise a day, essential medical needs, travelling to and from essential work, but only where this cannot be done from home. Social distancing is required by all people when outside the home.

Many people with ME have been self-isolating to some extent for years, because they have been too ill to mix with others. They will be practised in ensuring they have enough food, cleaning products, personal care items, ‘distractions’ and medications, but the coronavirus Covid-19 poses some extra problems and questions.

Much is still not known about this new virus, but some clues are emerging from US research and from the badly affected countries of China and Italy.

People don’t have to have symptoms to be infectious

  • symptoms appear 2-14 days after infection
  • infection can last weeks, up to 37 days (China)
  • people can be infectious before & after symptoms are apparent, or without symptoms
  • it is uncertain how many have no obvious symptoms and are spreading the virus
  • no symptoms doesn’t necessarily mean less able to spread the virus

Infected people without symptoms might be driving the spread of coronavirus more than we realized


What are the symptoms?

Regular flu has similar symptoms to COVID-19. However, COVID-19 is more likely to cause shortness of breath and other respiratory symptoms. Some people have only mild symptoms while others are very ill and struggle to breathe.

Coronavirus symptoms            Check your symptoms


How does the virus spread?

  • it might be airborne to a small extent
  • it definitely remains on surfaces
  • it probably doesn’t survive in water
  • it survives to some extent in faeces
  • they are unsure if it survives in sewerage systems
  • it enters the body via the eyes, nose, mouth, not through the skin
  • cats can catch it but it is uncertain if they can infect humans

Coronavirus can stay infectious for days on surfaces. But it’s still okay to check your mail


Who is most at risk?

Early indications in China and Italy was that the majority of people who died were over 60 with certain underlying health conditions, (but anyone can catch and pass on the virus):

  • heart disease
  • diabetes
  • hypertension – high blood pressure
  • chronic lung disease
  • some cancers

It has now become clear that younger people with no known health conditions can also be at risk.

It is unknown to what extent people with ME are at greater risk but Dr Nancy Klimas believes we could be, as ‘one of the underlying problems is that the cells protecting you against viruses are less functional because overworked.’  Dr Charles Shepherd says: ‘an infection such as this will almost certainly cause a relapse, or significant exacerbation of symptoms’.

Public health England’s updated list of those at risk & requiring social distancing,  which includes Neurological Conditions, the obese and pregnant women.


What distance is safe when social distancing?

It may not be possible to avoid close contact with people giving you care, or for whom you care, but all sources say where possible stay 2 metres or 6 feet away from other people. If people are moving (cyclists or runners) it may be wise to stay up to 10m away. Face masks won’t stop you catching the virus, but they may reduce the likelihood of passing it on to others.

Prof Hugh Pennington adds: “This virus needs 15 minutes of close contact with someone carrying it for you to have a reasonable chance of contracting it…But if someone who is infected coughs or sneezes on you directly then the droplets can infect you — that will be a much higher risk.”


How long does it last on surfaces?

When self isolating we will need to receive post, groceries etc. Are they safe? US researchers measured how long the virus stays active on various surfaces:

  • up to 24 hours on cardboard
  • up to 2 or 3 days on plastic and stainless steel.
  • it remained viable in aerosols—attached to particles that stay aloft in the air—for up to 3 hours.

Accept goods from outside, then put away perishables without contaminating other items. Either thoroughly wash the outside of the items or leave them until they are safe to touch.  Wash your hands and don’t touch your face!!


Can you become re-infected?

  • it is uncertain if or how long immunity lasts
  • it appears to be possible to relapse, though numbers are small
  • there are 2 variations of the virus and potentially it could mutate, though probably unlikely
  • in some countries testing for the presence of the virus may not be reliable so people only think they have recovered
  • most people recover but some experience reduced lung function following recovery, which will require some rehab
  • some concerns have been expressed that the virus may trigger an ME-like reaction as happened with SARS.

Coronavirus: can you get covid-19 twice or does it cause immunity


What kills the virus?

  • soap & water – dried by single use paper or warm air
  • alcohol based sprays on surfaces – leave 5 mins before wiping
  • hand sanitisers
  • chlorine
  • cooking removes any danger from food
  • bleach – disinfects, but pollutes- 5 tbsp (1/3 cup) of bleach per gallon of water

BBC: How long does the coronavirus last on surfaces?


When to get tested?

The UK is stepping up testing of frontline workers but still only wants to test those whose symptoms become serious due to shortage of tests – if experiencing severe symptoms ring 111 anywhere in Wales.  (Don’t press any numbers, just hold to be connected to NHS Wales, rather than NHS England)


How should it be treated?

Treatment for Coronavirus Disease (COVID-19)


How can I self-isolate?

Information on what it means to self-isolate in your home, or in a room within your home can be found on the UK Government website.  Increasingly local support schemes are being set up by concerned citizens to make it possible for people to self-isolate, even when they don’t have friends or family nearby, or access to online deliveries.

For info about how to get or give support, find your COVID-19 Facebook support group here Some Council & AVO websites list local sources of help and delivery services. Age Cymru and RVS provide support.

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Why we need a study like DecodeME

Why we need a study like DecodeME – scientific paper published, by the ME/CFS Biomedical Partnership, 26 Jan 2021

Today, we know almost nothing for sure about what causes ME/CFS. We do know that the illness can be triggered by certain infectious diseases, such as glandular fever. But we don’t know why most people recover from those infections but a minority instead develop ME/CFS.

There are many competing hypotheses about what causes the illness, all with some evidence to support them. But nothing has yet been nailed down.

A scientific paper reviewed the available evidence about ME/CFS genetics and explained how big new DNA studies can help find causes of the disease.

The paper was written by Joshua Dibble, the PhD student of DecodeME’s lead scientist Professor Chris Ponting. He was funded by Action for ME and Scotland’s Chief Scientist Office. The other authors were Chris himself and Simon McGrath, who has ME/CFS and is also on the DecodeME team. In this blog post, we summarise our review.

Genetic studies offer a way forward because if genes are linked to ME/CFS, they must be a cause of the illness and not simply an effect of it. This is because diseases don’t change our DNA. In contrast, for studies looking at other molecules, any differences between patients and controls might simply be a consequence of the illness rather than a cause that drives it.

A very large genetic study can identify causes that have not previously been considered. In Alzheimer’s disease, for example, researchers were initially focusing on nerve cells in the brain. But big genetic studies drew researchers’ attention to other brain cells called glia that support the normal functioning of nerve cells.

In rheumatoid arthritis, genetic studies have helped to identify what goes wrong at the molecular level to set off the disease.

Comparing findings between different autoimmune diseases found that some of them shared a disease mechanism. As a result, drugs already used successfully in some autoimmune diseases are now used to treat patients with other autoimmune diseases that share a common mechanism.

Progress in all these diseases came from a type of genetic research called genome-wide association studies (GWAS).

GWAS shed light on many diseases that are caused not by a single gene but by many. In simple genetic diseases, such as cystic fibrosis, the illness is caused by a fault in a single gene. However, the role of genetics in most diseases is weaker, and usually the result of many different genetic differences, each having a small effect. Non-genetic factors, such as environmental influences and infections, also play a big role in most illnesses.

To reliably find the small genetic differences that occur in most diseases, we need very large studies: typically with at least 10,000 participants.

Evidence of a role for genetics in ME/CFS

Although usually just one person in a family gets ME/CFS, quite often more than one person is affected. This indicates that an increased risk of becoming ill with ME/CFS can run in families. Several studies have now provided evidence of an inherited, genetic role in ME/CFS, though the studies don’t agree on how big the role is.

ME/CFS genetics studies so far

Several studies of the genetics of ME/CFS have linked the disease to particular genes. However, none of these specific genetic links have yet been independently confirmed. Our paper critically reviews these studies.

The strongest genetic evidence to date

Human leucocyte antigens (HLA) proteins allow the immune system to target cancerous cells and cells infected by viruses and other bugs.

The situation with HLA genes (and proteins) is unusually complex. There are many genes for HLA proteins and often many versions of each gene.

The upshot of this is that we each have a set of HLA genes and while we will share individual HLA gene versions with other people, we are unlikely to have exactly the same set as anyone else.

(HLA genes also determine whether or not an organ transplant will be rejected. For an organ to be accepted, there must be a good match between the organ donor’s set of HLA genes and those of the person receiving the transplant.)

Certain versions of HLA genes increase the risk of autoimmune disease. Recently, two versions of HLA genes were linked to ME/CFS and each roughly doubled the risk of having ME/CFS. The study was large (458 patients, 4,500 controls) and done well, though the finding will need replication.

Other studies

The largest genetic studies to date used data from the UK Biobank of over half a million individuals. Nearly 2,000 of these individuals said they had a CFS diagnosis from a doctor (but it is not clear if they would meet specific ME/CFS criteria).

One analysis of these people with CFS found a link to a protein that transports an amino acid into mitochondria, the mini-power-stations of the cell. There is some evidence to support this finding. However, other slightly different analyses of the same data didn’t confirm this finding.

Our review also examines several other ME/CFS genetic studies. Most of them are rather small and some also appear to have technical shortcomings that we cover in the paper. For our review, we looked to see if the gene versions linked to ME/CFS in these studies were also linked to CFS using data from the UK Biobank. But disappointingly, they did not.

Benefits expected from ME/CFS Genome Wide Association Studies (GWAS)

Our review of available genetic studies and findings provides limited evidence that particular genes play a role in ME/CFS. It also highlights the need for larger and more rigorous studies that give more robust results. ME/CFS GWAS can do that.

GWAS have already helped to improve our understanding of the causes of many diseases and have helped to develop new treatments. GWAS for ME/CFS are long overdue. DecodeME will be the first study of this kind, and a Norwegian group is planning a separate ME/CFS GWAS. Replicated results from such studies would have four important benefits:

1. Finding causes

Positive results would help provide much needed insight into the biological causes of ME/CFS. In combination with other technologies, GWAS can pinpoint variations in DNA that change the activity of genes and as a result alter the risk of ME/CFS.

It is likely that many genes will be involved in increasing the risk of ME/CFS, each in a small way. If the genes turn out to have an activity in common (such as a particular immune function or the functioning of a certain type of brain cell), then that effectively flags up possible cellular or molecular causes of the disease. This would provide strong leads for further research.

2. Learning from other diseases

Researchers could investigate if the genetics of ME/CFS is shared with any other disease, indicating possible shared disease mechanisms. This provides the potential for reusing existing treatments to treat ME/CFS.

3. Subtypes and targeted treatments

GWAS findings could help split ME/CFS into different groups. This could eventually lead to identifying distinct subtypes of ME/CFS, each with a different cause and potentially a different treatment.

4. Respect

Lastly, discovering genetic factors that play a role in causing ME/CFS might improve how the disease is seen by both health professionals and society at large.

Find out more about the DecodeME GWAS and register for updates here on the DecodeME website.

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Risks for developing ME/CFS in college students following infectious mononucleosis

Risks for developing ME/CFS in college students following infectious mononucleosis: a prospective cohort study, Leonard A Jason, PhD, Joseph Cotler, PhD, Mohammed F Islam, PhD, Madison Sunnquist, PhD, Ben Z Katz, MD in Clinical Infectious Diseases, [] 25 Dec 2020


Research abstract:


Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) involves severe fatigue, unrefreshing sleep, and cognitive impairment, leading to functional difficulties; prior studies have not evaluated risk factors with behavioral and immune data collected prior to developing ME/CFS. Up to 5% of university students develop infectious mononucleosis (IM) annually, and 9-12% meet criteria for ME/CFS six months later. We sought to determine predictors of ME/CFS.

We enrolled college students at the start of the school year (Time 1), identified those who developed IM (Time 2) and followed them for 6 months (Time 3), identifying three groups: those who developed ME/CFS, those who developed severe ME/CFS (meeting >1 set of criteria) and those who were asymptomatic. We conducted 8 behavioral and psychological surveys and analyzed cytokines at three time points.

238 of the 4501 students (5.3%) developed IM; 6 months later, 55 of the 238 (23%) met criteria for ME/CFS and 157 (66%) were asymptomatic. 67 of the 157 asymptomatic students served as controls. Students with severe-ME/CFS were compared to students who were asymptomatic at three time points. The former group was not different from the latter group at Time 1 (prior to developing IM) in stress, coping, anxiety or depression, but were different in several behavioral measures and had significantly lower levels of IL-6 and IL-13. At Time 2 (when they developed IM), the two ME/CFS groups tended to have more autonomic complaints and behavioral symptoms while the severe- ME/CFS group had higher levels of IL-12 and lower levels of IL-13 than the recovered group.

At baseline, those who developed ME/CFS had more physical symptoms and immune irregularities, but not more psychological symptoms, than those who recovered.

DePaul University Newsroom press release: NIH-funded study examines mono, chronic fatigue syndrome in college students 22 January 2021

“Some people who are attacked by a virus stay sick. What we’ve found is that their emotional functioning and psychological states are not statistically different from those who get attacked by the same virus and recover. This becomes important validating information for those people who have this illness,” said Jason.

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Large Long COVID study & major media articles underscore link to ME/CFS

Large Long COVID study and major media articles underscore link to ME/CFS – plus countdown for the NIH, by Cort Johnson in Health Rising, 22 Jan 2021


Article excerpt:

ME/CFS scores as a large study cements the link between it and long COVID just after over a billion dollars is slated to go for long COVID research

“The findings show that—even in those people who don’t require hospitalization for severe COVID-19—the condition’s prolonged symptoms are having a major impact on lives and livelihoods, both here and around the world. While the number of people affected isn’t yet known, if even a small proportion of the vast numbers of people infected with COVID-19 develop Long COVID syndrome, it represents a significant public health concern.” Francis Collins Director of the NIH

The latest Body Politic study indicates that long COVID looks much like ME/CFS.
A important long COVID study, “Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact“, was recently released which left no doubt that long COVID patients are closely tracking with people with chronic fatigue syndrome (ME/CFS) symptom-wise. For once, the ME/CFS community was the beneficiary of superb timing: the study arrived not long after Congress had appropriated over a billion dollars to study long COVID.

The preprint (meaning it has not been peer-reviewed) study from Body Politic researchers and patients assessed a wide variety of symptoms only to have the top three symptoms associated with ME/CFS pop out. Just as in ME/CFS, fatigue (77.7%), post-exertional malaise (PEM) (72.2%) and cognitive dysfunction (55.4%) were the most common symptoms found in those still sick after six months. The researchers didn’t target these symptoms. Out of the 205 symptoms they asked about, these rose – like the cream in milk – to the top all by themselves. The symptoms slowly increased over time and tended to plateau about 2 months in.

The large study size – almost 4,000 respondents took part in the web-based study – added to the study’s cachet. While future studies will undoubtedly utilize long COVID patients diagnosed by doctors, this was a great start.

Post-exertional malaise rose to the fore. The fact that over 85% of long COVID patients reported experiencing a relapse mostly due to engaging in too much exercise, physical or mental activity, or stress, placed many of them firmly in the ME/CFS camp. (Note that the term post-exertional malaise (PEM) – which quickly found its way into the long COVID camp – was birthed in the ME/CFS community.)

Sixty-five percent reported still being ill six months after being infected. Only 27 percent had returned to their normal work schedules, 46% were working part-time and 23% were not working at all. The 23% unable to work bore some resemblance to the 25% of ME/CFS patients reported to be severely ill.

The most likely symptoms to persist after six months demonstrated that – as with ME/CFS – a body-wide illness had emerged which provided few avenues for relief:

The most likely symptoms to persist after 6 months: fatigue, post-exertional malaise, cognitive dysfunction (“brain fog”), neurologic sensations (neuralgias, weakness, coldness, electric shock sensations, facial paralysis/pressure/numbness), headaches, memory issues, insomnia, muscle aches, palpitations, shortness of breath, dizziness/balance issues, and speech and language issues.

The Gist

  • Not long after Congress provides a billion dollars plus for long-COVID research, a large web-based preprint study from the Body Politic finds striking connections between the symptoms found in long-COVID patients and people with ME/CFS.
  • The top three symptoms in long COVID (fatigue, post-exertional malaise and cognitive problems) are emblematic of those found in ME/CFS.
  • The vast majority of long-COVID patients reported experiencing an exertion-triggered relapse.
  • Over 20 percent were still unable to work after six months and almost 50% were working part-time. Only about 25% were still working full-time.
  • Long-COVID patients also commonly reported problems with sleep, cardiovascular and gut problems and a wide range of strange symptoms that many people with ME/CFS will relate to.
  • The study also uncovered a significant cohort of patients distinguished by high levels of fatigue and no post-exertional malaise.
  • A recent long and in-depth feature New York Times article uses ME/CFS experts to underscore the connection between ME/CFS and long COVID.
  • The NIH’s failure to develop programs to support long-COVID research smacks of its approach to ME/CFS over the years.
  • Despite acknowledging the immense nature of the long-COVID problem, and knowing that long-COVID money was coming its way, the NIH has not, almost a month later, provided a plan for spending the money.
  • Meanwhile, as the vaccines roll out, the opportunity to the catch long COVID in the act is beginning to diminish.

Read the full article

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Homebound versus bedridden status among those with ME/CFS

Homebound versus bedridden status among those with Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome, by  Karl Conroy, Shaun Bhatia, Mohammed Islam and Leonard A Jason in Healthcare 2021, 9(2), 106 [] (This article belongs to the Special Issue ME/CFS – the Severely and Very Severely Affected)


Research abstract:

Persons living with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) vary widely in terms of the severity of their illness.

It is estimated that of those living with ME/CFS in the United States, about 385,000 are homebound. There is a need to know more about different degrees of being homebound within this severely affected group. The current study examined an international sample of 2138 study participants with ME/CFS, of whom 549 were severely affected (operationalized as ‘Homebound’).  A subsample of 89 very severely affected participants (operationalized as ‘Homebound-bedridden’) was also examined.

The findings showed a significant association between severely and very severely affected participants within the post-exertional malaise (PEM) symptom domain. The implications of these findings are discussed.

4. Discussion (excerpt)
The findings of the current study indicated that PEM, social functioning, and physical functioning were significant predictors of a participant with ME/CFS being ‘Homebound’ (compared to ‘Not homebound’). Among symptom items in the DSQ-1 PEM domain, “next day soreness or fatigue after non-strenuous, everyday activity” and “physically drained or sick after mild activity” were the strongest predictors of ‘Homebound’ status. These predictive results were consistent with the mean comparisons reported by Pendergrast and colleagues [21].

Moreover, the unique aspect of our study was subdividing the ‘Homebound’ group into two subgroups: ‘Homebound-bedridden’ and ‘Homebound-not bedridden. We found that higher symptom scores in the PEM domain decreased the odds of a participant being ‘Homebound-bedridden’ (versus ‘Homebound-not bedridden’). Among the PEM symptom items, “minimum exercise makes you physically tired” significantly decreased the odds of a participant being ‘Homebound-bedridden’…

Our study found that participants who reported worse symptoms in the PEM domain [25] and less physical and social functioning [32] were at increased odds of being ‘Homebound’ (compared to ‘Not homebound’). Among participants who were classified as ‘Homebound,’ those who reported worse symptoms in the PEM domain were at decreased odds of being ‘Homebound-bedridden’ (compared to ‘Homebound-not bedridden’). We hypothesized that for participants who are ‘Homebound,’ those who are ‘Homeboundbedridden’ may experience less PEM symptomology because they are expending less energy. Based on the proportion of participants who were ‘Homebound’ in our study, we estimate that as many as 385,000 persons with ME/CFS are homebound in the United States. There is a pressing need to find ways of providing services to this under-resourced group.

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Multi-omics examination of Q fever fatigue syndrome identifies similarities with CFS

Multi-omics examination of Q fever fatigue syndrome identifies similarities with chronic fatigue syndrome, by Ruud PH Raijmakers, Megan E Roerink, Anne FM Jansen, Stephan P Keijmel, Ranko Gacesa, Yang Li, Leo AB Joosten, Jos WM van der Meer, Mihai G Netea, Chantal P Bleeker-Rovers & Cheng-Jian Xu in Journal of Translational Medicine vol 18, Article: 448 (2020)


Research abstract: 

Q fever fatigue syndrome (QFS) is characterised by a state of prolonged fatigue that is seen in 20% of acute Q fever infections and has major health-related consequences. The molecular mechanisms underlying QFS are largely unclear. In order to better understand its pathogenesis, we applied a multi-omics approach to study the patterns of the gut microbiome, blood metabolome, and inflammatory proteome of QFS patients, and compared these with those of chronic fatigue syndrome (CFS) patients and healthy controls (HC).

The study population consisted of 31 QFS patients, 50 CFS patients, and 72 HC. All subjects were matched for age, gender, and general geographical region (South-East part of the Netherlands). The gut microbiome composition was assessed by Metagenomic sequencing using the Illumina HiSeq platform. A total of 92 circulating inflammatory markers were measured using Proximity Extension Essay and 1607 metabolic features were assessed with a high-throughput non-targeted metabolomics approach.

Protein MMP-1

Inflammatory markers, including 4E-BP1 (P = 9.60–16 and 1.41–7) and MMP-1 (P = 7.09–9 and 3.51–9), are significantly more expressed in both QFS and CFS patients compared to HC. Blood metabolite profiles show significant differences when comparing QFS (319 metabolites) and CFS (441 metabolites) patients to HC, and are significantly enriched in pathways like sphingolipid (P = 0.0256 and 0.0033) metabolism.

When comparing QFS to CFS patients, almost no significant differences in metabolome were found. Comparison of microbiome taxonomy of QFS and CFS patients with that of HC, shows both in- and decreases in abundancies in Bacteroidetes (with emphasis on Bacteroides and Alistiples spp.), and Firmicutes and Actinobacteria (with emphasis n Ruminococcus and Bifidobacterium spp.). When we compare QFS patients to CFS patients, there is a striking resemblance and hardly any significant differences in microbiome taxonomy are found.

We show that QFS and CFS patients are similar across three different omics layers and 4E-BP1 and MMP-1 have the potential to distinguish QFS and CFS patients from HC.

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The evidence base for physiotherapy in ME/CFS

The evidence base for physiotherapy in myalgic encephalomyelitis/chronic fatigue syndrome when considering post-exertional malaise: a systematic review and narrative synthesis, by Marjon E A Wormgoor & Sanne C Rodenburg in Journal of Translational Medicine vol 19, Article no: 1 (2021)


Review abstract:

Due to the inconsistent use of diagnostic criteria in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), it is unsure whether physiotherapeutic management regarded effective in ME/CFS is appropriate for patients diagnosed with criteria that consider post-exertional malaise (PEM) as a hallmark feature.

To appraise current evidence of the effects of physiotherapy on symptoms and functioning in ME/CFS patients in view of the significance of PEM in the applied diagnostic criteria for inclusion.

A systematic review of randomized controlled trials published over the last two decades was conducted. Studies evaluating physiotherapeutic interventions for adult ME/CFS patients were included. The diagnostic criteria sets were classified into three groups according to the extent to which the importance of PEM was emphasized: chronic fatigue (CF; PEM not mentioned as a criterion), CFS (PEM included as an optional or minor criterion) or ME (PEM is a required symptom). The main results of included studies were synthesized in relation to the classification of the applied diagnostic criteria. In addition, special attention was given to the tolerability of the interventions.

Eighteen RCTs were included in the systematic review: three RCTs with CF patients, 14 RCTs with CFS patients and one RCT covering ME patients with PEM. Intervention effects, if any, seemed to disappear with more narrow case definitions, increasing objectivity of the outcome measures and longer follow-up.

Currently, there is no scientific evidence when it comes to effective physiotherapy for ME patients. Applying treatment that seems effective for CF or CFS patients may have adverse consequences for ME patients and should be avoided.

Intervention characteristics

The therapeutic applications evaluated in this review and considered relevant for physiotherapy consisted of one or more of the following elements: physical activity, body awareness, health education or orthostatic training.

The main physical activity interventions were GET and activity pacing (AP). GET is based on the notion that the fatigue is maintained by deconditioning and avoidance of activity. Accordingly, it is assumed that one can overcome the fatigue by increasing the activity level and physical fitness by means of low-level aerobic exercise with a rigid gradual increase of intensity and amount. In some studies, heart rate monitors were used during exercise sessions to help participants meet the prescribed intensity levels [58, 61, 73, 74]. GET was given alone [58, 74] or as part of a rehabilitation program [59, 68, 76].

AP is a strategy aimed at reducing the frequency and severity of PEM by focusing on awareness and knowledge of one’s limits and early signs of exacerbation. It targets on prioritizing of activities, being as active as possible within one’s limits, and alternating active and rest periods [77]. In some programs focusing on AP [67, 75], the principles of the Energy Envelope Theory [78] were applied. According to this theory, ME/CFS patients should not expend more energy than they perceive they have (energy-envelope), as this results in PEM and increased disability. In another program [58], adapted pacing therapy (APT) was applied to encourage participants to restrict their activity levels to below 70% of their perceived limits. AP was given alone as a therapy [58], as part of GET with pacing [73], as graded exercise self-help (GES) guided by symptoms [63], as part of a rehabilitation [61], educational [75] or self-help program [63, 64, 67], or as a comparison intervention [65].

Body awareness incorporates coordinated body posture and movement, breathing, and meditation techniques. Two original eastern approaches of exercise and healing techniques, Qigong [69,70,71] and isometric yoga [72], were evaluated. In addition, body awareness therapy was included in a rehabilitation program [66]. Several health education programs with different objectives were included. They aimed at encouraging GET [60] or AP [75], focused on pain physiology [65] with the intention to alter pain cognitions and thereby reduce catastrophizing and kinesiophobia, or provided self-management education aimed at accepting and improving ability to cope with ME [67]. In one study, orthostatic (tilt) training was used to reduce orthostatic intolerance [62].

The control interventions consisted of care as usual [58,59,60, 63, 67, 74], waitlist for intervention [69,70,71,72], relaxation therapy [61, 64, 73], exercise [65, 68], CBT [58, 76], sham-training [62] or supportive listening [59]. One of the RCTs included CBT [58] and one supportive listening [59] as additional experimental arms; these were considered as control interventions in this review.

The median treatment duration was 12 weeks. It was not always clear by whom the intervention was delivered, but all interventions were considered relevant for physiotherapy despite the fact that some were led in cooperation with or by peers [67, 75], a nurse [59], an occupational therapist [58, 64, 67], a clinician therapist [60], an exercise physiologist [58, 73], a yoga instructor [72], a qigong master [69,70,71] or an interdisciplinary team [66, 68].

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Viruses belonging to anelloviridae or circoviridae as a possible cause of chronic fatigue

Viruses belonging to Anelloviridae or Circoviridae as a possible cause of chronic fatigue, by Bjørn Grinde in Journal of Translational Medicine vol 18, no. 485 (2020)


Article abstract:

Chronic fatigue often starts with an acute viral infection—as witnessed in the case of SARS-CoV-2—but indirect consequences of these infections are presumably the actual cause of the condition. As recently reviewed in this journal, the culprit could be a virus already present in the patient. The review covers several types of viruses, but concludes that the question is still open. The focus is on well known, pathogenic viruses for which there are ample diagnostic tools.

I argue that there is one lesser-known group of viruses, the related anello– and circoviruses, which ought to be investigated. More or less everyone harbours at least one strain of these viruses in the blood, while not in the spinal fluid. They normally replicate at a low level, but their activity increases in an immune suppressed host; and there are cases where they do reach the brain. The initial infection could facilitate their access to the brain.


… Generally, even a distinct presence of virus in samples taken from affected tissue is not conclusive as to the role of that virus in aetiology. For one, any severe disease may suppress the immune defence leading to an activation (and concomitant increased detectability) of chronic viruses; and two, many viruses use leukocytes for replication and these tend to aggregate in inflamed tissue. However, if certain viral strains correlate strongly with chronic fatigue, this suggests a role.

Ideally, one should have therapeutic agents that inhibit viral replication. If the agents also alleviate symptoms, there would be both a rational explanation for the fatigue and a treatment option. Due to their supposedly benign nature, the anello- and circoviruses have not been the focus of antiviral research. However, a recent report claims that a three-month treatment with the malaria medication artesunate did eliminate anelloviral DNA from blood cells in 62% of the cases. If these viruses can be linked to chronic fatigue, more therapeutics are likely to appear.

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Webinar 3 Feb 2021: 5 steps to mental wellbeing

Webinar: 5 steps to mental wellbeing during the COVID-19 pandemic


The Wales Neurological Alliance, in partnership with Digital Communities Wales, invite you to an online training session to help people living with a neurological condition to use digital technology.

This is the third in the series of  free digital training sessions to support those living with a neurological condition to use digital technology more effectively during the COVID-19 pandemic.

We have had to adapt our daily routines to meet the needs of lockdown restrictions and the challenges this has presented. The way you support your own health and well-being or that of others may have also changed.

Within this free, 1-hour long webinar, Digital Communities Wales will overview several digital options for supporting the health and wellbeing of yourself or someone you know. They will provide you with an overview of digital options you may wish to explore and relate the summary to the NHS’s Five Steps to Mental Wellbeing guidance.

This session is aimed at staff, volunteers, health professionals, carers and those living with  a neurological condition.

Register for session on Wednesday 3 Feb, 3.15 – 4.15 pm:

WAMES is a member of the Wales Neurological Alliance.

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Demystifying ME/CFS: talk by Dr Shepherd, Dr Muirhead & Caroline Kingdon RN

UK Cambridge University GP Society: Demystifying ME/CFS


On 14 January an online event about ME/CFS was held by the CUGPS for healthcare professionals, students and patients. Speakers:

  • Dr Charles Shepherd (starts 3 mins) – Dispelling common misconceptions about ME/CFS and highlighting current research into ME’s aetiology
  • Dr Nina Muirhead (28 mins) – Patient, Diagnosis and Management
  • Caroline Kingdon RN (57 mins) – How visiting the patient at home has helped to demystify severe ME/CFS

View video  

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WAMES needs a volunteer Virtual Office Manager

WAMES volunteer Virtual Office Manager vacancy


This role offers the opportunity to support the work of WAMES and make a difference for people with ME in Wales.

We provide support and information to people with ME, carers and families – approximately 13,000 families in Wales. We also campaign to change attitudes and misunderstandings about the condition and improve services. We expect the need for our support and information to increase as some people with long COVID can develop ME.

The role of the Virtual Office Manager would be to:

set up and manage a virtual online office for a small team of trustees and volunteers

You would be based at home, but working with, and responsible to the management Team.

Main activities:

The office manager is responsible for the following tasks but can enlist help to complete them.

  • advise management team on the best admin platform and software
  • set up the virtual office and help volunteers to make use of it
  • maintain a central diary and notify the volunteers of key dates & actions
  • keep documents up to date on a cloud storage platform, ensuring all relevant volunteers have access
  • enable communications between remote workers and with the ME community

Useful qualities and skills:

  • some office management and administration skills
  • some experience of business digital technology & willingness to learn
  • ability to work virtually with a team of volunteers with varying levels of experience and health
  • an eye for detail and methodical way of thinking
  • the role would be ideal for someone who has a long-term plan of returning to work and needs experience, or who wishes a career in the 3rd sector.

More information:

Download Volunteer Info Pack

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