Can patients with CFS really recover after GET or CBT?

Research abstract:

BACKGROUND: Publications from the PACE trial reported that 22% of chronic fatigue syndrome patients recovered following graded exercise therapy (GET), and 22% following a specialised form of CBT. Only 7% recovered in a control, no-therapy group. These figures were based on a definition of recovery that differed markedly from that specified in the trial protocol.

PURPOSE: To evaluate whether these recovery claims are justified by the evidence.

METHODS: Drawing on relevant normative data and other research, we critically examine the researchers’ definition of recovery, and whether the late changes they made to this definition were justified. Finally, we calculate recovery rates based on the original protocol-specified definition.

RESULTS: None of the changes made to PACE recovery criteria were adequately justified. Further, the final definition was so lax that on some criteria, it was possible to score below the level required for trial entry, yet still be counted as ‘recovered’. When recovery was defined according to the original protocol, recovery rates in the GET and CBT groups were low and not significantly higher than in the control group (4%, 7% and 3%, respectively).

CONCLUSIONS: The claim that patients can recover as a result of CBT and GET is not justified by the data, and is highly misleading to clinicians and patients considering these treatments.

Can patients with chronic fatigue syndrome really recover after graded exercise or cognitive behavioural therapy? A critical commentary and preliminary re-analysis of the PACE trial, by Carolyn Wilshire, Tom Kindlon, Alem Mathees, Simon McGrath in Journal Fatigue: Biomedicine, Health & Behavior Pp 1-14 [Published online: 14 Dec 2016]

MEAction blog post, Simon McGrath, 14 Dec: The PACE trial: where “recovery” doesn’t mean getting your health back

 

Posted in News | Tagged , , , , , , , , | Comments Off on Can patients with CFS really recover after GET or CBT?

Alison Hunter case report

ME Australia blog post: Case report: Alison Hunter by Christine Hunter, 13 December 2016

For the past decade patients diagnosed with chronic fatigue syndrome have been shamefully mistreated due to government policy failure and lack of medical education.

Case Report by Sukocheva et al.BMC Infectious Diseases (2016) 16:165, Coxiella burnetii dormancy in a fatal ten year multisystem dysfunctional illness: case report.

Read more

Alison Hunter Memorial Foundation  The Foundation is an enduring memorial to Alison Hunter and all those whose lives have been devastated by ME/CFS. Alison died in 1996, aged 19, from complications arising from ME/CFS which included seizures, paralysis, gastrointestinal paresis and overwhelming infection resembling Behcets Disease.

 

Posted in News | Tagged , , , | Comments Off on Alison Hunter case report

Microbial fermentation in the gut may affect energy metabolism in ME/CFS

Research abstract:

Introduction: The human gut microbiota has the ability to modulate host metabolism. Metabolic profiling of the microbiota and the host biofluids may determine associations significant of a host–microbe relationship.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a long-term disorder of fatigue that is poorly understood, but has been linked to gut problems and altered microbiota.

Objectives: Find changes in fecal microbiota and metabolites in ME/CFS and determine their association with blood serum and urine metabolites.

Methods: A workflow was developed that correlates microbial counts with fecal, blood serum and urine metabolites quantitated by high-throughput 1H NMR spectroscopy. The study consists of thirty-four females with ME/CFS (34.9 ± 1.8 SE years old) and twenty-five non-ME/CFS female (33.0 ± 1.6 SE years old).

Results: The workflow was validated using the non-ME/CFS cohort where fecal short chain fatty acids (SCFA) were associated with serum and urine metabolites indicative of host metabolism changes enacted by SCFA. In the ME/CFS cohort a decrease in fecal lactate and an increase in fecal butyrate, isovalerate and valerate were observed along with an increase in Clostridium spp. and a decrease in Bacteroides spp.

These differences were consistent with an increase in microbial fermentation of fiber and amino acids to produce SCFA in the gut of ME/CFS patients. Decreased fecal amino acids positively correlated with substrates of gluconeogenesis and purine synthesis in the serum of ME/CFS patients.

Conclusion: Increased production of SCFA by microbial fermentation in the gut of ME/CFS patients may be associated with deleterious effects on the host energy metabolism.

The association of fecal microbiota and fecal, blood serum and urine metabolites in myalgic encephalomyelitis/chronic fatigue syndrome by Christopher W. Armstrong,  Neil R. McGregor, Donald P. Lewis, Henry L. Butt, Paul R. Gooley in Metabolomics January 2017, 13:8 [Published online 12 December 2016]

Posted in News | Tagged , , , , | Comments Off on Microbial fermentation in the gut may affect energy metabolism in ME/CFS

How me & my ME became worse… following an exercise programme

Rosa rainbows blog post: How me and my ME became worse, 17 September 2016

Extracts:

I haven’t written a blog post for about two months, and the reason is that I have become very ill. For my friends who do not know much about ME, I hope you will read what I am about to write so you can understand the severity of the situation in the UK – it is not just happening to me, but to many other hundreds of thousands of people across the UK.

I have both Lupus and ME, and while Lupus is taken somewhat seriously, ME absolutely isn’t. Looking back, from June onwards, I was starting to notice more and more days when I felt overly unwell. This coincided with the time that I was put on a new CBT/ Graded Exercise trial, called the PRINCE Secondary Trial, run in St Thomas Hospital in London…

For a few months, from about March to June, I had been feeling better. Before then, I had spent about 8 months with complete bed rest and meditating and reading. It had made me feel stronger. I was doing gentle stretching and yoga to help my muscles. So now I was able to leave the house once in a while in the wheelchair, and was also able to walk for about 5 minutes with breaks, once a week on good weeks. I was even able to go to the cinema and see my friends for meals. Life was good!

But from June, I was enrolled on the PRINCE Secondary Trial. It was a trial where I had CBT sessions – but the sessions were based on a special form of CBT which told me I had false illness beliefs, and in every session I was given an exercise programme to do. The booklet I was given said, “The best advice would be to try out this practical approach because nothing will be lost by trying but much may be gained“. I was told to increase my exercising – so to go on a 5 minute walk, twice a week, instead of the once a week I was able to do. I did what they said, but was starting to feel more unwell than before, and told my therapist – she told me to meditate more, rest more in between (although that was all I was doing in between anyway!), and continue the walking. So I did.

Then, she told me to increase it to 5 minutes, three times a week. I was given a booklet that told me that it was my beliefs that were perpetuating the illness, that even if I felt unwell or got pains, or wanted to cancel plans, I should rethink it, and not think negatively. I was having more and more “bad” days but kept going. The message was that even if I got pains or dizzy or got tired, it was my body getting used to new patterns and doing more exercise and I shouldn’t look into it too much.

I booked a trip to wilderness festival, thinking, well even though I am feeling more and more ill, at some point my body will get used to its new pattern. and I still wasn’t as bad as I was last August (when I first got ill) so I continued.

During wilderness, I became very unwell and had to come back early by cab all the way from Oxford – by this point my body had gone numb and I was in tears. I came back from Wilderness, and I went into hospital a few days later and was told I should get out of my wheelchair and be more active. When I told them I often had a lot of pain in my arms, which is why I couldn’t do a lot of things and needed help with having a bath,  they told me to do weights.

By this point in the trial, I was too unwell to travel to my appointments so was having phone appointments – I was told to do a 10 minute walk. During the walk, my legs wobbled and stopped being able to work properly. Despite this, I desperately tried to push through it and did a yoga session a few days later (the trial therapist knew about the yoga too), because I had been told that that pain wasn’t a big deal. And that was when my body finally collapsed in exhaustion.

I had shooting, electrical-like nerve pain throughout my arms and legs, it was terrifying and I couldn’t sleep with the pain. I had palpitations, my body started shaking and twitching, I would burn up one minute and be freezing cold the next – I was feverish for over a week.

I got even worse orthostatic intolerance, which means I couldn’t tolerate being upright or even sitting upright, sometimes even for more than a few seconds without feeling nauseous and dizzy and shivery. I felt sick all the time, found it difficult to tolerate food (or even sit up to eat) and the headaches were there all the time. My brain felt foggy. I became sensitive to light, and sound, and had to lie in a darkened room or I would get palpitations.

The smallest thing I did- even eating a few spoons of breakfast, meant I had to lie down for hours to recover. I needed my mum and my boyfriend for every single thing. I couldn’t walk a few steps or type without horrendous pain. I couldn’t talk more than a few words or the exhaustion was too intense. I could drag myself to the toilet next door a few times a day, and that was enough to make me more unwell.

All in all, I was back to how I was last year. This relapse happened in the middle of August. It is now a month on from that, and although I am a little better, I am still very unwell – it has taken a lot out of me, lying down, to write this on my phone. And I know I will feel very unwell after this, and am feeling it now. But I am writing all this, however horrible it is to talk about, because I want people to know this is the reality of how ME can be – that a young woman, who was getting better by herself with rest, and who had already lost so much, can be pushed into this state by being told that they should just “push through it”. And I also have Lupus, and the complications which arise from that.

Read the full blog post

More info: PRINCE Secondary Trial 

King’s College London CFS Research & Treatment Unit

 

Posted in News | Tagged , , , , , , | Comments Off on How me & my ME became worse… following an exercise programme

Dr Phil Hammond writes about the ME campaigners’ challenge to the science of CBT & GET

Private eye Medicine Balls column, 10 December 2016: ‘ME campaigners don’t ignore CBT and GET… but they do challenge the science’ Private eye Medicine Balls column, 25 November 2016: ‘ME cluster bomb’  [Written by ‘M.D.’, the nom de plume of Dr Phil Hammond and reproduced by the ME Association]:

The Eye received many supportive letters for stating in the last issue that CFS/ME (chronic fatigue syndrome/myalgic encephalopathy) has biological causes, but also some criticisms.

As one doctor put it: “Every illness has a physical, psychological and social component, and limiting diagnosis or treatment to only one aspect of someone’s illness is likely to lead to a much poorer outcome. This ‘triple diagnosis’ applies to any disorder you care to consider, although obviously in varying proportions. The one exception seems to be CFS/ME where any suggestion that there might be a psychological or social component leads to criticism. That cognitive behavioural therapy (CBT) is the only treatment which has repeatedly been shown to have any benefit is conveniently ignored.”

ME campaigners don’t ignore the fact that CBT and graded exercise therapy (GET) have been shown to work in randomised controlled trials and are endorsed by lofty scientific institutions such as the Cochrane Collaboration and NICE, but they do challenge the science.

The PACE trial, set up to compare the effectiveness of the four treatments for CFS/ME, has caused particular controversy and activists have had to fight to gain access to sue of the data which they are re-analysing to determine if claims about the efficacy of GET and CBT have been over-stated. For the PACE researchers to accept any such re-analysis would require it to be published as a credible peer-reviewed journal with independent analysis that is free from bias. It is a long and complex process.

M.D. agrees that the split between mind and body is unhelpful, and there are indeed physical, psychological and octal elements in all illnesses, either as causes or consequences. But it was doctors who initially dismissed a physical basis for CFS/ME, and as a consequence insufficient attention and resources have been given to doing large scale biological nutritional and genetic studies that might provide alternative treatments to the non-drug options currently on offer.

Read more

Posted in News | Tagged , , , , , | Comments Off on Dr Phil Hammond writes about the ME campaigners’ challenge to the science of CBT & GET

Make Welsh streets more walkable questionnaire for age 50+

Here is a chance to let people know about the additional challenges ME brings to walking in Welsh streets.

Ageing well in Wales announcement: Help us make Welsh streets more walkable

Many of us take walking for granted. However, for many older people, walking is their main form of transport, and essential to maintain independence and to reach vital public services such as GPs, pharmacists and libraries. Walking is also a great way to stay active, helping to maintain health and wellbeing, and reducing the risk of falling.

We have teamed up with Living Streets and CADR (the Centre for Ageing and Dementia Research) to collect older people’s thoughts and experiences of walking in their neighbourhoods. If you’re aged 50 or over, we’d like to know why you walk, how often you walk, and what helps or hinders you in walking where you live.

We’ve put together a short questionnaire to find out how age-friendly our streets are for people walking. In 2017, we will produce a report summarising the findings of the survey, and making recommendations of how we can make our towns, villages and cities better places to walk, and grow older in.

You can download the questionnaire at www.ageingwellinwales.com/streets

Posted in News | Tagged , | Comments Off on Make Welsh streets more walkable questionnaire for age 50+

Danish RCT of cognitive behavior therapy for whatever ails your physician about you

PLOS blog post by James Coyne PhD, 7 December 2016: Danish RCT of cognitive behavior therapy for whatever ails your physician about you

I was asked by a Danish journalist to examine a randomized controlled trial (RCT) of cognitive behavior therapy (CBT) for functional somatic symptoms. I had not previously given the study a close look.

I was dismayed by how highly problematic the study was in so many ways.

I doubted that the results of the study showed any benefits to the patients or have any relevance to healthcare.

I then searched and found the website for the senior author’s clinical offerings.  I suspected that the study was a mere experimercial or marketing effort of the services he offered.

Overall, I think what I found hiding in plain sight has broader relevance to scrutinizing other studies claiming to evaluate the efficacy of CBT for what are primarily physical illnesses, not psychiatric disorders. Look at the other RCTs. I am confident you will find similar problems. But then there is the bigger picture…

[A controversial assessment ahead? You can stop here and read the full text of the RCT  of the study and its trial registration before continuing with my analysis.]

Schröder A, Rehfeld E, Ørnbøl E, Sharpe M, Licht RW, Fink P. Cognitive–behavioural group treatment for a range of functional somatic syndromes: randomised trial. The British Journal of Psychiatry. 2012 Apr 13:bjp-p.

A summary overview of what I found:
The RCT:

  • Was unblinded to patients, interventionists, and to the physicians continuing to provide routine care.
  • Had a grossly unmatched, inadequate control/comparison group that leads to any benefit from nonspecific (placebo) factors in the trial counting toward the estimated efficacy of the intervention.
  • Relied on subjective self-report measures for primary outcomes.
    With such a familiar trio of design flaws, even an inert homeopathic treatment would be found effective, if it were provided with the same positive expectations and support as the CBT in this RCT. [This may seem a flippant comment that reflects on my credibility, not the study. But please keep reading to my detailed analysis where I back it up.]
  • The study showed an inexplicably high rate of deterioration in both treatment and control group. Apparent improvement in the treatment group might only reflect less deterioration than in the control group.

The study is focused on unvalidated psychiatric diagnoses being applied to patients with multiple somatic complaints, some of whom may not yet have a medical diagnosis, but most clearly had confirmed physical illnesses.
But wait, there is more!

It’s not CBT that was evaluated, but a complex multicomponent intervention in which what was called CBT is embedded in a way that its contribution cannot be evaluated.
The “CBT” did not map well on international understandings of the assumptions and delivery of CBT. The complex intervention included weeks of indoctrination of the patient with an understanding of their physical problems that incorporated simplistic pseudoscience before any CBT was delivered. We focused on goals imposed by a psychiatrist that didn’t necessarily fit with patients’ sense of their most pressing problems and the solutions.

And the kicker.

The authors switched primary outcomes – reconfiguring the scoring of their subjective self-report measures years into the trial, based on a peeking at the results with the original scoring.

Investigators have a website which is marketing services. Rather than a quality contribution to the literature, this study can be seen as an experimercial doomed to bad science and questionable results from before the first patient was enrolled. An undeclared conflict of interest in play? There is another serious undeclared conflict of interest for one of the authors.

For the uninformed and gullible, the study handsomely succeeds as an advertisement for the investigators’ services to professionals and patients.

Personally, I would be indignant if a primary care physician tried to refer me or friend or family member to this trial. In the absence of overwhelming evidence to the contrary, I assume that people around me who complain of physical symptoms have legitimate physical concerns. If they do not yet have a confirmed diagnosis, it serves little purpose to stop the probing and refer them to psychiatrists. This trial operates with an anachronistic Victorian definition of psychosomatic condition.

Posted in News | Tagged , , , , , | Comments Off on Danish RCT of cognitive behavior therapy for whatever ails your physician about you

Exercise exposes new types of POTS

Health rising blog post, by Cort Johnson, 6 December: Exercise Exposes New Types of Postural Orthostatic Tachycardia Syndrome (POTS)

Extracts:

Exercise has been used in many studies to understand chronic fatigue syndrome (ME/CFS), but nobody until recently has used exercise to try to understand POTS.  Exercise is a particularly interesting tool in the case of POTS because exercise intolerance is often present, and because like with fibromyalgia, exercise has become a kind of go-to therapy for POTS.

In these two studies researchers at the Mayo Clinic in Rochester, New York exercised adolescent POTS and ME/CFS patients (in one of the studies)  to exhaustion while measuring their heart rates, oxygen usage, anaerobic threshold, ventilation, gas exchange, etc. The hypothesis – POTS is a heterogeneous condition that is caused in several ways.  The goal – to elucidate different subsets.

POTS is characterized by high heart rates upon standing which attempt to compensate for blood pooling in the lower body

  • Exercise stress tests exposed types of POTS that tilt tests failed to reveal
  • The high cardiac outputs and blood flows in hyperkinetic POTS patients attempt to compensate for a failure to vasoconstrict or tighten down their blood vessels when they stand.
  • The overly vasoconstricted blood vessels in hypokinetic POTS patients attempt to compensate for reduced blood volume, low venous capacity and reduced blood flows to the heart
  • The study suggested that deconditioning adds another burden to both adolescent POTS and ME/CFS patients.

Neuropathic POTS – caused by decreased vasoconstriction of the blood vessels in the legs and/or abdomen causing blood to pool in the lower body upon standing. Not associated with autoimmune issues according to a 2014 review. Treatment is focused on improving circulation with exercise and vasoconstricting drugs such as Midodrine, droxidropa and Mestinon (pyridostigmine)

Hyperadrenergic POTS – associated with increased sympathetic nervous system activity which can be caused in multiple ways. Treatment includes exercise, beta blockers and possibly angiotensin receptor blockers and droxidopa.

Hyperkinetic – The high cardiac output seen in the “hyperkinetic” POTS group attempts to compensate for problems constricting their blood vessels. During exercise our blood vessels should narrow in order to develop enough pressure (perfusion pressure) to force more blood into our tissues. In the hyperkinetic group, however, their blood vessels remain open; instead the group kicks their heart output up in order to produce the needed perfusion pressure.

That compensatory effort – like so many compensatory efforts in the body – is not entirely successful. These patients get lots of blood flowing through their systems but still get reduced oxygen extraction at the muscles. The authors noted that the reduced oxygen extraction  could be due to metabolic issues but they believe is probably simply a blood flow problem. They characterized these patients’ muscles as starving in the land of plenty – and becoming fatigued because of it.

Unlike the hypokinetic group, these patients do not have problems with  blood volume or preload.

The Hypokinetic Group – Hypokinetic POTS  patients have the opposite problem; their low blood volume and decreased blood vessel capacity means they can’t increase their cardiac output. Instead, they tighten down their blood vessels in order to apply pressure.

In 2004 Stewart called this group of patients the “low-flow” group. Low blood volume clearly plays a major role. These patients’ low calf blood volumes, reduced venous capacitance and tightened down blood vessels left Stewart describing them as being “chronically vasoconstricted”.  The “muscle pump” that’s supposed to kick in to keep their blood from draining into their lower body when they stood isn’t working either.

This study indicates that this group of POTS patients also has reduced stroke volume (cardiac output) due to reduced preload. Reduced preload  – or the inability to fill the heart with enough blood to pump it out in normal amounts – is same problem that Systrom uncovered in his large exercise study of patients with unexplained exercise problems.

The only thing the body can do to combat a problem like this is to clamp down on the blood vessels in an attempt to build up enough pressure to get the blood to the tissues (e.g. perfusion pressure again).

Read the full article

 

 

 

 

 

 

Exercise Exposes New Types of Postural Orthostatic Tachycardia Syndrome (POTS)

Posted in News | Tagged , , , , , | Comments Off on Exercise exposes new types of POTS

High-frequency rTMS for the treatment of CFS

Research abstract:

Structural and functional abnormalities of the prefrontal cortex seem to correlate with fatigue in patients with chronic fatigue syndrome (CFS).

We consecutively applied facilitatory high-frequency repetitive transcranial magnetic stimulation (rTMS) to the dorsolateral prefrontal cortex (DLPFC) of seven CFS patients over three days. Five patients completed the 3-day protocol without any adverse events.

For the other two patients, we had to reduce the stimulation intensity in response to mild adverse reactions. In most of the patients, treatment resulted in an improvement of fatigue symptoms. High-frequency rTMS applied over the DLPFC can therefore be a potentially useful therapy for CFS patients.

High-frequency rTMS for the Treatment of Chronic Fatigue Syndrome: A Case Series. by W Kakuda, R Momosaki, N Yamada, M Abo in Intern Med. 2016;55(23):3515-3519. [Epub 2016 Dec 1.]

Extract from the full text:

The present study has certain limitations.

First, this is a case-series pilot study with only a small number of patients that lacked a control group. Comparative studies, such as randomized controlled design studies that include a large number of patients, are needed to confirm the efficacy of rTMS in CFS patients.

Second, although all patients met the inclusion criteria for rTMS application, they were a heterogeneous group based on the wide variability of age, duration of illness and severity of the fatigue symptoms. The identification of the clinical factors that correlate with the efficacy of rTMS can help in the selection of patients who will best benefit from the treatment.

Third, although it is difficult to stimulate deep brain lesions using the currently available technology, the stimulation of other brain areas with functional or structural  abnormalities in CFS, such as the cingulate cortex and brainstem, may produce a better clinical improvement.

Furthermore, for one left-handed patient, we applied high-frequency rTMS to the right hemisphere unlike the other six patients. The appropriateness of this therapeutic strategy of rTMS depending on whether patients were righthanded or left-handed should be also confirmed.

Posted in News | Tagged , , | Comments Off on High-frequency rTMS for the treatment of CFS

TV interview with Dr Nancy Klimas

US TV news report [NBVDFW Dallas], December 1, 2016

Dr Nancy Klimas of the Institute for Neuro Immune Medicine and ex marine Paula Bushman are interviewed.

dr-klimas

Researchers helping those tired of chronic fatigue [2 mins 4 sec]

Now Dr. Klimas and her team are on the verge of a breakthrough identifying a specific gene which will allow them to predict the best medications.

 

Posted in News | Tagged | Comments Off on TV interview with Dr Nancy Klimas