Systematic review of the epidemiological burden of ME/CFS across Europe: current evidence and EUROMENE research recommendations for epidemiology, by Fernando Estévez-López, Kathleen Mudie, Xia Wang-Steverding, Inger Johanne Bakken, Andrejs Ivanovs, Jesús Castro-Marrero, Luis Nacul, Jose Alegre, Paweł Zalewski, Joanna Słomko, Elin Bolle Strand, Derek Pheby, Evelina Shikova, Lorenzo Lorusso, Enrica Capelli, Slobodan Sekulic, Carmen Scheibenbogen, Nuno Sepúlveda, Modra Murovska, and Eliana Lacerda, on behalf of The European Network on ME/CFS (EUROMENE) inJ. Clin. Med. 2020, 9 (5), 1557; [https://doi.org/10.3390/jcm9051557]
Review abstract:
This review aimed at determining the prevalence and incidence of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS) in Europe. We conducted a primary search in Scopus, PubMed and Web of Science for publications between 1994 and 15 June 2019 (PROSPERO: CRD42017078688).
Additionally, we performed a backward- (reference lists) and forward-(citations) search of the works included in this review.
Grey literature was addressed by contacting all members of the European Network on ME/CFS (EUROMENE). Independent reviewers searched, screened and selected studies, extracted data and evaluated the methodological and reporting quality.
For prevalence, two studies in adults and one study in adolescents were included. Prevalence ranged from 0.1% to 2.2%. Two studies also included incidence estimates. In conclusion, studies on the prevalence and incidence of ME/CFS in Europe were scarce.
Our findings point to the pressing need for well-designed and statistically powered epidemiological studies.
To overcome the shortcomings of the current state-of-the-art, EUROMENE recommends that future research is better conducted in the community, reviewing the clinical history of potential cases, obtaining additional objective information (when needed) and using adequate ME/CFS case definitions; namely, the Centers for Disease Control & Prevention−1994, Canadian Consensus Criteria, or Institute of Medicine criteria
Excerpt from Conclusions:
Potential causes of this paucity of knowledge may be due to a European lack of (i) official disease recognition, (ii) consensus over case definitions, or (iii) investment by funding agencies, among others.
Heart rate thresholds to limit activity in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome patients (Pacing): Comparison of heart rate formulae and measurements of the heart rate at the lactic acidosis threshold during Cardiopulmonary Exercise Testing, by C (Linda) MC van Campen, Peter C Rowe, Frans C Visser inAdvances in Physical Education Vol. 10 No.2, May 2020 [DOI: 10.4236/ape.2020.102013]
Research abstract:
Introduction:
Based on the hypothesis that oxidative metabolism is impaired in ME/CFS, a previous study recommended a pacing self-management strategy to prevent post-exertional malaise. This strategy involved a prescription to maintain a heart rate below the anaerobic threshold during physical activities. In the absence of lactate sampling or a cardiopulmonary exercise test (CPET), the pacing self-management formula defines 55% of the age-specific predicted maximal heart rate as the heart rate at the anaerobic threshold. Thus far there has been no empiric evidence to test this self-pacing method of predicting heart rate at anaerobic threshold.
The aim of this study was to compare published formula-derived heart rates at the anaerobic threshold with the actual heart rate at the lactic acidosis threshold as determined by CPET.
Methods and Results:
Adults with ME/CFS who had undergone a symptom-limited CPET were eligible for this study (30 males, 60 females). We analysed males and females separately because of sex-based differences in peak oxygen consumption. From a review paper, formulae to calculate maximal predicted heart rate were used for healthy subjects. We compared the actual heart rate at the lactic acid threshold during CPET to the predicted heart rates determined by formulae. Using Bland-Altman plots, calculated bias: the mean difference between the actual CPET heart rate at the anaerobic threshold and the formula predicted heart rate across several formulae varied between -28 and 19 bpm in male ME/CFS patients. Even in formulae with a clinically acceptable bias, the limits of agreement (mean bias ± 2SD) were unacceptably high for all formulae. For female ME/CFS patients, bias varied between 6 and 23 bpm, but the limits of agreement were also unacceptably high for all formulae.
Conclusion:
Formulae generated in an attempt to help those with ME/CFS exercise below the anaerobic threshold do not reliably predict actual heart rates at the lactic acidosis threshold as measured by a cardiopulmonary exercise test. Formulae based on age-dependent predicted peak heart rate multiplied by 55% have a wide age-specific variability and therefore have a limited application in clinical practice.
Todd Davenport of the Workwell Foundation responded to the conclusions of this study on twitter:
Todd Davenport @sunsopeningband May 23
I think it’s important to point out the equation we proposed was never intended to accurately predict heart rate at VAT. It was intended to slightly under-estimate heart rate at ventilatory anaerobic threshold. The thought was this underestimation would provide a safety margin.
The authors of the present study, very helpfully, provide us with some important subject-level data in Figure 1. These data can help us get an idea of whether the formula we proposed in 2010 actually underestimates the heart rate at lactic acid threshold, as originally intended…
“All models are wrong. Some models are useful.” Formula based estimation for metabolic output using heart rate is fraught. We know there are additional problems with it from our work on chronotropic intolerance in #MECFS.
However, because (repeat) CPET measurements is still not a common evaluative assessment for people with #MECFS, patients and their physical therapists are left with few objective tools to monitor activity in our collective attempt to reduce post-exertional neuroimmune exhaustion.
Calculated values, for all their acknowledged problems with picking accurate values in single patients, still can be useful to help patients and clinicians select appropriate activity thresholds for pacing self management. The data from this study seems to support this premise.
Background:
Chronic fatigue syndrome (CFS, also known as myalgic encephalomyelitis (ME)) is defined as fatigue that is disabling, is accompanied by additional symptoms and persists for ≥ 4 months. Treatment of CFS/ME aims to help patients manage their symptoms and make lifestyle adjustments. We do not know whether intervening early in primary care (< 4 months after onset of fatigue) can prevent the development of CFS/ME.
Methods:
This was a feasibility randomised controlled trial with adults (age ≥ 18 years) comparing usual care with usual care plus an early intervention (EI; a combination of psycho-education and cognitive behavioural therapy, CBT). This study took place in fourteen primary care practices in Bristol, England and aimed to identify issues around recruitment and retention for a full-scale trial. It was not powered to support statistical analysis of differences in outcomes. Integrated qualitative methodology was used to explore the feasibility and acceptability of recruitment and randomisation to the intervention.
Results:
Forty-four patients were recruited (1 August 2012-November 28, 2013), falling short of our predicted recruitment rate of 100 patients in 8 months. Qualitative data from GPs showed recruitment was not feasible because it was difficult to identify potential participants within 4 months of symptom onset. Some referring GPs felt screening investigations recommended by NICE were unnecessary, and they had difficulty finding patients who met the eligibility criteria.
Qualitative data from some participant interviews suggested that the intervention was not acceptable in its current format. Although the majority of participants found parts of the intervention acceptable, many reported one or more problems with acceptability. Participants who discontinued the intervention or found it problematic did not relate to the therapeutic model, disliked telephone consultations or found self-reflection challenging.
Conclusions:
A randomised controlled trial to test an early intervention for fatigue in adults in primary care is not feasible using this intervention and recruitment strategy.
Purpose:
The EU COST Action 15111 collaboration on myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) aims to assess current research and identify knowledge gaps in Europe. Presently, our purpose is to map the effects of non-pharmacological therapies (NPTs) for ME/CFS, and what patients find important in the treatment process.
Methods:
A scoping mixed methods literature review of European studies identified 16 papers fulfilling our inclusion criteria. The quantitative and qualitative studies were synthesized separately in tables. Additionally, extracts from the qualitative studies were subjected to translational analysis.
Results:
Effect studies addressed cognitive behavioural therapy (CBT, n = 4), multimodal rehabilitation (n = 2) and activity-pacing (n = 2). CBT reduced fatigue scores more than usual care or waiting list controls. The effects of rehabilitation and activity-pacing were inconsistent. The contents, assessment methods and effects of rehabilitation and activity pacing studies varied. For patients, health professionals’ recognition of ME/CFS and support were crucial, but they expressed ambiguous experiences of what the NPTs entail.
Conclusions:
Methodological differences make comparisons across NPTs impossible, and from a patient perspective the relevance of the specific contents of NPTs are unclear. Future well-designed studies should focus on developing NPTs tailored to patients’ concerns and evaluation tools reflecting what is essential for patients.
Excerpt:
Methodological issues
The content and delivery of NPTs varied considerably in the studies, and any theoretical reasons for including the various components are not given. As NPTs are based on various theoretical assumptions, each NPT should first be tested to see if it is successful in achieving what it theoretically is supposed to do, and whether the changes are relevant in helping patients with ME/CFS. If successful in both respects, other components could be added step by step and tested in accordance with the framework of developing complex interventions (Craig et al., 2013; Richards & Hallberg, 2015). Future RCTs should also include long-time follow-up and cost-benefit analysis, and in particular, more studies on the role of NPTs for children and adolescents are needed.
The studies of CBT showed rather consistent results in having an effect on modifying fatigue, while the effects of activity pacing and multimodal rehabilitation were inconsistent. However, a timely question is whether the outcome measures were appropriate in evaluating whether the intentions of the NPTs, and what was found relevant for patients, were reached. At present, generic instruments, such as SF-36 and the CIS fatigue subscale, mostly assessed effects. A systematic literature review by Haywood et al. (2012) examined whether patient-reported measures, including those used in our review, had undergone rigorous, scientific evaluations in patients with ME/CFS. No evidence was found that patients had been involved in evaluating the relevance of any questionnaire, the content validities of which are therefore questionable. Likewise, measures showed little or moderate responsiveness to NPTs, which is essential in detecting effects. Another issue to be considered is how to interpret statistically significant differences in relation to clinical importance. It is questionable how much change is needed in an instrument’s scale to make it both clinically relevant and meaningful for patients (Angst et al., 2017). For future research, we recommend developing robust patient-reported disease-specific measures in collaboration with patients, and international consensus should be reached about the use of such instruments in making findings comparable across studies.
Patients with ME/CFS are not homogenous. Severely affected patients are house- or bedbound, while others, well represented in the effect studies we identified, struggle to maintain their living patterns. We did not find any studies on NPTs for severely affected patients. One reason for this may be that RCT designs are not appropriate in evaluating effects of such therapies for severely affected patients. To attempt to close this knowledge gap, case studies are high priority. Interviews with severely afflicted patients about their illness experiences, and interviews with patients that have become better after being bed- or house bond about what mattered for their progress, are needed to develop meaningful NPTs in the future. An alternative means of testing such new NPTs could be to apply single subject experimental designs in which a subject serves as his/her own control (Bates, 1996; Zhan & Ottenbacher, 2001). Patient-specific measures, such as Canadian Occupational Performance Measure as used by Kos et al. (Kos et al., 2015) can be appropriate to examine eventual progress but are less easy to use because of the semi-structured format. In terms of clinical practice, the semi-structured format has the advantage of being already a first step in the communication with the patients, but in research, reliability can be an issue when the assessors are not well trained.
Background:
Chronic Fatigue Syndrome/Myalgic Encephalomyelitis/Systemic Exertion Intolerance Disease (CFS/ME/SEID) is a complex illness that has an unknown aetiology. It has been proposed that metabolomics may contribute to the illness pathogenesis of CFS/ME/SEID. In metabolomics, the systematic identification of measurable changes in small molecule metabolite products have been identified in cases of both monogenic and heterogenic diseases. Therefore, the aim of this systematic review was to evaluate if there is any evidence of metabolomics contributing to the pathogenesis of CFS/ME/SEID.
Methods:
PubMed, Scopus, EBSCOHost (Medline) and EMBASE were searched using medical subject headings terms for Chronic Fatigue Syndrome, metabolomics and metabolome to source papers published from 1994 to 2020. Inclusion and exclusion criteria were used to identify studies reporting on metabolites measured in blood and urine samples from CFS/ME/SEID patients compared with healthy controls. The Joanna Briggs Institute Checklist was used to complete a quality assessment for all the studies included in this review.
Results:
11 observational case control studies met the inclusion criteria for this review. The primary outcome of metabolite measurement in blood samples of CFS/ME/SEID patients was reported in ten studies. The secondary outcome of urine metabolites was measured in three of the included studies. No studies were excluded from this review based on a low-quality assessment score, however there was inconsistency in the scientific research design of the included studies. Metabolites associated with the amino acid pathway were the most commonly impaired with significant results in seven out of the 10 studies. However, no specific metabolite was consistently impaired across all of the studies. Urine metabolite results were also inconsistent.
Conclusion:
The findings of this systematic review reports that a lack of consistency with scientific research design provides little evidence for metabolomics to be clearly defined as a contributing factor to the pathogenesis of CFS/ME/SEID. Further research using the same CFS/ME/SEID diagnostic criteria, metabolite analysis method and control of the confounding factors that influence metabolite levels are required.
This paper focuses on the illness behavior of patients with myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS) to clarify difficulties in their lives through comparison with a five-stage model of illness behavior.
[Suchman is the one who describes the five stages of illness behavior namely: Symptoms, sick role, medical care contact, dependent client role, and recovery.] https://tinyurl.com/ycbldvx8
ME/CFS is considered a typical disease with medically unexplained symptoms (MUS), which refers to a condition where symptoms suggest the presence of a physical disease whose cause cannot be found by examination. Although previous studies of ME/CFS have focused on specific events, such as diagnosis, and the psychological changes that accompany them, the chronological events experienced by patients and the transformation of the problems they face have not been adequately grasped.
This paper analyzes ME/CFS patients’ illness behavior through interviews and explores the difficulties patients face at each stage of illness behavior. In ME/CFS patients’ narratives, their illness behavior shows complexities of going back and forth between stages, rather than progressing step by step like an acute illness.
The seemingly excessive treatment behavior called “doctor shopping” is actually linked to doctors’ ignorance, suspicion, and incomprehension of diseases without a biomarker, rather than the desire of the patient to dispel an “inappropriate” label of laziness and mental illness. Indeed, it would be more accurate to say that interviewees were not accepted by several hospitals. In addition, since patients are often suspected of not being really ill even after diagnosis, they cannot experience the dependent-patient role.
Therefore, by becoming an “active patient” by themselves, ME/CFS patients must undertake the “independent-patient role” to secure necessary treatment and welfare services. It should be noted that these patient behaviors are not undertaken for secondary gain but are due to their having no other way to receive necessary care.
Posted inNews|Tagged5 stages of illness behaviour, Natsuko Nojima|Comments Off on Difficulties of living with an illness not considered a “Disease”: focusing on the illness behavior of ME/CFS patients
Save4Children – helping children with ME in psychiatric wards
The charity Save4Children has been created by the editors of the ME Global Chronicle and helps parents whose children have been forced into psychiatric wards by authorities, to try and set them free by legal procedures.
In recent years, the Save4Children fund has directed its attention and help at the Danish ME patient Karina Hansen.
Karina had been forcibly accepted into the Neurocenter in Hammel, Jutland. On Monday November 17th, 2017, she returned back home, never to return to the clinic at which she had been staying – a clinic for patients with brain conditions.
The primary obstacle on the road to fully getting her personal freedom back was her state-appointed guardian, who had been sort-of cooperating during the duration of her forced stay at the Hammel Neurocenter.
On October 10th 2018, a judge deemed Karina to have legal capacity to make decisions about her own life, and revoked guardianship over her, with her guardian’s permission.
The Save4Children fund has been able to contribute a small amount towards undoing the high costs this event has brought with it.
Report new cases:
Now is the time to spend this fund’s donations on one or multiple new cases. They’re still at a stage of deliberation, but if you’re familiar with any cases where young ME patients are being forced to stay at psychiatric institutions or are about to, make sure to tell them via email info@let-me.be .
The fund is intended for parents who can’t afford to dispute such a process, who can prove their lack of sufficient funds.
New way of donating:
GBP bank details:
Account Holder: Save4Children
Account number: 70983145
UK Sort Code: 23-14-70
Address:
TransferWise
56 Shoreditch High Street
London
E1 6JJ
United Kingdom
New CPD: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, May 13, 2020
A new training module for doctors and medical students has been developed by the CMRC Medical Education Group led by Dr Nina Muirhead, and leads to the award of 1 CPD (Continuing Professional Development) point.
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a common and severe complex multisystem disease with many sufferers waiting years for a diagnosis. The narrative and education to date has neither aligned with the patient experience of this illness, nor communicated the emerging biomedical evidence.
Following the coronavirus pandemic thousands of people will know how severe and debilitating the symptoms of fatigue can be. Millions will understand the experience of being housebound, but for most these experiences will have lasted days, weeks or months.
Imagine feeling viral, exhausted, unwell and in pain, confined to your bed or house, lying in a dark room for years or even decades. The world has been shocked by the damage that viruses can do, and soon we will need to examine the consequences of chronic post-viral illness including ME/CFS.
In writing this module I have started from scratch. I have drawn on the international peer reviewed literature and emerging international ME/CFS educational resources and have been fortunate to receive significant contributions from medical experts, scientists and patients.
I am humbled by the contributions of those who are severely ill and the effort and energy they have devoted to this collaboration. I recommend that you read the four pre-course peer reviewed papers before embarking on the learning module. It would be of great help if you could take a minute to click through the anonymous pre-and post-course questionnaire so that more accurate information can be gathered to help develop and update future ME/CFS learning materials.
This module is just the start. There will be some who take time picking through the evidence and I welcome your opinion and future collaboration. For others it may be an extra CPD point. For the patients who are recognised, believed and diagnosed because you have taken the time to do this learning module – it could be life changing.
Contributing post written by Nina Muirhead BA(oxon) BMBCh(oxon) MRCS DOHNS MEd PGDipDerm. Nina is also associated with or alumni of:
Oxford University
Open University
Cardiff University
Buckinghamshire Healthcare NHS Trust
Royal College of Surgeons
Royal College of Physicians
My ME lockdown with the invisible “terrible triplets”
I have been living in ME lockdown on my own, yet it doesn’t feel as though I am alone.
My lockdown experience started long before Covid-19 appeared on the scene as I have been ill for many years, often unable to leave the house for weeks or months at a time. This new lockdown has just added another layer of complexity to my life.
The will to get better is there and I desperately want to live a productive, peaceful life, but my brain and body don’t listen to me, or each other, and won’t cooperate. They’re like troublesome children who argue and fight no matter what I want, or what is happening in the outside world.
My body
My body misbehaves in so many ways, some of them most unexpected – painful muscles and joints, shooting pains, minimal energy reserves, post activity delayed reaction, haywire temperature regulation, sensitivity to prescription meds. I could go on!
You’ve heard of ‘brain freeze’ after eating ice cream? I get ‘body and brain freeze’ when overstretched. All of a sudden my temperature plummets, I go cold all over and I am in agony. The sun has been shining outside during lockdown. People are gardening, sunbathing and having barbecues in their back gardens, (or risking illegal trips to the beaches and parks!). I remain indoors fully dressed, plus dressing gown, wrapped in a thermal blanket, shivering in bed with the electric blanket on, sometimes for hours or days, attacks coming back to back sometimes!
Then just as suddenly heat surges take me over and trigger a polar opposite experience. I have days where I am super sensitive to light and sound and need to cocoon myself in a quiet darkened room until my tolerance levels increase. Some days I get eye distortion, even double vision, and cannot see clearly. The harder I try, the more difficult it becomes and again some downtime is needed.
My brain
My brain really lets me down frequently. Some years ago I earned the equivalent of 2 degrees but now my brain rarely works well and frustration reigns. I find it hard to follow, absorb, process and retain information. The concentration required really hurts. Sometimes the more active my body is the more impaired my brain functions become, as though it is being cooked in a pressure cooker. My brain processing power ceases but the pressure & pain continue and all the things I once learned to do, I rarely can do.
Pronouncing or spelling familiar words can be difficult. Although I once excelled at maths without using a calculator, I now find basic calculations near impossible, even with one. My brain reacts as though I’ve become dyslexic with both words & numbers alike, as I struggle to make sense of what I see written down or even what I say.
Learning to shop in a different way during lockdown has really hurt my brain. I was unable to get a supermarket delivery slot but eventually discovered a local teacher who was volunteering to shop for those of us who are shielding. She turned up as planned to get my shopping list. Momentarily forgetting my recalcitrant brain I gratefully gave her a list of 6 items (2 pate, bread, cereal, milk, chicken). She looked puzzled, but I assured her that was all I needed. Once she had brought the shopping and I had put it away, I looked around the kitchen in horror, wondering what I was going to eat for the next week! I have been too embarrassed to contact her again, yet.
An acquaintance who lives some distance away offered to collect shopping for me. He helped me find a supermarket with a click & collect slot & spent at least 4 hours over a few days making and amending an order for me, as I tried to work out the most important 80 items I needed. Then he drove nearly 100 miles round trip to collect and deliver it to me. I was very touched and grateful and gave him a cheque. I was mortified when he got home and noticed it was unsigned. Another bad brain moment! Fortunately he had a sense of humour.
Cognitive difficulties are not a sign of low intelligence, a behavioural problem or a learning disability, but they really can make you feel daft.
My belly
And then there’s my tummy. It is such a problem it also has a life of its own – pain, food intolerances, bloating, diarrhoea etc. Most of my stories about this family delinquent are too unpleasant to relate! I got so tired of watching doctors nodding sagely and unmoved when I mentioned the bloating that I took a selfie so they could compare it to the person in front of them. That got their attention! As you can imagine I have been offered seats to sit my weary pregnant body down on (though I was not of an age where pregnancy was possible) – a bittersweet moment to be considered so young.
I was pleased to receive 2 food boxes recently. Although I communicated my dietary restrictions beforehand they were misinterpreted, maybe unable to accommodate. I found half the items were unsuitable, which made me then feel ungrateful, and guilty at depriving someone else, because I couldn’t return them.
The terrible triplets
The terrible triplets. 24 hours a day, 365 days a year these triplets have minds of their own. My ME lockdown is not imposed from outside, by governments or health services, but by my own discontented and argumentative ‘family’. I call them the ‘3 Bs’ and not just because of the alliteration!
The hardest lesson in my life is to learn to accept my new self and life difficulties with humility and kindness, forgiving myself for my lack of previous abilities. I have to postpone activities that use physical or cognitive functions knowing there will be moments later when I get to catch up on critical life tasks. And there will be the odd momentary flash of the old me, which is still within me and can bring me joy, and then sadness as my abilities retreat again.
It is a real relief when the triplets calm down a bit and I can focus on something useful, productive, even enjoyable, when I can inhale a breath of sanity before chaos resumes. What impact does this have on my mental health? I sometimes think I am going doolally, but mostly I just try to remember to acknowledge that anxiety and depression are normal side effects to such a chronic health condition, and wait for them to pass.
People only see me occasionally, on better days, not when I am behind closed doors. It is difficult to communicate to people the difficulties I deal with on a minute to minute basis. I don’t talk about the invisible triplets obviously. That might lead me up the path to the asylum on the hill, though I’d happily go if I could leave the terrible triplets behind!
8 weeks into Covid-19 lockdown.
12 years 5 months into my ME lockdown.
PF, Wales
PS Thanks to my ‘editor’ who made sense of my incoherent ramblings and scribbles!