Even severe illness may not be instantly apparent – for example your friend/relative may be able to walk to the toilet, yet be too ill to go out in a wheelchair, watch TV or even sit up in bed for more than a few minutes.
They may spend most of their energy on something as basic as eating. They may look remarkably well for half an hour or an hour, but then spend the rest of the day in pain in a darkened room.
Flare up of symptoms after activity or stimuli is a key feature of the illness. The activity may be tiny by healthy standards and stimuli things you probably don’t even notice (such as light, movement, or background noise).
Here are a few ways to help: shut doors (to reduce noise), use headphones if watching TV nearby, be aware that talking uses energy – ask your friend/relative how long the conversation needs to be and try to stick to that. If they seem particularly energetic, ironically this may be a sign that they are doing too much (and running on adrenaline!) – ask if they need a rest.
Stonebird:the lived experience of severe ME – a website with information and help for and about people with severe ME, such as Severe ME: notes for carers
Metabolic features of Gulf War illness, by Robert K Naviaux, Jane C Naviaux, Kefeng Li, Lin Wang, Jonathan M Monk, A Taylor Bright, Hayley J Koslik, Janis B Ritchie, Beatrice A Golomb inPLoS ONE 14(7): e0219531 [Published: July 26, 2019] https://doi.org/10.1371/journal.pone.0219531
Research abstract:
Background
More than 230,000 veterans—about 1/3 of US personnel deployed in the 1990–1991 Persian Gulf War—developed chronic, multi-symptom health problems now called “Gulf War illness” (GWI), for which mechanisms and objective diagnostic signatures continue to be sought.
Methods
Targeted, broad-spectrum serum metabolomics was used to gain insights into the biology of GWI. 40 male participants, included 20 veterans who met both Kansas and CDC diagnostic criteria for GWI and 20 nonveteran controls without similar symptoms that were 1:1 matched to GWI cases by age, sex, and ethnicity. Serum samples were collected and archived at -80° C prior to testing. 358 metabolites from 46 biochemical pathways were measured by hydrophilic interaction liquid chromatography and tandem mass spectrometry.
Metabolic similarities & differences between Gulf War illness & CFS
Results
Veterans with GWI, compared to healthy controls, had abnormalities in 8 of 46 biochemical pathways interrogated. Lipid abnormalities accounted for 78% of the metabolic impact. Fifteen ceramides and sphingomyelins, and four phosphatidylcholine lipids were increased.
Five of the 8 pathways were shared with the previously reported metabolic phenotype of males with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). However, 4 of the 5 shared pathways were regulated in opposite directions; key pathways that were up-regulated in GWI were down-regulated in ME/CFS. The single pathway regulated in the same direction was purines, which were decreased.
Conclusions
Our data show that despite heterogeneous exposure histories, a metabolic phenotype of GWI was clearly distinguished from controls. Metabolomic differences between GWI and ME/CFS show that common clinical symptoms like fatigue can have different chemical mechanisms and different diagnostic implications. Larger studies will be needed to validate these findings.
In a recent paper psychologist Prof Michael Sharpe and sociologist Monica Greco discuss CFS as an ‘illness without disease’ in comparison to cancer, a known disease, and argued that, while illness-focused treatments like CBT and GET can ameliorate the symptom of fatigue, there is also a need to address the paradoxical predicament of illness-without-disease that patients find themselves in.
More science and less philosophy needed, by Susanna Agardy, Retired due to ME/CFS
At the heart of Sharpe and Greco’s article lies the complaint that while cancer patients accept CBT/GET treatments for their fatigue, ME/CFS patients reject these treatments. Of course they do! ME/CFS patients have a different disease, the main feature of which makes them unable to increase exertion.
The article contains several omissions and misinterpretations…
The argument provides a rationale for a science-denying approach to ME/CFS and endangers patient welfare. It is a departure from the previous model of more directly trying to correct patients’ ‘dysfunctional thinking’ and consequent ‘deconditioning’. This version of the Emperor’s New Clothes is also unacceptable…
Science, physiology and clarification of misleading terms, by Adi C Wood, Scientist ME
The view held by these authors that chronic fatigue syndrome is an illness without disease is at odds with the findings of the National Academy of Science, physiological and bio-medical researchers worldwide…
Sharp & Greco want us to abandon science, by Michael N Dyson, Computer Technician
Sharp & Greco state: “This new approach assumes that the reality of illness has a complex and indeterminate character”.
If by this they mean that the cause of any given illness cannot in principle be determined – as I suspect they are – then it is clear that they are abandoning the scientific enterprise. We ask Sharp and Greco: do they say illness is an effect? If they do then ipso facto they concede it has a cause or causes, and it is the task of science, in the broadest sense, to elucidate those causes…
Children and adolescents with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) are less active than the general child population, but not all are inactive. 9.4% of participants met physical activity recommendations.
Compared with being ‘inactive’, ‘active’ children reported greater physical function but increased anxiety, while ‘lightly’ active children reported greater physical function and reduced fatigue.
Paediatricians need to recognise that physical activity varies between patients with CFS/ME when they recommend treatment.
Contrary to what is claimed by Solomon-Moore et al., [1] the study by Van der Werf et al., (reference 17) [2] found little evidence of a boom and bust activity pattern in adult patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The Dutch researchers measured physical activity using actimeters worn for 12 consecutive days. There was no significant difference in day-to-day fluctuations in physical activity between ME/CFS patients and controls. The peak amplitude and peak duration of physical activity were larger in controls than in ME/CFS patients while the latter had longer rest duration after an activity peak. Another actimeter study [3] found no supporting evidence of a more fluctuating activity pattern in patients with ME/CFS compared to controls, during the day, nor during consecutive days.
Now, Solomon-Moore et al. report that in children and adolescents with ME/CFS, no fluctuating active or boom-bust physical activity pattern could be identified.
It would be helpful if the authors could clarify how the actimeter data impacted the treatments in the MAGENTA trial. According to the trial protocol [4], one of the interventions aimed to “convert a boom–bust pattern of activity (lots 1 day and little the next) to a baseline with the same daily amount”. Was this aspect removed from the intervention now that participants showed little indication of a boom–bust activity pattern? Or were young ME/CFS patients instructed to correct illness behavior they did not display when tested objectively?
Solomon-Moore et al., [1] also report that 9.4% of participants achieved government recommended levels of physical activity for children and adolescents, namely a minimum of 60 minutes of moderate to vigorous physical activity per day. This is of interest given that approximately half of healthy children and adolescents do not reach this target. [1] These results indicate that activity patterns are unlikely to be a key factor in perpetuating ME/CFS symptoms, at least for this subgroup. Nonetheless, one of the interventions in the MAGENTA trial aims for a gradual increase in physical activity by prescribing exercise targets. Were ME/CFS patients who already met government health recommendations for physical activity also instructed to increase their amount of exercise by 10-20% a week or were they exempted?
I look forward to reading the authors’ response to these questions.
References
[1] Solomon-Moore E, Jago R, Beasant L, Brigden A, Crawley E. Physical activity patterns among children and adolescents with mild-to-moderate chronic fatigue syndrome/myalgic encephalomyelitis. BMJ Paediatr Open. 2019 May 2;3(1):e000425. 2019.
[2] van der Werf SP, Prins JB, Vercoulen JH, et al. Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. J Psychosom Res 2000;49:373–9.
[3] Meeus M, van Eupen I, van Baarle E, De Boeck V, Luyckx A, Kos D, et al. Symptom fluctuations and daily physical activity in patients with chronic fatigue syndrome: a case-control study. Arch Phys Med Rehabil. 2011 Nov;92(11):1820-6.
[4] Brigden A, Beasant L, Hollingworth W, et al. Managed activity graded exercise iN teenagers and pre-Adolescents (magenta) feasibility randomised controlled trial: study protocol. BMJ Open 2016;6:e011255.
Background
Acceptance is a coping strategy associated with chronic pain management, but its effectiveness is unclear for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME).
Objective
The aim of the study was to investigate the relationship between acceptance, fatigue severity, pain and self-reported physical activity in individuals with CFS/ME.
Result
CFS/ME and control groups were compared using Independent t-tests and Spearman’s Rho correlations. The CFS/ME group reported significantly greater fatigue severity and psychological inflexibility, and lower pain willingness and time spent sitting than controls. However, no between-group differences for activity engagement or physical activity. The CFS/ME group showed a negative relationship between pain willingness and psychological inflexibility, and a positive relationship between walking time and the time since symptom onset, and time since diagnosis.
Conclusion
Despite reporting greater fatigue and less acceptance of their illness, CFS/ME patients had comparable levels of physical activity to controls, possibly due to pacing their activity to avoid symptom exacerbation. CFS/ME patients with an older diagnosis walked further than the newly diagnosed, suggesting the development of better coping skills and management strategies over time.
When does an illness become a disease? When the underlying biological abnormalities that cause the symptoms and signs of the illness are clarified.
The illness now called myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS) was first described in the mid-1980s. At that time, nothing was known about its underlying biology. Indeed, because many
standard laboratory test results were normal, some clinicians explained to patients that ‘there is nothing wrong.’ There was, of course, an alternative explanation: the standard laboratory tests might not have been the right tests to identify the underlying abnormalities.
Over the past 35 years, thousands of studies from laboratories in many countries have documented underlying biological abnormalities involving many organ systems in patients with ME/CFS, compared with healthy controls: in short, there is something wrong. Moreover, most of the abnormalities are not detected by standard laboratory tests. In 2015, the Institute of Medicine of the National Academy of Sciences concluded that ME/CFS ‘is a serious, chronic, complex systemic disease that often can profoundly affect the lives of patients,’ affects up to an estimated 2.5 million people in the United States, and generates direct and indirect expenses of approximately $17 billion to $24 billion annually…
A 2-day conference at the NIH in April 2019 highlighted recent progress. New research was presented that both reinforced and expanded on previous reports. Equally important, several plausible models were proposed that could explain many of the abnormalities that have been described.
The Central and Autonomic Nervous System
Metabolic Changes
Immunologic Changes
Provocation Studies
Potential Unifying Models
Conclusions
A great deal more is known today than 35 years ago about the underlying biology of ME/CFS. It is clear that many biological measurements clearly distinguish patients with ME/CFS from healthy control individuals.
At the same time, some areas of ME/CFS research remain a challenge, and research has not yet given practicing physicians 2 important tools. First, there are as yet no US Food and Drug Administration-approved treatments. Second, although various biological measurements distinguish patients with ME/CFS from healthy controls, none yet have demonstrated the high sensitivity and specificity required for a good diagnostic test. However, 1 small study (20 cases and 20 controls) described at the NIH conference (and recently published9) reported perfect sensitivity; the specificity of the test in individuals with other fatiguing illnesses remains to be shown.
With growing international interest in the illness, and increased research support from the NIH, the day is coming when physicians will be able to explain to patients not only that there is something wrong but also that advances in understanding the pathophysiology have led to effective therapy.
The underlying molecular basis of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is not well understood. Characterized by chronic, unexplained fatigue, a disabling payback following exertion (“post-exertional malaise”) and variably presenting, multi-system symptoms, ME/CFS is a complex disease which demands concerted biomedical investigation from disparate fields of expertise. ME/CFS research and patient treatment have been challenged by the lack of diagnostic biomarkers and finding these is a prominent direction of current work. Despite these challenges, modern research demonstrates a tangible biomedical basis for the disorder across many body systems.
This evidence is largely comprised of disturbances to immunological and inflammatory pathways, autonomic and neurologic systems, abnormalities in muscle and mitochondrial function, shifts in metabolism, and gut physiology or gut microbiome disturbances. It is possible that these threads are together entangled as parts of an underlying molecular pathology reflecting a far-reaching homeostatic shift affecting each of these systems.
Due to the variability of non-overlapping symptom presentation or precipitating events such as infection or other bodily stresses, the initiation of body-wide pathological cascades with similar outcomes stemming from different causes may be implicated in the condition.
Patient stratification to account for this heterogeneity is therefore one important consideration during exploration of potential diagnostic developments.
Conclusion
ME/CFS is a heterogeneous condition that may encompass scenarios where uncertain, and possibly varying, underlying insults trigger body-wide molecular and cellular perturbations perpetuated by alternative, stable homeostatic states. Diagnostic advancement and the development of tools which objectively and accurately phenotype patients is therefore paramount for the development of mechanistic insight and effective therapeutics.
It is likely that the inflammation and immune dysfunction classically studied in ME/CFS are entangled with dysfunctional energetics, gut health, or autonomic and adrenal dysregulation. The evidence for metabolic and mitochondrial dysfunction indicates inefficient respiration, impaired provision of TCA cycle substrate, and metabolic shifts towards the utilization of alternative metabolites.
Immune effector cell dysfunction, chronic inflammation, defective signalling and elevated oxidative stress may interact with not only the dysfunctional energetics but also with abnormal gut physiology and microbiota composition. These effects on the gut may also tie back to mitochondrial function and vice versa.
The reciprocal interactions between these affected systems and the varied clinical presentation of relevant symptoms between individuals make it difficult to postulate cause-effect relationships with confidence. Furthermore, while disturbances to this range of interconnected systems across the body have been demonstrated, in some cases concurrently, this body of research has historically relied upon correlations, which creates the urgent need for research utilising direct experimental investigation of cause-effect relationships.
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a severe fatigue illness that occurs most commonly following a viral infection, but other physiological triggers are also implicated. It has a profound long-term impact on the life of the affected person.
ME/CFS is diagnosed primarily by the exclusion of other fatigue illnesses, but the availability of multiple case definitions for ME/CFS has complicated diagnosis for clinicians. There has been ongoing controversy over the nature of ME/CFS, but a recent detailed report from the Institute of Medicine (Academy of Sciences, USA) concluded that ME/CFS is a medical, not psychiatric illness.
Importantly, aspects of the biological basis of the ongoing disease have been revealed over the last 2-3 years that promise new leads towards an effective clinical diagnostic test that may have a general application.
Our detailed molecular studies with a preclinical study of ME/CFS patients, along with the complementary research of others, have reported an elevation of inflammatory and immune processes, ongoing neuro-inflammation, and decreases in general metabolism and mitochondrial function for energy production in ME/CFS, which contribute to the ongoing remitting/relapsing etiology of the illness.
These biological changes have generated potential molecular biomarkers for use in diagnostic ME/CFS testing.
Red blood cell biomechanics in Chronic Fatigue Syndrome, by Amit K Saha, Brendan R Schmidt, Arun Kumar, Amir Saadat, Vineeth C Suja, Vy Nguyen, Justin K Do, Wendy Ho, Mohsen Nemat-Gorgani, Eric SG Shaqfeh, Anand K Ramasubramanian, Ronald W Davis in Summer Biomechanics, Bioengineering and Biotransport Conference papers, June 25 -28, Seven Springs, PA, USA, SB3C2019-221 [Published July 1, 2019]
Introduction:
Chronic Fatigue Syndrome (CFS) is a multi-systemic illness of unknown etiology, affecting millions worldwide, with the capacity to persist for several years. It is characterized by persistent or relapsing unexplained fatigue of at least 6 months’ duration that is not alleviated by rest.
CFS can be debilitating, and its clinical definition includes a broad cluster of symptoms and signs that give it its distinct character, and its diagnosis is based on these characteristic symptom patterns including cognitive impairment, post-exertional malaise, unrefreshing sleep, headache, hypersensitivity to noise, light or certain food items.
Although an abnormal profile of circulating proinflammatory cytokines, and the presence of chronic oxidative and nitrosative stresses have been identified and correlated with severity in CFS, there are no reliable molecular or cellular biomarkers of the disease.
In the present work, we focus on the pathophysiological changes in red blood cells (RBCs) since CFS is a systemic disease rather than of a particular organ or tissue, and RBCs, comprising ~45% of blood volume, are responsible for microvascular perfusion and tissue oxygenation.
RBCs deform and travel through microvessels smaller than their diameter to facilitate the optimal transfer of gases between blood and tissue. The usual shape of a RBC is a biconcave discoid, which is changed to an ellipsoid due to shear flow. This shape gives them a specific surface area-to-volume ratio which facilitates large reversible deformations and elastic transformation [3].
We used a high throughput microfluidic platform to assess the changes in RBC deformability between CFS patients and matching healthy controls. We also performed computational studies to have a better understanding of the cell deformation. In order to explore the mechanisms for observed changes in cell deformability, we explored the membrane fluidity, reactive oxygen species, and surface charge, of RBCs.
Erythrocyte deformability refers to the ability of erythrocytes (red blood cells, RBC) to change shape under a given level of applied stress, without hemolysing (rupturing). Wikipedia
Discussion:
Together, the various estimates show that the RBCs in CFS patients are significantly less deformable than those of healthy controls. We speculate that the larger and less deformable RBCs in CFS patients may partly explain the musculoskeletal pain and fatigue in the pathophysiology of CFS due to impaired microvascular perfusion and tissue oxygenation.
It has been shown that the quality of life of ME/CFS patients was significantly worse as compared to patients with diseases like sclerosis, cancer (multiple types, such as colon, breast and prostate), type II diabetes, rheumatoid arthritis and chronic renal failure, among others.
This work introduces a new paradigm in our understanding of the mechanistic aspects of ME/CFS. It also opens the possibility of a diagnostic platform for ME/CFS using RBC deformability as the biomarker.
Background:
Dysautonomia describes a group of conditions associated with a malfunction of the autonomic nervous system. Symptoms of dysautonomia and inflammation have been described in Fibromyalgia (FM) and Myalgic encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) [1-4]. Symptoms include increased disabling fatigue, pain, dizziness and digestive problems.
Objectives:
This ongoing study investigates, for the first time, how a sympathetically mediated challenge and induced systemic inflammatory state impact on mood, pain, fatigue, and autonomic function.
Methods:
In a randomized, double-blind, placebo-controlled study, 25 participants with FM and/or ME/CFS underwent an autonomic- and inflammatory challenge during three visits. Outcome measures included a range of questionnaires including the Profile of Mood States (POMS), Pain visual analogue scales (VAS), measures of heart rate (HR), Pressure Pain Threshold (PPT), alongside subjective pain and fatigue measures. Autonomic function was
assessed using a passive non-invasive tilt-test (upright tilt of 60°) and active-stand (AS) with beat-to-beat HR and blood pressure monitoring. Remaining visits involved an inflammatory challenge using intramuscular typhoid- and saline (placebo) injection.
Results:
Tilt-table test was positive in 20% participants and AS in 92% participants indicated by HR rise >30 bpm or a sustained HR of 120 bpm. Overall fatigue correlated with peak HR during tilt (r=.465, p=.025, n=23). There was a positive correlation between the average HR during AS under typhoid after controlling for placebo and average HR during tilt
(r=.517, p=.049, n=15). Scores on the Wide Spread Pain Index (WPI) at screening correlated with the change in POMS pre-and post-typhoid after controlling for placebo (r=.479, p=.045, n=18).
Scores on the Fibromyalgia Severity Scale correlated with the change in physical fatigue pre-and post-typhoid after controlling for placebo (r=.633, p=.015, n=14). Pain at screening correlated with change in physical fatigue pre-and post-tilt (r=.405, p=.044, n=25). Scores on the pain severity scale at baseline correlated with change in pain measured on a visual analogue scale pre and post tilt (r=.517, p=.049, n=15). Mean change in heart rate pre-post active stand correlated with a change in pain VAS pre-and post-typhoid after controlling for placebo (r=.582, p=.047, n=12).
Conclusion:
Preliminary findings suggest that dysautonomia and induced inflammation significantly impacts on pain, fatigue, and autonomic function in FM and ME/CFS. On-going data collection of 100 participants (25 controls) will allow extended analyses to test how autonomic function and inflammation affect symptom domains that impact on quality of life.
