With the back to the future

Health care is confronted regularly with patients we understand little of and where our advice is inadequate. Chronic fatigue syndrome is one such condition. It is now more important to think than to summarize the discouraging research findings that have emerged so far.

You can read the rest of this comment here:  http://tidsskriftet.no/2006/10/kommentar/med-ryggen-mot-fremtiden

 

Source: Bruusgaard D. With the back to the future. Tidsskr Nor Laegeforen. 2006 Oct 19;126(20):2686. [Article in Norwegian] http://tidsskriftet.no/2006/10/kommentar/med-ryggen-mot-fremtiden (Full article)

 

Translation and validation of the Dutch language version of the CDC Symptom Inventory for assessment of Chronic Fatigue Syndrome (CFS

Abstract:

BACKGROUND: In a study by Wagner et al., the CDC Symptom Inventory was validated in a population selected from the inhabitants of a city in the USA, and proofed reliable for the assessment of the accompanying symptoms of CFS. The Dutch translation of the CDC Symptom Inventory is compared to the original and the psychometric properties are presented for patients in a tertiary care setting.

METHODS: One hundred thirty-nine consecutive patients who visited the CFS Center Amsterdam for the first time were asked to complete the CDC Symptom Inventory in the Dutch Language Version (DLV) together with the usual set of questionnaires. Sixty-one patients had Chronic Fatigue (CF) and 78 patients fulfilled the criteria for CFS. Forty-three healthy accompanying persons completed the CDC Symptom Inventory DLV, the Physical Functioning scale of the Medical Outcome Survey Short Form-36 DLV, and the Fatigue and Concentration scales of the Checklist Individual Strength (CIS-20).

RESULTS: The healthy controls group contained fewer women and was overall older than the patient groups. The influence of gender on the CDC Symptom Inventory DLV was significant but the effect of age was not. The Dutch version had a good internal consistency and convergent validity. The results were comparable to the original English version, but the sex-related difference needs further study.

CONCLUSION: The Dutch version of the CDC Symptom Inventory is a reliable tool for the assessment of the secondary criteria for CFS. The results show that it is comparable to the outcome of studies in English speaking countries.

 

Source: Vermeulen RC. Translation and validation of the Dutch language version of the CDC Symptom Inventory for assessment of Chronic Fatigue Syndrome (CFS). Popul Health Metr. 2006 Oct 18;4:12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1621077/ (Full article)

 

Favourable results of a rehabilitation programme with cognitive behavioural therapy and graded physical activity in patients with the chronic-fatigue syndrome

Abstract:

OBJECTIVE: To determine whether a specific course of interdisciplinary rehabilitation might lead to clinically significant changes in fatigue, experienced disability and physical function in patients with the chronic-fatigue syndrome (CFS).

DESIGN: Prospective and uncontrolled.

METHOD: ‘Het Roessingh’, a rehabilitation centre in Enschede, the Netherlands, has developed an interdisciplinary clinical rehabilitation programme for patients with CFS in cooperation with the ‘Nijmeegs Kenniscentrum Chronische Vermoeidheid’ [Chronic-Fatigue Knowledge Centre] in Nijmegen, the Netherlands. In this programme, physical, mental and social activities are gradually increased on the basis of cognitive behavioural principles and graded activity. Of the 127 successive persons who enrolled for the therapy during the period from August 2000 to December 2004, 99 fulfilled the inclusion criteria; they had a median duration of symptoms of 6 years. The results of treatment were evaluated by a measurement with the ‘Checklist individuele spankracht’ [Checklist individual muscle tone] before and after treatment and the scores on the ‘Patiëntspecifieke beperkingen’ [Patient-specific disability] and the Short form-36. The measured data were complete in 74 patients.

RESULTS: Before rehabilitation, the levels of fatigue, disability and distress were high. After treatment, the studied population showed significant improvement in fatigue, experienced disability and physical function. The magnitude of the improvement was generally ‘average’. At the end of treatment, 70% of the patients were clinically less fatigued, 68% experienced less disability and 55% functioned better physically. In 34% the level of fatigue was normalised after treatment, but 9.5% of the patients was more fatigue.

CONCLUSION: The rehabilitation programme offered for CFS led to significant improvements in function and fatigue.

Comment in: [Treatment of patients with the chronic-fatigue syndrome]. [Ned Tijdschr Geneeskd. 2006]

 

Source: Torenbeek M, Mes CA, van Liere MJ, Schreurs KM, ter Meer R, Kortleven GC, Warmerdam CG. Favourable results of a rehabilitation programme with cognitive behavioural therapy and graded physical activity in patients with the chronic-fatigue syndrome. Ned Tijdschr Geneeskd. 2006 Sep 23;150(38):2088-94. [Article in Dutch] https://www.ncbi.nlm.nih.gov/pubmed/17036861

 

 

Treatment of patients with the chronic-fatigue syndrome

Abstract:

In the last few years, the chronic-fatigue syndrome has been recognised as an important health problem. In a recent report, the Health Council of the Netherlands suggested that the capacity for treatment be increased. Cognitive behavioural therapy and graded exercise training are treatment options of first choice.

A recently published, uncontrolled evaluation of a Dutch clinical rehabilitation programme based partly on these methods proved to be successful. Unfortunately, due to the uncontrolled character of the study, it remains unclear which elements in the treatment were responsible for the success. Which patients should be included in a costly clinical rehabilitation programme also remains unclear. More in general, there is room for empirical studies of treatment allocation, not in the least because of the frequently occurring comorbidity. Good progress has been made in the treatment of the chronic-fatigue syndrome, but we are still far removed from evidence-based, stepped care, treatment programmes.

Comment on: [Favourable results of a rehabilitation programme with cognitive behavioural therapy and graded physical activity in patients with the chronic-fatigue syndrome]. [Ned Tijdschr Geneeskd. 2006]

 

Source: Jonker K, van Hemert AM. Treatment of patients with the chronic-fatigue syndrome. Ned Tijdschr Geneeskd. 2006 Sep 23;150(38):2067-8. [Article in Dutch] https://www.ncbi.nlm.nih.gov/pubmed/17036854

 

Chronic fatigue in complementary rehabilitative medicine–predictors of the outcomes

Abstract:

Chronic exhaustion and fatigue are increasingly important in rehabilitation medicine. Objectives of this study were (a) to describe the effects of in-patient rehabilitation on patients with chronic fatigue syndromes, (b) to identify predictors for treatment outcome, and (c) to analyze the impact of comprehensive diagnosing on these issues.

A total of 171 patients with chronic exhaustion or fatigue (90 % female, mean age 55 +/- 10 yrs) from a rehabilitation hospital with a complementary medicine-based treatment concept were included in a prospective observational study. Within the longitudinal study patients were examined three times (on admission to hospital, at discharge as well as six months later). Participation rate of the postal inquiry was 69 %. Besides items constructed ad hoc, Patient questionnaires included the Symptom Checklist and assessment instruments for depression, quality of life, sense of coherence as well as for changes in experience and behaviour. Treatment outcome was defined as sum score of binary-coded response criteria.

The pattern of complaints differed clearly between diagnostic subgroups (neurasthenia, affective disorders, adjustment disorders) before treatment. At discharge from hospital patients showed clinically relevant improvements lasting for six months after rehabilitation. Multiple regression analyses revealed a statistically significant relationship (R (mult) = 0.59) between predictors and outcome at discharge from hospital.

A better result was associated with higher trust in treatment success, active information seeking on complementary medicine, healthier feeding habits, better somatic health and a decreased mental status, with regard to the status before treatment. The prediction of outcome after six months was comparably poorer (R (mult) = 0.42).

Treatment success was higher in the absence of a diagnosis of neurasthenia, in patients accepting the group-oriented treatment concept and in patients not believing that their disease was due to their own way of living. Trust in the success of the treatment was a highly ranked predictor for longer lasting outcome, too. The results underline the importance of motivation aspects for treatment outcome indicating that individual expectations and attitudes should be considered in a more distinct way when allocating patients to rehabilitative programmes.

 

Source: Weidenhammer W, Wessel A, Hutter A, Melchart D, Schröder A. Chronic fatigue in complementary rehabilitative medicine–predictors of the outcomes. Rehabilitation (Stuttg). 2006 Oct;45(5):299-308. [Article in German] https://www.ncbi.nlm.nih.gov/pubmed/17024614

 

 

Interventions for the treatment, management and rehabilitation of patients with chronic fatigue syndrome/myalgic encephalomyelitis: an updated systematic review

Abstract:

OBJECTIVES: To determine whether any particular intervention or combination of interventions is effective in the treatment, management and rehabilitation of adults and children with a diagnosis of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME).

DESIGN: Substantive update of a systematic review published in 2002. Randomized (RCTs) and non-randomized controlled trials of any intervention or combination of interventions were eligible for inclusion. Study participants could be adults or children with a diagnosis of CFS/ME based on any criteria. We searched eleven electronic databases, reference lists of articles and reviews, and textbooks on CFS/ME. Additional references were sought by contact with experts.

RESULTS: Seventy studies met the inclusion criteria. Studies on behavioural, immunological, pharmacological and complementary therapies, nutritional supplements and miscellaneous other interventions were identified. Graded exercise therapy and cognitive behaviour therapy appeared to reduce symptoms and improve function based on evidence from RCTs. For most other interventions, evidence of effectiveness was inconclusive and some interventions were associated with significant adverse effects.

CONCLUSIONS: Over the last five years, there has been a marked increase in the size and quality of the evidence base on interventions for CFS/ME. Some behavioural interventions have shown promising results in reducing the symptoms of CFS/ME and improving physical functioning. There is a need for research to define the characteristics of patients who would benefit from specific interventions and to develop clinically relevant objective outcome measures.

Comment in: Chronic fatigue syndrome. [J R Soc Med. 2007]

 

Source: Chambers D, Bagnall AM, Hempel S, Forbes C. Interventions for the treatment, management and rehabilitation of patients with chronic fatigue syndrome/myalgic encephalomyelitis: an updated systematic review. J R Soc Med. 2006 Oct;99(10):506-20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592057/ (Full article)

 

Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme

Abstract:

OBJECTIVES: To test the hypothesis that group cognitive behavioural therapy (CBT) will produce an effective and cost-effective management strategy for patients in primary care with chronic fatigue syndrome/myalgic encephalopathy (CFS/ME).

DESIGN: A double-blind, randomised controlled trial was adopted with three arms. Outcomes were assessed at baseline and 6 and 12 months after first assessment and results were analysed on an intention-to-treat basis.

SETTING: A health psychology department for the management of chronic illness in a general hospital in Bristol, UK.

PARTICIPANTS: Adults with a diagnosis of CFS/ME referred by their GP.

INTERVENTIONS: The three interventions were group CBT incorporating graded activity scheduling, education and support group (EAS) and standard medical care (SMC).

OUTCOME MEASURES: The primary outcome measure was the Short Form with 36 Items (SF-36) physical and mental health summary scales. Other outcome measures included the Chalder fatigue scale, Hospital Anxiety and Depression Scale, General Health Questionnaire, physical function (shuttles walked, walking speed and perceived fatigue), health utilities index and cognitive function (mood, recall and reaction times).

RESULTS: A total of 153 patients were recruited to the trial and 52 were randomised to receive CBT, 50 to EAS and 51 to SMC. Twelve patients failed to attend for the 12-month follow-up and 19 patients attended one follow-up, but not both. The sample was found to be representative of the patient group and the characteristics of the three groups were similar at baseline. Three outcome measures, SF-36 mental health score, Chalder fatigue scale and walking speed, showed statistically significant differences between the groups. Patients in the CBT group had significantly higher mental health scores [difference +4.35, 95% confidence interval (CI) +0.72 to +7.97, p = 0.019], less fatigue (difference -2.61, 95% CI -4.92 to -0.30, p = 0.027) and were able to walk faster (difference +2.83 shuttles, 95% CI +1.12 to +5.53, p = 0.0013) than patients in the SMC group. CBT patients also walked faster and were less fatigued than those randomised to EAS (walking speed: difference +1.77, 95% CI +0.025 to +3.51, p = 0.047; fatigue: difference -3.16, 95% CI -5.59 to -0.74, p = 0.011).

Overall, no other statistically significant difference across the groups was found, although for many measures a trend towards an improved outcome with CBT was seen. Except for walking speed, which, on average, increased by +0.87 shuttles (95% CI +0.09 to +1.65, p = 0.029) between the 6- and 12-month follow-ups, the scores were similar at 6 and 12 months. At baseline, 30% of patients had an SF-36 physical score within the normal range and 52% had an SF-36 mental health score in the normal range. At 12 months, the physical score was in the normal range for 46% of the CBT group, 26% of the EAS group and 44% of SMC patients. For mental health score the percentages were CBT 74%, EAS 67% and SMC 70%. Of the CBT group, 32% showed at least a 15% increase in physical function and 64% achieved a similar improvement in their mental health. For the EAS and SMC groups, this improvement in physical and mental health was achieved for 40 and 60% (EAS) and 49 and 53% (SMC), respectively. The cost-effectiveness of the intervention proved very difficult to assess and did not yield reliable conclusions.

CONCLUSIONS: Group CBT did not achieve the expected change in the primary outcome measure as a significant number did not achieve scores within the normal range post-intervention. The treatment did not return a significant number of subjects to within the normal range on this domain; however, significant improvements were evident in some areas. Group CBT was effective in treating symptoms of fatigue, mood and physical fitness in CFS/ME. It was found to be as effective as trials using individual therapy in these domains. However, it did not bring about improvement in cognitive function or quality of life. There was also evidence of improvement in the EAS group, which indicates that there is limited value in the non-specific effects of therapy. Further research is needed to develop better outcome measures, assessments of the broader costs of the illness and a clearer picture of the characteristics best fitted to this type of intervention.

 

Source: O’Dowd H, Gladwell P, Rogers CA, Hollinghurst S, Gregory A. Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme. Health Technol Assess. 2006 Oct;10(37):iii-iv, ix-x, 1-121. https://www.ncbi.nlm.nih.gov/pubmed/17014748

 

Conceptual issues in undifferentiated somatoform disorder and chronic fatigue syndrome

Abstract:

PURPOSE OF REVIEW: To review the conceptual problems in distinguishing between undifferentiated somatoform disorder and chronic fatigue syndrome, for both may present with fatigue as the main symptom.

RECENT FINDINGS: The differences and/or similarities between undifferentiated somatoform disorder and chronic fatigue syndrome have not been studied, conceptually or empirically. The literature fails to present discriminant validity of chronic fatigue syndrome in relation to undifferentiated somatoform disorder. A critical feature is implied in the definition of undifferentiated somatoform disorder but absent from the definitions of chronic fatigue syndrome: some patients experience their fatigue as being exclusively physical and not as mental, which is prima facie peculiar, for fatigue is necessarily a mental experience. One is not able to experience fatigue without a mind (or a brain). This experience is characterized as a ‘mindless’ fatigue, underpinned by pathological reductionist thinking. By not recognizing this critical feature, diagnostic endeavours may perpetuate the problem as a function of the patient’s difficulty.

SUMMARY: Proponents of chronic fatigue syndrome should distinguish chronic fatigue syndrome from undifferentiated somatoform disorder, if chronic fatigue syndrome is a distinct entity at all. Further, the ‘mindless’ quality is a critical feature that needs consideration in refining the concept of undifferentiated somatoform disorder.

 

Source: van Staden WC. Conceptual issues in undifferentiated somatoform disorder and chronic fatigue syndrome. Curr Opin Psychiatry. 2006 Nov;19(6):613-8. https://www.ncbi.nlm.nih.gov/pubmed/17012941

 

Brief report: The accuracy of parents for the thoughts and feelings of their adolescent suffering from chronic fatigue: a preliminary study of empathy

Abstract:

OBJECTIVE: This study examined the actual and estimated empathic accuracy (EA) of the parents of adolescents with chronic fatigue syndrome(CFS).

METHODS: The actual EA of both parents (n = 24) was assessed in relation to the thoughts and feelings of their child (n = 14) about CFS and about other life events. Adolescents were also asked to estimate the parents’ EA.

RESULTS: For the actual EA, both parents were significantly less accurate regarding the adolescent’s thoughts and feelings about CFS than about other life events. Fathers were just as empathically accurate as mothers. For the estimated EA, however, results indicated that adolescents perceived their mother to be more empathically accurate than their father. Actual EA and estimated EA about CFS were negatively correlated for fathers, not for mothers.

CONCLUSIONS: Results are discussed in terms of the importance of assessing EA in relation to other dimensions of empathic understanding and distress in the observer.

 

Source: Vervoort T, Crombez G, Buysse A, Goubert L, Backer TD, Ickes W. Brief report: The accuracy of parents for the thoughts and feelings of their adolescent suffering from chronic fatigue: a preliminary study of empathy. J Pediatr Psychol. 2007 May;32(4):494-9. Epub 2006 Sep 29. http://jpepsy.oxfordjournals.org/content/32/4/494.long (Full article)

 

The influence of aerobic fitness and fibromyalgia on cardiorespiratory and perceptual responses to exercise in patients with chronic fatigue syndrome

Abstract:

OBJECTIVE: To investigate cardiorespiratory and perceptual responses to exercise in patients with chronic fatigue syndrome (CFS), accounting for comorbid fibromyalgia (FM) and controlling for aerobic fitness.

METHODS: Twenty-nine patients with CFS only, 23 patients with CFS plus FM, and 32 controls completed an incremental bicycle test to exhaustion. Cardiorespiratory and perceptual responses were measured. Results were determined for the entire sample and for 18 subjects from each group matched for peak oxygen consumption.

RESULTS: In the overall sample, there were no significant differences in cardiorespiratory parameters between the CFS only group and the controls. However, the CFS plus FM group exhibited lower ventilation, lower end-tidal CO2, and higher ventilatory equivalent of carbon dioxide compared with controls, and slower increases in heart rate compared with both patients with CFS only and controls. Peak oxygen consumption, ventilation, and workload were lower in the CFS plus FM group. Subjects in both the CFS only group and the CFS plus FM group rated exercise as more effortful than did controls. Patients with CFS plus FM rated exercise as significantly more painful than did patients with CFS only or controls. In the subgroups matched for aerobic fitness, there were no significant differences among the groups for any measured cardiorespiratory response, but perceptual differences in the CFS plus FM group remained.

CONCLUSION: With matching for aerobic fitness, cardiorespiratory responses to exercise in patients with CFS only and CFS plus FM are not different from those in sedentary healthy subjects. While CFS patients with comorbid FM perceive exercise as more effortful and painful than do controls, those with CFS alone do not. These results suggest that aerobic fitness and a concurrent diagnosis of FM are likely explanations for currently conflicting data and challenge ideas implicating metabolic disease in the pathogenesis of CFS.

 

Source: Cook DB, Nagelkirk PR, Poluri A, Mores J, Natelson BH. The influence of aerobic fitness and fibromyalgia on cardiorespiratory and perceptual responses to exercise in patients with chronic fatigue syndrome. Arthritis Rheum. 2006 Oct;54(10):3351-62. https://www.ncbi.nlm.nih.gov/pubmed/17009309