Tag: 1998

Chronic fatigue syndrome gets court’s nod of approval as legitimate disorder

Lawyer Karen Capen looks at the implications of a recent Alberta court case involving chronic fatigue syndrome. She thinks Canada’s physicians should pay close attention to this precedent-setting case.

 

Few medical diagnoses are more hotly debated than chronic fatigue syndrome (CFS). Now, an Alberta court has added to the controversy. In Baillie v. Crown Life, a judge ruled that a women with CFS qualifies for long-term disability benefits.1 Crown Life was ordered to pay benefits to plaintiff Sharon Baillie, a former senior computer systems analyst with the insurance company.

Part of the case dealt with the insurance policy and the time requirements for filing a claim. For physicians, however, the ruling’s importance centres on how difficult it is to diagnose the condition.

This legal recognition of CFS, which the Alberta court handed down in March, should alert doctors of the need to understand the range of symptoms that fall within the condition’s diagnostic profile. The symptoms assigned to CFS generally include at least 6 months of extreme fatigue that reduces a person’s activity by 50% or more. This is accompanied by at least 4 other problems such as aching muscles and joints, headache, sleep disturbances, memory and concentration problems, and sore throat. Although the cause has yet to be determined conclusively, it is thought to involve a virus and/or a weakened immune system.

In recognizing CFS, the Alberta court recognized that a number of medical bodies have done the same thing, including the World Health Organization and the Centers for Disease Control and Prevention in Atlanta.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229657/pdf/cmaj_159_5_533.pdf

Comment in:

What causes chronic fatigue? [CMAJ. 1999]

What causes chronic fatigue? [CMAJ. 1999]

 

Source: Capen K. Chronic fatigue syndrome get court’s nod of approval as legitimate disorder. CMAJ. 1998 Sep 8;159(5):533-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229657/pdf/cmaj_159_5_533.pdf

 

Chronic fatigue syndrome or just plain tired?

The complaint of unremitting fatigue has been around for centuries. Over the years, people with fatigue have been said to suffer from myalgic encephalomyelitis, Icelandic disease, neurasthenia, nervous exhaustion, febricula and Yuppie flu.1,2 Interest in the illness known today as chronic fatigue syndrome (CFS) grew when a cluster of patients in Nevada were found to have a chronic mononucleosis-like syndrome associated with persistently high titres of antibodies to Epstein–Barr virus (EBV) in the late 1980s.2 Today, the role of EBV and other potential viral and immunologic triggers of CFS remains unclear, and even in the wake of a recent flurry of research, the pathophysiology of CFS is poorly understood and no single diagnostic test can confirm its presence.

While CFS support groups lobby for disability coverage for individuals with CFS and insurance companies fight the claims, neither the public nor the medical community unanimously agrees on the existence of CFS as a real clinical entity. Some believe it is merely a presentation of depression or other psychosomatic illness; others argue that individuals claiming to have CFS have seized upon a convenient diagnosis to explain the effects of overwork or “normal” fatigue.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229654/pdf/cmaj_159_5_519.pdf

Comment in:

What causes chronic fatigue? [CMAJ. 1999]

What causes chronic fatigue? [CMAJ. 1999]

 

Source: Caplan C. Chronic fatigue syndrome or just plain tired? CMAJ. 1998 Sep 8;159(5):519-20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229654/

 

Structure and Determinants of Illness Representations in Chronic Disease: A Comparison of Addison’s Disease and Chronic Fatigue Syndrome

Abstract:

Although the clinical relevance of illness representations has been demonstrated in several studies, research on the structure and determinants of illness representations is rare. This article examines the illness representations of chronically ill patients, using a structured interview technique and taking chronic fatigue syndrome (CFS) and Addison’s disease (AD) as examples.

Considerable differences were found between the group of CFS patients (n = 98) and the group of AD patients (n = 63) with regard to their ideas about the identity, time line, control/cure , and consequences of their illness. Despite these differences, the pattern of correlations among these four dimensions of illness representation was found to be similar for the two groups. Moreover, the strength of the correlations points to the coherent nature of illness representations. The relations between the illness representations, personal variables, and disease- related variables were also explored.

Regression analyses showed the dimensions of illness representation to be explained rather well by personal and disease-related variables. Disease-related variables were the most important predictors for the dimensions of identity and consequences; personal variables showed strong associations with time line and control/cure.

 

Source: Heijmans M, De Ridder D. Structure and Determinants of Illness Representations in Chronic Disease: A Comparison of Addison’s Disease and Chronic Fatigue Syndrome. J Health Psychol. 1998 Oct;3(4):523-37. Doi: 10.1177/135910539800300406. http://www.ncbi.nlm.nih.gov/pubmed/22021411

 

Risk factors for ischemic heart disease in patients with chronic fatigue syndrome

Abstract:

Risk factors of coronary artery disease (CAD) between a group of patients suffering of chronic fatigue syndrome (CFS) and a control group of healthy persons (whose exercise activity was not health-limited) were compared.

Thirty three patients (27 women, 6 men, average age 39.9 +/- 11.7 years) and the same number of controls matched in age (39.8 +/- 10.3 years), gender and body weight. The Minnesota Questionnaire (by Taylor) and the Compendium of Physical Activities (by Ainsworth) were used to estimate total energetic expenditure in exercise activity as well as in job.

The risk factors of CAD in the patients with CFS were not higher than in the control group. Aerobic physical fitness, basic anthropometric data, blood pressure, spectrum of blood lipoproteins, blood uric acid and smoking habits were not different between the compared groups.

Patients suffering from CFS had lower total energetic expenditure in exercise activity. Nevertheless, this significant difference in sports activity was not large enough to cause any difference in risk factors of CAD between the CFS patients and the control group.

 

Source: Vilikus Z, Marecková H, Janatková I, Krystůfková O, Barácková M, Boudová L, Brandejský P, Fucíková T. Risk factors for ischemic heart disease in patients with chronic fatigue syndrome. Sb Lek. 1998;99(1):53-61. [Article in Czech] http://www.ncbi.nlm.nih.gov/pubmed/9748798

 

Attention and verbal learning in patients with chronic fatigue syndrome

Abstract:

Former neuropsychological studies with Chronic Fatigue Syndrome (CFS) patients evaluated a broad range of cognitive functions. Several, but not all, reported subtle attentional and memory impairments suggesting possible mild cerebral involvement.

In this study, a battery of attentional tests and a verbal memory task were administered to 20 CFS patients and 22 healthy controls (HC) in order to clarify the specific nature of attention and memory impairment in these patients. The results provide evidence for attentional dysfunction in patients with CFS as compared to HC.

CFS patients performed more poorly on a span test measuring attentional capacity and working memory. Speeded attentional tasks with a more complex element of memory scanning and divided attention seem to be a sensitive measure of reduced attentional capacity in these patients.

Focused attention, defined as the ability to attend to a single stimulus while ignoring irrelevant stimuli, appears not to be impaired. CFS patients were poorer on recall of verbal information across learning trials, and poor performance on delayed recall may be due to poor initial learning and not only to a retrieval failure.

 

Source: Michiels V, Cluydts R, Fischler B. Attention and verbal learning in patients with chronic fatigue syndrome. J Int Neuropsychol Soc. 1998 Sep;4(5):456-66. http://www.ncbi.nlm.nih.gov/pubmed/9745235

 

The case history of an elite ultra-endurance cyclist who developed chronic fatigue syndrome

Abstract:

An elite ultra-endurance athlete, who had previously undergone physiological and performance testing, developed chronic fatigue syndrome (CFS).

An incremental cycling exercise test conducted while he was suffering from CFS indicated decreases in maximum workload achieved (Wmax; -11.3%), the maximum oxygen uptake (VO2max; -12.5%), and the anaerobic threshold (AT; -14.3%) compared to pre-CFS data.

A third test conducted after the athlete had shown indications of significant improvement in his clinical condition revealed further decreases in Wmax (-7.9%), VO2max (-10.2%) and AT (-8.3%).

These data, along with submaximal exercise data and muscle biopsy electron microscopic analyses, suggest that the performance decrements were the result of detraining, rather than an impairment of aerobic metabolism due to CFS per se. These data may be indicative of central, possibly neurological, factors influencing fatigue perception in CFS sufferers.

 

Source: Rowbottom DG, Keast D, Green S, Kakulas B, Morton AR. The case history of an elite ultra-endurance cyclist who developed chronic fatigue syndrome. Med Sci Sports Exerc. 1998 Sep;30(9):1345-8. http://www.ncbi.nlm.nih.gov/pubmed/9741601

 

Chronic fatigue syndrome: identification of distinct subgroups on the basis of allergy and psychologic variables

Abstract:

BACKGROUND: We investigated a role for allergic inflammation and psychologic parameters in the development of chronic fatigue syndrome (CFS).

METHODS: The design was a comparison between subjects with CFS and age- and sex-matched control cohorts. Studies were performed on CFS subjects (n = 18) and control cohorts consisting of normal subjects (n = 11), allergic subjects (n = 14), and individuals with primary depression (n = 12). We quantified cytokines at baseline as cell-associated immunoreactive peptides and as transcripts evaluated by means of semiquantitative RNA-based polymerase chain reactions. Psychologic evaluations included administration of the Diagnostic Interview Schedule, the Structured Clinical Interview, and the Symptom Checklist 90-Revised.

RESULTS: Increases in tumor necrosis factor (TNF)-alpha were identified in individual subjects with CFS (50.1 +/- 14.4 pg TNF-alpha per 10(7) peripheral blood mononuclear cells [PBMCs]; mean +/- SEM) and allergic subjects (41.6 +/- 7.6) in comparison with normal subjects (13.1 +/- 8.8) (P < .01 and P < .05, respectively). Similar trends were observed for interferon (IFN)-alpha in allergic subjects (3.0 +/- 1.7 pg/10(7) PBMCs) and subjects with CFS (6.4 +/- 3.4) compared with normal subjects (1.9 +/- 1.4). A significant increase (P < .05) in TNF-alpha transcripts was demonstrated between subjects with CFS and depressed subjects. In contrast to these proinflammatory cytokines, both subjects with CFS (2.6 +/- 1.8 pg/10(7) PBMCs) and allergic subjects (3.4 +/- 2.8) were associated with a statistically significant (P < .01) decrease in IL-10 concentrations compared with normal subjects (60.2 +/- 18.2). As shown in other studies, most of our subjects with CFS were allergic (15 of 18) and therefore presumably demonstrated cytokine gene activation on that basis. The seasonal exacerbation of allergy was associated with a further increase in cellular IFN-alpha (from 2.1 +/- 1.2 to 14.2 +/- 4.5 pg/107 PBMCs; P < .05) but no further modulation of TNF-alpha or IL-10. Similarly, self-reported exacerbations of CFS were associated with a further increase in IFN-alpha (from 2.5 +/- 1.0 to 21.9 +/- 7.8; P < .05) and occurred at times of seasonal exposures to allergens. This linkage does not permit making any definitive conclusions regarding a causative influence of either seasonal allergies or the increase in cellular IFN-alpha with the increase in CFS symptoms. The close association between atopy and CFS led us to speculate that CFS may arise from an abnormal psychologic response to the disordered expression of these proinflammatory and antiinflammatory cytokines. Psychologic variables were predictive of immune status within the CFS sample (65.9% of the variance in immune status; F (3,10) = 6.44, P < .05). Specifically, the absence of a personality disorder but greater endorsement of global psychiatric symptoms was predictive of immune activation.

CONCLUSIONS: Most of our subjects with CFS were allergic, and the CFS and allergy cohorts were similar in terms of their immune status. However, the CFS subjects could be discriminated by the distinct psychologic profiles among subjects with and without immune activation. We propose that in at least a large subgroup of subjects with CFS who had allergies, the concomitant influences of immune activation brought on by allergic inflammation in an individual with the appropriate psychologic profile may interact to produce the symptoms of CFS. In a psychologically predisposed individual, symptoms associated with allergic inflammation are recognized as illness.

 

Source: Borish L, Schmaling K, DiClementi JD, Streib J, Negri J, Jones JF. Chronic fatigue syndrome: identification of distinct subgroups on the basis of allergy and psychologic variables. J Allergy Clin Immunol. 1998 Aug;102(2):222-30. http://www.ncbi.nlm.nih.gov/pubmed/9723665

 

Treating chronic fatigue with exercise. Exercise, and rest, should be tailored to individual needs

Comment on: Putting the rest cure to rest–again. BMJ. 1998

 

 

Editor – While I welcome Sharpe and Wessely’s reminder about the dangers of bed rest,1 I am concerned about the blanket advice regarding activity levels for patients with chronic fatigue. Chronic fatigue syndrome is now generally acknowledged to be a heterogeneous condition, not a single entity with a single cause. Accordingly, what may suit one person may be totally inappropriate for another. As research has shown, most patients with chronic fatigue syndrome remain ambulant, spend relatively few daytime hours resting, are no more inactive than people with mild multiple sclerosis, and tend to perform at or near their activity ceiling.2 What these patients need is not a strict programme in which rest is allowed according to a predetermined plan but a flexible approach that does not ignore current energy levels or make people feel guilty if they increase rest periods when they consider this to be right for them.

From a theoretical perspective, inactivity may well be an important factor in chronic fatigue syndrome, but I note that Sharpe and Wessely did not provide a single reference to back their claim that many patients simply “go home and rest,” let alone that most resort to “excessive rest.” Does this mean that the theory that “excessive inactivity” perpetuates chronic fatigue syndrome is based largely on anecdotal reports and articles in magazines? Moreover, in this age of evidence based medicine, discussions of a treatment should mention the negative reports of its efficacy as well as the positive.3,4

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113801/

 

Source: Goudsmit E. Treating chronic fatigue with exercise. Exercise, and rest, should be tailored to individual needs. BMJ. 1998 Aug 29;317(7158):599; author reply 600. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113801/

 

Sleep abnormalities demonstrated by home polysomnography in teenagers with chronic fatigue syndrome

Abstract:

To provide objective information about sleep physiology in young people with chronic fatigue syndrome (CFS), home polysomnography (PSG) was performed on 18 teenagers, aged 11-17 years, in whom CFS had been diagnosed according to internationally accepted criteria. The results were compared with those for healthy controls matched individually for gender and age.

Compared with controls, CFS subjects showed significantly higher levels of sleep disruption by both brief and longer awakenings. Disruption of sleep in this way could at least contribute to the daytime symptoms of young people with CFS. The underlying cause of the disruption needs to be considered in each individual case.

Further research is required to clarify the relative contribution of this neurobiological aspect of CFS in young people.

 

Source: Stores G, Fry A, Crawford C. Sleep abnormalities demonstrated by home polysomnography in teenagers with chronic fatigue syndrome. J Psychosom Res. 1998 Jul;45(1):85-91. http://www.ncbi.nlm.nih.gov/pubmed/9720858

 

Illness beliefs and treatment outcome in chronic fatigue syndrome

Abstract:

Longitudinal studies have shown that physical illness attributions are associated with poor prognosis in chronic fatigue syndrome (CFS). Speculation exists over whether such attributions influence treatment outcome. This study reports the effect of illness beliefs on outcome in a randomized controlled trial of cognitive-behavior therapy versus relaxation.

Causal attributions and beliefs about exercise, activity, and rest were recorded before and after treatment in 60 CFS patients recruited to the trial. Physical illness attributions were widespread, did not change with treatment, and were not associated with poor outcome in either the cognitive-behavior therapy group or the control group.

Beliefs about avoidance of exercise and activity changed in the cognitive behavior therapy group, but not in the control group. This change was associated with improved outcome. These findings suggest that physical illness attributions are less important in determining outcome (at least in treatment studies) than has been previously thought. In this study, good outcome is associated with change in avoidance behavior, and related beliefs, rather than causal attributions.

 

Source: Deale A, Chalder T, Wessely S. Illness beliefs and treatment outcome in chronic fatigue syndrome. J Psychosom Res. 1998 Jul;45(1):77-83. http://www.ncbi.nlm.nih.gov/pubmed/9720857