Tag: comment

Chronic fatigue syndrome

Comment in: Graded exercise for chronic fatigue syndrome: too soon to dismiss reports of adverse reactions. [J Rehabil Med. 2010]

Comment on: Chronic fatigue syndrome: an approach combining self-management with graded exercise to avoid exacerbations. [J Rehabil Med. 2008]

 

Sir, We read with interest the special report by Nijs et al. (1), entitled “Chronic fatigue syndrome: an approach combining self-management with graded exercise to avoid exacerbations”. The paper proposes to provide an integrated model for graded exercise therapy (GET) in patients with chronic fatigue syndrome (CFS).
The authors state that current GET programmes for people with CFS exacerbate symptoms. This is a familiar and mistaken criticism of GET, often quoted from the 2001 Action for myaligic encephalomyelitis (ME) (AfME) survey, which reported that 50% of patients with CFS/ME who received graded exercise felt worse (2). A follow-up survey reported that, in many cases, exercise was being undertaken independently, without the supervision of a therapist trained to deliver GET to patients with CFS (3). In other words, it was not GET.

You can read the rest of this comment here: https://www.medicaljournals.se/jrm/content/abstract/10.2340/16501977-0261

 

Source: Clark LV, White PD. Chronic fatigue syndrome. J Rehabil Med. 2008 Nov;40(10):882-3; author reply 883-5. doi: 10.2340/16501977-0261. https://www.medicaljournals.se/jrm/content/abstract/10.2340/16501977-0261

 

Change in grey matter volume cannot be assumed to be due to cognitive behavioural therapy

Comment on: Can CBT substantially change grey matter volume in chronic fatigue syndrome? [Brain. 2009]

Sir, In their reply to Dr Bramsen, De Lange et al. (2008) use a type of circular reasoning: cognitive behavioural therapy (CBT), they say, has previously been shown to be ‘effective’ for chronic fatigue syndrome (CFS) so the change they measured must be due to CBT.

First, it needs to be pointed out that CBT is far from a panacea for CFS. A recent meta-analysis (Malouff et al., 2008) of the efficacy of CBT in treating CFS found an effect size of d = 0.48 (95% CI 0.27–0.69).

In their letter, De Lange et al. (2008) refer to a review by Whiting et al. (2001) as part-evidence for their claim that CBT is effective for CFS. However, this review recommended the use of objective outcome measures e.g.

Outcomes such as ‘improvement,’ in which participants were asked to rate themselves as better or worse than they were before the intervention began, were frequently reported. However, the person may feel better able to cope with daily activities because they have reduced their expectations of what they should achieve, rather than because they have made any recovery as a result of the intervention. A more objective measure of the effect of any intervention would be whether participants have increased their working hours, returned to work or school, or increased their physical activities’.

Given one of the aims of CBT (for CFS) has been said to be ‘increased confidence in exercise and physical activity’ (O’Dowd et al.), we cannot have complete confidence that the improvements recorded in CBT trials thus far represent objective improvements [such as improvements in grey matter volume (GMV)], rather than simply being due to altering how patients answer questionnaires. An INAMI report (2006) on the use of CBT (combined with GET) in over 600 CFS patients in Belgium found that while patients reported improvements on their fatigue scores, there was negligible change on the tests of exercise capacity and there was actually a worsening of their employment status (as measured by the amount of hours worked per week), both at the end of the intervention and at follow-up.

You can read the rest of this comment here: http://brain.oxfordjournals.org/content/132/7/e119.long

 

Source: Kindlon T. Change in grey matter volume cannot be assumed to be due to cognitive behavioural therapy. Brain. 2009 Jul;132(Pt 7):e119; author reply e120. doi: 10.1093/brain/awn358. Epub 2009 Jan 29. http://brain.oxfordjournals.org/content/132/7/e119.long (Full article)

 

Can CBT substantially change grey matter volume in chronic fatigue syndrome?

Sir, I wish to comment on the paper ‘Increase in prefrontal cortical volume following cognitive behavioural therapy (CBT) in patients with chronic fatigue syndrome (CFS)’ (De Lange et al., 2008). The authors compared the grey matter volume (GMV) of 22 patients with CFS before and after treatment with CBT, and with 22 healthy controls who were assessed at a similar time interval but received no treatment. The patient sample at baseline had a 5% smaller GMV as compared to healthy controls. In patients, GMV at baseline was correlated with slow information processing speed and physical activity. At follow-up, in the patient group, mean GMV increased with 0.7% from 669.4 to 674.1 ml. This increase in GMV was correlated with changes in cognitive speed. On the basis of this result, the authors conclude ‘that the cerebral atrophy associated with CFS is partially reversed after effective CBT’. In the Netherlands, a press release of the author’s institution even states ‘CBT brings about structural changes in brains of patients’ (Radboud University, 2008). The question arises whether the study results indeed support such far reaching conclusions.

Two critical points need to be taken into consideration. First, the authors did not include a control group of patients receiving no treatment or a different treatment. Therefore, the increase in GMV cannot be attributed to the CBT treatment given. It is possible that the natural course of and fluctuations in the illness are responsible for this result. In addition, it might be possible that other treatments than CBT would have resulted in the same, or even better, results. Second, even if the results were indeed to be attributed to changes in lifestyle brought about by CBT, several questions still remain. To name a few, first, the increase in volume of <1% is very modest. Therefore, the question is whether, although statistically significant, this small increase is also of clinical significance. Second, if CBT brings about changes in lifestyle, and these changes are responsible for small improvements in the patients’ brain and activity levels, are these changes structural and related to the primary disease process? An alternative interpretation is that changing the lifestyle of patients, influences their quality of life, activity patterns and GMV, while the underlying disease process is not influenced.

Another critical remark relates to the fact that the authors in their paper do not mention the proportion of absolute increase in GMV of 0.7%, but rather report that the initial between-group difference between patients and healthy controls decreases with 12%. For readers, it is important to realize that the measure of change reported by the authors is influenced by the absolute size of the between-group difference: the smaller, and therefore less relevant, this difference is, the larger the reported proportion becomes, thereby making less relevant results looking more impressive.

The above considerations lead to the conclusion, that the author’s results, although interesting, do not support the far reaching conclusions regarding the power of CBT.

You can read the rest of this comment here: http://brain.oxfordjournals.org/content/132/6/e110.long

Comment in: Change in grey matter volume cannot be assumed to be due to cognitive behavioural therapy. [Brain. 2009]

Comment on: Increase in prefrontal cortical volume following cognitive behavioural therapy in patients with chronic fatigue syndrome. [Brain. 2008]

 

Source: Bramsen I. Can CBT substantially change grey matter volume in chronic fatigue syndrome? Brain. 2009 Jun;132(Pt 6):e110; author reply e111. doi: 10.1093/brain/awn207. Epub 2008 Aug 29. http://brain.oxfordjournals.org/content/132/6/e110.long (Full article)

 

NICE behaviour: ME guideline is unworkable

Comment on: Diagnosis and management of chronic fatigue syndrome or myalgic encephalomyelitis (or encephalopathy): summary of NICE guidance. [BMJ. 2007]

 

The National Institute for Health and Clinical Excellence (NICE) recommends that everyone with mild or moderate myalgic encephalopathy/chronic fatigue syndrome (ME/CFS) should be offered a course of either cognitive behaviour therapy (CBT) or graded exercise therapy (GET).1

This is despite published evidence remaining weak (especially for group CBT) and inconsistent 2. Patient evidence submitted to the chief medical officer’s report concluded that CBT produced “no change” in 67% of cases and made the condition “worse” in 26% of cases.3 Around 50% of respondents reported that inappropriate exercise therapy had also made their condition “worse.”3

When the NICE estimate on prevalence is used this controversial recommendation will affect some 200 000 people. A one to one course of CBT covering 12 to 16 sessions will cost well over £1500. The cost of a professionally supervised exercise therapy programme is also likely to be substantial.

So where is around £300 million of new money going to come from at a time when very limited funding for some of the newly established NHS clinical services for people with ME/CFS is now being cut?4 And where are all the therapists going to come from? Those already in post often cannot even cope with their current workload.

These are important questions that I raised at a NICE implementation and planning meeting in October 2006—but nobody from NICE could provide a convincing answer. These recommendations are going to be of no value whatsoever to many people with ME/CFS. They are also going to be impossible to implement owing to a lack of both funding and human resources.

You can read the rest of this comment here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1976494/

 

Source: Shepherd CB. NICE behaviour: ME guideline is unworkable. BMJ. 2007 Sep 15;335(7619):528. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1976494/ (Full article)

 

How common is chronic fatigue syndrome; how long is a piece of string?

Comment on: Prevalence of chronic fatigue syndrome in metropolitan, urban, and rural Georgia. [Popul Health Metr. 2007]

One of the most difficult tasks in medicine is to accurately measure how common illnesses are. Why do we do it? Justifications include being able to plan health care and public health priorities, as well as highlighting specific diseases for extra funding for both health care and research. Yet the jobbing physician at the sharp edge of clinical practice cares little about the exact prevalence of a disease or illness, since this is all too obvious from the frequency of the problems presented by patients who come through the door.

You can read the rest of this comment here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904177/

 

Source: White PD. How common is chronic fatigue syndrome; how long is a piece of string? Popul Health Metr. 2007 Jun 8;5:6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904177/ (Full article)

 

Chronic fatigue syndrome

I have just read the review of treatments for chronic fatigue syndrome (CFS) in the October issue of the JRSM. It included my study, but some of the details were inaccurate and the overall judgement was unfair and potentially misleading.

In the original ‘York’ review of the various treatments for CFS, my study received a validity score of two. However, after clarification regarding the statistical analysis, this was changed to three (Kleijnen, personal communication). Chambers et al. were clearly not aware of the ‘correction’ and published the original score. It’s a minor issue, but it wasn’t the only one.

Another example relates to the assessment of the results. According to the table (p. 511), the programme had no overall effect—but as the authors noted in their recent review for NICE (http://www.nice.org.uk/page.aspx?o=368933, appendix 1, p. 423), there were ‘significant differences between groups for fatigue… and somatic symptoms’. They would also have been aware that 82% of the patients rated themselves as ‘better’ or ‘much better’ and that 23% had improved to such a degree that they were discharged.

To summarize, patients reported less fatigue, fewer somatic symptoms, less anxiety and depression after six months compared to the controls, and the improvements were maintained at follow-up. Yet the authors judged the treatment had ‘no overall effect’.

My study is one of the few which has assessed an alternative to the CBT-based programmes. It’s also one of the few controlled trials to include pacing, a strategy which many patients regard as a particularly helpful way of managing their limited energy. In my opinion, it deserved an accurate evaluation and a fair summary of the outcome. It didn’t get that.

You can read the rest of this comment here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761664/

Comment on: Interventions for the treatment, management and rehabilitation of patients with chronic fatigue syndrome/myalgic encephalomyelitis: an updated systematic review. [J R Soc Med. 2006]

 

Source: Goudsmit EM. Chronic fatigue syndrome. J R Soc Med. 2007 Jan;100(1):7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761664/ (Full article)

 

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)

 

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

 

Psychiatric comorbidity and chronic fatigue syndrome

Prins et al (2005) assessed psychiatric comorbidity in chronic fatigue syndrome (CFS) using the Structured Clinical Interview for DSM–III–R. Comorbidity was remarkably low compared with similar investigations, and in particular the apparent absence of current post-traumatic stress disorder (PTSD) was striking. The authors speculated that the low comorbidity rates might result mainly from a lack of ‘psychiatric bias’ of the examiners. They also found that psychiatric comorbidity did not predict the outcome of cognitive–behavioural therapy.

You can read the rest of this comment here: http://bjp.rcpsych.org/content/188/4/395.2.long

 

Source: Van Houdenhove B. Psychiatric comorbidity and chronic fatigue syndrome. Br J Psychiatry. 2006 Apr;188:395; author reply 396. http://bjp.rcpsych.org/content/188/4/395.2.long (Full article)

 

 

Chronic fatigue syndrome, exercise, cortisol and lymphadenopathy

Dear Sir,

As in the past [1], the effects of exercise in the treatment of chronic fatigue syndrome (CFS) are conflicting. Indeed, while Powell et al. [2], in 2004, reported that graded exercise was beneficial to CFS patients, Black et al. [3] have lately written that ‘overall mood, muscle pain intensity, and time spent each day with fatigue worsened following increased activity’ [3] in CFS patients, despite the fact that their increase in daily physical activity was rather moderate (28%) [3]. The virtually opposite effects of exercise in different groups of CFS patients [1–3] may reflect their different cortisol levels [1], which, just as occurred some years ago [1], continue to be contradictory. For example, Inder et al. [4], in March 2005, reported that cortisol levels were normal in their patients with CFS, whereas Segal et al. [5], in the same month, reported that their subjects with CFS had hypocortisolism.

Considering that most features of CFS, such as ‘debilitating fatigue, an abrupt onset precipitated by a stressor, feverishness, arthralgias, myalgias, adenopathy, postexertional fatigue, exacerbation of allergic responses, and disturbances in mood and sleep are all characteristic of glucocorticoid insufficiency’ [6], it is not surprising that hypocortisolism has been convincingly shown to be implicated in the pathophysiology of CFS [7]. Therefore, especially the postexertional fatigue caused by glucocorticoid insufficiency [6] strongly suggests that exercise could be of benefit to CFS patients with high [1] or normal cortisol levels [4], whereas it could be harmful to CFS patients with hypocortisolism [1, 5, 6]. Unfortunately, because of the misleading coexistence of quite different diagnostic criteria for CFS [1], it is difficult to predict the patients with CFS who are more likely to have hypocortisolism and which would worsen with exercise. However, it is arguable that the presence or absence of lymphadenopathy [8], which is a sign of hypocortisolism [6, 9] and is one of the 43 clinical features that CFS shares with Addison’s disease [10–12], could reliably discriminate CFS patients who may worsen with exercise from those who may improve with it. Indeed, lymphadenopathy, unlike other symptoms of CFS [11, 12], many of which are non-specific and can also be found in depression and other affective disorders [11, 12], is far from being common in physical diseases and is absent in psychiatric conditions.

You can read the rest of this comment here: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2005.01526.x/full

 

Source: Baschetti R. Chronic fatigue syndrome, exercise, cortisol and lymphadenopathy. J Intern Med. 2005 Sep;258(3):291-2. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2005.01526.x/full (Full article)