Fatigue: Biomedicine, Health & Behavior - Volume 5, Issue 1, 2017

Volume 5, Issue 1, 2017

 * Editorial - Differing case definitions point to the need for an accurate diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome, by Luis Nacul, Caroline C. Kingdon, Erinna W. Bowman, Hayley Curran, and Eliana M. Lacerda Full Text
 * Profiles of fatigue severity and variability among adolescents and young adults with cerebral palsy "Abstract - Background: Individuals with cerebral palsy (CP) experience progressive changes in functional status with the development of secondary impairments such as fatigue. Detailed accounts of the fatigue experience in CP are lacking. Purpose: This study describes the severity and variability of fatigue in CP using the Fatigue Impact and Severity Self-Assessment. Methods: This was a descriptive cross-sectional study surveying 130 (61 males) individuals (mean age 18 years, 11 months; SD 4 years, 6 months) with CP. Analyses comprised comparisons between two groups (Gross Motor Function Classification System (GMFCS) I and II–V), frequency counts and proportions. Results: Significant differences exist between GMFCS groups for all fatigue severity questions. In addition, 38% of individuals classified as GMFCS level I reported their average fatigue as moderate to severe and 53% experienced fatigue on three or more days in the previous week. Sixty-eight percent of individuals classified as GMFCS levels II–V reported their average fatigue to be moderate to severe and 78% were fatigued on three or more days in the previous week. Conclusions: Fatigue is a highly individualised phenomenon with significant burden for individuals with CP regardless of functional ability. Individuals in GMFCS levels II–V reported increased fatigue severity and would benefit from specific management interventions."
 * Elevations of ventricular lactate levels occur in both chronic fatigue syndrome and fibromyalgia "Abstract - Background: Chronic fatigue syndrome (CFS) and fibromyalgia (FM) frequently have overlapping symptoms, leading to the suggestion that the same disease processes may underpin the two disorders – the unitary hypothesis. However, studies investigating the two disorders have reported substantial clinical and/or biological differences between them, suggesting distinct pathophysiological underpinnings. Purpose: The purpose of this study was to further add to the body of evidence favoring different disease processes in CFS and FM by comparing ventricular cerebrospinal fluid lactate levels among patients with CFS alone, FM alone, overlapping CFS and FM symptoms, and healthy control subjects. Methods: Ventricular lactate was assessed in vivo with proton magnetic resonance spectroscopic imaging (1H MRSI) with the results normed across the two studies in which the data were collected. Results: Mean CSF lactate levels in CFS, FM and CFS + FM did not differ among the three groups, but were all significantly higher than the mean values for control subjects. Conclusion: While patients with CFS, FM and comorbid CFS and FM can be differentiated from healthy subjects based on measures of CFS lactate, this neuroimaging outcome measure is not a viable biomarker for differentiating CFS from FM or from patients in whom symptoms of the two disorders overlap."
 * Patient change attributions in self-management of severe chronic fatigue syndrome "Abstract - Purpose: To identify patient change attributions arising from a home self-management intervention in severe chronic fatigue syndrome (CFS). Methods: This multi-method study of 126 participants with severe CFS collected data through phone interviews at 3-month follow-up in a self-management trial reported previously. Patient ratings (ranging from very much worse to very much better), were elicited on the global impression of change scale followed by this question: ‘Why do you think you are: “worse”, “unchanged”, “improved”’, etc.? The open-ended responses from participants were thematically organized and analyzed as study data. Results: Most improved participants referenced behavioral changes that included: increased relaxation, coping and stress reduction (44%), pacing (e.g. more rest, less exercise; 33%), and more physical activity/exercise (25%). For participants reporting ‘unchanged’ global ratings, the majority (63%) attributed their status to one or more of the following: nothing will help/illness acceptance/illness fluctuates without overall change (29%), everything is the same (24%) or does not know (17%). Participants with worsened global ratings most often attributed their decline to: changes in sleep (40.5%), deteriorating health (35%), specific life events (30%), and/or stress (30%). Treatment-assigned participants as compared to no treatment controls were significantly more likely (p = <.05) to cite increased awareness, relaxation/coping/stress reduction and pacing as their reasons for change. The frequency of active vs. passive coping categories also distinguished improved from non-improved patients. Conclusions: Patient attributions could be utilized by the clinician to shift patient perceptions of their illness status in a constructive direction, possibly leading to an enhanced quality of life."
 * Identifying symptom subgroups in patients with ME/CFS – relationships to functioning and quality of life "Abstract - Background: It is still not clear whether the diagnosis Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) constitutes one single disease entity, as diagnosis depends on clinical case definitions. The variation of symptoms across individuals indicates important differences between individuals diagnosed with ME/CFS. Also, the variation in daily functioning and quality of life measures among subgroups of symptoms is still unclear. Purpose: The present study examines the associations between symptoms in ME/CFS, and evaluates the relationships between symptom subgroups, functioning and quality of life. Methods: Data were collected from 106 adults as part of the assessment at a tertiary specialist clinic for ME/CFS. Principal component analyses (PCA) were utilized to identify symptom subgroups, and the relationships with functioning and quality of life were evaluated using bivariate correlations. Results: The PCA suggested four statistically distinct and clinically meaningful subgroups of symptoms. The latent constructs were labeled Inflammatory, Pain, Neurocognitive, and Autonomic. All symptom subgroups correlated significantly with measures of fatigue, mood, functioning and quality of life. Notably, the correlations between symptom subgroups and criteria variables (e.g. mood) varied in strength, indicating a difference in the relative importance of symptom subgroups. Conclusions: Although tentative, the results from this study support previous research and suggest that there are important symptom subgroups among individuals with ME/CFS. Furthermore, these results indicate that symptom profiles may be of importance to understand the variation between individuals in the impact of symptoms on functioning. Thus, more research is warranted to validate these findings and investigate possible differences in etiology between patient subgroups."
 * Can patients with chronic fatigue syndrome really recover after graded exercise or cognitive behavioural therapy? A critical commentary and preliminary re-analysis of the PACE trial, by Carolyn Wilshire, Tom Kindlon, Alem Matthees & Simon McGrath FULL TEXT "Abstract - Background: Publications from the PACE trial reported that 22% of chronic fatigue syndrome patients recovered following graded exercise therapy (GET), and 22% following a specialised form of CBT. Only 7% recovered in a control, no-therapy group. These figures were based on a definition of recovery that differed markedly from that specified in the trial protocol. Purpose: To evaluate whether these recovery claims are justified by the evidence. Methods: Drawing on relevant normative data and other research, we critically examine the researchers’ definition of recovery, and whether the late changes they made to this definition were justified. Finally, we calculate recovery rates based on the original protocol-specified definition. Results: None of the changes made to PACE recovery criteria were adequately justified. Further, the final definition was so lax that on some criteria, it was possible to score below the level required for trial entry, yet still be counted as ‘recovered’. When recovery was defined according to the original protocol, recovery rates in the GET and CBT groups were low and not significantly higher than in the control group (4%, 7% and 3%, respectively). Conclusions: The claim that patients can recover as a result of CBT and GET is not justified by the data, and is highly misleading to clinicians and patients considering these treatments."
 * Response to: "Do more people recover from chronic fatigue syndrome with cognitive behaviour therapy or graded exercise therapy than with other treatments?" "Abstract - Background: Wilshire et al. suggest that we have overestimated the number of patients that recover from chronic fatigue syndrome (CFS) after receiving a course of either cognitive behaviour therapy (CBT) or graded exercise therapy (GET), as reported in a secondary analysis of outcome data from the Pacing, graded Activity and Cognitive behavior therapy; a randomized Evaluation (PACE) trial. We provide counter-arguments to this view. Purpose: To provide an alternative view to that offered by Wilshire et al. Methods: We review the two different analyses of PACE trial outcome data to estimate recovery, and compare these to other published trials and cohort studies. Results: While there is no gold standard for recovery from CFS, previous trials and cohort studies provide support for our analysis of recovery in the PACE trial. Our finding that 22% of participants recover from the current episode of CFS after either CBT or GET, compared to 8% after adaptive pacing therapy and 7% after specialist medical care alone, is consistent with the literature. Conclusions: Our original conclusions that ‘ … recovery from CFS is possible, and that CBT and GET are the therapies most likely to lead to recovery’ is an important, reasonable, and hopeful message for both clinicians and patients."
 * PACE trial claims of recovery are not justified by the data: a rejoinder to Sharpe, Chalder, Johnson, Goldsmith and White (2017) "Abstract - Background: Recently, we critically evaluated the claim from the PACE trial that cognitive behavioural therapy (CBT) and graded exercise therapy (GET) can lead to recovery from chronic fatigue syndrome (CFS). We showed that the trial’s definition of recovery was so loose it failed to capture the term’s core meaning. Also, this definition was substantially loosened very late in the trial, in ways that favoured the study hypotheses. The investigators do not acknowledge any of these criticisms and stand by their original analyses. Purpose: To examine the arguments advanced in defence of PACE’s recovery claims. Methods: Drawing on various sources of evidence, we consider three major arguments raised in defence of PACE’s recovery claims: (1) that since there is no agreed definition of recovery, it comes down to a matter of opinion; (2) that the original definition was ‘too stringent’; and (3) the revised definition generates results that align with previous studies. Results: We find that: (1) ‘recovery’ is a strong claim, which implies evidence a return to health, and that the trial’s final definition did not preserve this core meaning; (2) there is no evidence to suggest that the original protocol-specified definition was ‘too stringent’; (3) absolute recovery rates from other studies are not a legitimate source of support for the recovery definition used. Conclusions: The PACE trial provides no evidence that CBT and GET can lead to recovery from CFS. The recovery claims made in the PACE trial are therefore misleading for patients and clinicians."