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Canadian Consensus Criteria for CFS/ME

Discussion in 'Latest ME/CFS Research' started by George, Jul 15, 2010.

  1. George

    George waitin' fer rabbits

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    This case definition was put together in 2003 by the following Doctors and Clinicians

    Bruce M. Carruthers, MD, CM, FRCP(C)
    Anil Kumar Jain, BSc, MD
    Kenny L. De Meirleir, MD, PhD
    Daniel L. Peterson, MD
    Nancy G. Klimas, MD
    A. Martin Lerner, MD, PC, MACP
    Alison C. Bested, MD, FRCP(C)
    Pierre Flor-Henry, MB, ChB, MD, Acad DPM, FRC, CSPQ
    Pradip Joshi, BM, MD, FRCP(C)
    A. C. Peter Powles, MRACP, FRACP, FRCP(C), ABSM
    Jeffrey A. Sherkey, MD, CCFP(C)
    Marjorie I. van de Sande, BEd, Grad Dip Ed

    An allstar cast to say the least. This esteemed group has been trying to get the CCC for CFS/ME established for years now. They are up against the CDC. (roll eyes) Maybe we can help them by starting a writing campaign that points out that the WPI used the CCC in their science study. Other studies have not used this criteria and have not found XMRV in CFS/ME patients. The leak (rumor mill) says that both the Dr. Alter (NIH) paper and Dr. Lo (FDA) paper used this criteria. Who know's but now's as good a time as any to get a criteria established.

    A patient with ME/CFS will meet the criteria for fatigue, post-exertionalmalaise and/or fatigue, sleep dysfunction, and pain;
    have two or more neurological/cognitive manifestations and
    one or more symptoms from two of the categories of autonomic, neuroendocrine and immune
    manifestations;
    and adhere to item 7.



    1. Fatigue: The patient must have a significant degree of new onset,
    unexplained, persistent, or recurrent physical and mental fatigue
    that substantially reduces activity level.

    2. Post-Exertional Malaise and/or Fatigue: There is an inappropriate
    loss of physical and mental stamina, rapid muscular and cognitive
    fatigability, post exertional malaise and/or fatigue and/or pain and
    a tendency for other associated symptoms within the patient's cluster
    of symptoms to worsen. There is a pathologically slow recovery
    period…usually 24 hours or longer.

    3. Sleep Dysfunction:* There is unrefreshed sleep or sleep quantity or
    rhythm disturbances such as reversed or chaotic diurnal sleep rhythms.

    4. Pain:* There is a significant degree of myalgia. Pain can be experienced
    in the muscles and/or joints, and is often widespread and migratory
    in nature. Often there are significant headaches of new
    type, pattern or severity.

    5. Neurological/Cognitive Manifestations: Two or more of the following
    difficulties should be present:
    confusion,

    impairment of concentration and short-term memory consolidation,
    disorientation,

    difficulty with information processing, categorizing and word retrieval,

    perceptual and sensory disturbances…e.g., spatial instability

    and disorientation and inability to focus vision.
    Ataxia, muscle weakness and fasciculations are common.
    There may be overload1 phenomena: cognitive, sensory…e.g., photophobia andhypersensitivity to oise …and/or emotional overload, which maylead to 1)crash 2) periods and/or anxiety. (Carruthers et al. (11)

    6. At Least One Symptom from Two of the Following Categories:

    a. Autonomic Manifestations: orthostatic intolerance…neurally mediated
    hypotenstion (NMH), postural orthostatic tachycardia
    syndrome (POTS), delayed postural hypotension; light-headedness;
    extreme pallor; nausea and irritable bowel syndrome; urinary
    frequency and bladder dysfunction; palpitations with or
    without cardiac arrhythmias; exertional dyspnea.

    b. Neuroendocrine Manifestations: loss of thermostatic stability…
    subnormal body temperature and marked diurnal fluctuation,
    sweating episodes, recurrent feelings of feverishness and cold
    extremities; intolerance of extremes of heat and cold; marked
    weight change…anorexia or abnormal appetite; loss of adaptability
    and worsening of symptoms with stress.

    c. Immune Manifestations: tender lymph nodes, recurrent sore
    throat, recurrent flu-like symptoms, general malaise, new sensitivities
    to food, medications and/or chemicals.

    7. The illness persists for at least six months. It usually has a distinct
    onset,** although it may be gradual. Preliminary diagnosis may be
    possible earlier. Three months is appropriate for children.
    To be included, the symptoms must have begun or have been significantly
    altered after the onset of this illness.

    It is unlikely that a patient will suffer from all symptoms in criteria 5 and 6. The disturbances tend
    to form symptom clusters that may fluctuate and change over time. Children often have numerous prominent symptoms but their order of severity tends to vary from day to day.

    *There is a small number of patients who have no pain or sleep dysfunction, but no other diagnosis fits except ME/CFS. A diagnosis of ME/CFS can be entertained when this group has an infectious illness type onset.
    **Some patients have been unhealthy for other reasons prior to the onset of ME/CFS and lack detectable triggers at onset and/or have more gradual or insidious onset.

    Exclusions: Exclude active disease processes that explain most of the
    major symptoms of fatigue, sleep disturbance, pain, and cognitive
    dysfunction. It is essential to exclude certain diseases, which would be
    tragic to miss: Addison's disease, Cushing's Syndrome, hypothyroidism,
    hyperthyroidism, iron deficiency, other treatable forms of anemia,
    iron overload syndrome, diabetes mellitus, and cancer. It is also
    essential to exclude treatable sleep disorders such as upper airway resistance
    syndrome and obstructive or central sleep apnea; rheumatological
    disorders such as rheumatoid arthritis, lupus, polymyositis
    and polymyalgia rheumatica; immune disorders such as AIDS; neurological
    disorders such as multiple sclerosis (MS), Parkinsonism,
    myasthenia gravis and B12 deficiency; infectious diseases such as tuberculosis,
    chronic hepatitis, Lyme disease, etc.; primary psychiatric
    disorders and substance abuse. Exclusion of other diagnoses, which
    cannot be reasonably excluded by the patient's history and physical
    examination, is achieved by laboratory testing and imaging. If a
    potentially confounding medical condition is under control, then the
    diagnosis of ME/CFS can be entertained if patients meet the criteria
    otherwise.

    Co-Morbid Entities: Fibromyalgia Syndrome (FMS), Myofascial Pain
    Syndrome (MPS), Temporomandibular Joint Syndrome (TMJ), Irritable
    Bowel Syndrome (IBS), Interstitial Cystitis, Irritable Bladder
    Syndrome, Raynaud's Phenomenon, Prolapsed Mitral Valve, Depression,
    Migraine, Allergies, Multiple Chemical Sensitivities (MCS),
    Hashimoto's thyroiditis, Sicca Syndrome, etc.

    Such co-morbid entities may occur in the setting of ME/CFS. Others such as IBS may precede
    the development of ME/CFS by many years, but then become
    associated with it. The same holds true for migraines and depression.
    Their association is thus looser than between the symptoms within the
    syndrome. ME/CFS and FMS often closely connect and should be
    considered to be overlap syndromes.

    Idiopathic Chronic Fatigue: If the patient has unexplained prolonged
    fatigue (6 months or more) but has insufficient symptoms to meet the
    criteria for ME/CFS, it should be classified as idiopathic chronic fatigue.
    General Considerations in Applying the Clinical Case Definition
    to the Individual Patient
    1. Assess Patient's Total Illness: The diagnosis of ME/CFS is not arrived
    at by simply fitting a patient to a template but rather by observing
    and obtaining a complete description of their symptoms and
    interactions, as well as the total illness burden of the patient.
    2. Variability and Coherence of Symptoms: Patients are expected to exhibit
    symptoms from within the symptom group as indicated, however
    a given patient will suffer from a cluster of symptoms often
    unique to him/her. The widely distributed symptoms are connected
    as a coherent entity through the temporal and causal relationships revealed
    in the history. If this coherence of symptoms is absent, the diagnosis
    is in doubt. (Carruthers et al. (13)
  2. George

    George waitin' fer rabbits

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  3. Otis

    Otis Señor Mumbler

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    I'm with you George.

    BUT, I'm a bit reticent to completely throw out idiopathic fatigue, especially as we get to Fukuda. We need to define cohorts very well and prioritize how to study them, for sure.

    But here's why even empiric cases may deserve SOME attention and we definitely some long-term longitudinal studies of high fidelity.

    Despite an obvious post-viral illness (at 15 which leads us into the confusing medical worlds of pediatric criteria and puberty) I recovered to 80-90%. After recovery, for the 80s all I could say I had was no ability to get aerobically fit, IBS and sleeping lightly. Not even Empiric.

    During the 90s I definitely added fatigue, PEM, some pain, unrefreshing sleep, headaches and ever-decreasing stamina. I moved "up" to Fukuda.

    During the '00s I added significant fatigue, a very exponential decline in function, and beginning in 06/07 severe pain. It took until about '06-'09 for the neuro symptoms to knock out down my mental capacity and for dysautonomia (esp. thermostatic and POTS). Debatable Fibro Dx.

    With the possible exception of one downturn I didn't have obvious acute viral infections, except for sinus infections that go back to the beginning of all of this and maybe before. Very few colds or even. One, maybe two, infections in my lungs since onset.

    So I probably wasn't obviously CCC until 07-09, despite a nearly 30 year, every accelerating decline. No problem getting studied now with the exception of my onset...

    I think I'm an odd case (even for a gradual onset given the duration) but I believe it would be very instructive to have blood and other measures over the course of this wild ride.

    FWIW... Otis
  4. Andrew

    Andrew Senior Member

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  5. George

    George waitin' fer rabbits

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    Dang, good catch Andrew.

    Otis have you had an XMRV test yet?
  6. CBS

    CBS Senior Member

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    My take on cohorts is that no one be left behind but at some point, we all lose when studies are compromised of heterogeneous subjects as any type of signal is lost in the noise. Even if you aren't in the group being studied in a particular project, you benefit from the possibility of having the "noise" of the group being studied removed from "your" group.

    The trick is in knowing where to draw the distinctions. Some of that is trial and error, some evidence collected over time and the balance clinical experience (and not forgetting that the groups you aren't studying are still sick and in need of answers - we need to stop repeating the same mistakes).

    Dr. Jason and a few others are trying very hard to get people's attention as to the importance of this issue. The CDC did everyone with CFS a huge favor by failing to get the cohort issue even close on such a big stage. It's quite ironic that the CDC accomplished more for CFS in getting the cohort issue SO wrong than they have in the past 25 years with any other CFS related undertaking ("No, our 'CFS' patients don't have significant health problems. What we're studying does not apply to a million people. No, we don't have a clue as to what's wrong with them. And no, we've never bothered to look!"). We needed Reeves around to drive one last nail in the CDC coffin.
  7. Otis

    Otis Señor Mumbler

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    No. I have a VIP Dx kit right now but I'm waiting for the antibody test to be rolled out (any day now?) and then I have to talk over the costs with my wife given the state of treatment.
  8. Otis

    Otis Señor Mumbler

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    Well said. I'm happy with over-constrained studies early on if the larger picture and the the group on the fuzzy boundary is considered. Dr. Bateman will handle that well, I'm sure.

    Dr. Jason is able to lay out the issues better than anyone I've ever heard. His was a GREAT webinar.

    Finally a CDC failure is helping is. Who woulda thunk it?!

    Dr. Racaniello gets the cohort issue and he doesn't have the history.
  9. SOC

    SOC Moderator and Senior Member

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    Otis' case is a good example of gradual progression that eventually led to CCC-defined ME/CFS. In an ideal world he would have been diagnosed 30 years ago and treated, but this is far from an ideal world for PWCs.

    Assuming for the moment that XMRV is at the root of ME/CFS, it seems very likely we will find that XMRV patients show some symptoms before they would (by today's criteria) be diagnosed with ME/CFS. I'm guessing "ME/CFS" is actually a later stage of XMRV infection. Those of us with acute onset may have run into a particularly virulent virus that progressed our illness faster, perhaps in a way similar to the way HHV-6 is a progression factor in HIV/AIDS.

    By this theory, in the future PWCs will be diagnosed with whatever-the-heck we have much earlier than we are now. That said, are many of us originally diagnosed nowadays before we meet the CCC?

    To ask the question simply, are there many of us here that who are diagnosed with ME/CFS but don't meet CCC? Are there many people who are Fukuda, but not CCC?
  10. xchocoholic

    xchocoholic Senior Member

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    Anyone else notice that there aren't any REAL tests involved in this method of diagnosing CFS/ME ? What about the testing done by Pacific Labs that proves someone has PEM or excercise intolerance ? Better yet, instead of just diagnosing someone with PEM or excercise intolerance, come up with the reason why they have PEM or excercise intolerance ? Aren't we to the point where we know what to look for ? I don't understood all the technical medical info we have on this board but we certainly have some who do understand it. I've had quite a few tests myself that point to leaky gut but I've seen others diagnosed with LYME, or mold intolerance, or celiac disease, or whatever it is that RichV is looking at, etc etc ...

    IMHO, as long as we leave a diagnosis of CFS/ME as vague as this, we'll never be taken seriously or have a chance of healing from whatever is at the root of our illness ... X
  11. Otis

    Otis Señor Mumbler

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    It will be interesting to see how the straws combine to break the camel's back and in what combinations.
    - Genetic predispositions
    - One virus like XMRV
    - More virulent strain(s)
    - Double and triple (or more) whammys (viruses, bacteria, fungi)

    If we can get testing cheap and widely available we have a chance to catch things early.

    In my early subtle case, I had 4-6 months of obvious post-viral symptoms including fatigue, with a Dr. who was sure I had EBV (negative tests) which was eventually blamed on rhinitus and 'activity-induced asthma' by an ENT after an exercise test. I could have easily been ignored and fallen through the cracks altogether then were it not for a couple of docs willing to dig a little. Especially rare 30 year ago. I'm only putting these pieces together now after combining my Mom's memory with mine recently, so knowing this as it happens will be harder.

    - I'm sure if I got a pacific labs (with the Bateman/Light add-on) type workup that measured cytokines I would have look atypical. After exercise from there forward I felt like throwing up. It was a short-term thing, no true PEM. Heart was ruled out but no stress test done. Couldn't get aerobically fit.

    - Also, this would have been a good time for a virus chip test, if it existed back then. Test for everything. Something would have lit up in my case. I think we need this technology to be a cheap and to be used liberally to head off cancers and our own brand of fun.and who knows what else.

    For a start we need to be able measure our complete virus profile (virus chip) for CCC patients and controls in a study with really a detailed history. That's probably feasible soon. Then we need to be able to get this profile as orderd. If it were $500 bucks now I'd do it in a heartbeat.

    Fun to theorize...
  12. Andrew

    Andrew Senior Member

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    There test seemed promising at first, but it has to been reliable.
  13. George

    George waitin' fer rabbits

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    Hi ya
    I did notice that there are no tests involved in this "criteria", course there ain't no test in the Holmes 1984 criteria, or the Fukuda 1991 criteria or the Oxford criteria or the lovely Reeve's Empirical criteria. (big grins)

    Right now there are no "Accepted Test" because there is no test that covers 100% or even 90% of all CFS patients so they all get tossed out as not being a correct diagnostic marker for CFS.

    As you point out there are test that can be used to provide concrete evidence to people (doctors, family, employers, social workers and psychologist) that there is dysfunction in CFS/ME patients. It might be good to start a thread and list them in order to help all patients talk to their doctors about getting some diagnostic test done. Again that nasty problem rears it's head that not every test will diagnose every CFS/MEer.

    What I though I would try to achieve in this thread is to look at a the very best CLINICAL diagnostic criteria put together by the very best people and maybe spark some interest in getting the information out, pushing to get the CDC criteria changed and neaten up the playing field for researchers. If you listened to Dr. Bateman yesterday on the presentation she uses the CCC for diagnosing patients. She noted "most doctors are not aware of the Canadian Clinical Criteria."

    Maybe we can help get out the information. Or not.
  14. Sean

    Sean Senior Member

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    I think this is very likely. When this is all sorted I think we will find that many of us had subtle signs of health problems, possibly going back decades before full blown ME/CFS arrived. Pretty sure that is the case for me. I will also bet that these 'pre-onset' symptoms are often conventionally interpreted as behavourial pathologies, and this is one reason for psychological bias (up to recently, at least).

    Hopefully this will all change with a reliable XMRV test.

    Once an accepted reliable test for XMRV is available then we are going to see a straight division of patients into XMRV -ve and +ve. The +ves will be sent off to biomedical clinicians. The -ves will, unfortunately, get claimed by the existing psycho-social school in a desperate attempt to save face and retain some power.

    About the -ves, people like Wessely will still say:
  15. taniaaust1

    taniaaust1 Senior Member

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    I agree completely with this statement.. everyone is loosing out when possibly ones with other things are falling into the studies. I'd like to see the more severe cases more studied (but then that is often impossible as those are far too sick).

    One can know they have CC defined CFS but not be fitting that criteria at current time.. but ones who havent ever fit that picture should not be used for studies with ones who do.

    I myself dont currently fit CC defined CFS but i KNOW i have it as I did fit all the criteria for many many years.. and have never fully recovered. I could easily fall back into CC defined CFS/ME if i wasnt careful.
  16. taniaaust1

    taniaaust1 Senior Member

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    I dont know if its me just missing things or what.. but when i looked at those links there.. i couldnt find things which is in my Overview of the Canadian Consensus Document (this one i find much easier to read being an overview of the CC document). My local CFS/ME society has these booklets for only a couple of dollars, they are great to take with one to a doctor

    In this is also the recommended tests for the CFS/ME abnormalities which can help to back up a CFS/ME diagnoses

    http://sacfs.asn.au/download/consensus_overview_me_cfs.pdf CFS/ME "An overview of the Canadian Consensus Document"

    (there is also one for fibro)
    ......................

    This is another one which Sth Australia follows.. it also has the CC criteria there (but i like the CC overview Doc better)
    http://sacfs.asn.au/download/guidelines.pdf
  17. Angela Kennedy

    Angela Kennedy *****

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    I think establishing RESEARCH cohorts that fit CCC are an urgent need in order to progress research because of the other research criteria which are so flawed. That doesn't mean the CCC are perfect, not at all, but at least they could be superceded in due course if they helped establish stricter research cohorts with specific neuro-endocrine, cardiovascular, immunological and other abnormalities, instead of what the others allow (weeding those people OUT of research cohorts!!!)

    I think this in itself is an urgent research project and I am concerned that no researchers, with the exception of Jason, have been working on establishing the usefulness of the CCC in identifying more disabled people with more specific symptoms and signs . I do also think 'tweaking' the CCC for research should be done also.

    The failure of research groups to work on this has led to the chaos we see today. Many people appear, in Britain, to be a situation where they are exclusionary for CFS under the rubric of Oxford and Fukuda (and likely Reeves if they were in the US), so wouldn't be eligible for research cohorts, but nevertheless are treated as if they WERE Oxford or Fukuda patients (i.e. organic illness has been excluded) CLINICALLY. This is crazy stuff.

    This should be done whether XMRV pans out - or whether other culprits are still in sight: Lyme, parvo, mycoplasma etc.
  18. Sean

    Sean Senior Member

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    It is.

    But if XMRV pans out (including, of course, a reliable standardised test for it) then it will cut through all this nonsense very quickly, and we will be left with two basic groups, XMRV +ve and -ve.
  19. Angela Kennedy

    Angela Kennedy *****

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    And I have to say, So? There might (I'd argue will) still be people with severe neuro-endocrine-cardiovascular-immunological muti system dysfunction, possibly caused by OTHER micro-organisms.

    Leaving THOSE people (whoever they are, likely to be many of you) at the mercy of a psychiatric paradigm by default (because that is what is happening) is not an option. XMRV is NOT yet established as THE smoking gun, and may never be. So I have to disagree, 'cutting through the nonsense' will not be achieved by the mere 'panning out' of XMRV- presuming that ever pans out, considering the dog's breakfast currently being made over it.
  20. Sean

    Sean Senior Member

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    I don't disagree with that. But it does not negate what I said. If XMRV works out then we will end up with two groups, -ve and +ve, and that will help clarify things an awful lot. I don't see what is so contentious about that statement.

    I never said it was.

    Besides, I am one of those who think that their are almost certainly some primary psych patients being selected with the current definitions (at least with Fukuda, Oxford, and Reeves). We are probably going to end up with some -ve patients whose problems are primarily psychiatric (ie they never had true ME/CFS to start with). I don't have an inherent problem with that (though how they are managed is another issue).

    My problem has always been with the psych paradigm being applied to the wrong patients, or inappropriately applied to the right patients, not with psychiatry/psychology itself. Don't count me among the reflexively anti-psych ideologues.

    I did say if XMRV works out.

    With respect I think you do not fully understand just how major the change will be if XMRV does work out, and just how solid is the scientific work being done on it right now. I believe that many on the patient's side of the fence have been caught up in the fight with the psychs for too long, and (understandably) can't see the forest for the trees. Psychs may have had the upper hand for a while now, but they are not God, they do not have absolute authority, they are not invulnerable, and at least sometimes they can be held to account. Things change, and sometimes for the better. That may not be much comfort for many right now or even for a while to come, but have a little faith in the science, and its consequences. People can only deny reality for so long. One way or another it will out in the end.

    If, say, 80% of current CFS patients turn up +ve, and especially if it responds well to ARVs, then the psychs will be largely sidelined (particularly if XMRV also turns up in the general population at 5-10%, and is associated with other particular conditions and generally poorer health, including so called psychological problems). I know some of you can't believe that yet, and I understand why. But that has nothing to do with whether it will happen or not.

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