Multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for CFS Vos-Vromans

[Dolphin]

They plan to publish long-term data:

In recognition of the importance of long-term outcome in patients with CFS, follow-up of the participants in this trial at 5 years after the end of treatment is planned.

 

[Dolphin]

Final comment from me (for the moment anyway): as is common with these studies, there was no mention of biology/biological abnormalities that have been found in the condition (that I recall anyway).

 

[alkt]

Final comment from me (for the moment anyway): as is common with these studies, there was no mention of biology/biological abnormalities that have been found in the condition (that I recall anyway).

everything i have read which refers to psychological treatments downplays biological causes for disease. in the uk the psychological approach denies any research that points to biological causes for symptoms they advise doctors not to test patients once they have a diagnosis of c f s .m e. if you look back at liverpool patient handout from the c f s clinic no 2 on your informative threads list. you will know exactly where i am coming from.

 

[Kati]

Lots and lots of questionnaire data in this paper.

There is one set of objective measurements from an actometer:

Multidisciplinary rehabilitation treatment

So a 5.8% increase.

cognitive behavioural therapy

So a 6.55% increase

Note however that this was over 12 months and people after they get diagnosed are more likely to improve than disimprove, I think it's fair to say.

Quite a lot of people were in fairly early stages so quite likely to improve:


Even the people who are ill more than >5 years might improve "naturally", without therapy, if they have only been diagnosed. I think lots of people get a bounce in the year after getting diagnosed.

There is quite a lot of missing data with the activity monitors:

The researchers don't mention any sort of analysis to see whether the groups are different.

Thank you for your analysis, @Dolphin. Obviously there is no control in this study, where there are no interventions, or just family practitioner follow up.

 

[Kati]

These therapies, especially MRT, would not be cheap.

Actually health care systems rationalize that multi-disciplinary, mostly group education is still cheaper than providing this patients with competent medical treatments which includes access to testing and therapeutics which are not yet approved and which will need clinical trials.

They are still wanting to get the easy way out.

Vancouver opened such clinic offering mix CBT, then alternative medicine but essentially no medical care, no tilt table test, no blood testing, essentially very little in terms of medication if any at all. It will take quite a bit to get the program to change direction, because the province has to approve and like the director said: we can't give IV therapy because our nurse doesn't start IV's.

 

[Dolphin]

Actually health care systems rationalize that multi-disciplinary, mostly group education is still cheaper than providing this patients with competent medical treatments which includes access to testing and therapeutics which are not yet approved and which will need clinical trials.

In this case, it was one to one.

 

[A.B.]

Is it just me or are MRT and CBT basically the same approach?

The supposedly biopsychosocial approach in MRT is described as involving only psychosocial interventions.

Given the MRT treatment lasted 2.5 times as long as CBT, and given the lack of control group to see how the natual disease progression is when left untreated or with GP care, I'm not even sure this study shows anything.

 

[Valentijn]

@Dolphin - Does the study list the names of the clinics involved? I suspect my own ex-fatigue clinic is one And do they specify the CFS criteria used? Most patients at these clinics do not have any physical disability, though it's possible they selected the tiny subsection who do.

But basically MRT is being brainwashed by a small group of therapists instead of a single therapist. So I would expect that aspect to be a bit more effective for some patients, when the therapists team up to exert pressure.

My experience was also that the occupational therapist was of some use. They bizarrely include legitimately helpful suggestions for dealing with OI and PEM limitations while the other therapists are trying to suggest those limitations are very easily overcome with a little exercise, pregnancy, or "getting out more".

Other things they do are useful even if they intend them not to be. My occupational therapist asked me about an obstacle I had faced due to ME/CFS. I mentioned that after a bath I went downstairs immediately after drying off and getting dressed, but more-or-less collapsed about half-way down the stairs, and had to sit there for a while until I could stand up again. I came to the conclusion that I need to rest after baths before going downstairs. Though I later learned (reading the Dutch CBT manual) that they are supposed to use those scenarios to demonstrate our incorrect thinking about our illness, rather than how to better cope with the limitations of it

 

[medfeb]

Dolphin provided a link to the protocol - http://www.trialsjournal.com/content/13/1/71

which stated that they used Fukuda

Of the current definitions of CFS 3], we use the definition of the US Centers for Disease Control and Prevention (CDC-94): a persistent or relapsing unexplained fatigue, of new or definite onset and lasting for at least 6 months, in which fatigue is not the result of an organic disease or ongoing exertion. Rest does not alleviate the fatigue, and there is substantial limitation of occupational, educational, social and personal activities. To support the diagnosis, four or more of the following symptoms should be present for more than 6 months: impaired memory or concentration, sore throat, tender cervical or axillary lymph nodes, muscle pain, pain in several joints, new headaches, unrefreshing sleep or malaise after exertion.​

I don't know what the final paper said or whether it gives any information on the profile of patients by the core symptoms. Jason did a review of 53 Fukuda studies in which the percent of patients with PEM ranged from 25-100 percent.

 

[Dolphin]

@Dolphin - Does the study list the names of the clinics involved? I suspect my own ex-fatigue clinic is one And do they specify the CFS criteria used? Most patients at these clinics do not have any physical disability, though it's possible they selected the tiny subsection who do.

Patients referred to the Revant Rehabilitation Centre in Breda, Rehabilitation Centre Blixembosch in Eindhoven, Reade Centre for Rheumatology and Rehabilitation in Amsterdam and Adelante Rehabilitation Centre in Hoensbroek between December 2008 and January 2011 were invited to participate if they met the US Centers for Disease Control and Prevention (CDC-94) criteria for CFS [1].

I don't recall any mention of the percentage who had PEM in the paper.

 

[Valentijn]

Patients referred to the Revant Rehabilitation Centre in Breda, Rehabilitation Centre Blixembosch in Eindhoven, Reade Centre for Rheumatology and Rehabilitation in Amsterdam and Adelante Rehabilitation Centre in Hoensbroek between December 2008 and January 2011 were invited to participate if they met the US Centers for Disease Control and Prevention (CDC-94) criteria for CFS [1].

Interesting ... these aren't the usual fatigue centers. At least some handle both biological conditions (MS, cardiac, injury, etc) and what they likely view as psychological conditions (FM, CF, burnout, post-cancer fatigue, idiopathic pain). At least one specifically rejects people with the wrong attitude :

Contraindications are insufficient motivation, psychiatric disorders and a conflict with the employer.

I hope the CBT crap isn't spreading here. But at least people who also handle "real" illnesses should be able to understand concepts like "tachycardia" and "abnormal 2-day CPET" a bit better than the usual psychobabblers.

 

[jimells]

like the director said: we can't give IV therapy because our nurse doesn't start IV's.

Bureaucrats can always find some idiotic excuse to justify policies. I guess they just assume that since most of us are sick and poor we must also be stupid and ignorant. It says a lot about their attitudes when they can't even bother to make the lies sound plausible.

 

[jimells]

Is it just me or are MRT and CBT basically the same approach?

The supposedly biopsychosocial approach in MRT is described as involving only psychosocial interventions.

I was thinking that maybe MRT was CBT++ but my brain isn't digesting dense text too well right now. sigh.

 

[Kati]

Bureaucrats can always find some idiotic excuse to justify policies. I guess they just assume that since most of us are sick and poor we must also be stupid and ignorant. It says a lot about their attitudes when they can't even bother to make the lies sound plausible.

This is not a bureaucrat. It is a physician the director of the program.

 

[Snow Leopard]

The therapies were not matched for contact hours. MRT involved 44.5 contact hours and CBT 16 contact hours. This could affect how people might respond to questionnaires.

It potentially shows how a certain notable UK study could have been biased...

 

[Woolie]

I wonder could there be other things going on. Might low levels of education be associated on average with social deprivation and a greater array of problems in people's lives than perhaps could be helped a bit with all the contact hours they got with MRT?

Or maybe the less educated are more "suggestible" when it comes to filling in self-report scales?

 

[Woolie]

For those without the brain power to look right now, here is what MRT is:

A collaborating team from multiple disciplines examines and analyses patients’ functions, activities and level of participation, social environment and personal factors to develop an individual rationale for the development and persistence of fatigue. Following this individual rationale, CBT and elements such as gradual reactivation, pacing, mindfulness, body awareness therapy, normalization of sleep/wake rhythm and social reintegration are combined in a treatment programme.
...
It is hypothesized that a different combination of factors is responsible for the persistence of fatigue in each patient.

Other fun facts from the paper:

On recruitment: An interview with a psychologist was scheduled if the consultant suspected another psychiatric illness or motivational problem.

Reasons for withdrawing:
increase in complaints (1 CBT, 1 MRT)
no improvement (3 CBT,)
unwillingness to change behaviour (2 CBT, 2 MRT)
problems combining treatment with work and home (2 CBT)
unable to set treatment goals (1 CBT)
other (6)

And this gem:
On the finding that only those with low education showed the expected treatment effect, they say "Patients with a lower level of education might be less willing to accept that CFS may respond to a solely psychological treatment such as CBT and be more willing to believe that physical therapy and occupational therapy are necessary"

Final Discussion:
"... increasing patients’ insight into the relation and reciprocity between the mind and body, might cause a change in behaviour and influence sensitization processes in the central nervous system"

 

[alkt]

Or maybe the less educated are more "suggestible" when it comes to filling in self-report scales?

it could just be they had some patients with mild reactive depression about the only thing that cbt can actually improve although i am not aware of any studies regarding the longevity of any benefits accrued . it also seems the psychiatric lobby are not ready to give up on this particular golden goose.

 

[Cheshire]

There has been an "healthday news" short article (they don't even explain what is MRT) about this study, an it was published on a few websites:

http://www.gulfbend.org/poc/view_doc.php?type=news&id=175331&cn=72
http://medicalxpress.com/news/2015-08-multidisciplinary-rehab-tops-cbt-chronic.html
http://www.empr.com/medical-news/mu...-for-chronic-fatigue-syndrome/article/435698/
http://www.neurologyadvisor.com/sle...nary-rehabilitation-treatment/article/435703/

 

[Snow Leopard]

Final Discussion:
"... increasing patients’ insight into the relation and reciprocity between the mind and body, might cause a change in behaviour and influence sensitization processes in the central nervous system"

"Might" = weasel words. So many studies on this and all they have are unproven hypotheses.