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Russell, Wearden: Do evidence based interventions for CFS improve sleep? A systematic review

Discussion in 'Latest ME/CFS Research' started by mango, Aug 16, 2016.

  1. mango

    mango Senior Member

    Do evidence based interventions for chronic fatigue syndrome improve sleep? A systematic review and narrative synthesis

    Russell C1, Kyle SD2, Wearden AJ3.
    1. School of Psychological Sciences, University of Manchester, UK. Electronic address:
    2. Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
    3. School of Psychological Sciences, University of Manchester, UK.
    Sleep Med Rev. 2016 May 13. pii: S1087-0792(16)30012-0. doi: 10.1016/j.smrv.2016.05.001.


    Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) are recommended evidence based treatments for chronic fatigue syndrome (CFS), with research supporting their effectiveness in reducing fatigue and functional impairment.

    However, little research has focussed on the effect of these treatments on sleep, despite high reported sleep disturbance in CFS.

    Using a narrative synthesis approach, we aimed to 1) systematically identify and summarise the current evidence for the effectiveness of CBT and GET in improving sleep; 2) consider factors influencing treatment effectiveness, including incorporation of sleep management techniques; and 3) consider the appropriateness of sleep outcome measures used within evaluations.

    Studies evaluating CBT and/or GET for CFS, and including a sleep outcome were eligible for inclusion. Eight studies were identified.

    We found that GET interventions can improve sleep but this effect is inconsistent across studies.

    For CBT the evidence is limited with only one of two evaluations demonstrating sleep-related improvements. We conclude from existing research that we know little about the effects of including sleep management components within CBT and GET interventions.

    We suggest that future research should explore the effectiveness of sleep components within interventions, and sleep specific interventions, using comprehensive outcome measures that fully capture the range of sleep difficulties experienced in CFS.

    CBT; Chronic fatigue syndrome; Cognitive behavioural therapy; GET; Graded exercise therapy; Narrative synthesis; Sleep
  2. TiredSam

    TiredSam The wise nematode hibernates

    Oh good, my favourite. So precise, such a safeguard against bias ...
    Last edited: Aug 16, 2016
  3. Esther12

    Esther12 Senior Member

    After the Cochrane review found GET only improved self-reported sleep (although they spun other outcomes too) what a surprise that researchers suddenly decide that self-reported sleep is now a key outcome for patients.
  4. Keith Geraghty

    Keith Geraghty Senior Member

    there's nothing wrong with narrative reviews per se - I have written a few -

    if you want to find bias perhaps the beginning of the paper shows some

    "Moreover, a recent empirical study found that poorer perceived sleep predicted increased following-day fatigue in CFS [9], suggesting that improving perceptions of sleep is likely to be beneficial as a target in CFS interventions."

    this could easily be re-written as poor sleep predicts next day fatigue, suggesting that better sleep predicts less next day fatigue - but alas this paper is written by psychologists who like talking about 'perceptions and thoughts and feelings'

    For GET, a gradual increase in regular exercise may improve perceived sleep quality, as has been demonstrated in insomnia [14] and non-clinical samples [15].
    - some nice extrapolation from exercise studies - not CFS studies

    Next - a common problem in these types of reviews (one I have encounter myself) lack of evidence. The team only found 8 papers that related to ME/CFS and interventions CBT-GET that mentioned sleep - this is not the same as studied sleep, just sleep was in some way part of study or measured or looked at or mentioned. So the conclusions of this paper are based on this - 8 studies. *but wait

    Where appropriate data were available, the standardised mean difference (SMD) between treatment and control groups at follow up was calculated as a measure of effect size.
    2 had no SMD calculation Powell et al 1999 and Powell et all 2004
    1 had insufficient evidence Thompson et al 2006
    1 no SMD listed Fulcher et al 1997
    No control group for Wearden et al 2010 and CDC study 2011 we get down to 4 studies that looked at nterventions PR - GET and CBT

    from what I see all had no significant change on sleep other than Powell et al 2001 and White et al 2010 Which I assume is the PACE trial (White et al 2011) -- I think authors have made mistake in table 2 (ok where was reviewer)
    * so basically the positive evidence rests on Powell et al and White et al only -- 2 studies

    Ironically Wearden's FINE trial found no sig benefit on sleep using PR (the co-author of this paper)
    - they make some arguements the therapists werent trained enough in FINE or the patients were too ill to get benefit *isnt this a biased statement of speculation

    they say
    "We found that no studies had examined the effects of interventions on sleep as a primary outcome.
    but then go on (as I have often found the beginnings of exaggeration) to say
    "Taken together, the findings of the GET and PR interventions show that interventions based on GET principles can be effective at improving sleep in CFS but in line with what was reported in the a recent Cochrane review [17], this positive effect is not consistent across studies." yet this was not the case in my reading of this study

    then back to a bit of realism saying
    "Due to this variation and because of the small number of studies available, it is unclear whether incorporating sleep management components within CBT and GET enhances their effectiveness"

    this is where you just start wondering whats going on here:

    We did not find any CFS intervention studies which used objective recordings of sleep, such as polysomnography or actigraphy, to measure sleep-related outcomes possibly due to the fact that substantial research investigating sleep in CFS has found little evidence for objective sleep disturbance [42] and [43].

    - I dont think Ive met a CFS person who didnt say they had sleep problems; yet substantial investigating has failed to uncover any objective sleep disturbances ---- and I know this to be untrue I looked at IOM live talks by US sleep researchers

    read this
    However, because of the small number of studies, and because studies differed substantially both in design, sample inclusion criteria and outcomes, it was not possible to make strong conclusions based on our synthesis.

    then read this Im starting to think conclusion sections are a license to say what ever you want
    in conclusion, in spite of a limited number of high quality studies and some methodological limitations, the current evidence suggests that CBT and GET can improve sleep in CFS under certain conditions.

    An analysis of mechanisms of change in the White et al. [11] trial showed that the most important mediator of improvement in fatigue and physical functioning after both CBT and GET was a reduction in fear avoidance.

    - this paper didnt examine fear avoidance (what analysis) they keep quoting the trial not this analysis

  5. Sean

    Sean Senior Member

    In other words, you didn't find an effect.
  6. A.B.

    A.B. Senior Member

    More like, we haven't found a way to p-hack that into a positive result yet.
    Snow Leopard, Valentijn and Sean like this.
  7. Keith Geraghty

    Keith Geraghty Senior Member

    as far as I can see this paper is the work of a new psychologist who has done here PhD thesis on this topic. Now, I was a junior PhD myself, so my work probably wasnt the best in terms of quality, but what is difficult about this paper is that it is co-written by senior researchers from Oxford and Manchester. There is no way in the world one could argue that there is definitive evidence that CBT and GET improve sleep in CFS on the basis of 4 studies, two of which were poor. Now the most glaringly obvious problem here is that it probably wasnt the CBT or GET at all, even in those 2 or 4 studies - could it not be that the CBT therapist asked the patient with CFS to try get better sleep, turn off alarms, go to bed on time, focus on sleep. This is just sleep advice - its not part of CBT, theres no cognitive restructuring of dysfunctional beliefs but the authors give their game away in the conclusion that talks about fear avoidance.

    Its a paper with a good objective, but it should of stated theres too little evidence to draw any real conclusions and it should have mentioned that better sleep may well of come from sleep advice not CBT or GET.
  8. 2kidswithME


    Oxfordshire, England
    Thanks Keith, for your attention to the weak points in this research. great example of how to read papers thoughtfully and critically.
    Keith Geraghty and mango like this.

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