Here's my email to the CMAJ (main contact and ombudsman), copy to Dr. Jane Philpott, Canadian Minister of Health.
"The mission statement of the CMAJ includes the intent to “promote the health and well-being of the Canadian public.” By publishing the article “Prescribing exercise interventions for patients with chronic conditions”, you failed to do so with respect to one patient group – those with the illness Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). You further failed to meet four of eight CMAJ goals and objectives as follows:
- To provide accurate and up-to-date scientific and clinical information . . .
- To provide balanced insight and analysis, with a Canadian perspective . . .
- To maintain the highest standards of editorial integrity independent of any special interest.
- To keep readers abreast of trends and events that affect health and the delivery of health care in Canada and abroad.
The above-referenced article included chronic fatigue syndrome as a condition for which exercise intervention is effective. This advice is contraindicated for patients with ME/CFS, defined by the US National Institutes of Health as “an acquired, chronic multi-system disease characterized by systemic exertion intolerance”. In fact, the central characteristic of worsening symptoms and function after physical or cognitive activity is a feature that helps distinguish ME/CFS from other conditions. Subjective reports of Post Exertional Malaise (PEM) and prolonged recovery are supported by objective evidence in the scientific literature, including failure to normally reproduce exercise test results (2-day cardiopulmonary exercise test) and impaired cognitive function after exertion.
http://www.ncbi.nlm.nih.gov/pubmed/24755065
The authors of the article in question are all from Australia. Where’s the Canadian perspective? Regardless, by publishing inaccurate scientific and clinical information with respect to ME/CFS, you missed the opportunity to highlight several documents published domestically. For example:
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome – Canadian Consensus Document (CCC) http://sacfs.asn.au/download/consensus_overview_me_cfs.pdf
This is among the most-respected ME/CFS criteria documents in the world – so much so that it is being used to select patients for the US National Institutes of Health NIH Intramural Study on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.
http://mecfs.ctss.nih.gov/faq.html
The CCC states, on page four of the overview:
“Post-Exertional Malaise and/or Fatigue: Physical or mental exertion often causes debilitating malaise and/or fatigue, generalized pain, deterioration of cognitive functions, and worsening of other symptoms that may occur immediately after activity or be delayed. Patients experience rapid muscle fatigue and lack endurance. These symptoms are suggestive of a pathophysiology which involves immune system activation, channelopathy with oxidative stress and nitric oxide related toxicity, and/or orthostatic intolerance. Recovery time is inordinately long, usually a day or longer, and exercise may trigger a relapse.”
From the accompanying table, documented dysfunctional reactions to exercise experienced by ME/CFS patients include:
“elevated resting heart rate, reduced heart rate at maximum workload, sub-optimal cardiac output, decreased cerebral blood flow, decreased cerebral oxygen, decreased body temperature, breathing irregularities, and impaired oxygen delivery to the muscles”. Based on these impacts, how can exercise be deemed an appropriate intervention for ME/CFS patients?
Review of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: an evidence-based approach to diagnosis and management by clinicians (Alison C. Bested and Lynn M. Marshall)
http://www.degruyter.com/view/j/reveh.2015.30.issue-4/reveh-2015-0026/reveh-2015-0026.xml
This review, from one of Canada’s leading ME/CFS specialists, states the following:
“Graded exercise therapy: The Oxford criteria for chronic fatigue syndrome were used to assess graded exercise therapy (GET) and also for the Cochrane analysis. The Oxford CFS criteria do not exclude patients with psychiatric disorders: depressive illness, anxiety disorders and hyper-ventilation syndrome. It is known that depressed patients improve with activity. ME/CFS is a physical illness with post-exertional malaise. As a result of including patients with depression in the Oxford studies, the studies erroneously concluded that CFS patients improve with GET. . . Therefore GET is contraindicated and can be harmful for patients with ME/CFS using the CCC criteria.”
IDENTIFICATION AND SYMPTOM MANAGEMENT OF MYALGIC ENCEPHALOMYELITIS/CHRONIC FATIGUE SYNDROME -- Summary of the Clinical Practice Guideline – January 2016
http://www.topalbertadoctors.org/download/1929/MECFS CPG.pdf?_20160414151652
In Alberta, clinicians who take the time to study the above document (as opposed to reading the recent CMAJ article) will have accurate information and the tools necessary to appropriately diagnose and treat ME/CFS patients. With respect to exercise, this clinical practice guideline states the following on pages 12 and 13:
“COGNITIVE BEHAVIOUR THERAPY AND GRADED EXERCISE THERAPIES
In ME/CFS, both cognitive behavioural therapy (CBT) and graded exercise therapy (GET) have been rigorously studied using randomized control trial (RCT) analysis). . . . However on closer analysis of the literature,
there are several areas of concern. . . .
There is now an extensive literature showing that many of the assumptions underlying the use of CBT and GET in ME/CFS are incorrect for some or even most patients with ME/CFS. . . . . high rather than low activity level is a risk factor for ME/CFS.
. . . although the authors of a recent meta-analysis conclude that there is "no evidence suggesting that exercise therapy may worsen" outcomes,
data not included in this systematic review suggest otherwise. Although harms are not well reported in the RCTs, one trial reports patients receiving GET reported more adverse events compared with those receiving. . .adaptive pacing, or usual care; . . .
A growing literature shows that some patients with ME/CFS are unique from individuals with other conditions in that they are not able to replicate a maximal exercise test two days in a row despite objectively measurable maximal effort. Patients with other, serious medical conditions, even end stage heart disease and COPD are able to replicate their effort even if it is subnormal. The two-day cardio pulmonary exercise test (CPET) protocol may be a way to measure post exertional malaise though
the side effects of the test are considerable and less rigorous tests are being sought. . . . These data suggest that
increased activity has measurable physiological consequences and should be undertaken with caution in ME/CFS. In summary, all patients with ME/CFS have post exertional malaise (PEM) which limits the ability to exercise."
The “clear evidence” of exercise benefiting ME/CFS patients, as regularly regurgitated in medical journals and the media, originates from the discredited U.K. PACE study.
http://www.stats.org/pace-research-sparked-patient-rebellion-challenged-medicine/
In fact, 42 ME/CFS physicians, scientists and medical researchers are so strongly opposed to the PACE study’s recommendations regarding exercise for ME/CFS patients, they have sent a letter to the Lancet asking for an independent re-analysis of the individual-level trial data. In the opinion of these esteemed experts, “such flaws have no place in published research”.
http://www.virology.ws/2016/02/10/open-letter-lancet-again/
In closing, the article published in your journal is neither accurate, nor up-to-date. According to your website, “CMAJ has had substantial impact on health care and the practice of medicine in Canada and around the world.” You have done a grave disservice to ME/CFS patients by recommending a medical intervention that is harmful. I respectfully request that you correct this egregious mistake by publishing a retraction, together with articles that provide physicians with safe and appropriate options for diagnosing and treating this vulnerable and under-served patient population."