Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Posted on
June 30, 2015
PD White, MD,1 DJ Clauw, MD,2 JWM van der Meer, MD,3 R Moss-Morris, PhD,4 RR
Taylor, PhD,5
1. Wolfson Institute of Preventive Medicine, Barts and the London
School of Medicine, Queen Mary University, London, UK 2. Department of
Anesthesiology, Medicine and Psychiatry, University of Michigan
Conflict of Interest: PDW, JWMvdM and RMM were principal investigators or
co-investigators in some of the trials reviewed. PDW does consultancy work
for the UK government and a re-insurance company.
In their systematic review, Smith and colleagues concluded that "trials of .
counseling therapies, and graded exercise therapy suggest benefit for some
patients meeting case definitions for CFS, whereas evidence for .. harms is
insufficient."(1)
While we support the general conclusion of benefit with these treatments, we
suggest that some aspects of this review may be misinterpreted. Firstly, the
most frequently tested behavioural intervention has been cognitive behaviour
therapy (CBT), which aims to reduce symptoms and improve functioning, and it
would be unusual to consider this as "counseling", which has different
objectives and content. One would not combine different types of medicines
in a review; why do this with therapies? A review that combines counselling
and CBT simply dilutes the efficacy of CBT, which has been amply
demonstrated in several previous meta-analyses (2).
Secondly, there is little evidence of harm caused by graded exercise therapy
(GET); a Cochrane systematic review of eight trials of exercise therapy for
chronic fatigue syndrome (CFS), published this year, concluded that "..no
evidence suggests that exercise therapy may worsen outcomes." (3) Suggesting
evidence of harm by stating that "one trial reported significantly more
serious adverse events ..and more nonserious adverse events . in the GET
versus comparison groups,." without mentioning that serious adverse events
were independently judged to be unrelated to the intervention, and that the
differences between non-serious adverse events was not statistically
significant, is a potentially misleading representation of the evidence.
Adding that "..in a trial of GET, 20% of patients declined to repeat
exercise testing because of perceived harm of testing" encourages further
misunderstanding by failing to mention that the exercise testing was not
part of the therapy and that the proportion of patients in the control
intervention who also declined exercise testing was 50% (4). (Incidentally
the proportion declining testing in the GET arm was 44%, not 20%.4) There is
a world of difference between the effects of maximum exercise testing and
graded exercise therapy. It is important not to overemphasise the harms
associated with an effective treatment when there are so few others
available.
Finally, the authors concluded that we need trials with analyses of patients
meeting different case definitions; we agree and this has already happened.
White and colleagues found no statistically significant differences in the
efficacy of CBT and GET in sub-groups of those patients meeting Oxford
criteria for CFS who also met either CDC defined CFS or myalgic
encephalomyelitis (ME)(5).
Note: Seven other CFS clinical scientists supported and approved this
letter.
References
1. Smith MEB, Haney E, McDonagh M, Pappas M, Daeges M, Wasson N, et al.
Treatment of myalgic encephalomyelitis/chronic fatigue syndrome: A
systematic review for a national Institutes of Health pathways to prevention
workshop. Ann Intern Med 2015; 162: 841-50.
2. Castell BD, Kazantzis N, Moss-Morris RE. Cognitive behavioral
therapy and graded exercise for chronic fatigue syndrome: A meta-analysis
Clin Psychol Sci Prac 2011; 18: 311-24.
3. Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy
for chronic fatigue syndrome. Cochrane Database of Systematic Reviews 2015,
Issue 2. Art. No.: CD003200.
4. Moss-Morris R, Sharon C, Tobin R, Baldi JC. A randomized controlled
graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms
of change. J Health Psychol 2005; 10: 245-59.
5. White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC,
et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy,
graded exercise therapy, and specialist medical care for chronic fatigue
syndrome (PACE): a randomised trial. The Lancet 2011;377:823-36.