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Posted to Co-Cure Tue, 13 Feb 2001 16:28:12 -0500 by Fred Springfield

Neuropsychological functioning in chronic fatigue syndrome: a review

Full Title: Neuropsychological functioning in chronic fatigue syndrome: a review.
Journal: Acta Psychiatr Scand 2001 Feb;103(2):84-93
Author: Michiels , Cluydts R
Affiliation: Department of Psychology, Free University of Brussels, Brussels, Belgium.
NLM Citation: PMID: 11167310

OBJECTIVE: In this paper we review critically the current status of neurocognitive studies in patients with chronic fatigue syndrome (CFS).

METHOD: CFS literature was monitored as part of a large research project which involved several neuropsychological and psychopathological studies. The literature survey was the result of several consecutive searches on Medline and PsycInfo databases.

RESULTS: The neurocognitive studies are reviewed in terms of scientificaly accepted aspects of attention and memory. In addition, we review possible explanations for cognitive dysfunction in CFS. This is preceded with a discussion of the methodological limitations that are considered to explain inconcistencies across neuropsychological studies in CFS.

CONCLUSION: The current research shows that slowed processing speed, impaired working memory and poor learning of information are the most prominent features of cognitive dysfunctioning in patients with CFS. Furthermore, to this date no specific pattern of cerebral abnormalities has been found that uniquely characterizes CFS patients. There is no overwhelming evidence that fatigue is related to cognitive performance in CFS, and researchers agree that their performance on neuropsychological tasks is unlikely to be accounted solely by the severity of the depression and anxiety.

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Posted to Co-Cure Sun, 28 Jan 2001 21:49:59 -0500 by Fred Springfield

Fibromyalgia: Time to Consider a New Taxonomy?

Full Title: Fibromyalgia: Time to Consider a New Taxonomy?
Journal: Journal of Musculoskeletal Pain, Vol. 8(4) 2000, pp. 41-47
Author: Jan Dommerholt, MPS, PT
Affiliation: Pain and Rehabilitation Medicine, International Myofascial Pain Academy, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2432 [E-mail:prmdocs@ix.netcom.com ].
Submitted: November 3, 1999.
Revision accepted: January 12, 2000.

ABSTRACT.
Objectives: The purpose of this paper is to review whether the time has come to reconsider the use of the term “fibromyalgia" to describe this syndrome.

Findings: The term “fibromyalgia” suggests that fibrous and muscular abnormalities are causally involved in the etiology of the syndrome or that muscle pain is the most relevant clinical finding, however, current research suggests that there are no significant structural or functional differences between fibromyalgia and normal muscles. Persons with fibromyalgia have altered nociception, hyperalgesia, allodynia, and hypervigilance. The hyperalgesia is present not only over fibromyalgia tender points but also in nonpainful regions. Several studies have suggested that fibromyalgia is due to hypersensitivity of the central nervous system rather than pathologically painful muscles.

Conclusions: The etiology and symptoms of fibromyalgia are not due to structural or functional changes in muscle or fibrous tissues. Hence, the term “fibromyalgia” does not describe the etiology of the syndrome adequately. The International MYOPAIN Society could be a conduit for a change in taxonomy from “fibromyalgia" to tor example, “complex widespread pain syndrome,” or other name that adequately reflects the etiology and complexity of the syndrome that is now known as “fibromyalgia.”

KEYWORDS. Fibromyalgia, taxonomy, hypersensitivity, allodynia, etiology

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com   Website: www.HaworthPress.com ]

© 2000 by The Haworth Press, Inc. All rights reserved.

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Posted to Co-Cure Tue, 23 Jan 2001 11:05:04 +0100 by Dr. Marc-Alexander Fluks

Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy?...

Full Title: Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial.
Journal: British Journal of General Practice 51: (462) 19-24 Jan 2001
Authors: Leone Ridsdale, Emma Godfrey, Trudie Chalder, Paul Seed, Michael King, Paul Wallace, Simon Wessely and the Fatigue Trialists Group

Abstract:
Background: Fatigue is a common symptom for which patients consult their doctors in primary care, with usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care.

Aim: To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care.

Design of study: Randomised trial with parallel group design.

Setting: Ten general practices located in London and the South Thames region of the united Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas.

Method: Data were collected before randomisation, after treatment; and sir months later Patients were offered sir sessions of up to one hour each of either CBT or counselling. Outcomes include self-report of fatigue symptoms sir months later, anxiety and depression, symptom attributions, social adjustment and patients' satisfaction with care.

Results: One hundred and sixty patients with chronic fatigue entered the trial; 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al's standard criteria for fatigue. Mean fatigue scores were 23 on entry tar baseline) and 15 at sir months' follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after sir months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups.

Conclusion: Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.

Author Keywords:
chronic fatigue, cognitive behaviour therapy, counselling, randomised controlled trial

Addresses:
Ridsdale L, Univ London Kings Coll, Guys Kings & St Thomass Sch Med, Dept Gen Practice, 5 Lambeth Walk, London SE11 6SP, England.
Univ London Kings Coll, Guys Kings & St Thomass Sch Med, Dept Gen Practice, London SE11 6SP, England.
Univ London Kings Coll, Guys Kings & St Thomass Sch Med, Dept Publ Hlth Sci, London SE11 6SP, England.
Univ London Kings Coll, Inst Psychiat, Dept Psychol Med, London WC2R 2LS, England.
Royal Free & Univ Coll Med Sch, Dept Psychiat & Behav Sci, London, England.
Royal Free & Univ Coll Med Sch, Dept Primary Care & Populat Sci, London, England.

Publisher:
ROYAL COLL GENERAL PRACTITIONERS, LONDON IDS Number: 387HY
ISSN: 0960-1643

© 2001 Institute for Scientific Information

Remarks by Dr. Ellen Goudsmit

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Posted to Co-Cure Tue, 23 Jan 2001 11:03:52 +0100 by Dr. Marc-Alexander Fluks

Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy

Full Title: Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy
Journal: British Journal of General Practice 51: (462) 15-18 Jan 2001
Authors: Daniel Chisholm, Emma Godfrey, Leone Ridsdale, Trudie Chalder, Michael King, Paul Seed, Paul Wallace, Simon Wessely and the Fatigue Trialists Group

Abstract:
Background: There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue.

Aim: To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primacy care settings for the treatment of fatigue.

Design of study: A randomised controlled trial incorporating a cost-consequences analysis.

Setting: One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months.

Method: An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving; and lost employment. The principal outcome measure war the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale.

Results: Although the mean cost of treatment was higher for the CBT group (pound 164, standard deviation = 67) than the counselling group (pound 109, SD=49; 95% confidence interval = 35 to 76, P<0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score).

Conclusions: Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.

Author Keywords:
chronic fatigue, counselling, cognitive behaviour therapy, randomised controlled trial, cost-consequences analysis

Addresses:
Chisholm D, WHO, GPE EIP, CAS Team, Room 3173, CH-1211 Geneva 27, Switzerland.
Kings Coll Med, Ctr Econ Mental Hlth, London, England.
Kings Coll Med, Dept Neurol, London, England.
Inst Psychiat, London, England.
Univ London Kings Coll, Inst Psychiat, Dept Psychol Med, London WC2R 2LS, England.
Guys Kings & St Thomass Med Sch, Dept Publ Hlth Sci, London, England.
Guys Kings & St Thomass Med Sch, Dept Gen Practice, London, England.
Royal Free & Univ Coll Sch Med, Dept Psychiat & Behav Sci, London, England.
Royal Free & Univ Coll Sch Med, Dept Primary Care & Populat Sci, London, England.
Publisher:
ROYAL COLL GENERAL PRACTITIONERS, LONDON

IDS Number: 387HY
ISSN: 0960-1643

© 2001 Institute for Scientific Information

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Posted to Co-Cure Mon, 22 Jan 2001 11:51:20 -0500 by Fred Springfield

Treatment of Fibromyalgia with Intravenous Application of Tropisetron

Full Title: Treatment of Fibromyalgia with Intravenous Application of Tropisetron
Journal: Journal of Musculoskeletal Pain, Vol. 8(4) 2000, pp. 31-40
Authors: Thomas Stratz, Lothar Färber, Boglarka Varga, Ulrike Haus, Christoph Baumgartner, Wolfgang Müller
Affiliations:
Dr. Thomas Stratz, Dr. Boglarka Varga, Dr. med. Christoph Baumgartner, and Dr.Wolfgang Müller, Professor, are affiliated with Hochrheininstitut für Rehahiliationsforschung, Bergseestr. 61, D-79713 Bad Säckingen.
Dr. Lothar Färber and Dr. Ulrike Haus are affiliated with Novartis Pharma GmbH, Abt. MEO, Roonstr. 25, D-90429 Nürnberg.
Address correspondence to: Professor Dr. Wolfgang Müller, Hochrheininstitut für Rehabilitationsforschung, Bergseestr. 61, D-79713 Bad Säckingen, Germany.
Submitted: July 2, 1999.
Revision accepted: February 14, 2000.

ABSTRACT.
Objective: As in a prospective, randomized, placebo-controlled, multicenter, double-blind trial in fibromyalgia [FMS] a significant reduction of pain especially, but of other symptoms as well, could be gained after 10 days of peroral daily treatment with 5 mg tropisetron, the question was evaluated as to whether quicker and better effects could be achieved with intravenous application of 2 mg tropisetron daily for a limited period of time.

Methods: In the first cohort, 18 FMS patients received a single bolus intravenous [i.v.] injection of 2 mg tropisetron, in the second cohort 24 FMS patients were treated with 2 mg i.v. bolus injection [of] tropisetron daily for five days. Pain intensity was measured with the visual analog scale and the pain score; pain at the tenderpoints and control points [dolorimeter] was evaluated as well as 17 ancillary symptoms before and after treatment; furthermore, pain intensity was followed up by means of a patient diary, until pain recurrence.

Results: Even with a single i.v. injection of 2 mg tropisetron a significant pain reduction as well as an enhancement of the pain threshold provable by dolorimetry could be achieved; however, this lasted only a few days. Three out of these 18 patients did not respond at all to therapy. If 2 mg tropisetron were applied daily for five days, 23 of 24 patients showed a pain reduction, which lasted for two weeks to two months in 20 of these patients. Two patients stopped filling in the pain diary. Twelve ancillary symptoms such as sleep disturbances, fatigue, morning stiffness, and others, were also significantly improved by the latter treatment. In the global assessment 16 out of 24 patients showed a significant improvement and seven showed a slight improvement of their disease. There was only one patient who did not experience any improvement. Tolerability was good.

Conclusion: Intravenous injection of 2 mg of the 5-HT[3] receptor antagonist tropisetron once daily for five days can often produce a longer-lasting therapeutic effect on fibromyalgia symptoms. The results achieved are now being evaluated in a randomized, placebo-controlled,double-blind trial.

KEYWORDS. Fibromyalgia, pain, treatment, tropisetron

INTRODUCTION

Serotonin metabolism seems to play an important role in the pathophysiology of primary fibromyalgia [FMS] as lowered levels of tryptophan in plasma (1) and serotonin in serum and plasma have been found by various groups(2,3). One reasonable explanation for the lowered levels may be an enhanced serotonin binding to 5-hydroxytryptamine-3 [5-HT3] receptors which in turn leads to the release of substance P (4). Substance P is a highly potent mediator of pain and seems to be important in triggering pain in FMS as high concentrations of it are found in the liquor (5, 6 and others) as well as, perivascular, in the skeletal muscle (7) in FMS patients. One may assume that the release of substance P is inhibited by blocking the 5-HT[3] receptors. Thus, one could explain why patients experienced a significant pain reduction in a pilot study (8) as well as later in a prospective, randomized, placebo-controlled, multicenter study (9) using the 5-HT[3] receptor antagonist tropisetron over 10 days of treatment.

In the above-mentioned study by Färber et al. (9), FMS patients showed a significant pain reduction on 5 mg tropisetron orally once a day over 10 days as compared to placebo. As emesis caused by treatment with cytotoxic drugs can he suppressed faster by intravenous [i.v.] application of 5-HT[3] receptor antagonists, we addressed the question of whether or not pain reduction and improvements of other symptoms in FMS might be more pronounced by i.v. injection of tropisetron and whether treatment outcome on oral treatment could be predicted by i.v. application upfront.

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com   Website: www.HaworthPress.com ]

© 2000 by The Haworth Press, Inc. All rights reserved.

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Posted to Co-Cure Sat, 20 Jan 2001 14:47:08 -0500 by Fred Springfield

Correlation Between Tender Points and the Fibromyalgia Impact Questionnaire

Full Title: Correlation Between Tender Points and the Fibromyalgia Impact Questionnaire
Journal: Journal of Musculoskeletal Pain, Vol. 8(4) 2000, pp. 19-29
Authors: Bente Jensen, MD, PhD student; Irene Hechmann Wittrup, MD, PhD student; Henrik Røgind, MD, PhD student; Bente Danneskiold-Samsøe, MD, DMSc; Henning Bliddal, MD, DMSc, Professor
Affiliation: Parker Institute, Department of Rheumatology, Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Copenhagen, Denmark.
Address correspondence to: Bente Jensen, P.G. Ramms Alle 11, Ith, 2000 Frederiksberg, Denmark.
Received: September 28, 1999.
Revision accepted: December 1, 1999.

ABSTRACT.
Objectives: To investigate a possible correlation between the number of tender points [TePs] and the myalgic score versus the Activities of Daily Living [ADL] items and the pain visual analog scale [VAS] of the Fibromyalgia Impact Questionnaire [FIQ].

Methods: Consecutive patients with fibromyalgia were included [N = 221; 213 females, eight males, mean age 46 years] The diagnosis was established using the criteria of the American College of Rheumatology: widespread pain for at least three months and pain on palpation in at least 11 out of 18 specified TeP locations. A 4-point (0-3) scale of pain severity was used. Each patient was evaluated by the number of TePs and by a myalgic score expressed by the summation of the pain severity score multiplied by the respective number of TePs.

Before the clinical examination the patients filled in the FIQ. The first 10 subitems of the FIQ, measuring physical functioning [FIQ-ADL], were used.

Results: The FIQ-ADL was correlated to the following parameters: pain on the VAS [r(s) = 0.46; P < 0.001], the myalgic score [r(s) = 0.30; P < 0.001], and the number of TePs [r(s) = 0.20; P 0.003].

Some correlation between the myalgic score and pain on the VAS was seen [r(s) = 0.15; P = 0.004]. We found no correlation between the number of TePs and pain on the VAS.

Conclusion: As an indicator of disability the myalgic score appears to be preferable to the number of TePs. Self-reported pain is correlated to the physical function as expressed by the FIQ-ADL.

KEYWORDS. Tender points, myalgic score, fibromyalgia, pain, fibromyalgia impact questionnaire

INTRODUCTION

Fibromyalgia [FMS] is a common chronic musculoskeletal disorder characterized by widespread pain and multiple painful tender points [TePs]. This condition is accompanied by varying degrees of disability and impaired function (1).

The lack of objective standardized outcome variables and measures represents a major problem in FMS treatment research, and complicates a comparison of the outcome of different treatment programs. Reliable measures for the assessment of change among FMS patients are important to determine treatment efficacy in controlled clinical trials.

Treatment has proved difficult with mostly disappointing results (2). One explanation could be that there are subgroups of patients who require different treatments according to differences in etiology and pathogenesis. However, until FMS patients can be dissected into such subgroups it is important to use the most sensitive general outcome measure for this population.

Tender point count has not only been used diagnostically, but also as an indicator of disease severity and outcome measure in FMS (3,4). Although TePs are the hallmark of the diagnosis, their number, location, and how to measure the tenderness are controversial.

Recent population studies (5,6) indicate that FMS is not a discrete disorder, and that FMS may be regarded as the upper end of a spectrum characterized by distress. The number of TePs per se may not be sufficient for the description of the severity of the disease. The patient’s reaction to the examination of the TeP may add important information of both physiological and psychological factors.

The severity of pain in each TeP as measured in the myalgic score may be a more sensitive marker of separating FMS from other pain conditions. A total myalgic score has been defined as the summed tenderness score of the individual (7).

Tenderness can be measured by direct digital palpation or by pressure dolorimetry. In dolorimetry it is expressed in kilograms per square centimeter and in digital palpation by estimating the tenderness at each point on a scale rating from 0-3 or from 0-4. Previous studies have used both methods as outcome measures in clinical trials (3,7-12) as presented in Table 1.

Several well established instruments are available for the measurement of health status and functional disability in persons with rheumatic diseases. The Fibromyalgia Impact Questionnaire [FIQ] is a brief 10-item self-administered instrument that measures physical functioning, work status, depression, anxiety, sleep, pain, stiffness, fatigue, and well being. Thus it measures the overall severity of FMS. A decreasing score would indicate improvement or less negative impact. The first 10 subitems of the FIQ concern different Activities of Daily Living [ADL]. The FIQ has been shown to be suitable for FMS (13).

Objective measures of physical function of the FMS patients are assessed by different walk, step, and endurance tests (3), by spinal mobility tests (14), and by the muscle strength (15). However, they are of limited value since motivation plays an important role in these tests.

The aim of this study was to investigate a possible correlation between the number of TePs and the myalgic score versus the ADL items and the pain visual analog scale [VAS] of the FIQ.

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com   Website: www.HaworthPress.com ]

© 2000 by The Haworth Press, Inc. All rights reserved.

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Posted to Co-Cure Sat, 20 Jan 2001 13:14:15 -0500 by Fred Springfield

Raised Plasma Adenosine Associated with CFS...

Full Title: Raised Plasma Adenosine Associated with Chronic Fatigue Syndrome: A Preliminary Study
Journal: Journal of Chronic Fatigue Syndrome, Vol. 7(3) 2000, pp. 77-85
Authors: John A. Duley, PhD; D. Paul Garrick, MA, FRC Path; David A. Pratt, BCom (Ace)
Affiliations:
John A. Duley is Clinical Scientist, Purine Research Laboratory, and Honorary Lecturer in Chemical Pathology, Guy’s & St. Thomas’ Hospitals, London, UK.
D. Paul Garrick is Clinical Scientist in Chemical Pathology, Leicester Royal Infirmary, Leicester, UK.
David A. Pratt is a CFS sufferer, who both conceived the idea of studying adenosine and organised the CFS volunteers for this study.
Address correspondence to: Dr. John A. Duley, Purine Research Laboratory, Guy’s Hospital, London, SE1 9RT, UK.
The authors are indebted to Dr. J. G. Astles, a Leicester GP, for his invaluable aid in collecting specimens and for his much appreciated support of this study.

ABSTRACT.
Plasma adenosine levels were measured in a small trial study of eighteen volunteers, aged 36-85 years. Volunteers comprised nine with chronic fatigue syndrome (CFS), four with ‘other fatigue’ illnesses, and five with no history of fatigue illnesses but some of whom were related to chronic fatigue sufferers. Plasma adenosine was slightly raised above the minimum detectable level (approx. 1 micromole/L) in one healthy non-fatigued volunteer and grossly raised (greater than 5 micromoles/L) in two non-fatigued volunteers, both of whom were related to CFSs. Among the nine CFSs, all had plasma adenosine raised above baseline, and seven were grossly raised. High adenosine levels were also seen in two of the volunteers with ‘other fatigue.’ Raised adenosine occurred among certain families, suggesting a genetic metabolic element. Instability of adenosine in frozen stored plasma was noted. High levels of adenosine probably do not exist freely within peripheral plasma but may be released from blood cells locally within tissues or in response to venipuncture stress or other factors. The results may be highly relevant to other pathologies such as heart disease.

KEYWORDS. Chronic fatigue syndrome, adenosine, myeloadenylate deaminase, platelets, nucleotides

INTRODUCTION

The vasoconstrictive or dilative effects of adenosine in differing tissues are well known. More recently, adenosine in cerebrospinal fluid has been shown in animal studies to accumulate with brain cell activity, acting as a circadian rhythm modulator by increasing during wakefulness and decreasing during slow wave sleep (1). Other studies show that adenosine also increases interleukin-10, a cytokine which suppresses the immune system (2), an explanation of why sleep deprivation (or excessive physical/mental effort) may lead to a diminution of the immune response. In the central nervous system, adenosine has been shown to have profound depressive effects on neuronal function (3). Fatigue is a common complaint in many illnesses, but particularly with multiple sclerosis (MS) and chronic fatigue syndrome (CFS). Definition and causation of the latter have been complicated by the diversity of symptoms (4,5), but immune abnormalities, sleep disturbance and low blood flow to the brain have all been reported (6), possibly implicating adenosine as a causative or etiological factor. As there have been no reports on extracellular adenosine in CFS, it was decided to measure plasma adenosine in a small group of fatigued and non-fatigued volunteers to provide some preliminary data.

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com   Website: www.HaworthPress.com ]

© 2000 by The Haworth Press, Inc. All rights reserved.

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