People who have chronic fatigue syndrome (CFS) and Fibromyalgia (FM) often struggle with a kind of mental “fog”. We don’t understand why and there’s been little research on how to think more clearly. Mild Cognitive Impairment or MCI presents with a different kind of cognitive “fog” but it’s form might feel familiar. MCI affects some 15-20% of Americans, aged 65 and older. While anyone can develop MCI, the risk is higher among people who have a high blood level of the amino acid homocysteine. High homocysteine also predicts a higher risk for developing full-fledged Alzheimer’s Disease.
I interviewed Dr. ALan Light, Ph. D by Skype in a three part video series. His research is among the very most innovative and important in the fields of chronic fatigue syndrome and Fibromyalgia. He, along with Lucinda Bateman, M.D. and colleagues from the University of Utah School of Medicine, has successfully conducted one study out of a very few that identify an objective laboratory marker which closely correlates with the patients’ “subjective” complaint of prolonged fatigue after modest exertion. This proves that the patients’ subjective reports of post-exertional malaise (PEM) are honest, real and based on physical events. More details on this study and its significance can be found on the following three 10-minute videos and text below.
Segment 1: Provides background on why and how this research was developed
Segment 2: Provides details about this critical study
Segment 3: Reactions from the scientific study and next steps
Details of Study
Dr. Light, Lucinda Bateman, M.D. and colleagues from the University of Utah School of Medicine measured output of messenger RNA output from 13 selected genes. They did this just before, shortly after, and for 48 hours following very modest exercise on a stationary bicycle. The subjects included 48 patients with CFS with or without co-occurring FM, 18 patients who had FM but not CFS, and 49 healthy controls. The 13 genes monitored related to sensory nerve signaling, cytokine and immune function and the sympathetic nervous system.
All CFS and FM patients reported increased symptoms of pain or fatigue for a full 48 hours following the exercise. In controls, there was no reported fatigue and no significant change in gene expression. All subjects showed objective changes in the RNA output from key genes which also lasted a full 48 hours.
There were two distinct patterns of response: In 71% of patients with CFS moderate exercise increased messenger RNA output from 12 of the 13 genes. This was true whether or not they also had FM. Most of these genes related to inflammation or nerve signaling. In the other 29% of CFS patients, exercise caused a decrease in output of messenger RNA from an adrenalin related gene. Many of these patients also had a clinical history of orthostatic intolerance (low blood pressure with prolonged standing). In contrast, the FM-only patients showed no post exercise changes in gene expression. Text on the full study and results can be found at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2011.02405.x/full
By showing changes in gene output this objectively proves that the fatigue and pain are real and are mainly physical., Dr. Light’s work appears to identify two different subgroups of CFS patients—one where pro-inflammatory genes turn on, and a second type where blood pressure tends to fall and an adrenalin related gene turns down its activity. Dr. Light’s work also suggests that Fibromyalgia can occur in two different forms—one that is closely associated with CFS and one which is not.
In the U.S., few physicians or scientists still believe that ME/CFS is mostly “all in your mind”. At last, the National Institutes of Health (NIH) has also come on board. NIH has charged the National Institute of Neurological Disorders and Stroke with the (not yet budgeted) task of advancing research on ME/CFS. But, in Europe, influential elements remain committed to the view that ME/CFS is mainly a problem of psychological distress. This stress, they argue, causes people to become inactive. Inactivity then causes physical deconditioning—much like the astronaut who can barely stand up when she first returns from space.
The PACE Study
Sadly, promoting this “psychosomatic” view tends to discourage research institutions, aspiring scientists, drug companies and philanthropies from committing to research toward understand our illness. The PACE study, done in England, is often cited to justify the “all in your mind” hypothesis. This study created three groups of patients with a chronic fatigue like illness. The researchers gave patients in one group a cognitive behavioral psychotherapy program. A second group did a gradually graded exercise program. The control group had no exercise or psychotherapy program. Instead they were treated by physicians who were said to specialize in ME/CFS but did not receive psychotherapy or graded exercise.
Issues with PACE
The PACE study has flaws. Some of these flaws could undermine the study’s conclusions. For example, it’s not at all clear that all the study subjects actually had what we would agree is either ME or CFS. Serious questions have been raised as to potential bias in how the authors’ decided which patients had improved and which patients had not. Nor is the claimed degree of improvement anywhere close to what one might view as a “cure”. But, even more troublesome is the false extrapolation from the PACE data that people who should know better have made—even if the study’s reported results were perfectly correct.
Cognitive behavioral therapy is a useful technique to help train people into the habit of positive thinking. Basically, this means seeing the glass as half full instead of half empty. Cognitive therapy has been shown to help people cope better with many different forms of indisputably physical health problems including heart disease, cancer, rheumatoid arthritis and others. Similarly, carefully monitored exercise reconditioning, if done within a patient’s limits, can modestly help people with physical illness of many types somewhat improve how they feel and function.
What’s mischievous about how the PACE study has been used is that by implying that better coping through psychological support and/or reconditioning is the answer gives the impression that the illness involved is substantially psychosomatic. No one would claim that for a patient with angina, emphysema, rheumatoid arthritis or cancer. Why assign that blame to patients with ME/CFS? But, since PACE study-related debate continues, it might be refreshing to review a study, also from England, where a psychological intervention for chronic fatigue indisputably FAILED.
298 patients with long term chronic fatigue (not clearly defined as ME/CFS) received either one of two forms of psychological counseling—“pragmatic rehabilitation” or “supportive listening”. The “control group” had routine treatment with their general practitioner. The “pragmatic rehabilitation” therapy taught patients about physical deconditioning, coping with anxiety, improving sleep and “overcoming impediments to change”. “Supportive listening” focused on “creating an emotional and physical environment conducive to helping relationship”.
Researchers scored each patient’s fatigue and related symptoms, using the Chalder fatigue scale (an 11 questions survey asking about people’s symptoms and activities) at entry, after 20 weeks and then again about a year later. After 20 weeks the average score in all three groups improved but only modestly. Scores in the pragmatic rehabilitation group were modestly better than either the “supportive listening” or the general practitioner groups. At 20 weeks the advantage to pragmatic rehabilitation was statistically significant. But, by 70 weeks no further improvement had occurred in any of the 3 groups. And the difference between pragmatic rehabilitation treatment and the general practitioner group was no longer statistically significant. Basically, the two different forms of behavioral/psychological counseling had at best a very modest short term impact on the severity of illness. Over the long run the psychological component had no meaningful impact.
Take Away Thoughts
Why is this important? So as long as those who matter believe ME/CFS is mainly “all in your mind”, everyone suffers—patients, their families, aspiring scientists, health care budgets and society in general. (Well maybe not the disability insurance companies.) But our patients’ battle is far from won even in the USA.
NIH has committed itself to look seriously at ME/CFS. But, no increase in budget has yet been set. Please recall this. For 2015 and 2016 NIH budgeted only about $5 million a year to study ME/CFS, while the Centers for Disease Control estimates that more than one million Americans suffer from chronic fatigue syndrome. In contrast, an estimated 400,000 Americans have Multiple Sclerosis. NIH’s budget for MS? About $98 million a year. This isn’t a knock against MS research; just a comparison.
NIH has not yet committed to a new and presumably higher budget for ME/CFS. As all such decisions reflect a mix of political and scientific issues, those among us who have any credibility with federal legislators or bureaucrats—this might be a good time to employ some of our clout.
We welcome any comments you have especially your experiences with psychological counseling. Thank you.
When we talk with Chronic Fatigue Syndrome patients we learn that before they became ill, some were exposed to water-damaged buildings (WDB) or other mold sources. This raises two questions:
- Are people with CFS more likely to have been exposed to WDB or mold than are healthy persons?
- If we reduce a CFS patient’s mold burden would this improve their symptoms?
We can’t answer either question definitively yet. But, both questions are highly relevant–especially the first. One reason is the commercial availability of a new test that measures the amount of mold toxin (mycotoxin) in a person’s urine.
Dr. Joseph Brewer, an infectious disease specialist from St. Louis, addressed the first question. Dr. Brewer reports that chronic fatigue syndrome patients are much more likely than healthy people to have mold toxin in their urine. This suggests that mold exposure might be an important causal contributor to CFS.
Dr. Brewer studied 112 patients all of whom met the Center for Disease Control’s 1994 criteria for Chronic Fatigue Syndrome. Using RealTime Lab’s urine test for a panel of three mycotoxins, Brewer found that 94% of his CFS patients had at least one kind of mycotoxin detected in their urine. Most importantly, these patients were NOT selected because they were already known to have a history of mold or WDB exposure. They were selected for this study only because they had presented with CFS. However, as it turned out, 90% of these patients did have exposure to a water damaged building.
But, wait! Might many healthy people also have mold toxins in their urine? Dr. Brewer did not recruit healthy controls to compare with his patients. Instead he relied on an earlier study done by RealTime Laboratories. RealTime tested 51 healthy persons who had no history of exposure to water damaged buildings. Among these not even one tested positive for mycotoxins.
My thoughts: The validity of RealTime’s study is critical.
If this “stand in” for a control group reasonably represents the general population then Dr. Brewer’s finding that almost all CFS patients had mold toxin in their urine strongly supports a causal connection between mold exposure in this illness. Therefore, it is a critical priority to confirm or deny RealTimes report that healthy people rarely have mycotoxin in their urine.
Others are skeptical. The Center for Disease Control and several “mainstream” environmental specialists I spoke to doubt the usefulness of urine mycotoxin testing. From CDC’s Morbidity and Mortality report:
Low levels of mycotoxins are found in many foods; therefore, mycotoxins are found in the urine of healthy persons. Mycotoxin levels that predict disease have not been established. Urine mycotoxin tests are not approved by FDA for accuracy or for clinical use … Persons using direct-to-consumer laboratory tests that have not been approved by FDA for diagnostic purposes and their health care providers need to understand that these tests might not be valid or clinically useful. Additional information about molds and their health effects is available at www.cdc.gov/mold/faqs.htm#mold.
Paradigmchange.me, a resource which focuses on mold problems, is also skeptical about the use of the mycotoxin test especially the claim that people who have not lived in sick buildings almost never have urine mycotoxins. But, they do believe that mold is an important trigger for ME/CFS.
Dr. Brewer understands these issues and welcomes further research that can confirm our deny his findings.
Dr. Brewer also addressed the second question – Does treating for mold help CFS patients feel better? Brewer treated 151 mycotoxin positive CFS patients with intra-nasal Amphotericin, a potent anti-fungal agent.
Ninety-four patients of the original 151 tolerated Amphotericin and remained on treatment for six months or more. Among these 88 out of 94 reported an improvement in their symptoms of at least 25%. Twenty six patients (30%) rated themselves as between 75-100% improved. If confirmed, these are very impressive results. Brewer reported similar benefits with intra-nasal Nystatin.
Sadly, neither of Brewer’s treatment trials had a placebo arm. So, we cannot say for sure whether the reported benefits are real. Perhaps patients told Dr. Brewer what they thought he wanted to hear. Perhaps they felt better because Dr. Brewer took them seriously. Perhaps a placebo effect, etc.
For now, all we can say is that Brewer’s results are encouraging, but not conclusive. And the mainstream literature is discouraging. For example, patients with chronic sinusitis often have fungal infections. But 3 double blind studies found that treatment with Amphotericin was no more effective than was using a placebo.
My Bottom Line: Dr. Brewer’s work is strong enough to justify that the CFS-advocacy community invest time and money to do a rigorous controlled study testing whether Dr. Brewer’s potentially critical findings can be reproduced.
I suggest that until more evidence appears:
- Dr. Brewer should be praised for his great effort in launching his studies. Doing research from a private practice base is very demanding.
- Since there are no proven treatments for ME/CFS and since preliminary evidence favors a role for mold, it’s not unreasonable for CFS patients to consider consulting Dr. Brewer or other “alternative medicine” minded health specialists such as Ritchie Shoemaker, M.D. who have experience treating CFS patients for mold.
- BUT be aware that these treatments might or might not in fact be useful. Without better research we cannot know for sure. Mainstream environmental specialists, including CDC, doubt the clinical value of urine mycotoxin testing.
- Evaluation for mold can be expensive. RealTimes Laboratories’ urine panel for 4 mycotoxins costs about $700. Most insurance plans don’t cover it. However, Medicare has started covering the test –if the physician submits a proper set of codes. (Physicians may contact me directly for advice on coding.) Cleaning up a home or office can be extremely expensive.. Let the buyer beware.
- A controlled study to confirm or refute RealTime Laboratories and Dr. Brewer’s data should be fairly simple and relatively inexpensive. Therefore, we should all pray that an Angel or NIH or CDC will be inspired to fund this critical study: Compare the rate of urine mycotoxin and sick building exposure among chronic fatigue syndrome patients with that for appropriate controls. Such a study should quickly decide whether the fungal hypothesis for CFS is or is not truly a breakthrough.
- If the fungal hypothesis has merit, it might also affect a broader spectrum of illness. For example, a Spanish research group did autopsies on ten Alzheimer’s patients. They claim to have seen fungus within the brains of all ten. No fungus was seen in the brains of 15 controls. (Additional information can be found on www.alzforum.org/news/research-news/dementia-la-mold-fungi-may-lurk-alzheimers-brains.) A similar study reported fungus in the brains of patients with ALS (Lou Gehrig’s disease.)
We welcome comments from anyone with experience with mold testing and any health issues, especially CFS, related to mold.
I previously posted an analysis of a double blind study where Namenda, a medicine for Alzheimer’s, showed benefit for fibromyalgia pain. In the previous study from Spain, Namenda was significantly better than a placebo for treating Fibromyalgia. But only a minority of patients improved. As importantly, it took a six-month’s long trial of treatment before the benefit from Namenda compared to placebo was statistically significant.
After reviewing that data, I had mixed feelings about recommending memantine for my patients. (I will now call Namenda “memantine,” the generic version which is much less expensive.) Since then I’ve recommended memantine to five FMS patients. In a bow to reality, I suggested they try memantine for a two-month trial period, instead of the six months used in the double-blind study. The results; two patients improved meaningfully. One could not tolerate raising the dose. Two followed through but memantine did not help.
Now I’m writing to alert you to an encouraging study where memantine helped a very different kind of pain, the chronic pain that can occur from a mastectomy among women treated for breast cancer. (There have been no further studies on memantine and fibro.) After mastectomy, 30% or more of women develop a burning or shooting pain in the chest, arm and armpit that lasts for three months or more. In a single blind study, 20 women received memantine for two weeks before and two weeks after their mastectomy. Twenty other women who had a mastectomy took a placebo.
After three months, the women rated the intensity of their pain on a scale of zero to ten. The results: Women who had taken memantine experienced substantially less pain than did the women who took placebo. The p value was 0.017. (Less than .05 is “significant”.) Memantine also reduced the need for prescription pain medicines. Only one of 20 women who had taken memantine needed a prescription compared to six of 20 women who had taken placebo. (Six months post operation memantine patients still had less pain, but the difference was no longer statistically significant.)
Memantine is probably useful for some forms of pain. But we should keep in mind it might react differently for different forms of pain. Post-mastectomy pain results from obvious trauma to peripheral nerves. FM reflects abnormalities in the brain and the spine that are not classically “traumatic.” Since we have only one controlled study for memantine and fibromyalgia, anecdotal experience might be our next most useful resource.
Some scientists doubt that anecdotes are useful. As a practicing physician, I strongly disagree. Anecdotal experiences can and should influence our judgments—especially if we can create a mechanism through which many, many individuals can share their experience. The Internet has become such a mechanism. Our challenge: how to adapt this mechanism to the practical needs of clinicians, researchers and patients who care about Fibromyalgia, Chronic Fatigue Syndrome and related health problems.
Two key questions: Who has the skill and the interest to create a practically useful forum on line? Who has the interest and ability to organize and/or provide the necessary funding?
Please feel free to comment especially if you have taken memantine for any type of pain.
Flexeril (cyclobenzaprine) is FDA approved for the short term relief of “muscle spasm associated with acute, painful muscoskeletal conditions.” It’s not approved for long term usage or to treat Fibromyalgia (FM).
Still, Fibromyalgia specialists sometimes prescribe Flexeril for use as a sleeping aid and to reduce Fibromyalgia pain. But at standard doses, Flexeril’s sedating effect often carries over to the next day, worsening fatigue. There may be a better way of prescribing Flexeril; not only a way that improves sleep and pain, but to actually lessen feelings of daytime fatigue also.
Cognitive function tends to declines as we age. For most people the decline is modest. This “semi-normal” decline is thought to be due to a decrease in the ability of cells to communicate with each other through connections called synapses. A similar defect is seen with Alzheimer’s disease.
Animal studies show that one way to increase the number and function of synapses is to raise the brain’s level of the mineral magnesium. When scientists increase brain magnesium in lab rats, the rats become smarter. They can think more rapidly and accurately than they did before.
But, most forms of oral magnesium don’t pass easily from the blood into the brain. An exception is a new form of magnesium developed by a research team from MIT specifically for the purpose of passing from the blood into the brain. This form is magnesium threonate,. It is being developed by Neurocentria, Inc., a pharmaceutical company, under the brand name of MMFS-01.
Neurocentria’s team recently published a very important study. Their results strongly suggest that MMFS-01 can substantially improve mild cognitive function in aging humans. MMFS-01 is not yet commercially available. However, a “generic” magnesium threonate is available from the Life Extension Foundation under the brand name of Neuro-mag. Likely other “generics” are or will soon be available.
What is truly remarkable about the MMFS-01 study is that improvement in over-all cognitive function was seen within just six weeks. Improvement continued through 12 weeks, the full length of the study. Subjects treated with placebo did not improve overall.
Volunteers for the Neurocentria study were age 50 to 70. All had test score evidence of mild cognitive impairment. Twenty five subjects took MMFS-01 and 26 took placebo. The treatment dose was between 1.5 and 2.0 grams per day in divided doses. Four different cognitive tests were taken before treatment and again at six and twelve weeks. These tests measured executive function, working memory, attention and a concept called episodic memory.
Findings: With magnesium threonate executive function significantly improved compared to placebo at 6 and 12 weeks. Working memory improved significantly at six weeks but at 12 weeks the placebo group had improved also. So, the difference for working memory was no longer statistically significant. Attention improved in the MMFS-01 group compared to baseline, but this improvement was not statistically better than for those taking placebo. Episodic memory improved with MMFS-01 by week 12, but was not significantly better than that seen with placebo.
However, when overall cognitive ability was calculated by combining results from the four tests, subjects taking MMFS-01 scored significantly better than subjects taking placebo. This was true at week 6 (P=.017) and at week 12 (p=.003). As important, subjects taking MMFS-01 who had the greatest increase in red blood cell magnesium levels were alsomost likely to show major cognitive improvement. There were no major side effects.
Separate research suggests that magnesium might also help for fibromyalgia pain. This benefit might be because magnesium tends to inhibit the activity of NMDA receptors. Activation of NMDA receptors is believed to be one mechanism that creates fibromyalgia pain. A recent open label study from Mayo Clinic found that transdermal magnesium chloride spray taken twice daily for 3 weeks was followed by a reduction in fibromyalgia pain.
Take Home Thoughts
Should physicians treating FM or ME-CFS “brain fog” by offer magnesium threonate as a potential treatment? The arguments against: 1) We don’t know whether brain fog in fibromyalgia or ME-CFS has any relationship to the cognitive decline that is common with aging. 2) We have only one clinical study to support the beneficial effects of magnesium threonate.
The argument for: 1) Brain fog is a major problem for our patients 2) We have no proven treatments 3) For most (but not all patients), side effects from magnesium are minimal—mainly diarrhea if we get the dose up too high.
Should patients with FM or ME-CFS try magnesium threonate on their own? I strongly recommend that all patients work with their doctor. Certain patients should not take extra magnesium, especially those with any degree of kidney dysfunction. Also, it would be useful to obtain a baseline red blood cell magnesium level and to monitor that level as treatment proceeds.
Since MMFS-01 is not available, using Life Extension’s or other generic equivalents is reasonable. Of course, ideally, some angel would fund a proper controlled study. But, as usual, that’s not likely to happen anytime soon.
If any readers decide to work with their doctors and try magnesium threonate, I and other readers would be grateful to learn whether or not it helped. In the absence of research funding the best way for us to learn which treatments help will be for each of us to report our personal anecodatal experience along to each other. We look forward to your comments.