Powerful Proof that Symptoms of Chronic Fatigue Syndrome and Fibromyalgia are REAL and MAINLY PHYSICAL

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.

Results

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
Significance

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.

Psychotherapy for ME/CFS Does Not Help Fatigue (much)

option 3
psychotherapy for ME/CFS

Background
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.

Contradictory Study
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.

 

Can Mold Cause Chronic Fatigue Syndrome? Is Mold a “Breakthrough” or Just a False Lead?

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:

  1. Are people with CFS more likely to have been exposed to WDB or mold than are healthy persons?
  2. If we reduce a CFS patient’s mold burden would this improve their symptoms?
mold and chronic fatigue syndrome
mold and CFS

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.

link of mold to CFS
mold damaged building

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:

  1. Dr. Brewer should be praised for his great effort in launching his studies. Doing research from a private practice base is very demanding.
  2. 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.
  3. 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.
  4. 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.
  5. 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. 
  6. 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.

Exercise and FM/CFS – Segment 2

This post is the second segment of three with Kim Jones, RN, PhD associate professor at the School of Nursing of the Oregon Health and Science University and one of the world’s leading experts on Fibromyalgia.  The discussion continues from the first segment providing practical advise on how to successfully exercise with Fibromyalgia (FM) or Chronic Fatigue Syndrome (CFS).  If you have FM or CFS, feel free to post any personal experiences you may have from following the tips that are provided in this video.

Part 2 of 3:

 

If you have not viewed Segment 1 yet, link to it here,
Part 3 is coming soon!