"CBT & exercise in #ChronicFatigueSyndrome have no evidence". Translation of Swedish article. #MEcfs #CFS #ME
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(Some automated translations are not that good but this one seems pretty good)

CBT and exercise in chronic fatigue syndrome have no evidence

Lack of objective outcome parameters that the utility of CBT and gradually increasing exercise in chronic fatigue syndrome must be questioned. Furthermore, the risk of deterioration after training considered in treatment recommendations, writes Stone Helmfrid and Johan Edsberg.

Authors:
Stone Helmfrid, Associate Professor of Physics
sten.helmfrid@bredband.net
Johan Edsberg
a specialist in internal medicine, medical clinic Mälarsjukhuset, Eskilstuna

The past 20 years it has published a number of studies of cognitive behavioral therapy (CBT) and gradually increasing exercise in chronic fatigue syndrome (ME / CFS) [1-3]. The results of the studies vary. Cochrane analysis suggests a cautiously positive trend [4, 5], but the evaluation has apart from the studies almost totally relies on subjective outcome parameters. This has led to that the benefit of treatment methods have been overstated and the risks ignored.

The treatment model is based on a biopsychosocial approach launched by British psychiatrist in the late 1980s. [6] They claimed that ME / CFS is perpetuated by cognitive processes (fear of deterioration after activity) and behavioral responses (avoidance of activity) [7]. Symptoms are caused by this model of cognitive attitudes and reduced fitness, and disease can thus be cured with CBT and gradually increasing exercise.

The biopsychosocial theory has been received with great skepticism by biomedical researchers and patient organizations [8, 9]. The assumption of an activity phobia are misaligned with our knowledge of the disease. When patients overexert themselves trigger is often a deterioration and then a period of reduced activity capacity ("push-crash cycle«) [10]. If lack of condition would cause symptoms ought to ME / CFS-like symptoms occur in individuals who are inactive for other reasons, such as people who are in plaster for a long time or prisoners in isolation.

Criticism has also been extensive studies on the treatment of CBT and gradually increasing exercise. It has addressed, inter alia selection criteria. The British psychiatrists created its own criteria for the disease that only require a prolonged severe fatigue that occurred at a time [11]. The patient group chronically tired covers about 10 percent of the population [12] and include many different diseases. It is unlikely that the results for a broader defined group is also representative of a narrowly defined group of patients with neurological and immunological symptoms. A study of chronic fatigue individuals in the UK primary care [13] shows that a strong predictor of poor outcome with CBT and gradually increase the training is that the patient meets the CDC (Centers for Disease Control and Prevention) criteria for ME / CFS [14] .

A more fundamental problem with the studies of CBT and gradually increased training in ME / CFS is that they almost completely relies on subjective self-reports. In clinical trials of drugs are always compared the treatment results of a blinded randomized reference group that received placebo. This is not possible at the psychological intervention, but there are opportunities for objective evaluation. The patients' activity levels could be measured with a aktometer, a device the size of a wristwatch attached to the ankle or wrist.

The few objective evaluations that have been made have generally contradicted subjective signs of improvement. A Dutch group went through data from aktometrar in three studies of CBT. Although the patients themselves reported a decrease in fatigue did not increase the measured level of activity [15]. In another study of CBT in which the subjective cognitive impairment declined were the neuropsychological test results before and after the study remain unchanged [16].

In the British PACE study was one six minute walking test to compare the different treatments. All groups showed a small improvement, but the group that underwent progressive exercise improved a bit more than the others [1]. The results of the fitness tests that were also made, however, was unchanged [17], suggesting that the improvement was due to the change in attitude rather than enhanced exercise capacity [18].

It has consistently been difficult to demonstrate results of practical importance for patients treated with CBT and gradually increasing exercise. A follow up of the PACE show that the treatment does not lead to any significant reduction in either the number of sick days or paid out in sickness compensation [19]. The same picture emerged from an examination of the four Belgian specialist centers. The patients' physical abilities after 6-12 months of treatment were unchanged, and working hours decreased [20]. In two independent surveys of patient associations in which different treatments evaluated were the percentage of positive responses for CBT and gradually increase workout lower than for homeopathy (ie in practice placebo) [21, 22].

Gradually increase the training means that patients increases the activity level according to a predetermined plan. The treatment has been criticized because exertion may trigger a period of deterioration. Independent studies have shown that ME / CFS patients have poorer performance on day two at maximal exercise stress test of oxygen uptake that are repeated every 24 hours [23-25]. It has also demonstrated the immunological changes [26] and cognitive impairment [27] after the effort. Data from ten independent patient surveys in four countries shows that 52 percent felt worse and 33 percent much worse by the progressive exercise [21, 22, 28]. Studies have reported a lower proportion than the surveys impaired patients, but on the other hand not have control over how the protocols followed. Comparison with aktometrar shows that self-reports of activity levels are unreliable [29] and that patients have difficulty following a progressive exercise program [30, 31].

Competing interests: The authors work for voluntary patient association RME.

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