Syndrome (ME/CFS) program and Interdisciplinary Research Symposium on
Disabling Fatigue in Chronic Illness
E. Stein, MD (1); M. MacQuarrie, BSc MRP LLB (2)
Chronic Dis Can. 2009;29(3):136-8.
http://www.phac-aspc.gc.ca/publicat/cdic-mcc/29-3/pdf/cdic29-3-6-eng.pdf
Background
This program at the University of Calgary was the first comprehensive
program on myalgic encephalomyelitis/chronic fatigue
syndrome (ME/CFS) held in Canada. There were three parts: a continuing
medical education program for physicians, a research symposium on
fatiguing illnesses and a public lecture. ME/CFS is one cause of
disabling fatigue. ME/CFS alone is
a serious medical condition that affects between 150,000[1] and
340,000[2] Canadians. The core symptoms have been described by Fukuda
et al.[3] and were further refined in the Canadian Consensus
Guidelines for the Diagnosis and Treatment of ME/CFS.[4]
Program
The physician program was divided into two segments: Part I (October
24, 2008) covered the diagnosis and assessment of patients with ME/CFS
and Part II (November 7, 2008) covered clinical management.
A full-day interdisciplinary research symposium on disabling fatigue
in chronic illness took place on November 8, 2008, in a mix of plenary
and concurrent sessions. This symposium was organized to assist in
both the development of a collaborative research agenda to understand
disabling fatigue in chronic disease as well as in the knowledge
transfer process among health
care professionals, researchers and the Canadian public. Disabling
fatigue exists in numerous chronic conditions, including autoimmune
disorders, chronic infection, chronic liver disease, pulmonary and
heart disease, ME/CFS, overtraining and stress syndromes, some
psychiatric conditions and fatigue due to unknown causes.
The plenary sessions included Karin Olson, RN, PhD, University of
Alberta (Conceptual Model of Fatigue: The Edmonton Fatigue Framework);
Leonard Jason, PhD, DePaul University (Epidemiology and Case
Definition of ME/CFS); Nancy Klimas, MD, University of Miami
(Biological Markers in Disabling Fatigue); Bryan Kolb, PhD, University
of Lethbridge (Neuroplasticity and Implications for Disabling
Fatigue); and a video of Gerry Thomas, with a patient perspective.
Dr. Olson presented the Edmonton Fatigue Framework (EFF), a proposed
etiological model of fatigue based on 15 years of research with five
populations experiencing fatigue: those with cancer, depression and
ME/CFS, as well as shift-workers and recreational runners. In this
model, fatigue (subtyped as tiredness, fatigue and exhaustion) is
considered a behavioural marker of the inability to adapt to stress
and is secondary to changes in muscle endurance, sleep quality,
cognitive function, dietary intake and other factors.[5]
Dr. Klimas, an internationally renowned research immunologist and
clinician, profiled current work, including dynamic modelling using an
exercise stressor model, showing that one must stress a subject with
ME/CFS to get reliable differences
versus controls. Mathematical modelling by Gordon Broderick, PhD
(Computational Biology, University of Alberta and one of Dr. Klimas=92
team) is identifying which biomarkers could serve as a diagnostic test
for ME/CFS.[6]
Dr. Jason spoke about the definition, prevalence and social impact of
ME/CFS and, in the concurrent session, about a four-arm,
non-pharmacological intervention study in ME/CFS. Both of his
presentations underscored the importance of properly identifying and
subtyping ME/CFS patients. Not every ME/CFS patient reacts to
treatment in the same way.
Dr. Bryan Kolb (Director of the Canadian Centre for Behavioural
Neuroscience at the University of Lethbridge and author of the
classical textbook, Fundamentals of Human Neuropsychology[7]) reviewed
the literature on brain plasticity and implications for ME/CFS. He
made the provocative hypothesis that the increased prefrontal volume
post =93effective cognitive behavioural therapy=94 reported by de Lange et
al.[8] may have been due to the impact of the therapy on depression
rather than ME/CFS. Many symptoms, including depression and stress,
correlate with structural changes in the prefrontal cortex.
The concurrent sessions were also filled with some very stimulating
findings, including:
-Bruce Dick, PhD (Departments of Anesthesiology and Pain Medicine and
Psychiatry, University of Alberta), presented work on cognitive
function in fibromyalgia.[9] He reported that the spatial span test
was the most difficult task for people with fibromyalgia and that
cognitive function did not improve in the short term with pain
intervention. However, patients on long-term opiate treatment did
better on cognitive tests overall than those who were not on opiates.
-Patrick Neary, PhD (Kinesology and Health Studies, University of
Regina), presented his data on prefrontal cortical oxygenation, as
measured by nearinfrared spectrophotometry during exercise to
exhaustion.[10] There was no difference at rest between the ME/CFS and
control groups, but with exercise, both the total haemoglobin and
oxygenated haemoglobin were reduced in the ME/CFS group. He has shown
in unpublished work that oxygen flow to the brain is slow to recover
when patients with ME/CFS stand up. This reinforces the need for
provocation testing in ME/CFS.
-Carey Johnson, MD (private practice, Calgary), presented his
observations that approximately 50% of patients with Erlers Danlos
(ED) syndrome have clinical features meeting the Canadian Consensus
Guidelines for the Diagnosis and Treatment of ME/CFS; the other 50%
have the typical features of connective tissue disorder, but not
chronic fatigue, sleep disorder, pain or sensory sensitivity. He has a
study in progress to identify genetic markers for this subgroup of ED
patients.
-Neil Skjodt, MD (Medical Director, Edmonton Sleep Institute; Director
of Research, Canadian Sleep Institute), noted that the sleep
irregularities in ME/CFS were, for various reasons, not getting
specialized attention. He suggested a more appropriate sleep
assessment protocol for these patients.
Other thought-provoking and informative presentations were given by:
-Denise Adams, BSc (PhD candidate, University of Alberta), on
Traditional Chinese Medicine for the Treatment of Chronic Fatigue: A
Systematic Review;
-Brian MacIntosh, PhD (Kinesology, University of Calgary), on
Measuring Peripheral vs. Central Fatigue;
-Lynn Marshall, MD (Environmental Health Clinic, Women=92s College
Hospital, Toronto), on Functional Impairment in an Environmental
Clinic Sample;
-Kathleen Pierson, MD, PhD (Department of Psychiatry, University of
Calgary), on Measuring Fatigue in Early Psychosis;
-Steve Simpson, MD, FRCP(C) (Psychiatry, University of Calgary;
Consulting Psychiatrist, Tom Baker Cancer Centre), on the Management
of Cancer Fatigue;
-Mark Swain, MD, FRCP(C) (Professor of Medicine, University of
Calgary), on Disabling Fatigue in Inflammatory Disorders; and
-Mark van Ness, PhD, Staci Stevens, MSc, and Kylie Kumasaka, PhD
candidate (Pacific Fatigue Laboratory, University of the Pacific,
California), on Metabolic Dysfunction in ME/CFS.
The public lecture on November 9, 2008 featured Nancy Klimas, MD,
giving an update on ME/CFS research, Alison Bested, MD, FRCP(C)
(private practice, Toronto), providing clinical pearls[11] and a tag
team of Stevens, van Ness and Kumasaka presenting on Exercise
Tolerance in ME/CFS.
Podcasts (i.e. audio and slides only) of the ME/CFS continuing medical
education program and the public lecture are currently available free
of charge. To view the podcasts go to:
http://podcast.med.ucalgary.ca/groups/cfs/weblog/. The research day is
not a podcast, although handouts from many of the presentations are
available on the University of Calgary Continuing Medical Education
site, at www.cme.calgary.ca.
Conclusion
There were many coinciding concepts from various presenters in
different fields, specifically, the interrelation of all body systems
and the need to take an interdisciplinary approach to understanding
ME/CFS and disabling fatigue in chronic illness. The opportunity for
so many disciplines to gather and benefit from =93crosstalking=94 and the
fertilization of ideas was immense, and new ideas and collaborations
are ongoing. The objective of the symposium to develop a collaborative
research agenda was ambitious. Meeting this objective will take time,
effort and funding.
Acknowledgements
This program was co-endorsed by the University of Calgary, Faculty of
Medicine, and the University of Alberta, Faculty of Medicine and
Dentistry. It was supported by Alberta Health and Wellness, the Public
Health Agency of Canada and the Canadian Institutes of Health
Research. The ME-FM Society of Alberta was a major sponsor. Other
sponsors (in alphabetical order) were Bayda Ludwar Law Firm, Cambrian
Drug Mart, Ferring Pharmaceuticals, Genuine Health, Metagenics, Pfizer
Canada, Script Pharmacy and Varsity Natural Health Center. The
podcasts are available thanks to sponsorship from the Alison Hunter
Memorial Foundation (www.ahmf.org).
Author References
1. Private practice, Calgary, AB, Canada
2. Myalgic Encephalomyelitis Association of Ontario, Toronto, ON,
Canada and member of the National ME/FM Action Network
Submitted by Ellie Stein, MD, (Chair, Program Committee) on behalf of
the Planning Committee: Drs. Terrie Brandon (Family Medicine,
Calgary); Brian MacIntosh (Kinesiology, University of Calgary); Karin
Olson (Nursing, University of Alberta); Steve Simpson (Medicine,
University of Calgary); Elaine Stapon (Family Medicine, Calgary); and
Ms. Glenda Wong (Department of CME, University of Calgary).
Correspondence: Ellie Stein, MD, 4523-16A St. SW Calgary, AB, T2T 4L8,
Tel.: 403-287-9941, Fax: 403-287-9958, Email: espc@shaw.ca
References
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3. Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A.
The chronic fatigue syndrome: a comprehensive approach to its
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4. Carruthers BM, Jain AK, DeMeirleir K et al. Myalgic
Encephalomyelitis/Chronic Fatigue Syndrome: clinical working case
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7. Kolb B, Whishaw IQ. Fundamentals of human neuropsychology. 6th ed.
New York: Freeman-Worth; 2008. 763 p.
8. de Lange FP, Koers A, Kalkman JS, et al. Increase in prefrontal
cortical volume following cognitive behavioural therapy in patients
with chronic fatigue syndrome. Brain. 2008;131:2172=9680.
9. Dick BD, Verrier MJ, Harker KT, Rashiq S. Disruption of cognitive
function in Fibromyalgia Syndrome. Pain. 2008; 139(3):610=966.
10. Neary JP, Roberts AD, Leavins N, Harrison MF, Croll JC, Sexsmith
JR. Prefrontal cortex oxygenation during incremental exercise in
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2008;28(6):364=9672.
11. Bested, AC, Logan AC. Hope and help for chronic fatigue syndrome
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p.
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