Work Rehabilitation and Medical Retirement for ME/CFS Patients. A Review and Appraisal of Diagnostic Strategies

Open AccessReview

Work Rehabilitation and Medical Retirement for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Patients. A Review and Appraisal of Diagnostic Strategies

by  Mark Vink ^1,* and Friso Vink-Niese ²

¹

Family and Insurance Physician, 1096 HZ Amsterdam, The Netherlands

²

Independent Researcher, 49032 Osnabrück, Germany

^*

Author to whom correspondence should be addressed.

Diagnostics 2019, 9(4), 124; https://doi.org/10.3390/diagnostics9040124

Received: 7 June 2019 / Revised: 11 September 2019 / Accepted: 13 September 2019 / Published: 20 September 2019

(This article belongs to the Special Issue Biomedical Insights that Inform the Diagnosis of ME/CFS)

View Full-Text Download PDF

Abstract

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome leads to severe functional impairment and work disability in a considerable number of patients. The majority of patients who manage to continue or return to work, work part-time instead of full time in a physically less demanding job. The prognosis in terms of returning to work is poor if patients have been on long-term sick leave for more than two to three years. Being older and more ill when falling ill are associated with a worse employment outcome. Cognitive behavioural therapy and graded exercise therapy do not restore the ability to work. Consequently, many patients will eventually be medically retired depending on the requirements of the retirement policy, the progress that has been made since they have fallen ill in combination with the severity of their impairments compared to the sort of work they do or are offered to do. However, there is one thing that occupational health physicians and other doctors can do to try and prevent chronic and severe incapacity in the absence of effective treatments. Patients who are given a period of enforced rest from the onset, have the best prognosis. Moreover, those who work or go back to work should not be forced to do more than they can to try and prevent relapses, long-term sick leave and medical retirement. View Full-Text

Keywords: CFS (Chronic Fatigue Syndrome); ME (Myalgic Encephalomyelitis); medical retirement; prognosis; work rehabilitation

PACE trial's principal investigator Peter White has retired from clinical practice with immediate effect to avoid ...

PROOF POSITIVE ? (REVISITED)

Margaret Williams, 14th September 2016  

"The role of Professor Peter Denton White OBE
In 2004, Professor Peter Denton White was awarded an OBE for “services to medical education”;
notices circulating at the time proclaimed him as leading the research into “CFS/ME” and said his OBE was “a well-deserved honour and acknowledgement of his contribution to work on CFS/ME”.

He was born in November 1952: aged only 64, he suddenly retired from clinical practice just before he was compelled by an order of the court to release the raw data from the PACE trial, so any
investigation by the General Medical Council for alleged professional misconduct is unlikely to be
pursued, but is he guilty of misfeasance in public office?

According to the Crown Prosecution Service (CPS) website, misfeasance in public office is a cause of
action in the civil court against the holder of public office, the allegation being that the office-holder
has misused or abused their power: such misuse or abuse is an affirmative act that causes harm to
another party without reasonable justification. The NHS is a State body as it provides public health
care, so this matter is one in which the public has a significant interest.

Facts to be considered
1. Peter White has used his own money, as well charitable money and public money, in order to
lobby support for his belief that ME/CFS is a psycho-behavioural disorder that can be
overcome through “cognitive restructuring” and graded aerobic exercise
2. he has egregiously used large sums of public money (£250,000) to prevent the disclosure of
data that would falsify his belief
3. for nearly 30 years, he has ignored evidence that disproves his belief, including evidence from
his own trials
4. he has failed to correct errors of fact after being alerted to them
5. he has consistently failed to disclose significant financial, institutional and ideological
conflicts of interest
6. he has been in breach of his NHS contractual obligations in that he has persistently ignored
mandatory directives and has wilfully encouraged other clinicians to do the same
7. as a consequence of his actions:
 money which should have been used for biomedical research into the aetiology of
ME/CFS has been diverted to fund studies into therapies which were already known
to be ineffective and even harmful
 patients have been stigmatised as sociopaths and malingerers who refuse to accept
they have a behavioural disorder
 patients have been denied financial support from private insurers for whom Peter
White and his colleagues work (for example, he was Chief Medical Officer for the
giant re-insurer Swiss Re and was also CMO to Scottish Provident) and from the" ...

Proof positive (revisited) .pdf

Important message from the PACE trial psychiatrists to Mr. Matthees

Study by professor White proves Simon Wessely suffers from false illness beliefs

Toxic exposures caused illness in Gulf War veterans, new report says

Date:

January 26, 2016

Source:

Boston University Medical Center

Summary:

Twenty-five years after 700,000 U.S. troops fought and won the first Gulf War with remarkably low casualties, research "clearly and consistently" shows that exposure to pesticides and other toxins caused Gulf War Illness, a complex and debilitating disorder that affects as many as 250,000 of those deployed, according to a new report.

http://www.sciencedaily.com/releases/2016/01/160126130134.htm#  

Twenty-five years after 700,000 U.S. troops fought and won the first Gulf War with remarkably low casualties, research "clearly and consistently" shows that exposure to pesticides and other toxins caused Gulf War Illness, a complex and debilitating disorder that affects as many as 250,000 of those deployed, according to a new report led by a Boston University School of Public Health (BUSPH) researcher.

In a special issue of the journal Cortex that coincides with the 25th anniversary of the war, Roberta White, professor of environmental health at BUSPH, and colleagues from a dozen other institutions comprehensively review studies on Gulf War Illness (GWI), especially those since 2008. They conclude that exposure to pesticides and ingestion of pyridostigmine bromide (PB) -- prophylactic pills intended to protect troops against the effects of possible nerve gas -- are "causally associated with GWI and the neurological dysfunction in Gulf War veterans."

The research team also cites multiple studies showing a link between veterans' neurological problems and exposure to the nerve-gas agents sarin and cyclosarin, as well as to oil well fire emissions.

These "toxic wounds" resulted in damage to veterans' nervous systems and immune systems, including neuroendocrine and immune dysregulation, autonomic nervous system irregularities, and reduced white and gray matter in veterans' brains, the review says.

White and colleagues have been studying the health of troops deployed in the 1991 Gulf War for more than 20 years to determine why so many of them suffer from a multi-system disorder characterized by fatigue, joint and muscle pain, headaches, concentration and memory problems, gastrointestinal distress, and skin rashes. They note that effective treatments for the illness have been elusive, but that a recent treatment research effort has begun to produce promising leads.

"Further research into the mechanisms and etiology of the health problems of (Gulf War) veterans is critical to developing biomarkers of exposure and illness, and preventing similar problems for military personnel in future deployments. This information is also critical for developing new treatments for GWI and related neurological dysfunction," they write.

In 2008, a Congressionally mandated panel directed by White -- the Research Advisory Committee on Gulf War Veterans' Illnesses -- issued a landmark report concluding that Gulf War Illness was a "real" disorder, distinct from stress-related syndromes, and urging a robust research effort into its causes and potential cures. Gulf War veterans have complained for years that the Department of Veterans Affairs (VA) has not taken the illness seriously.

In terms of toxic exposures, the authors note, six out of seven research studies have found "significant associations between self-reported pesticide exposure and GWI." Similarly, ingestion of PB pills dispensed by the military has been "consistently linked to ill health in GW veteran populations."

James Binns, a co-author of the report and former chairman of the Research Advisory Committee, equated the main causes of GWI to "friendly fire."

"We did it to ourselves," Binns said. "Pesticides, PB, nerve gas released by destroying Iraqi facilities -- all are cases of friendly fire. That may explain why government and military leaders have been so reluctant to acknowledge what happened, just as they tried to cover up Agent Orange after Vietnam. Certainly, the government should have been facing the problem honestly and doing research from the start to identify diagnostic tests and treatments."

In the report, the research team notes that in addition to veterans suffering from GWI, other deployed troops from the first Gulf War report a variety of neurological disorders, either in conjunction with GWI or as separate ailments. Studies have found that deployed troops suffer a higher incidence of stroke, brain cancer and ALS (amyotrophic lateral sclerosis), compared to non-deployed veterans. The VA's own study, published in 2009, found that deployed veterans were diagnosed with seizures, stroke and neuralgia at higher rates than non-deployed service members. Other studies have found excess rates of brain structure alterations and brain cancer deaths among veterans who had the greatest exposure to nerve agents or oil fire smoke.

The report makes clear that psychiatric problems "have been ruled out" as a cause of Gulf War Illness, noting that Gulf War veterans have lower rates of post-traumatic stress disorder (PTSD) and other psychiatric disorders than their counterparts who served in other wars.

The research team says that a number of studies using diagnostic imaging and EEG probes have identified "structural and electrical abnormalities" in the central nervous systems of deployed troops with GWI. Fourteen of 15 papers published since 2008 support that conclusion, the report says.

White and colleagues say that overall, the research to date supports the conclusion that veterans are suffering from a "persistent pathology due to chemical intoxication." They say further research into GWI could benefit other occupational groups, such as farmers and insecticide applicators, who have similar exposures. White said she is hopeful that new research efforts will lead to effective treatments, especially as veterans age and are at increased risk of neuro-degenerative diseases.

---

Story Source:

The above post is reprinted from materials provided by Boston University Medical Center. Note: Materials may be edited for content and length.

---

Journal Reference:

1. Roberta F. White, Lea Steele, James P. O'Callaghan, Kimberly Sullivan, James H. Binns, Beatrice A. Golomb, Floyd E. Bloom, James A. Bunker, Fiona Crawford, Joel C. Graves, Anthony Hardie, Nancy Klimas, Marguerite Knox, William J. Meggs, Jack Melling, Martin A. Philbert, Rachel Grashow. Recent research on Gulf War illness and other health problems in veterans of the 1991 Gulf War: Effects of toxicant exposures during deployment. Cortex, 2016; 74: 449 DOI:10.1016/j.cortex.2015.08.022

---

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Boston University Medical Center. "Toxic exposures caused illness in Gulf War veterans, new report says." ScienceDaily. ScienceDaily, 26 January 2016. <www.sciencedaily.com/releases/2016/01/160126130134.htm>.

Just when you think it can't get worse, more shocking PACE trial revelations‏

From Margaret Williams : further details about PACE Trial data security. Permission to repost.

"Two points merit further consideration: (i) the matter of guaranteed confidential storage of PACE trial data and (ii) the Principal Investigators’ undeclared conflict of interest until after the consent forms were signed by participants.

The PACE trial Protocol published in BMC Neurology on 8 March 2007 was an abridged version
but, as noted by Alem Matthees, the Full Protocol (226 pages) states on page 110:
“Your GP and any other doctors you are consulting will be told you are joining our study. And occasionally, other researchers will need to see your notes so they can audit the quality of our work. An audit might be run by one of the universities helping with our study or hospital regulatory authorities, or by one of the organisations funding our study” http://www.meactionuk.org.uk/FULL-Protocol-SEARCHABLE-version.pdf

What Matthees did not mention was the fact that one of the organisations funding the study was the UK Department for Work and Pensions (DWP). How many participants looked at the funding bodies before signing the consent forms and realising to what they were giving their consent?
Quite how “confidentiality” could be guaranteed if the DWP had access to the data has never been explained, especially as ME/CFS is known to be a targeted disorder for the withdrawal of state benefits, with patients being harassed by the DWP who required a 60-page form to be completed because the DWP menacingly informed such patients: “We have reason to believe that you are capable of work”.
If the PACE trial therapists and Investigators deemed a participant “recovered” enough to resume work, then might that participant quickly discover that the DWP stopped paying benefit? The PACE Trial has been described as a “Trojan horse” for the DWP.
Regarding the secure storage of data, the Full Protocol is unambiguous:
“Will you keep my details confidential?”
“Yes. All your details and all recordings will be kept strictly confidential and held in a locked filing cabinet or on a secure computer. People on our research team will only see your records if they need to for the research”.
The DWP was not involved in research but still had participants’ signed permission to access their records/data.

From the outset, recordings were not kept in a locked filing cabinet: some were stolen and thus lost to review (see previous post on 19th December 2015: https://jcoynester.wordpress.com/2015/12/18/kings-college-london-stalls-some-more-reiterating-refusal-to-release-the-pace-trial-data/#comment-1375
 ).

The Consent Form 1 for baseline assessment which participants were required to sign was clear:

“3. I understand that any of my medical notes may be looked at by responsible individuals from either the trial or regulatory authorities where it is relevant to my taking part in research.

4. I give permission for these individuals to have access to my records.
…

14. I understand that information collected about me for the trial, including my personal details, a copy of this consent form and all of the questionnaires I complete for the trial, will be held securely by the local trial staff and at the PACE trial centre at Queen Mary, University of London. I give permission for this to happen”.
The PACE PIs obtained participants’ consent on the promise of keeping trial data secure, yet they had made no provision to do any such thing.
When the PACE Trial had been running for two years, the Participants’ newsletter (Issue 1, June 2006) reaffirmed that the trial data was safe: “The information is being entered onto a large and secure database, designed and maintained by an independent clinical trial unit at King’s College, London”. This was provided for participants even though the PIs knew that trial data had already been stolen (see previous post #‎comment
-1375).

In relation to the PIs’ undeclared conflict of interest, one of the pre-trial assessments was at Baseline Visit 1; this set out to collect personal data that seems to have little bearing on a clinical trial but could be of value to the DWP and the permanent health insurance industry because the collected data included not only the customary demographic details, date of birth, age, sex, ethnicity, marital or partner status, years of education, occupation (the latter would obviously afford information about a participant’s earnings) but also very detailed questions about participants’ permanent health insurance payments, for example, questions on page 172 ff of the Full Protocol included the following:
“Do you currently receive income protection benefit (income protection or total and permanent disability)?”
“ If yes, how much annually do you receive? £”
“If the participant chooses not to give an answer, please use the prompt card to show income brackets, and record the letter [an alphabetical letter designating an income bracket] that corresponds to the participant's income”.

“Do you currently receive a private medical / retirement pension?”
“If yes, how much weekly do you receive? £
OR
If yes, how much monthly do you receive? £
OR
If yes, how much annually do you receive? £”

“If the participant chooses not to give an answer, please use the prompt card to show income brackets, and record the (alphabetical) letter that corresponds to the participant's income”.

“In the past six months, have you received any one-off payments from income protection or insurance schemes as a result of your health?”

Such specific questions have no clinical relevance but would be of interest to the Chief PI of the PACE trial in his dual role as the re-insurer Swiss Re’s Chief Medical Officer.
As detailed by David Tuller, participants could not give fully informed consent because the PIs’ Iong-standing involvement with the permanent health insurance industry was never disclosed to them. Indeed, it appears that this significant conflict of interest was not initially disclosed even to the Trial Steering Committee: at the meeting on 22nd April 2004, all members present were asked to declare any conflict of interest. It was minuted that no financial conflicts of interest were declared and it was agreed that no-one present had any other substantial or material conflict relevant to their work on the PACE Trial. Amongst those present were Professors Peter White, Michael Sharpe and Trudie Chalder, all of whom worked for the permanent insurance industry. There was a brief mention of paid consultancy work done by the PIs in the BMC Neurology version of the Protocol, which was long after signed consent forms had been obtained."

Open letter to the editor of The Lancet, Dr. Richard Horton by 6 professors about the PACEtrial's fatal flaws

@ www.virology.ws:

Dr. Richard Horton
The Lancet125 London Wall
London, EC2Y 5AS, UK

Dear Dr. Horton:

In February, 2011, The Lancet published an article called “Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomized trial.” The article reported that two “rehabilitative” approaches, cognitive behavior therapy and graded exercise therapy, were effective in treating chronic fatigue syndrome, also known as myalgic encephalomyelitis, ME/CFS and CFS/ME. The study received international attention and has had widespread influence on research, treatment options and public attitudes.

The PACE study was an unblinded clinical trial with subjective primary outcomes, a design that requires strict vigilance in order to prevent the possibility of bias. Yet the study suffered from major flaws that have raised serious concerns about the validity, reliability and integrity of the findings. The patient and advocacy communities have known this for years, but a recent in-depth report on this site, which included statements from five of us, has brought the extent of the problems to the attention of a broader public. The PACE investigators have replied to many of the criticisms, but their responses have not addressed or answered key concerns.

The major flaws documented at length in the recent report include, but are not limited to, the following:

*The Lancet paper included an analysis in which the outcome thresholds for being “within the normal range” on the two primary measures of fatigue and physical function demonstrated worse health than the criteria for entry, which already indicated serious disability. In fact, 13 percent of the study participants were already “within the normal range” on one or both outcome measures at baseline, but the investigators did not disclose this salient fact in the Lancet paper. In an accompanying Lancet commentary, colleagues of the PACE team defined participants who met these expansive “normal ranges” as having achieved a “strict criterion for recovery.” The PACE authors reviewed this commentary before publication.

*During the trial, the authors published a newsletter for participants that included positive testimonials from earlier participants about the benefits of the “therapy” and “treatment.” The same newsletter included an article that cited the two rehabilitative interventions pioneered by the researchers and being tested in the PACE trial as having been recommended by a U.K. clinical guidelines committee “based on the best available evidence.” The newsletter did not mention that a key PACE investigator also served on the clinical guidelines committee. At the time of the newsletter, two hundred or more participants—about a third of the total sample–were still undergoing assessments.

*Mid-trial, the PACE investigators changed their protocol methods of assessing their primary outcome measures of fatigue and physical function. This is of particular concern in an unblinded trial like PACE, in which outcome trends are often apparent long before outcome data are seen. The investigators provided no sensitivity analyses to assess the impact of the changes and have refused requests to provide the results per the methods outlined in their protocol.

*The PACE investigators based their claims of treatment success solely on their subjective outcomes. In the Lancet paper, the results of a six-minute walking test—described in the protocol as “an objective measure of physical capacity”–did not support such claims, notwithstanding the minimal gains in one arm. In subsequent comments in another journal, the investigators dismissed the walking-test results as irrelevant, non-objective and fraught with limitations. All the other objective measures in PACE, presented in other journals, also failed. The results of one objective measure, the fitness step-test, were provided in a 2015 paper in The Lancet Psychiatry, but only in the form of a tiny graph. A request for the step-test data used to create the graph was rejected as “vexatious.”

*The investigators violated their promise in the PACE protocol to adhere to the Declaration of Helsinki, which mandates that prospective participants be “adequately informed” about researchers’ “possible conflicts of interest.” The main investigators have had financial and consulting relationships with disability insurance companies, advising them that rehabilitative therapies like those tested in PACE could help ME/CFS claimants get off benefits and back to work. They disclosed these insurance industry links in The Lancet but did not inform trial participants, contrary to their protocol commitment. This serious ethical breach raises concerns about whether the consent obtained from the 641 trial participants is legitimate.

Such flaws have no place in published research. This is of particular concern in the case of the PACE trial because of its significant impact on government policy, public health practice, clinical care, and decisions about disability insurance and other social benefits. Under the circumstances, it is incumbent upon The Lancet to address this matter as soon as possible.

We therefore urge The Lancet to seek an independent re-analysis of the individual-level PACE trial data, with appropriate sensitivity analyses, from highly respected reviewers with extensive expertise in statistics and study design. The reviewers should be from outside the U.K. and outside the domains of psychiatry and psychological medicine. They should also be completely independent of, and have no conflicts of interests involving, the PACE investigators and the funders of the trial.

Thank you very much for your quick attention to this matter.

Sincerely,

Ronald W. Davis, PhD
Professor of Biochemistry and Genetics
Stanford University

Jonathan C.W. Edwards, MD
Emeritus Professor of Medicine
University College London

Leonard A. Jason, PhD
Professor of Psychology
DePaul University

Bruce Levin, PhD
Professor of Biostatistics
Columbia University

Vincent R. Racaniello, PhD
Professor of Microbiology and Immunology
Columbia University

Arthur L. Reingold, MD
Professor of Epidemiology
University of California, Berkeley

Doctor treats Ebola successfully with HIV drug in Liberia

* http://edition.cnn.com/2014/09/27/health/ebola-hiv-drug/  

(CNN) - A doctor in rural Liberia inundated with Ebola patients says he's had good results with a treatment he tried out of sheer desperation: an HIV drug.

Dr. Gorbee Logan has given the drug, lamivudine, to 15 Ebola patients, and all but two survived. That's about a 13% mortality rate. Across West Africa, the virus has killed 70% of its victims."

"Doctor treats Ebola with HIV drug in Liberia -- seemingly successfullyA doctor in rural Liberia inundated with Ebola patients says he's had good results with a treatment he tried out of sheer desperation: an HIV drug.

Whistleblower Scientist Dr. Lewis Accuses British Medical Journal of Institutional Research Misconduct

Posted by Age of Autism at January 09, 2012: Actions of BMJ Editor and Reporter “More Tabloid News than Science” According to Dr. David Lewis, and “a Genuine Threat to Public Health”

WASHINGTON, D.C., Jan. 9, 2012 (SEND2PRESS NEWSWIRE) -- Dr. David Lewis, internationally known whistleblower and respected expert on institutional fraud, released a report today calling for a formal investigation into the practices of the British Medical Journal (BMJ), and specifically into the actions of its editor, Dr. Fiona Godlee, and Brian Deer, a reporter she hired to write a series of articles which appeared in the journal beginning on January 4, 2011.

The BMJ articles accuse Dr. Andrew Wakefield of committing scientific fraud in a 1998 Lancet publication he co-authored that brought global attention to a link many parents and physicians suspect may exist between autism and children who are genetically predisposed to adverse reactions from the Measles/Mumps/Rubella (MMR) vaccine.

The BMJ, Deer, and Godlee alleged that Wakefield fabricated a diagnosis of colitis in most of the 12 children described in The Lancet article — calling Wakefield’s work an "elaborate fraud" intended to create an "MMR scare" — so Wakefield could profit from a patent related to his research.

“Documents recovered from Dr. Wakefield's files during my investigation at the National Whistleblowers Center (NWC) - www.researchmisconduct.org - reveal that a pathologist associated with the study, Dr. Andrew Anthony, interpreted a number of the children's biopsies as evidence of colitis,” explained Dr. Lewis. “Altogether, the evidence contained in Wakefield's files suggested to me that the BMJ's fraud theory was more tabloid news than science.”

According to documents Lewis filed with Sir John Tooke, Vice-Provost for Health at the University College London (UCL) where The Lancet study was done, BMJ Editor Godlee responded to the Lewis revelations by “cherry-picking the evidence and coming up with a grand conspiracy theory involving ‘institutional research misconduct’. Alleged fraudsters now include University College London (UCL) administrators, the Royal Free Hospital, and all 13 co-authors of the Lancet study.”

UCL President Malcolm Grant notified Lewis that, because his charges were “so serious,” he urged Dr. Lewis to inform Dr. Godlee and Deer “at the earliest opportunity.”

Lewis also reports that Godlee has previously acknowledged the BMJ Group receives funding from the two manufacturers of the MMR vaccine, Merck and GlaxoSmithKline, and has testified in a Parliamentary inquiry that peer-reviewed medical journals are “the marketing arm of the pharmaceutical industry.” Lewis added: “Apparently scientists who question certain government policies and industry practices can be destroyed for a price. If so, this kind of tabloid science poses a genuine threat to public health.”

On January 3, 2012, Dr. Wakefield filed suit against the BMJ and Brian Deer ( http://www.courthousenews.com/2012/01/04/BritMedJ.pdf ). Last September, Columbia University published a major study supporting the link Dr. Wakefield established between autism and enterocolitis ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174969/ ).

Lewis Investigation Available Online:

Dr. Lewis’ detailed investigation of the BMJ series in question can be downloaded here.pdf

----------------------------------------------------

Marketing drugs with tabloid science

Commentary
Editors at the British Medical Journal (BMJ) and Brian Deer, a freelance reporter
with no formal training in science or medicine, alleged that Andrew Wakefield
fabricated the diagnosis of colitis in a 1998 Lancet study involving 12 children with
autistic spectrum disorder (ASD). In the study, some parents and physicians linked
MMR vaccine to the children's gastrointestinal problems and rapid regression into
autism. In 2010, Deer alleged in the BMJ that Wakefield alone made up the diagnosis
by misinterpreting grading sheets from pathologists A.P. Dhillon and A. Anthony, who
reviewed the children's colonic biopsy samples.

In the article, Deer wrote that, according to specialists, grading sheets "don’t
generate clinical diagnoses such as colitis." Grading sheets I recovered from
Wakefield's files, however, show that Anthony wrote "colitis" in marginal notes on a
number of his grading sheets. And, Dhillon included boxes to check for various
diagnoses, such as Crohn's disease and "UC" for ulcerative colitis. Consistent with the
Lancet article, both pathologists found that only one child showed no evidence of
inflammation.

Last September, BMJ's chief editor, Fiona Godlee, rejected a commentary I wrote
about Wakefield's documents. In its place, she invited me to submit a Rapid Response,
which I did. But, instead of admitting she had falsely accused Wakefield of making up
the diagnosis of colitis, she and Deer simply cherry-picked the evidence to come up
with a new theory involving "institutional research misconduct." The alleged fraudsters
now include University College London (UCL) administrators, the Royal Free
Hospital, and all 13 authors of the Lancet study.

Their objective, according to an editorial and feature article Godlee and Deer
published with my Rapid Response, was to create the MMR scare so that UCL could
sell its own safer measles vaccine, diagnostic kits and "autism products." In her
editorial, Godlee acknowledged "the BMJ Group receives funding from the two
manufacturers of MMR vaccine, Merck and GSK."

To support their new fraud theory, Godlee rewrote my Rapid Response, removing
any evidence that undermined their allegations against Wakefield and others. Then, to
prevent me from publishing this evidence on my NWC website, Deer filed a flurry of
false allegations of ethical misconduct against me with the NWC. Godlee ignored my
protests over Deer's behavior; and some of his false and misleading characterizations of
my professional credentials and current work appeared in her editorial and Deer's
feature article

When testifying before Parliament in 2011, Godlee agreed that peer-reviewed
journals have become "the marketing arm of the pharmaceutical industry." Therefore, it
shouldn't surprise anyone if her fraud allegations turn out to be nothing more than a
scheme to protect the BMJ's financial interests in companies marketing the MMR
vaccine. What's frightening is that it requires one of Great Britain's leading medical
journals to utterly destroy the reputation of one of the world's most prestigious
academic institutions.

Dr. Lewis’ detailed investigation of the BMJ series in question can be downloaded here.pdf

Dr. Lewis's direct contact information:
(706) 296 3675 LewisDaveL@aol.com .

Car Sleepers – The New American Homeless

Kevin Hayden, Mon Jul 11 2011:

Santa Barbara boasts a classic laidback California lifestyle, with uncongested beaches, wholesome cafes and charming Spanish-style architecture.

Of course there’s a hefty price tag: nestled between the gentle Santa Ynez mountains and the inviting Pacific Ocean are multi-million dollar homes.

But in this sun-washed haven of wealth, many live far from the American dream.

In a car park across the street from luxury mansions, the evening brings a strange sight.

A few cars arrive and take up spaces in different corners. In each car, a woman, perhaps a few pets, bags of possessions and bedding.

Across the street from homes with bedrooms to spare, these are Santa Barbara’s car sleepers.

Homeless within the last year, they are a direct consequence of America’s housing market collapse.

In this woman-only parking lot, Bonnee, who gives only her first name, wears a smart blue dress and has a business-like demeanour.

A year ago, she was making a healthy living as, ironically, a real estate agent. But when people stopped buying houses, her commission-based income dried up, and, like many clients, she too was unable to pay her mortgage.

Soon she found herself with nowhere to live but her 4×4.

Piles of blankets are in the back of the vehicle. Personal documents are stuffed into seat pockets. Books litter the back seat. A make-up bag and gym membership card (she washes at the gym) are in the front. With her constantly, are photos of her former life.

She can’t quite believe her situation.

“My God, America’s heart is bleeding,” she tells me.

Tears fill her eyes.

“I know it’ll get better. But it feels sad. I really fought hard.”

Read more>>

A subset of Chronic Fatigue Syndrome is caused by HIV

International M.E. Association:

Several possible mechanisms for exercise and activity dysfunction in people with HIV have been reported. Structural and inflammatory muscle abnormalities in people with HIV, which may impair the muscle's ability to extract or utilize oxygen during exercise, have been widely reported. HIV infection-mediated myopathy, as identified by the presence of necrosis (cell death), nemaline rod bodies (rod-shaped inclusion bodies consisting of alpha-actinin and desmin), inflammation, and vasculitis (inflammation of microvasculature) were found in 26% of individuals infected with HIV who either had never taken antiretroviral therapy or had a low lifetime dose, indicating a deleterious effect of HIV infection on skeletal muscle. Read more>>

See also: The main characteristic of ME is an abnormally delayed muscle recovery after doing trivial things, if you don't have that, you don't have ME

Study was a sham, researchers say in medical journal

By Lisa Girion, Los Angeles Times, June 27, 2011:

The maker of Neurontin disguised an effort to promote the anti-seizure drug to physicians as a clinical trial and failed to inform involved physicians and patients, according to a new analysis published Monday in the Archives of Internal Medicine journal.

That conclusion was based on an analysis of internal corporate documents that companies involved in marketing Neurontin, including the drug’s current owner, Pfizer Inc., were required to be disclosed in litigation. The authors of the analysis in the Archives of Internal Medicine include paid consultants to plaintiffs in litigation over the drugmaker’s promotion of Neurontin for off-label indications.

After the U.S. Food and Drug Administration approved Neurontin for epileptic seizures, the company launched what it presented as a dosing study to institutional review boards and physicians participating in the Neurontin trial, according to the Archives of Internal Medicine article.

In fact, the Archives of Internal Medicine article says, the study was a “seeding trial” aimed at ... Read more>>

Say a prayer and light a candle for all ME / CFS sufferers and thank all those who are working hard to solve this terrible illness

Study Blowback Shows Controversy Over Chronic Fatigue Syndrome

By Katherine Hobson, MAY 17, 2011, The Wall Street Journal:

We could have told the Lancet it would get a lot of blowback on a study it recently published suggesting that chronic fatigue syndrome can be helped by cognitive behavioral therapy and a slowly ramped-up exercise program — we got 53 comments on our original post about the research, many of them critical.

Sure enough, the medical journal said today that the paper was one of those that, every few years, “elicits an outpouring of consternation and condemnation from individuals or groups outside our usual reach.”

Many patients have long been told that their problems are psychological in nature, while they report symptoms that are similar to those seen in viral diseases. Suggesting that the condition can be significantly improved by psychotherapy and exercise didn’t sit well with many people. (The WSJ’s Amy Dockser Marcus has written about the search for a biological cause of CFS, also known as myalgic encephalomyelitis.)

The Lancet says it received 44 formally submitted letters to the editor, and published eight, along with a response from the paper’s authors. (You can read them all here, on the lower right.)

Critics focused on whether or not the exercise and cognitive behavioral therapy programs actually produced a clinically useful difference and, as the Lancet summarizes, “critique the definitions of secondary outcomes, question protocol changes and express concern over generalizability.”

In their reply, the authors go over their methods and say that “however we compared the results and however we defined CFS and myalgic encephalomyelitis,” exercise and cognitive behavioral therapy programs combined with specialist care showed a “significant and clinically useful advantage of moderate size” over specialist care alone, as well as over that care combined with therapy teaching patients how to recognize symptoms and ratchet down their activity as needed.

See also: Lancet Editor Dr Horton and PACE trial's chief investigator Prof White: no one with ME gets cured by CBT or exercise

See also: Two videos that clearly show how the "results" of the PACE study were manipulated

See also: Dr. Hilary Jones, When you say, "ME is controversial", did you check that with Alison, Annabel and Sophia?

The HealthWell Foundation

The HealthWell Foundation® is a 501(c)(3) non-profit organization established in 2003 that is committed to addressing the needs of individuals with insurance who cannot afford their copayments, coinsurance, and premiums for important medical treatments. Our vision is to ensure that no patient goes without health care because they cannot afford it.

As patients are required to pay a larger share of health care costs each year, even many individuals with insurance find health care unaffordable. These patients face challenges affording the treatments they need to fight chronic and life-altering medical conditions. The HealthWell Foundation was established to address and alleviate this problem. Read more>>

Why does the CDC keep an empty milk carton in their fridge?

By CAK: Why does the CDC keep an empty milk carton in their fridge?

In case somebody asks for black coffee. :-)

Is the charity Action for ME (AfME) strengthening its links to the insurance industry ?

Action for ME and its latest links to the Insurance Industry

Permission to repost:


Action for ME and its latest links to the Insurance Industry

Margaret Williams 9th May 2011


Disturbing evidence exists that the charity Action for ME (AfME) seems to be strengthening its links to the insurance industry, which may be to the potential detriment of people with ME/CFS (whose best interests the charity is required by The Charity Commission to represent).


1. The appointment of Alan Cook CBE as Chairman of AfME

On 8th February 2010 AfME announced that Alan Cook CBE was the charity’s new Chairman. Sir Peter Spencer, CEO of AfME, said: “It’s great news that Alan is coming on board to contribute his experience to this forward thinking organisation. We will benefit hugely as he extends his fantastic track record for achieving success in all that he does”.

Alan Cook also happens to be Chairman of the insurance group that includes Irish Life & Permanent Group Holdings plc.

An Occupational Health doctor who works for Irish Life is Dr Deidre Gleeson, and there is mounting evidence that she is recommending termination of benefit payments to Irish Life policy holders with severe ME/CFS who make claims on their income protection policies because they are simply unable to work.

Can AfME not comprehend that it is not appropriate for it to have a Chairman with such an obvious conflict of interest, whose company is responsible for denying insurance benefits to people with ME/CFS?

For AfME to be so closely linked to the insurance industry that has done so much harm to people with a devastating multi-system disorder must surely be a matter of concern.


2. Allen & Overy LLP

AfME has announced that it is to hold its Annual General Meeting and Open Conference on 22nd October 2011, and that this will take places at the London offices of the law firm Allen & Overy LLP.

Allen & Overy is an international law firm that claims insurance law as one of its areas of expertise: “Our International Insurance Group…advises many of the world’s leading insurers (and) financial institutions….The group consists of lawyers with specialist insurance expertise, some of whom have spent part of their careers in the industry or with insurance regulators. This practical industry experience ensures that we are able to provide commercially driven legal advice. Our insurance lawyers work…with specialists from other market leading practices, such as corporate, capital markets, banking (and) litigation….As a result, our clients receive the best possible technical and commercial legal advice at both a domestic and international level….Practices within Insurance (include) Insurance advice for corporates (and) Insurance disputes”.


3. Professor Michael Sharpe

Although not listed publicly, it is a matter of record that the charity secured the services of psychiatrist Professor Michael Sharpe as a medical advisor, and that he is deeply involved with the insurance industry (particularly with UNUMProvident) in the dismissal of income protection claims submitted by people with ME/CFS.

In February 2000 a Conference on Insurance Medicine was held at The Royal College of Physicians in London, attended by Professors Simon Wessely and Michael Sharpe, at which it is believed Sharpe advised that he was recommending to insurance companies that claimants with ME/CFS should be subject to covert video surveillance.

On 9th May 2001 Michael Sharpe appeared before the Cross Party Group on ME of Members of the Scottish Parliament in Edinburgh, where he informed the meeting that the disorder is not a neurological disorder.

Despite denials from Professor Sharpe that he has ever harmed “CFS” patients, there is evidence that such may not be the case; documented and detailed evidence of the consequences of inappropriate psychiatric intervention has been put before the Chief Medical Officer and is also variously recorded in Hansard. Patients with ME/CFS have been threatened with being sectioned under the Mental Health Act unless they agree to psychiatric interventions, and other kinds of harm include the refusal and/or withdrawal of state benefits; difficulty amounting to the impossibility of obtaining insurance payments, with policy holders being refused benefits; the withdrawal of cover by private health companies for those with ME/CFS (often on the grounds that no cover is available for ‘psychiatric’ illness); an almost total lack of suitable provision or care by the NHS, with no facilities for specialist referral other than to a psychiatrist; an overtly hostile and unfavourable attitude being shown by doctors and other health professionals to those with ME/CFS and special problems for children and adolescents, with increasing numbers of young people being threatened with being removed from their parents and put into care (which has led to litigation).

Perhaps a unique form of harm is to be found in the persistent recommendation by Wessely School psychiatrists that no investigations (or only limited investigations) are necessary and appropriate in patients with ME/CFS. Why are these psychiatrists so insistent that patients should not be medically investigated? As the Countess of Mar asked, where is their natural curiosity about this condition? Why should sufferers and those doctors who observe their suffering accept the limitations of scientific knowledge? These psychiatrists refer to a lack of proven causality, yet they actively advise that no investigations should be performed on patients with ME/CFS and that no research into its organic nature should be undertaken. Is it because they do not wish to know? (Hansard, Lords, 19 December 1998:1011-1024).

AfME must surely be aware that Sharpe was one of the authors of the 1994 (CDC) Fukuda case definition and that the 1994 CDC case definition was unambiguous: “The use of tests to diagnose the chronic fatigue syndrome should be done only in the setting of protocol-based research. In clinical practice, no additional tests, including laboratory tests and neuro-imaging studies, can be recommended. Examples of specific tests (which should not be done) include serologic tests for enteroviruses; tests of immunologic function, and imaging studies, including magnetic resonance imaging scans and radionuclide scans (such as single photon emission computed tomography (SPECT) and positron emission tomography (PET) of the head. We consider a mental status examination to be the minimal acceptable level of assessment” (Ann Int Med 1994:121:12:953-959).

Professor Sharpe was one of the Principal Investigators of the notorious PACE Trial, and AfME was intimately involved with that trial and with the production of the Manuals used in the trial.

It may be recalled that AfME received substantial Section 64 funding (Health Services Act 1968) in return for supporting Department of Health policy priorities (which currently include managing “CFS/ME” as a behavioural disorder).

AfME members and those who fund-raise for it may wish to consider in whose best interest the charity is acting.

Why the psyche school have been purposefully obfuscating the facts

PACE is Dead. Kevin Short:

Dear All,

In my view, in relation to the PACE trial into 'CFS/ME'[1] and some subsequent supportive publications, it is timely for the ME community and interested observers to consider three questions and revisit some previously published material for possible answers.

The first question is, just why do certain UK psychiatrists apparently refuse to adhere to WHO taxonomy as per ICD-10-G93.3 neurological ME/PVFS and ICD-10-F.48.0 psychiatric FATIGUE SYNDROME respectively by erroneously conflating what the WHO and an increasing body of biomedical evidence rightly separate? (That, according to some such psychiatrists, 'CFS/ME' is allegedly and primarily both physical and psychiatric and that most illnesses are comprised of both such primary components is often cited as justification: an unlikely assertion if, for example, applied to lung-cancer or HIV/AIDS. Like cancer and AIDS patients, ME sufferers do not object to secondary/co-morbid psychiatric complications being addressed for what they are. They do however object to primary physical illness being misrepresented and mistreated as psychiatric. Such misrepresentation of primary physical illness in the case of cancer and AIDS would rightly be dismissed as ludicrous by most informed people and ditto should be the case for ME.)

Perhaps in no small part the answer is to be found in earlier published comment. In this case the 2006 UK Parliamentarian Group on the Scientific Research into ME (GSRME) which, in connection with such psychiatrists' role in advising the UK Department of Work and Pensions (DWP) on ME/CFS, cautioned:
"There have been numerous cases where advisors to the DWP have also had consultancy roles in medical insurance companies. Particularly the Company UNUM Provident. Given the vested interest private medical insurance companies have in ensuring CFS/ME remain classified as a psychosocial illness there is blatant conflict of interest here. The Group find this to be an area for serious concern and recommends a full investigation of this possibility by the appropriate standards body. It may even be that assessment by a medical `expert' in a field of high controversy requires a different methodology of benefit assessment."
- GSRME Report, Page 30. See:
www.erythos.com/gibsonenquiry/index.html

The second question is, how on earth does so much psychiatric 'research' that is poorly-conceived, of questionable-quality and undertaken by investigators with demonstrable conflicts of interest receive so much funding and peer-reviewed journal exposure?

Again, in no small part, perhaps the explanation is to be found in earlier published comment. In this case taken from the introductory summary of Professor Bruce Charlton's 2008 peer-reviewed paper entitled 'Zombie Science – a sinister consequence of evaluating scientific theories purely on the basis of enlightened self-interest':

"Although the classical ideal is that scientific theories are evaluated by a careful teasing-out of their internal logic and external implications, and checking whether these deductions and predictions are in-line-with old and new observations; the fact that so many vague, dumb or incoherent scientific theories are apparently believed by so many scientists for so many years is suggestive that this ideal does not necessarily reflect real world practice. In the real world it looks more like most scientists are quite willing to pursue wrong ideas for so long as they are rewarded with a better chance of achieving more grants, publications and status."

"The classic account has it that bogus theories should readily be demolished by sceptical (or jealous) competitor scientists. However, in practice even the most conclusive `hatchet jobs' may fail to kill, or even weaken, phoney hypotheses when they are backed-up with sufficient economic muscle in the form of lavish and sustained funding. And when a branch of science based on phoney theories serves a useful but non-scientific purpose, it may be kept-going indefinitely by continuous transfusions of cash from those whose interests it serves. If this happens, real science expires and a `zombie science' evolves."

In seeking examples of such 'zombie science', in my opinion, few contenders can match the recent UK PACE trial study by Professor Peter White et al published in The Lancet that was rightly, and eruditely, criticised by Professor Malcolm Hooper. Outside of the usual supporters, The Science Media Centre and what many would regard as misinformed converts, PACE is widely viewed as a disgrace: having conflated illness rightly separated by the WHO, having effectively ignored a large body of biomedical evidence, having used unscientific and disingenuous patient selection criteria, and having almost exclusively employed subjective and highly unreliable measurement techniques. See:
http://www.meactionuk.org.uk/COMPLAINT-to-Lancet-re-PACE.htm

With PACE etc in mind, Professor Charlton's 'Zombie Science' critique paper is well worth reading in full. The reference & link for the full text of the paper is:
Professor Bruce Charlton – Zombie Science – a sinister consequence of evaluating scientific theories purely on the basis of enlightened self-interest, Medical Hypotheses (2008) 71 327-329, DOI: 10.1016/j.mehy.2008.05.018:
http://medicalhypotheses.blogspot.com/2008/07/zombie-science-dead-but-wont-lie-down.html

If the psychiatrists involved in the PACE trial were serious about science, and genuinely believed ME was maintained by fear of activity and muscle deconditioning, they would have exclusively used rigorous and internationally accepted patient selection criteria. They did not. If they were serious about science they would have applied objective assessment criteria to properly informed patients. They did not. In my view PACE represents a gross abuse of the scientific process and a gross abuse of ME patients. Ditto for much of the largely rhetorical and uncritical literature supportive of PACE that, unlike the many patient protestations such as this article, find their way into the so-called scientific literature. From its inception, PACE was roundly and eruditely criticised as being seriously flawed, that it was publicly funded amounts to a gross abuse of millions of pounds of UK taxpayers' money.

In terms of the real-world clinical setting amongst real-world ME patients, I believe the full scientific evidence-base shows that PACE CBT/GET will ultimately contribute nothing positive. It will not improve ME patient function in the medium to long term, if at all, and will eventually be seen by most as having been dead on arrival and a complete waste of money: Zombie therapies based upon Zombie science. Moreover, I believe that most of the PACE PIs actually know this. If so, my third question is what then could be the real purpose of PACE? Professor Charlton's following observation seems to me to answer that question perfectly:

"If zombie science is not scientifically-useable – what is its function? In a nutshell, zombie science is supported because it is useful propaganda to be deployed in arenas such as political rhetoric, public administration, management, public relations, marketing and the mass media generally. It persuades, it constructs taboos, it buttresses some kind of rhetorical attempt to shape mass opinion. Indeed, zombie science often comes across in the mass media as being more plausible than real science; and it is precisely the superficial face-plausibility which is the sole and sufficient purpose of zombie science."

In my opinion PACE is an issue for more than just ME patients. It is an affront to British science and British society.

Anglia ME Action.
April 2011.
contact@angliameaction.org.uk

[1] Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial; PD White et al; published online February 18, 2011 DOI:10.1016/S0140-6736(11)60096-2.

- Message Ends - Permission to Repost -

Royal College backtracks on its statement that ME is psychological

by tonybritton on April 27, 2011:

The Royal College of Paediatrics and Child Health has reaffirmed its belief that ME/CFS is a biological illness and disowned a statement made to the recent mini-review of the NICE Guideline on ME/CFS that it is “a psychological illness with physical manifestations” with clinical experience suggesting that the incidence “appears to be falling in children and young people”.

In a letter sent to the Countess of Mar on 21 April, Cambridgeshire paediatrician Dr David Vickers – a member of the Royal College’s ‘President’s Advisory Group’ – writes:

“I have reviewed our submission to the NICE consultation and can confirm this comment was from one individual who assisted in our response. As such it does not represent RCPCH policy, and in retrospect should not have been included. The phrase ‘as a psychological illness with physical manifestations’ was unhelpful.”

Lady Mar, who chairs the Forward ME Group of ME charities and patient support groups, gave permission for the letter to be released today after she has raised the issue with Care Services Minister Paul Burstow and Mary-Jane Willows, chief executive of the Association for Young People with ME, had raised it directly with the Royal College.

Full text of the letter from Dr Vickers to the Countess:

21 April 2011

Dear Lady Mar

The Chief Executive of AYME has forwards us a copy of your letter of 5 April 2011 to Paul Burstow in which you express concern about the RCPCH response to NICE on their consultation on possible revisiom of guidelines on CFSME. In our response we stated that “Regarding the epidemiology of chronic fatigue syndrome: as a psychological illness with physical manifestations, clinical experience suggests that the incidence appears to be falling in children and young people.

As our President stated in his latter dated 25 February 2011, RCPCH views CFSME as a biological illness and continues to stand by its own guidelines issued in 2004. I have reviewed our submission to the NICE consultation and can confirm this comment was from one individual who assisted in our response. As such it does not represent RCPCH policy, and in retrospect should not have been included. The phrase “as a psychological illness with physical manifestations” was unhelpful.

My prime reason for writing is to reassure you RCPCH continues to view this condition as a biological illness, which benefits from expert multidisciplinary management.

I am aware that these comments have caused some concern, and hope that this letter reassures you that our position has not altered.

Yours sincerely

Dr David Vickers

The Royal College of Paediatrics and Child Health was one of a couple of dozen organisations who made brief representations when NICE (the National Institute for Health and Clinical Excellence) invited them to comment last November on whether there was a need for a a major review on their August 2007 Guideline on ME/CFS.

The comments were published in summary form by NICE and this document can be viewed HERE:
http://www.nice.org.uk/nicemedia/live/11824/53853/53853.pdf?forumid=331851

Wanted - psychiatrists / therapists

Source: craigslist.org:

Date: 2011-04-26
I'm looking for psychiatrists and therapists to potentially make them famous and rich! Read more>>

PACE trial: CBT and GET are not effective for ME/CFS

Frank NM Twisk, Michael Maes, Cort Johnson:

Letter to the Editor,


Cognitive behaviour therapy/graded exercise therapy is not an effective treatment for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.

Frank NM Twisk, Michael Maes, Cort Johnson.


According to White et al. (1) "either cognitive behaviour therapy (CBT) or graded exercise therapy (GET), when added to specialist medical care (SMC), are effective treatments for chronic fatigue syndrome (CFS)".

The size of this effect is however very moderate, while 60% reported they did not see a positive result in Global Impression of Health Scale benefit.

The Work and Social Adjustment scale indicated the average CBT/GET patient was still at the borderline of being 'very severely impaired'.

The conclusion is that these treatments cannot be considered to be effective (1) or curative (2).

More importantly, due to the selection criteria, the participants cannot be considered to be CFS patients, e.g. 47% met criteria for psychiatric disorders, while the two subjective measures fatigue and physical function are largely insufficient to establish recovery:

cut-off scores on these measures do not correspond with a CFS diagnosis.

Moreover, an improvement in "fatigue" is not reflected by a significant objective improvement,
e.g. in physical activity (3).

When looking at the only objective measure (1), i.e., meters walked in 6 minutes (CBT: 354; GET: 379; compared to 349 for SMC after treatment), CBT and GET hardly qualify as "moderately effective".

As recently has been confirmed (4),

CBT and GET are not effective and even potentially harmful for many ME/CFS patients (5).

According to (1)

non-serious adverse events for CBT (89%) and GET (93%)

are very common.



Therefore the claim that

"CBT and GET can safely be added to SMC" (1)

cannot be substantiated.


References:

1. White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. The Lancet 2011 Feb 17. doi: 10.1016/S0140-6736(11)60096-2.
2. Wessely, S. Chronic fatigue syndrome - trials and tribulations. JAMA 2001; 286; 1378-9. doi: 10.1001/jama.286.11.1378.
3. Wiborg JF, Knoop H, Stulemeijer M, Prins JB, Bleijenberg G. How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity. Psychol Med 2010; 40: 1-7. doi: 10.1007/s10067-009-1339-0.
4. Núñez M, Fernández-Solà J, Nuñez E, Fernández-Huerta JM, Godás-Sieso T, Gomez-Gil E. Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up. Clin Rheumatol 2011 Jan 15. doi: 10.1007/s10067-010-1677-y.
5. Twisk FNM, Maes M. A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients. Neuro Endocrinol Lett 2009; 30: 284-99.