BACK HOME to Canberra FM/CFS page

SUBMISSION ON DRAFT CFS GUIDELINES

Part 2

Continued from Part 1 ...

8. The draft guidelines extrapolated from a study on graded exercise to support Cognitive Behaviour Therapy when the authors of the exercise paper specifically condemned that extrapolation - is it not therefore bias to fail to make the lesser extrapolation of graded exercise supporting the lipid/efam model in accordance with the voluminous published basic science connecting exercise to lipid/efam physiology and pathophysiology ?

Fulcher and White stated of their Graded Exercise study vs separate CBT studies :

"The treatments cannot fairly be compared" ?

While Graded Exercise is not in any case equal to CBT and Fulcher and White should not have been misrepresented as CBT, if the draft guidelines regarded the graded exercise without Cognitive therapy to be a sub-component of CBT and ( if honestly clarified in referencing ) used the graded exercise trial to support the working group hypotheses; why then was not this principle applied even-handedly e.g. trials of Graded Exercise and CBT studies as sub-components of the EFAM model of treatment were not used to support that treatment model even though the working group's model was retrospectively fitted to the data but the EFAM model's predictions preceded the corroborating studies ?

MISREPRESENTING FUKUDA ET AL ON DIAGNOSIS

9. Why have the draft guidelines misrepresented Fukuda et al's assessment and diagnostic criteria as being the same as the draft guidelines assessment and diagnostic criteria? Is it not correct that they have introduced extra exclusions from a diagnosis of CFS contrary to the express opinion of Fukuda et al and failed to table a diagnosis "idiopathic chronic fatigue" ?

Why do the draft guidelines seriously misrepresent Fukuda et al's assessment criteria for Chronic Fatigue and diagnostic criteria for chronic fatigue syndrome (CFS), as being synonymous with the draft guidelines assessment criteria for Chronic Fatigue and diagnostic criteria for CFS :

A. Table 1.1 and elsewhere claim to use Fukuda et al's criteria for diagnosing CFS but do not list the Fukuda et al criteria for exclusion from diagnosis of unexplained chronic fatigue, rather elsewhere in the text add to the list of exclusions from a diagnosis of CFS contrary to the express position of Fukuda et al that such conditions should not be excluded ? e.g.

• on p 956 of Fukuda et al "hypothyroidism for which the adequacy of replacement hormone has been verified" is specifically mentioned as an example of conditions treated sufficiently to alleviate symptoms that are not excluded, but p 9 of the draft guidelines excludes "hypothyroidism and receiving thyroxine replacement" from a diagnosis of CFS
• Fukuda et al states "anxiety disorders, somatoform disorders" as examples of conditions defined primarily by symptoms "do not exclude a patient from a diagnosis of unexplained chronic fatigue" and hence do not exclude them from a diagnosis of CFS, but on p 9 of the draft guidelines "generalized anxiety, and somatoform disorders" are listed as alternative diagnoses, and then immediately going on that if a patient is "being treated for .... a psychiatric condition ... a separate diagnosis of CFS is not justified".

B. in table 1.1 the draft guidelines reference Fukuda et al after espousing a methodology for assessing chronic fatigue - but no where do the guidelines even mention "Idiopathic Chronic Fatigue" let alone define it as part of the differential diagnosis of chronic fatigue as did Fukuda et al ?

Fukuda et al had four pivotal alternatives at 6 months after commencement of fatigue:

1 - resolved
2 - explained chronic fatigue ( somatoform disorder did not explain chronic fatigue so as to exclude a CFS diagnosis see "A" above ) - unexplained chronic fatigue, which in turn was broken into :
3 - Chronic Fatigue Syndrome
4 - and for those not meeting the CFS definition "Idiopathic Chronic Fatigue"


The draft guidelines in failing to allow "Idiopathic Chronic Fatigue" when combined with table 2.2 flow chart for diagnosis, only allow a case to be:

1 - resolved
2 - explained by alternative diagnoses
3 - CFS


Hence those chronic fatigue cases that do not resolve but do not meet restrictive and somewhat arbitrary CFS diagnostic criteria ( e.g. having 4 of 8 symptoms selected out of the many dozens reported by CFS patients ) are then thrust back to either the "1 - resolved" ( hence malingering ) or the "2 - explained" basket. Various psychiatric diagnoses (such as somatoform disorder) are proffered by the draft guidelines to fill this artificial void in stark contrast to Fukuda et al.

Hickie, Lloyd et al 1995 published that a subset of CFS has somatoform disorders, openly arguing against the 4 out of 8 specific symptoms required of Fukuda et al because it encouraged heterogeneity ( Fukuda et al even noted Hickie et al's dissent on this issue); and Hickie and Lloyd are two of the three acknowledgements noted re writing the initial drafts of the guidelines. Why wasn't their knowledge of the issues expressed clearly in the draft guidelines ?

Whatever the reason, misrepresenting Fukuda et al as being the same as the draft guideline diagnostic/ assessment criteria when they clearly are not, is untenable for evidence based guidelines.

---

[ Top ] [ Guidelines page ] [ Australian/NZ information] [ Library]  



BACK HOME to Canberra Fibromyalgia and Chronic Fatigue Syndrome Page at http://www.masmith.inspired.net.au/

Moira A Smith - Canberra, Australia
last revised 14 March, 1998