Solve ME/CFS Initiative 2014 Webinar Series

July 8, 2014

Workplace-WebinarBeginning in July and continuing through year-end, the Solve ME/CFS Initiative (SMCI) will be bringing you a free, monthly webinar series. Anyone that is interested can RSVP to participate live. Each webinar will be recorded and posted to our website and YouTube channel within a week of the live date, so if you miss it, don’t worry! You can still have access to the great content at your convenience.

Read more about the series and RSVP today!



Research Institute Without Walls – Progress and Promise

HELD on Thursday, July 31, 2014
Video Link

Suzanne D. Vernon, Ph.D., scientific director of the Solve ME/CFS Initiative will provide an update on the work being conducted through our Research Institute Without Walls. Participants can also expect to learn more about how the SolveCFS Biobank works and is attracting some of the brightest investigators from the best institutions to ME/CFS research.  You will leave with an understanding of what makes the SolveCFS BioBank unique, how to get enrolled and what to expect when you participate.  Vernon will also provide a sneak peek at some of the types of research being conducted on samples using the SolveCFS BioBank.



Investigator Report: Epigenetics of ME/CFS

Thursday, August 21, 2014
2-3:00pm Eastern (1pm Central/Noon Mountain/11am Pacific)

Space is limited –  RSVP to Reserve Your Slot – Click HERE

Patrick O. McGowan, Ph.D., is one of the Solve ME/CFS Initiative 2011 funded investigators.  McGowan is an assistant professor in the Department of Biological Sciences, University of Toronto at Scarborough.  He will talk about his latest results from our grant funding.  McGowan used blood samples from the SolveCFS BioBank to identify the chemical modifications (e.g., methylation) to the DNA that is different in ME/CFS patients compared to healthy people.  This type of research will help explain the immune dysfunction of ME/CFS.



Investigator Report: Deciphering Post-Exertional Malaise

Thursday, September 18, 2014
2-3:00pm Eastern (1pm Central/Noon Mountain/11am Pacific)

Space is limited –  RSVP to Reserve Your Slot – Click HERE

Dane B. Cook, Ph.D. is assistant professor of Kinesiology at the University of Wisconsin, Madison.  Cook is one of the Solve ME/CFS Initiative’s 2011 funded investigators.  Cook will describe the system biology approach his team is taking to provide a clear picture as to what causes post-exertional malaise.  This is critically important research for ME/CFS because as Cook notes, “You can’t begin to fix a problem like post-exertional malaise until you can understand its underlying cause.”



Investigator Report: Decoding the Human Immune Response

Wednesday, October 1, 2014
2-3:00pm Eastern (1pm Central/Noon Mountain/11am Pacific)

Space is limited –  RSVP to Reserve Your Slot – Click HERE

Derya Unutmaz, MD, is Professor of Microbiology, Pathology and Medicine at NYU Langone Medical Center.  Unutmaz is using samples from the SolveCFS BioBank to understand the “Good, Bad and Ugly” aspects of the immune response in ME/CFS.  Unutmaz hypothesizes that a disproportionate immune response leads to damage in ME/CFS.   He will describe what the immune signature of ME/CFS looks like compared to a healthy immune response.


PeterRoweInvestigator Report: Neuromuscular Strain in ME/CFS

Thursday, October 23, 2014
2-3:00pm Eastern (1pm Central/Noon Mountain/11am Pacific)

Space is limited –  RSVP to Reserve Your Slot - Click HERE

Peter Rowe, MD, who directs the Chronic Fatigue Clinic at Johns Hopkins Children’s Center, will describe some novel observations about restrictions in range of motion in the limbs and spine in those with ME/CFS. Many affected individuals have restricted movements and increased mechanical tension in nerves. Applying a further mechanical strain to the nervous system can provoke increased symptoms in some patients. These concepts are starting to help explain the pathogenesis of some symptoms and neurological abnormalities in the illness—not only how they might arise but also how we might treat them more effectively.



November and December webinars to be announced at a later date.



Same Mission | New Name

May 30, 2014

Solve ME/CFS Initiative

We’re delighted to announce that The Solve ME/CFS Initiative has a new name – the Solve ME/CFS Initiative.   While our name has changed, our mission steadfastly remains the same:  We will make ME/CFS understood, diagnosable and treatable.

Why the change?  We recognize the many changes in our organization and our illness space since the organization was first named so long ago in 1987.  While the name of our illness continues to be controversial, “ME/CFS” better reflects today’s understanding. And we believe that the word “initiative” (defined as ‘leading action’), expresses our strong commitment to funding ground-breaking research.

Since our organization was founded and named in 1987, we have been the leading organization focused on this illness.  Over the years, we’re proud of our remarkable advances regarding this controversial and misunderstood disease.

  • Under the 22-year leadership of Kim McCleary, the organization’s first CEO, the Association played an integral part in developing a policy ruling for the Social Security Administration that recognized CFS as a disabling condition.
  • We are the leading private funder of ME/CFS research, directly funding $5.5 million in ground breaking research which has been leveraged into more than $12 million in additional ME/CFS research.
  • The organization fought to create and continues to advocate to sustain a dedicated federal advisory committee on ME/CFS research and education (CFSAC).
  • We helped expose the misappropriation of $12.9 million in CDC spending, restoring these funds to ME/CFS research.
  • We led the first-ever public awareness campaign for ME/CFS, led lobbying events, organized Congressional briefings and regularly deliver testimony at numerous federal hearings and meetings.

Four years ago, guided by a desire to move into a new era of scientific progress on ME/CFS, the Association made a strategic decision to heighten its focus on research.  Our thinking was simple – the best way to use our precious dollars is toward solving this despicable illness.

Today, led by President and CEO, Carol Head, the organization continues to drive its mission forward – to fund research that will make ME/CFS understood, diagnosable and treatable.  How do we do that? By providing more funding for high-quality ME/CFS studies, fostering increased collaboration among ME/CFS researchers and pushing the federal government to make ME/CFS research a higher priority.  We are working to leverage our experience, relationships and collective knowledge to propel the ME/CFS research field forward. We are a catalyst for scientific advances that translate into better care for ME/CFS patients. We are accelerating ME/CFS research.

As we continue our efforts to make ME/CFS widely understood, diagnosable, and treatable, it is fitting that we have a name that more accurately reflects who we are: The Solve ME/CFS Initiative. We trust that you will continue this journey with us as we work towards a day when ME/CFS is no more.


Research Digest – October 2014: The Search for Diagnostic Certainty

October 24, 2014

On Sept. 22nd the Agency for Healthcare Research and Quality (AHRQ) and their Evidence-Based Practice Centers published the draft systematic evidence review on the Diagnosis and Treatment of ME/CFS for comment. This report will be used for the Pathway to Prevention Workshop for ME/CFS to be held on December 9 & 10, 2014. (Read our full response to this draft report HERE.) One of the recommendations of the review is the need to test ME/CFS diagnostic criteria in other populations with diseases similar to ME/CFS where diagnostic uncertainty exists.  This is necessary because ME/CFS is defined by symptoms that are common in many other medical and psychiatric diseases.  Comparing ME/CFS to similar disorders helps determine effective diagnostic criteria to more specifically identify those who have ME/CFS.

Once ME/CFS is diagnosed there are many differences among patients; this is called heterogeneity and is common in most chronic diseases.  Objective biological measures – known as biomarkers – can be helpful for delineating this heterogeneity and identifying ME/CFS subtypes.  Importantly, biomarkers intended to be diagnostic for ME/CFS should be compared to diseases similar to ME/CFS to ensure the accuracy of the biomarker.

While there is more work to be done, in this month’s Research Digest we review three different studies that look at diseases that are common among patients labeled as ME/CFS and to identify more specific biomarkers for ME/CFS.


 There have been studies published over the years that have looked at whether ME/CFS patients defined by the 1994 Fukuda criteria have other medical and psychiatric diseases that more accurately explain their symptoms.  A study published in the 2013 Journal of Psychosomatic Medicine found that undiagnosed and comorbid disorders were common in people with a presumed diagnosis of ME/CFS.(1) The investigators set up an integrated diagnostic pathway designed to detect known medical and psychiatric diseases that may otherwise go undiagnosed.  There were 377 patients with a presumed ME/CFS diagnosed referred to the study. Of these 279 were eligible for the study.  An unequivocal ME/CFS diagnosis was given to 65 patients.  Another 59 patients had ME/CFS together with a comorbid disorder that did not exclude the ME/CFS diagnosis.  The remaining patients had sleep disorders, medical diseases or psychiatric diagnoses that excluded an ME/CFS diagnosis.  This study highlights the importance of and need for diagnostic criteria that accurately detects ME/CFS and distinguishes it from other disorders.  This will help target treatments appropriately and avoid diagnostic labels that are potentially harmful.


Several studies have used blood gene expression in an attempt to identify biomarkers that delineate ME/CFS subtypes.  Jonathan Kerr has spearheaded many of these studies and in September published a paper in the Journal of Clinical Pathology titled, “Use of single-nucleotide polymorphisms (SNPs) to distinguish gene expression subtypes of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME)”.(2) Kerr had previously identified 8 ME/CFS subtypes with different gene expression profiles (measuring the message RNA produced from genes.)  In this study, he used the DNA sequence information of these genes to determine if it could be used to identify the same 8 ME/CFS subtypes and distinguish from people with depression and healthy controls.  Kerr wanted to use the DNA genetic sequence rather than the message RNA because message RNA deteriorates quickly, making it challenging to use as a diagnostic biomarker.  Kerr found that only some of the 8 ME/CFS subtypes were identified using the DNA genetic sequence data but that this method was insufficient to reproducibly differentiate subtypes.  There are several reasons why this method did not delineate ME/CFS subtypes including small sample size and sample heterogeneity.  Nonetheless, these results help inform future studies using genomic technologies to develop objective biomarkers for ME/CFS.


Ekua Brenu and a team from Australia published an interesting paper about the potential for a particular type of biomarker  in PLOS ONE this September titled, “High-throughput sequencing of plasma microRNA in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis”.(3)  What makes this study interesting is the use of plasma – the clear liquid component of blood that is relatively easy and noninvasive to collect to detect microRNA.  Unlike message RNA (discussed in the above study) microRNA are a more readily measured because they are short and can evade destruction, making it intriguing for use as a biomarker.  MicroRNAs use their short sequence structure to regulate gene expression (they do not code for proteins as message RNAs do.)  Brenu and team identified 19 microRNAs that were differentially expressed in the plasma of ME/CFS patients compared to controls.  They confirmed significant up-regulation (increased expression) of three of these microRNAs. More ME/CFS patient samples need to be tested – as do diseases with similar symptoms – to determine the diagnostic utility of these plasma biomarkers for ME/CFS.



(1) Mariman A, Delesie L, Tobback E, Hanoulle I, Sermijn E, Vermeir P, Pevernagie D, Vogelaers D. Undiagnosed and comorbid disorders in patients with presumed chronic fatigue syndrome. J Psychosom Res. 2013 Nov;75(5):491-6.

(2) Shimosako N, Kerr JR. Use of single-nucleotide polymorphisms (SNPs) to distinguish gene expression subtypes of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). J Clin Pathol. 2014 Sep 19.

(3) Brenu EW, Ashton KJ, Batovska J, Staines DR, Marshall-Gradisnik SM. High-Throughput Sequencing of Plasma MicroRNA in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. PLoS One. 2014 Sep 19;9(9):e102783.

Article in APA Monitor Reaches 130,000 Professionals in the Field of Psychology, Seeks to Dispel Myths about CFS

October 23, 2014

APA_StoryThe Monitor on Psychology is a well-respected publication of the American Psychological Association (APA) – the largest scientific and professional organization representing psychology in the United States. According to its website, “APA is the world’s largest association of psychologists, with nearly 130,000 researchers, educators, clinicians, consultants and students as members.”

In May of this year a freelance reporter, Kirsten Weir, contacted the Solve ME/CFS Initiative (SMCI) concerning an article she was writing about Chronic Fatigue Syndrome for the Monitor. She was hoping we could get her in touch with a patient that could answer a few short questions about living with the disease.

Understanding that far too many ME/CF patients have been adversely affected by the painful practice of dismissing ME/CFS as a psychological disorder vs treating it as the debilitating physiological disease that it is, we asked her to tell us more about the goal of her article. In her reply she told us, “The goal of the article is to update readers on the latest thinking behind ME/CFS — to underscore that it has biological roots and is not a psychological condition. To look at what the science says about possible causes and best approaches to managing the disease. I’ve spoken to several researchers who noted that patients are really frustrated by the myths and misunderstandings associated with the disease, and I’m aiming to find some patients who can speak to that issue.”

With that understanding, we reached out to several patients to inquire as to their willingness and availability to talk to Ms. Weir for her article. Anna Zapp and Carollynn Bartosh both agreed to be interviewed via email, thrilled that the interview pointed to the American Psychological Association acknowledging bio-organic roots of ME/CFS. Bartosh remarked, “It’s been a very long time in coming, and I am honored to be asked for an interview as a patient under the circumstances.”

She went on to tell Weir, “I think my fellow patients would want to be sure that practicing psychologists are aware of the fight that happened over the American Psychiatric Association including CFS as a somatoform disorder in the DSM-V. In 2010 all of the leading clinician-researchers and advocacy organizations from around the world, not just the US, as well as many patients such as me wrote letters pointing out the more than 2,000 studies published by that date into the bio-organic roots of the illness. Including CFS as they did seemed to ignore the science while offering no improvement in care for patients so diagnosed. I’m certain that many patients have been, are, and will be quite hurt by that inclusion, even by well-meaning psychologists.”

Earlier this month the October issue of the APA Monitor was released and Weir’s article appears on page 67-71. You can read the full text here: 

This is a story that is long overdue. As the largest association of psychologists, the APA can and should play a role in dispelling disbelief that ME/CFS is a serious, debilitating illness. SMCI is happy to have helped this article come to fruition, but there is still work to be done. Old habits and attitudes can take time to be torn down, as evidenced by the quote pulled out at the top of page 69, which seems completely out of context with the rest of the article.APA_CallOut
Upon seeing the article, Bartosh, who is quoted in the piece, shared with us her preferred ‘call-out quote’ as the take-away from this article:

“…the take-home is simple: It’s time to give up the idea that CFS is a psychosomatic disease.”
-Marcie Zinn, PhD, neuropsychologist and research consultant at Stanford University

And we agree. Treating ME/CFS as a psychosomatic disorder is a practice that simply must end. It is our hope that this article in the hands of more than 130,000 professionals that are in a position to incite that change will begin to move us all forward.


P2P Draft Evidence Review

October 20, 2014

Can a Process that is Inappropriate for ME/CFS Inform the Research Path Forward?P2P_title

Summary Overview

As a research focused organization, the Solve ME/CFS Initiative (SMCI) understands the impact a program like the Pathway to Prevention workshop (P2P) can have on the research landscape.  Because of its importance, we have utilized the collective brainpower of our Research Advisory Council, led by our scientific director, Suzanne D Vernon, PhD, to perform a careful review and response to the Evidence-Based Practice Centers’ draft evidence-based review for ME/CFS. (Read our official submission HERE)  We have concluded that:

  • It confirms what we and others have suspected: the Pathway to Prevention (P2P) process is not appropriate for ME/CFS.  Among other reasons, it uses comparative effectiveness methodology to review the evidence to inform healthcare; in the case of ME/CFS the evidence base is much too slim for this method to be effective.
  • The P2P systematic review of the ME/CFS evidence base illustrates the lack of rigor in crucial research design elements and the absence of high quality clinical trial data. The review shines a bright light on the need for well-designed, adequately powered studies to identify diagnostic gold standards and safe and effective treatments.

Furthermore, it is important to note that the vast majority of ME/CFS research studies were omitted from this evidence review due to their inability to meet the rigorous standards required for inclusion. Of all of ME/CFS research studies funded by the NIH since 1991 ($191.5 million spent), less than 1% of those studies were included. So, not only has the NIH egregiously underfunded this illness (based on prevalence), but the research NIH has funded has not contributed to an evidence base that has moved the science forward.

This review substantiates the negative cycle currently in play with ME/CFS research – Because there is little funding, there is little research. And because there is little research, there is little evidence to prompt additional funding. But the P2P process may be what is needed to break through that negative cycle and move us to a day when ME/CFS is appropriately funded. It’s existence demonstrates that there is increasing recognition of the clinically devastating nature of ME/CFS and recognition of the disease as an urgent area of future study.


Background – How did we get here?
To review what has led up to this NIH P2P workshop for ME/CFS:

  • The 2011 NIH State of the Knowledge Workshop for ME/CFS concluded that there were problems with definitions, gaps in study design, and a lack of studies on co-morbid conditions, biomarkers, or genetics.
  • A year later, at the CFS Advisory Committee meeting, Dr. Sandra Kweder, FDA Deputy Director of the Office of New Drugs tells us there are so few applications to the FDA because there is no accepted ME/CFS definition, no accepted method for measuring how patients feel or function and no accepted biomarker to provide a simple, quantitative measure of disease presence or activity.
  • In 2013, ME/CFS is the first “patient-focused drug development” workshop held by the FDA. The outcome of that meeting, as expressed in the Voice of the Patient report, is that ME/CFS is a serious disease with significant unmet medical need that requires comparative effectiveness research to generate the evidence to assess the effectiveness, benefits, and harms of different treatment options.
  • In 2014, Dr. Susan Maier, Deputy Director of the Office of Research on Women’s Health at the NIH, who oversees ME/CFS research at NIH, successfully garnered a Pathways to Prevention workshop titled, “Advancing the Research on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome”.

For much of this year, the Solve ME/CFS Initiative (SMCI), as well as many other individual advocates and patient groups, has been talking about the National Institutes of Health (NIH) Pathways to Prevention (P2P) for ME/CFS workshop. In April, we first reported on the possibility of the P2P workshop, then in the approval process. Once it was approved, the NIH worked with the Agency for Healthcare Research and Quality (AHRQ) and their Evidence-Based Practice Centers to conduct this evidence-based review.

In June, SMCI expressed concerns that the search criteria used for the evidence-based literature review would bias the review toward studies on CBT and GET. On Sept. 22nd AHRQ published the draft systematic evidence review on the Diagnosis and Treatment of ME/CFS for comment.  Several members of our Research Advisory Council together with Suzanne D. Vernon, PhD reviewed the draft and have provided peer review comment directly to AHRQ. SMCI and our research advisors believe that this systematic review has identified important and significant gaps in research that have contributed to the dearth of evidence needed to diagnosis and treat ME/CFS. Indeed, it is almost all “gap” and almost no substance.


Dearth of Evidence
From 1991 to 2014, NIH Research Portfolio Online Reporting Tools (RePORT) indicates a total of $191.5 million has been awarded to investigators to directly study ME/CFS or conduct research relevant to ME/CFS.  Spending for other medically unexplained disorders that often occur with ME/CFS, like Fibromyalgia and irritable bowel syndrome (IBS), is about $400 million for each in the same time frame. This is in contrast to multiple sclerosis (MS) – a condition with objective diagnostic biomarkers and treatments – where NIH spending in the same period exceeds $4 billion.

Further, a search of for anything published on ME/CFS finds 5,450 peer reviewed scientific articles; there are 8,000 articles for Fibromyalgia and 9,000 for IBS.  This is in contrast to the 55,500 articles found in PubMed that make up the MS evidence-base.  There is a direct correlation between funding levels and the breadth of the published evidence-base.


The One Percentexamine
Now, the NIH P2P draft systematic review is out. All told there were 5,901 papers considered by the Evidence-Based Practice Center in the comparative effectiveness systematic review. In the end, less than 1% of these 5,901 paper met criteria for inclusion in the systematic review process. Why? 

  • Because comparative effectiveness systematic reviews are based on evidence-based facts. The P2P uses a rigorous process to empirically identify methodological and scientific weaknesses in each published paper.
  • The investigators conducting these evidence-based reviews are experts in this review process and come to the task at hand without any bias or preconceived notion about the topic they are reviewing.
  • The procedures for these reviews are possible because there are standard methods and procedures in place for conducting research; especially human research intended to impact clinical care. They systematically reviewed the ME/CFS papers using specific research design criteria known as PICOTS – Populations, Interventions, Comparators, Outcomes, Timing, and Setting.

While the draft comparative effectiveness review on the Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) may be a hard pill to swallow for patients and for the many ME/CFS scientists whose research studies were excluded from this review, it identifies vast research gaps and provides important information needed to chart the way forward.

The rationale for evidence-based reports makes sense:

  • “Systematic reviews are the building blocks underlying evidence-based practice; they focus attention on the strength and limits of evidence from research studies about the effectiveness and safety of a clinical intervention. In the context of developing recommendations for practice, systematic reviews can help clarify whether assertions about the value of the intervention are based on strong evidence from clinical studies.”

And …

  • “This review is not intended to address the question of etiology nor underlying factors that lead to the onset or perpetuation of ME/CFS but rather to focus on the diagnosis and treatment of this syndrome.”

With this is mind, the review identified only 64 studies that met evidence-based criteria to address the key questions; 1) ME/CFS diagnosis and 2) ME/CFS treatment. For a diagnosis study to be included it had to discriminate ME/CFS patients from healthy controls and (ideally) from other diseases with similar symptoms and if the study used biochemical marker it had to be in the context of treatment versus etiology. Twenty-eight studies addressed various aspects of diagnosis. Most of the studies pertaining to diagnosis were rated as fair quality (on a scale of “good”, “fair”, “poor”). These diagnosis studies showed that certain measures that assess function are able to distinguish between ME/CFS and healthy people reasonably well. The studies were rated “fair” because they were small and diseases similar to ME/CFS were seldom included. The lack of a gold standard for diagnosis of ME/CFS limits how broadly the limited evidence base can be generalized to the ME/CFS community as a whole. The review notes that clinical experts identify post-exertional malaise (PEM) as a cardinal feature of ME/CFS yet current methods of testing, comparing, and monitoring PEM are lacking.


So what few studies WERE included and do they shed light?
There were 36 randomized clinical trial studies for ME/CFS treatment; 9 for medications, 14 for counseling or behavioral therapies, 7 for complementary and alternative medicine, 6 for exercise, and 5 comparing therapies:

  • Seven were rated as “good-quality” trials: 5 counseling and behavioral therapies, 2 complementary and alternative medicine therapies
  • 24 were rated “fair-quality”
  • 5 were “poor-quality”
  • The phase III Ampligen trial was rated “fair to good-quality” and it was the only medication trial to get this rating; all other medication trials were fair and poor-quality.
  • The PACE trial was rated as “good-quality” for both counseling and behavioral and for exercise intervention but the strength of the evidence was moderate to low for cognitive behavioral therapy (CBT) and graded exercise therapy (GET).
  • The other 5 studies that used an exercise intervention were “fair-quality” and overall, exercise intervention trials showed moderate strength effect in function and well being and low-strength effect on fatigue. Importantly, the high rate of refusal in one study may indicate that patients are concerned the possible adverse effects of repeat exercise testing (e.g., the first exercise test may have caused PEM prohibiting the ability to do the second test). This deserves further study and consideration as a possible outcome.

All of the clinical trials were compromised because of small and heterogeneous patient populations, differences in inclusion criteria – including use of different case definitions, and measuring different outcomes (e.g., fatigue, function, etc). This is exactly what Dr. Peter Rowe reported at the 2013 FDA workshop on Development of Safe and Effective Drug Therapies for CFS and ME ( Measuring the effect of an intervention was likely diminished by the above factors. Ways to better detect the effect of an intervention are to measure certain clinical features present before treatment starts compared to after treatment, such as severity and frequency of specific symptoms like brain fog or PEM. This is called subgroup analysis; not one of the intervention studies did a subgroup analysis.


Is there a Silver Lining?
Despite the lack of an evidence-base, this systematic review shines a light on important areas that must be pursued to build the ME/CFS comparative effectiveness research evidence base:

1.  Determine diagnostic criteria that can be used as the gold standard for ME/CFS diagnosis.

  • We note that the work of determining ME/CFS diagnostic criteria is currently underway at the Institute of Medicine (IOM)

2. Test gold standard diagnostic criteria in other populations with diseases similar to ME/CFS where diagnostic uncertainty exists so that the treatment is specific to ME/CFS vs another similar condition.

  • Determine the outcomes that are clinically meaningful and ensure standardized assessment so that the effect of interventions can be measured
  • Post-exertional malaise is a cardinal feature of ME/CFS and potentially one of the most important outcome measures; research should be conducted to determine what it is and how to measure it

3. The biomarker research and clinical trials conducted to date provide clues to the possible causes of ME/CFS and can serve as “disease models” for further study of ME/CFS pathophysiology

  • All basic and intervention research should use methodological standards to  ensure that it meaningfully contributes to the ME/CFS evidence-base

This analysis illustrates the lack of coherence in the field and the absence of high quality clinical trial data.  NIH, through the P2P workshop, set out to identify gaps in the research, and they found more gaps than substance. Yet the existence of this effort shows increased recognition that ME/CFS is an urgent area of future study and clearly implies that more resources need to be focused on well designed, adequately powered studies. We believe that it is NIH’s responsibility to address their own finding.


What Happens Now?
The P2P panel will review this evidence-based report, including the comments and feedback now being submitted, in advance of the meeting that will take place on December 9 & 10, 2014. At that two-day workshop in Washington DC, the P2P panel will hear from the expert speakers and be able to ask clarifying questions in a town-hall-like Q&A that will take place after each session.

Experts in ME/CFS are being invited to address each agenda item. They will speak to their personal experience and expertise as a patient, caregiver, researcher, etc. The slate of speakers has not yet been released.

The day after the P2P meeting, the P2P Panel will write a draft report which will be published and the public will have time for comment on the final report, just as we are now commenting on the draft evidence review. The comment period is 30 days; the deadline should be around January 12th, 2015. Once the comment period closes, the report will be finalized and NIH will organize a plan to disseminate it widely.

The goal, as we understand it, is a report that contains a set of recommendations based on the totality of the evidence, in the hopes of having said recommendations carried out by Federal partners in 2015. These recommendations are aimed at improving the nature of the research being conducted in ME/CFS. The Solve ME/CFS Initiative will pass along additional information as it is received and when the opportunity for public comment is scheduled, we will report that and share the means by which you can participate.

For far too long, ME/CFS has been underfunded, misunderstood, and even disbelieved. Our community has been pushing a very heavy fly-wheel aimed at increasing understanding, acceptance and progress toward treatments and cure. Now there is federal activity, all aimed at moving the needle for ME/CFS – FDA Voice of the Patient, IOM activity on creating clean diagnostic tools and other much-needed tasks, and this P2P. What this evidence based report shows is that the status quo must change. We hope P2P will illuminate the clear need for more funding, increased research activity and faster progress.


What Can You Do?
Registration is now open for the Pathways to Prevention workshop for Advancing the Research on ME/CFS taking place on December 9 & 10. You can register to attend live or participate via webcast. It is our hope that many stakeholders will participate in this process in order to ensure the patients have a strong presence and a voice.

To register to attend live click HERE 

To register for the webcast click HERE



Many other patients and advocates are also weighing in on the P2P and the draft evidence review. Read what just a few others are saying:

Medscape Medical News – a log in is required to view the article, but it is free and anyone can create an account.

Jenny Spotila, Mary Dimmock & others via Occupy  CFS

Cort Johnson via HealthRising


P2P Releases Systematic Evidence Review

October 1, 2014

P2POn Sept. 22nd, the Association for Health Research and Quality (AHRQ) released the draft systematic evidence review on the Diagnosis and Treatment of ME/CFS NIH requested the literature review for the purposes of the Pathways to Prevention (P2P) Workshop, and the Agency for Healthcare Research and Quality contracted with the Oregon Health & Sciences University to perform it. 

We first wrote about the P2P workshop program in April ( and have been working with the advocacy community since then to stay abreast of the P2P process and assess its impact on ME/CFS. The NIH Office of Disease Prevention Pathway to Prevention (P2P) program approved the ME/CFS workshop earlier this summer and in June SMCI expressed its concerns about the protocol for the evidence-based literature review. (  

The draft report is an extensive review on ME/CFS literature covering diagnosis and treatment and is but one element of the NIH Pathways to Prevention (P2P) process. On December 9 & 10, the Pathways to Prevention workshop for Advancing the Research on ME/CFS will take place in Washington, D.C. and the panel will hear expert testimony at that time. Also, during the workshop stakeholders/patients will have the opportunity to participate in the discussion both in person and online by asking questions or making comments via microphones or computer; webcast viewers can type in comments and questions in a comment box on the webpage. There is a total of 3.5 hours of “Discussion” time noted on the draft agenda, where public input will be addressed. Interested individuals may register to attend live or participate via webcast.  It is our hope that many stakeholders will participate in this process in order to ensure the patients have a strong presence and a voice.

Learn more about how to register for the December 9 & 10 P2P Workshop in this earlier post:

Comments on the draft systematic evidence review can be made until October 20 – Learn more about that process HERE.

scrutinizeThe Solve ME/CFS Initiative is in the process of reviewing the draft report more thoroughly with members of its Research Advisory Council in order to provide the most informed comments prior to the deadline of October 20, 2014.

We will keep you informed and share our thorough review once completed.

Guest Blog: Laurie – Hope Springs Eternal

September 22, 2014



The year was 1989, six years after giving birth to my son and nine years into a career as the head of a private school. I was a single parent, in a serious relationship, active in volunteering, loved working out and had just finished overseeing a major construction project at the school.

One afternoon during a lunch meeting I started to feel like my equilibrium was off. Thinking I might be coming down with something, I returned to my office to lie down, hoping to feel better. I felt like the room was going to spin, my body ached all over and I broke into a cold sweat. I was so nauseous I thought I would throw up. I laid down on the floor and closed my eyes. I could not make sense of what was happening to me. I felt like my limbs and body were going to lose control. I was afraid to move. I laid on the floor for the remainder of the afternoon until I felt that I could go home.

My list of symptoms increased – among them, swollen glands and a chronic low grade fever – so I went to see my doctor.  Luckily, he was familiar with Chronic Epstein Barr and with my lab tests to prove it I didn’t have to go through the ugly maze of doctors telling me that there was nothing wrong with me.  However, my doctor had no idea of how to treat it. His best advice was “to continue working and ignore my symptoms”.  Since my initial symptoms would come and go, I took his advice. I thought I could navigate my illness and still handle the demands of my job. That lasted for two years and then I crashed.

Hoping that I would rebound, I took a 7 month leave of absence figuring that it would make a difference. Seven months later my symptoms had not gotten better, instead they exacerbated.  I had to write a letter of resignation.

This loss was devastating. It was the beginning of a thirteen year struggle in my quest to become an active working member of society again. I had always been successful at overcoming difficulties… mostly through keeping a positive attitude and pushing forward. I could not understand why I could not improve or overcome this illness.

My life slowed down. I was having to sleep 16-18 hours a day; a challenge since I was a single mother who wanted to be there for her son. I tried numerous alternative treatments and traditional therapies. Then a friend who had been diagnosed with the same illness died after receiving a new experimental treatment. I never knew if the treatment caused her death.

Given this and my own reactions to many of the medications and treatments, I became cautious. Eventually I learned to trust my body, navigate how it reacted, and go with what I felt would make a difference.  Through trial and error I learned that making adjustments to my diet, getting lots of rest, avoiding stress of any kind (even good) and not overdoing it helped.

Thirteen years later I was able to return to work. My high functioning abilities had returned and I was excited about using them. I took a Head of School position out of state, but immediately discovered that the school had more difficulties than revealed. The demands of the job were more than anticipated. After three months I started to experience mild symptoms but chose to ignore them hoping to succeed at all costs.

I was renting my house, knowing I would return to Colorado someday. My plans were to work until retirement age or beyond. Moving back and having to pack an entire household after only working three months was not an option that I wanted to court so I continued to push myself. I had forgotten how devastating my illness could be and my desire to fulfill my dreams of working again was strong.

Being high functioning again after thirteen years of being ill, I made sure to give my all. The fear of having to pack up and move back to Colorado led me to take an anti-depressant, hoping that it would make a difference.  It took away some of the emotional aspects that surrounded my fears but it did very little for my physical symptoms. The only thing that helped was rest and sleep which I did whenever I was not at work, leaving me with no social life.

Again, I started seeing an array of doctors and doing alternative therapies, hoping to find something that would help. I operated in that vein for 3 years doing my best to ignore my symptoms but they continued to get worse. Two and a half years later I crashed and could no longer work. For the second time this illness stripped me of my profession. This time I did not feel like a failure; instead I had finally learned the anatomy of an illness that would not allow me to be a working member of society. I was able to my new life.

There is an expression, “Hope Springs Eternal.”  I believe this applies to me as I continue my search for help.

  • I have learned that I know my body better than anyone else.
  • I will not allow someone to tell me it is all in my head or just depression “so just take a little pill”.
  • When I feel sad I know it is because my illness has flared up causing me to become more limited in my activities.  When my body is “depressed” for an extended period of time due to relapse I feel sad or depressed… and when the symptoms diminish the sadness and/or depression lifts.
  • Overall I am a positive person so when there are relapses I know in my heart of hearts that they will eventually pass.

hopeThe claims that doctors and alternative practitioner make I now approach cautiously. Even though their intentions are good and they have had success with a number of patients, I know that my body can react negatively to many of their pills or treatments causing a downward spiral. This is why I am so glad that the Solve ME/CFS Initiative is there.

They are “Working to make ME/CFS widely understood, diagnosable and treatable”.  We are so fortunate to have a team like this working on our behalf. By pooling the information they have received from doctors, researchers, and professionals in the field, I believe they will find something that will help each of us on our journey to wellness. I encourage everyone that has ME/CFS and their healthy friends and family members to help the incredible team at Solve ME/CFS Initiative by signing up for their SolveCFS BioBank, following their progress by signing up for their newsletter, and supporting their work financially.


Research Digest – September 2014: Cortisol in ME/CFS

September 15, 2014

Cortisol is a hormone that is produced in the adrenal glands where it enters into the circulation to dampen inflammation. It does this by entering into the cytoplasm of cells, binding to the cortisol receptor (called the glucocorticoid receptor) and then moving into the cell nucleus to bind to DNA and regulate the expression of inflammatory molecules.

Cortisol is an essential hormone for immune function and many studies have shown that cortisol is low in ME/CFS patients – known as hypocortisolism.  Recent articles find increased cortisol receptor expression is associated with post-exertion malaise (PEM), low cortisol is associated with more severe PEM and a return of cortisol to normal levels is associated with recovery.

In this month’s research digest, we review three studies that look at the effect of cortisol on function and post-exertional malaise in ME/CFS.


In a Solve ME/CFS Initiative funded study published in Fatigue: Biomedicine, Health & Behavior Jacob Meyer, a PhD candidate at the University of Wisconsin, worked with a team of investigators from the University of Wisconsin, Madison, Marshfield Clinic Research Foundation and the University of Utah to study gene expression using an exercise challenge.  Thirteen ME/CFS patients and 11 healthy controls had blood samples taken before and after a maximal exercise challenge.  Compared to controls, ME/CFS patients had increased expression of 2 genes – the glucocorticoid receptor and the adrenergic alpha 2a receptor.  This increased gene expression was associated with PEM symptoms.  The authors suggest that these finding, particularly as they relate to cortisol, may lead to an understanding of the biological mechanism of PEM.


A short communication titled “Stress management skills, cortisol awakening response, and post-exertional malaise in Chronic Fatigue Syndrome” was published online in the journal Psychoneuroendocrinology.  Daniel L. Hall and Michael Antoni from the Department of Psychology at the University of Miami together with Mary Ann Fletcher and Nancy Klimas from the Institute for Neuro Immune Medicine, Nova Southeastern University found that greater stress management skills was associated with higher cortisol levels upon wakening and less PEM severity.  The investigators recommend that similar research be conducted over longer periods of time to determine if by improving stress management skills, cortisol regulation improves and ME/CFS patients experience less PEM.


In another study published earlier this year in Psychoneuroendocrinology titled “The role of hypocortisolism in chronic fatigue syndrome”, investigators from the Netherlands examined cortisol levels in young ME/CFS patients participating in the FITNET (Fatigue In Teenagers on the interNET) trial.  FITNET, an internet-based cognitive behavioral therapy program for young ME/CFS patients. These investigators found that the cortisol levels in patients that improved after 6 months of treatment returned to normal levels.  ME/CFS patients that did not respond to treatment had slight increases in cortisol levels but still below normal.  The investigators conclude that the return of cortisol levels to normal is associated with treatment success and that poor functioning of the hypothalamic-pituitary-adrenal (HPA) axis that regulates cortisol levels plays a role in ME/CFS symptoms.  Understanding what contributes to HPA axis dysfunction could help improve ME/CFS treatment.


Guest Blog: Dr. Peter Rowe – Is The Physical Examination Normal in CFS? Part 3

September 11, 2014

In this 3rd piece of our three-part blog series Dr. Peter Rowe discusses range of motion in ME/CFS patients.

In the first post in the series, Dr Rowe discussed orthostatic heart rate and blood pressure changes. Read Part 1 HERE

In the second post, Dr Rowe discussed joint hypermobility. Read Part 2 HERE


Postural dysfunctions and movement restrictions

Some of those with joint hypermobility also have postural abnormalities that are thought to be a consequence of the effect of gravitational loading of the spine, including a head-forward posture, a rounded appearance of the thoracic spine, and increased lumbar curvature. My physical therapist colleague, Rick Violand, had originally identified a number of associated areas of reduced movement of the spine and limbs during his examination of those with CFS. These observations describing adverse neural tension (also termed neurodynamic dysfunction) have been reported elsewhere.1-3 During the clinical care of patients over the last decade, we had been struck by how many individuals with CFS had focal areas of restricted range of motion, and how adding an elongation strain to nerves and soft tissues could aggravate their typical CFS symptoms. With other co-investigators, we recently published a large study showing that reduced range of motion of the limbs and spine was significantly more common in adolescents and young adults with CFS than in carefully matched controls, and that adding a longitudinal strain to the nerves and soft tissues was another way of provoking common CFS symptoms.18 These examination abnormalities can be detected most readily by physical therapists and other manual practitioners. Physicians and nurse practitioners can become adept at screening for these problems if provided with extra training.

Why does the detection of movement restrictions matter? Our experience leads us to believe that the areas of adverse neural tension are treatable. In clinical care we have noted that improvement in the range of motion is usually accompanied by improvement in daily function for those with CFS. Much more work needs to be done to characterize these abnormalities further, to determine whether the same changes are also present in adults with CFS, and to identify the optimal treatment approaches. These observations open up new avenues for understanding the pathogenesis of CFS symptoms, and for further individualized approaches to treatment. We hypothesize that treating the movement restrictions first using gentle manual therapy techniques will help the most impaired CFS patients begin to tolerate exercise better.


These three related areas of dysfunction—circulatory disturbances, joint hypermobility, and movement restrictions—emphasize that there is much to be gained from the performance of a careful clinical examination in those with CFS. Given that aspects of each abnormality are treatable, their identification has the potential to improve the daily symptoms and function for those with CFS. We recommend the more widespread adoption of maneuvers to ascertain for these abnormalities in the clinical and research evaluation of those with CFS.


 As medicine becomes more and more dependent on sophisticated technology, the physical exam is in danger of becoming a lost art.  As Dr. Peter Rowe, Johns Hopkins University, has laid out in this three-part series, there is much to be learned in a physical exam in CFS. Our hope is that this information will be of great value to both you and your doctor. We believe it clearly illustrates the value of laying on of hands in the physical examination of ME/CFS.

Suzanne D Vernon, PhD
Solve ME/CFS Initiative Scientific Director



  1. Rowe PC, Fontaine KR, Violand RL. Neuromuscular strain as a contributor to cognitive and other symptoms in chronic fatigue syndrome. Frontiers in Integrative Physiology 2013; Front Physiol 2013;4:115. doi: 10.3389/fphys. 2013.00115
  4. Rowe PC, Marden CL, Flaherty M, Jasion SE, Cranston EM, Johns AS, Fan J, Fontaine KR, Violand RL. Impaired range of motion of limbs and spine in chronic fatigue syndrome. J Pediatrics 2014 (in press).


Guest Blog: Dr. Peter Rowe – Is The Physical Examination Normal in CFS? Part 2

September 9, 2014

In the 2nd part of this three-part blog series on physical examination in ME/CFS, Dr. Peter Rowe discusses joint hypermobility.  You can read the first blog post in the series where Dr Rowe discussed orthostatic heart rate and blood pressure changes HERE.


Joint hypermobility

Some patients meeting the criteria for CFS have a genetic disorder of connective tissue known as Ehlers-Danlos syndrome (EDS). Those with EDS have stretchy skin, very loose, hypermobile joints that often dislocate easily, along with delayed wound healing, fragile skin, and a tendency to develop an early onset of varicose veins. Those with EDS have chronic fatigue and widespread pain of uncertain cause, which of course overlaps with the central features of CFS.

We first drew attention to this association in 1999, noting that those with CFS and orthostatic intolerance had a much higher prevalence of EDS than expected.1 We then went on to examine whether those with CFS had a higher prevalence of joint hypermobility. Although we might expect less flexibility in a population that has had at least 6 months of reduced activity, in that study, 60% of new adolescent patients with CFS met criteria for joint hypermobility, compared to just 24% of healthy controls.2


The assessment of joint hypermobility takes only a couple of minutes, and can easily be performed using a goniometer for accurate measurement of joint angles. The most commonly used series of maneuvers is the 9 point Beighton score, as shown in the pictures above. It should be noted that the Beighton score does not do a good job of evaluating for laxity in the hips and shoulders, but it is a useful screening tool.

CFIDS PE article Fig 4

Other findings on the examination in those with EDS can include increased extensibility of the skin, abnormally widened and thin (“papyraceous”) scars, easy eversion of the eyelids, and stretch marks (striae) even in the absence of excessive changes in weight. Examples of these findings are shown in the pictures to the right.

Since the publication of these results, a number of studies have confirmed that those with joint hypermobility have more orthostatic symptoms and a reduced tolerance of upright posture,3 and that fatigue is a prominent contributor to lower quality of life in EDS.4 New work from investigators in Belgium confirms that those with hypermobile EDS have high rates of autonomic symptoms, abnormal heart rate responses to upright posture, and other features of autonomic dysfunction.5,6

Why does the assessment for joint hypermobility matter? Joint hypermobility is associated with other co-morbid disorders such as temporomandibular joint dysfunction, and the laxity in ligaments often contributes to arthralgias and myalgias. Better ascertainment of these problems can lead to more focused therapy directed at pain, and physical treatments directed at biomechanical dysfunctions.7 Beyond the effects on joints, connective tissue laxity also affects the blood vessel walls. The increased distensibility in blood vessels may be a factor in the early development of varicose veins in those with EDS. Vascular stretch also is thought to allow increased blood pooling in the dependent circulation during upright posture, leading to diminished blood return to the heart, and thus to orthostatic intolerance symptoms. Given the high prevalence of skin and joint laxity in those with CFS, and the contribution of connective tissue abnormalities to the development of orthostatic intolerance, we recommend that all those with CFS undergo screening with a Beighton score, and that clinicians look carefully for the skin changes of EDS in their patients with CFS.



  1. Rowe PC, Barron DF, Calkins H, Maumenee IH, Tong PY, Geraghty MT. Orthostatic intolerance and chronic fatigue syndrome associated with Ehlers-Danlos syndrome. J Pediatr 1999;135:494-9.
  2. Barron DF, Cohen BA, Geraghty MT, Violand R, Rowe PC. Joint hypermobility is more common in children with chronic fatigue syndrome than in healthy controls. J Pediatr 2002;141:421-5.
  3. Gazit Y, Nahir AM, Grahame R, Jacob G. Dysautonomia in the joint hypermobility syndrome. Am J Med 2003;115:33-40.
  4. Voermans NC, Knoop H, van de Kamp H, et al. Fatigue is a frequent and clinically relevant problem in Ehlers-Danlos syndrome. Semin Arthritis Rheum 2010;40:267-274.
  5. de Wandele I, Calders P, Peersman W, et al. Autonomic symptom burden in the        hypermobile type of Ehlers-Danlos syndrome: a comparative study with two other EDS types, fibromyalgia, and healthy controls. Semin Arthritis Rheum 2014 (in press).
  6. de Wandele I, Rombaut L, Leybaert L, et al. Dysautonomia and its underlying mechanisms in the hypermobility type of Ehlers-Danlos syndrome. Semin Arthritis Rheum 2014; (in press).
  7. Simmonds JV, Keer RJ. Hypermobility and the hypermobility syndrome, part 2: assessment and management of hypermobility syndrome: illustrated via case studies. Man Ther 2008;13:e1-e11.


Figure Legends

Fig 3a: The Beighton score. Possible scores are 0-9, with scores ≥ 4 indicating joint hypermobility. On each side, score 1 point for > 90o of hyperextensibility of the 5th finger, 1 point for the ability to appose the thumb to the forearm, and 1 point for > 10o of hyperextensibility at the elbow.

Fig 3b: On each side, score 1 point for >10o of hyperextensibility at the knee, and 1 point for the ability to place the palms on the floor.

Fig 4: Other features of EDS: clockwise from the top left, stretch marks (striae) in a non-obese individual who has not had excessive weight change, easy eversion of the upper eyelids and Gorlin’s sign (the ability to touch the tongue to the tip of the nose, increased extensibility of the skin of the upper eyelid, and wide, thin scarring at the site of wound dehiscence after a simple laparoscopy incision.


Guest Blog: Dr. Peter Rowe – Is The Physical Examination Normal in CFS? Part 1

September 5, 2014

The Laying on of Hands: Recently I read with great interest a Medscape article titled, “Patients Lose When Doctors Can’t Do Good Physical Exams”.  You can read the article here: but the crux is that as medicine becomes more and more dependent on sophisticated technology, the physical exam is in danger of becoming a lost art.

This Medscape article made me think about the experiences of our ME/CFS patient community and the frequency of physical examination. I reached out to Dr. Peter Rowe whose research we have funded that deals with neuromuscular strain and range of motion. This is the first in a series of blog posts from Dr. Peter Rowe of Johns Hopkins University titled “Is the physical exam in CFS normal?” We are certain that this information will be of great value to both you and your doctor and will clearly illustrate the value of laying on of hands in the physical examination of ME/CFS.

Suzanne D Vernon, PhD
Solve ME/CFS Initiative Scientific Director


Is the physical examination normal in CFS?

Papers in the early 1990s described a low yield of physical examinations in patients with chronic fatigue and CFS.1 Although there were some notable counter-arguments made by Komaroff—describing sore throat and swollen lymph nodes, as well as a 10-20% prevalence of abnormal Romberg tests (Romberg test is a neurological exam that assesses balance while standing)2—most reviews of CFS included statements like the one that appeared in the 2002 Australian CFS Guidelines: “Characteristically, there are no abnormal physical findings in people with CFS.”3

The absence of abnormalities on the physical examination, especially when contrasted with the profound functional impairment in CFS, was often interpreted to be consistent with a largely psychosomatic origin of the illness. Research in the past 20 years, however, provides a decidedly different view.  In this three-part blog post, Dr. Peter Rowe will describe three groups of abnormalities found on physical examination.

Orthostatic heart rate and blood pressure changes

One of the most readily apparent abnormalities on the examination of those with CFS is that heart rate and blood pressure abnormalities are present, sometimes at rest, and more consistently during relatively brief periods of upright posture. In response to standing or upright tilt table testing, individuals with CFS have a higher prevalence of neurally mediated hypotension (NMH) and postural tachycardia syndrome (POTS), or both (Figure 1). The prevalence of these and other blood pressure and heart rate abnormalities is higher in adolescent than in adults, but even in the absence of objective changes in blood pressure or heart rate, orthostatic (upright) stress in individuals with CFS of all ages provokes characteristic daily symptoms of increased fatigue, lightheadedness, mental fog, or headache. In adolescents, all published controlled studies have shown a numerically higher prevalence of orthostatic intolerance in CFS than in healthy individuals (4 of 5 reporting statistically significantly differences), and all studies looking at autonomic tone show a sympathetic predominance of heart rate variability, especially in response to orthostatic stress.

Slide1   Slide2

NMH occasionally can be provoked by a brief standing test, but more commonly requires a more prolonged head-up tilt table test. The median time to provoke a drop in blood pressure in our tilt laboratory in the mid-1990s was 28 minutes,4 although symptoms are usually exacerbated shortly after the patient is tilted upright.

The diagnosis of POTS in adults requires a ≥ 30 beat per minute (bpm) increase in heart rate (HR) during 10 minutes upright when compared to baseline supine values, or a HR increase to ≥ 120 bpm, together with the reproduction of typical orthostatic symptoms. Normative data on healthy young people showed that the adult HR criteria overdiagnosed POTS, so in adolescents the diagnosis now requires a ≥ 40 bpm HR increase in the first 10 minutes of head-up tilt or standing, or a HR ≥ 120 bpm.5 Some individuals with POTS at an early point of tilt testing subsequently develop a more profound drop in BP, consistent with delayed orthostatic hypotension or with NMH.

CFIDS PE article Fig 2Along with the changes in heart rate and blood pressure, a striking physical finding among those with CFS and orthostatic intolerance is a purple discoloration in the dependent limbs termed acrocyanosis (Figure 2). Acrocyanosis is readily apparent if the patient is examined in shorts, seated on the examination table, with the legs hanging down. This finding can be differentiated from Raynaud’s phenomenon by the absence of blanching of the fingers or toes, and by the fact that hands and feet are diffusely discolored.

Why does recognition of orthostatic physical examination findings matter? Open treatment studies show that people with CFS can enjoy improved function with standard measures to manage orthostatic intolerance. That management involves lifestyle adjustments, compression garments, and increased salt and fluid intake, along with judicious use of medications. These treatments provide another avenue for a pragmatic, individualized approach to symptoms in those with CFS.

Studies by MacLean and Allen in the 1940s had drawn attention to the similarity between the symptoms of neuromyasthenia (an older term for what we now call CFS) and the symptoms of patients who experienced orthostatic tachycardia and hypotension after assuming an upright posture. Most of the latter group experienced orthostatic exhaustion, blurring of vision, weakness on exercise, and syncopal episodes,6,7 familiar problems for those with CFS. Although these observations were neglected for several decades, the weight of the evidence now suggests that all subjects with CFS deserve careful assessment of their heart rate, blood pressure, and symptomatic responses to at least 10 minutes of quiet upright posture. The British NICE guidelines that strongly recommend against the routine use of orthostatic testing8 need to be revised in light of the available and compelling data.



  1. Lane TJ, Matthews DA, Manu P. The low yield of physical examinations and laboratory investigations of patients with chronic fatigue. Am J Med Sci 1990;299:313-318.
  2. Chronic fatigue syndrome: clinical practice guidelines—2002. Medical J Australia 2002; 176:S24.
  3. Komaroff AL, Buchwald D. Symptoms and signs of chronic fatigue syndrome. Rev Infect Dis 1991;13(Suppl 1): S8-11.
  4. Bou-Holaigah I, Rowe PC, Kan J, Calkins H. Response to upright tilt testing in 100 consecutive patients with chronic fatigue syndrome. Circulation 1995;92(8S): I-414.
  5. Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 2011;21:69–72
  6. MacLean AR, Allen EV. Orthostatic hypotension and orthostatic tachycardia: with the “head-up” bed. JAMA 1940;115:2162-7.
  7.  MacLean AR, Allen EV, Magath TB. Orthostatic hypotension and orthostatic tachycardia: defects in the return of venous blood to the heart. Am Heart J 1944;27:145-63.
  8. National Institute for Health and Clinical Excellence. Clinical guideline CG53. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management. London, NICE, 2007.


Figure Legends

Fig 1a. NMH. The hemodynamic response to upright tilt testing in an individual with CFS. Note the early onset of orthostatic symptoms of lightheadedness (LH) and pallor, without early HR elevations, following at a relatively early point by profound hypotension and relative bradycardia, consistent with NMH.

Fig 1b. POTS. The hemodynamic response to quiet standing in an individual with CFS. Note the normal supine heart rate and the dramatic 51 beat per minute change in heart rate with standing, accompanied by lightheadedness, fatigue, and headache, without major changes in blood pressure.

Fig 2: Acrocyanosis (left) and delayed capillary refill (right) appearing within 5 minutes of quiet standing in an adolescent with chronic fatigue syndrome and low orthostatic tolerance.

P2P Workshop – Registration Now Open

September 3, 2014

P2P_title Registration is now open for the Pathways to Prevention workshop for Advancing the Research on ME/CFS. Interested individuals may register to attend live or participate via webcast. It is our hope that many stakeholders will participate in this process in order to ensure the patients have a strong presence and a voice.

Our understanding is that stakeholders/patients will have the opportunity to participate in the discussion both in person and online by asking questions or making comments via microphones or computers in the room. Webcast viewers can type in comments and questions in a comment box on the webpage. There is a total of 3.5 hours of “Discussion” time noted on the draft agenda, where public input will be addressed.

To register to attend live click HERE 

To register for the webcast click HERE


More About the P2P: The National Institutes of Health (NIH), through the Office of Disease Prevention (ODP) has a program called the Pathways to Prevention. The goal is to host workshops that identify research gaps in a selected scientific area, identify methodological and scientific weaknesses in that scientific area, suggest research needs, and move the field forward through an unbiased, evidence-based assessment of a complex public health issue. You can read more about the P2P Workshop for ME/CFS HERE In June of 2012, the NIH launched the process of including ME/CFS in the P2P program. Several departments within the federal government came together to recommend ME/CFS for a P2P workshop. In November of 2012, the ODP received the recommendation to consider ME/CFS and approved the submission of a full proposal in December of 2012 based on “necessity, urgency and the identification of ME/CFS as a serious unmet medical need and a public health issue and that proposal was accepted then later approved. The workshop will take place on December 9 & 10, 2014. Topics for the two-day workshop agenda were defined by questions that formed the evidence review. Speakers have been recruited for the workshop for each question/agenda item. The speakers are all to be experts in ME/CFS and are able to speak to their personal experience and expertise as a patient, caregiver, researcher, etc. The evidence review is a concise presentation of the ‘evidence’ and literature in ME/CFS (that relates to the study questions), boiled down and presented to the panel. There is opportunity for the P2P panel to review unpublished data as well. The Solve ME/CFS Initiative submitted additional evidence for their review, as well as encouraged our funded investigators, colleagues and peers to do the same. The P2P panel will review the evidence-based report in advance of the meeting and the report will be released to the public at that time. There will be opportunity to comment and offer feedback on this report. We anticipate the report’s release in early October and will alert you to its publishing as soon as we hear more. At the two-day workshop, the P2P panel will hear from the expert speakers and be able to ask clarifying questions in a town-hall-like Q&A that will take place after each session during the meeting.  The P2P Panel will be made up of experts in areas or topics that have relevance to ME/CFS and the evidence based report, but they are not to be ME/CFS experts by design – an effort to avoid bias and produce a report based on the facts presented in the evidence-based report and through the speakers. We do not know if patients in the gallery will be able to engage in the Q&A. The day after the P2P meeting, the P2P Panel will write a draft report which will be published and the public will have time for comment. Originally the comment period was slated for 15 days. SMCI, along with other organizations and advocates, reached out to the P2P and asked that this comment period be extended in order to accommodate patient’s needs. We have received word that the comment period has been extended to 30 days, meaning the new deadline should be around January 12th, 2015. Once the comment period closes, the report will be finalized and NIH will organize a robust plan to disseminate it widely. The goal, as we understand it, is to have a report that contains a set of recommendations based on the totality of the evidence, in the hopes of having said recommendations carried out by Federal partners in one-nine months. These recommendations are aimed at improving the robust nature of the research being conducted in ME/CFS. The Solve ME/CFS Initiative will pass along additional information as it is received and when the opportunity for public comment is scheduled, we will report that and share the means by which you can effectively participate.