ME/CFS/FM Conference Wednesday 6th November 2002,   Organised by the Lismore based Northern Rivers ME/FM Country Network at the Lismore and District Workers Club, Lismore

" Muscle Fatigue and Fatigability."

By Dr Les Simpson. Director of the Red Blood Cell Research, Dunedin, New Zealand.

In order to understand the problems of tiredness and the adverse effects of exercise it is necessary to be clear about the difference between tiredness and fatigue and how those terms relate to muscle fatigue - which is a physiological term.

According to both English and American dictionaries, fatigue is the consequence of long-continued exertion.  But people with ME do not have to run up several flights of stairs to induce their ever-present tiredness.

 In a 1960 paper titled "The clinical significance of tiredness,"  Dr.George French wrote " There is no doubt that oxygen lack is the first cause of tissue cell exhaustion, which is manifested early as clinical tiredness." As an example of the effects of oxygen insufficiency, he referred to the dysfunctional state of a healthy young man in a pressure chamber simulating conditions at 25,000 feet, where there is only about 10% of the oxygen which is available at sea level.  His task was to pick up peas and drop them down a hole.  However the lack of oxygen prevented the muscle co-ordination needed to pick up a pea.  If he was able to grasp a pea, a lack of spatial perception prevented him from dropping the pea down the hole.

 Muscle fatigue also is the result of inadequate oxygen availability.  A textbook of medical physiology states "  muscle fatigue  is caused by both an oxygen deficiency and an accumulation of metabolites such as carbon dioxide and lactic acid which are not carried away in the blood stream as fast as they are produced."  So the primary problem is one of blood flow in capillaries as this is the only way by which oxygen is delivered and metabolites removed. 

   Thus it is possible to interpret the poor muscle function of ME people in terms of impaired capillary blood flow, which does not deliver oxygen at a rate sufficient to sustain muscle function.  Shape-changed red cells play a role in this problem as such cells are poorly deformable and for this reason provide a resistance to blood flow in capillaries smaller in diameter than red cells.

In other tissues (such as the brain) SPECT scans show the reduced rates of cerebral blood flow which would be expected when there are increased numbers of shape changed red cells. Fibromyalgia is associated with high values for flat cells  and a sophisticated technique (Laser Doppler Flowmetry) has shown that in patients with Fibromyalgia red cells pass very slowly through Capillaries, as would be expected.

Exercise intolerance and easy exhaustability on exertion are manifestations of easy muscle fatigability.  Such problems of muscle function also relate to the reduced availability of oxygen.  During normal (aerobic) muscle activity, glycogen is oxidised to carbon dioxide and water to provide the energy needed for muscle function.  When there is insufficient oxygen available, anaerobic respiration provides energy, but the glycogen is not completey oxidised and lactic acid is formed, with a much lower production of energy. Muscle pain probably relates to lactic acid formation. oxygen availability is the inability to store energy within muscle cells.  During the process of oxidative phosphorylation, energy is stored in "high energy bonds" in a family of chemicals with fancy names such as adenosine monophosphate, adenosine diphosphate and adenosine triphosphate. With each additional phosphate another "high energy bond" is formed.  To a major extent efficient muscle function is determined by the energy stored in this way.

 In concluding it is appropriate to quote from a 1999 paper from an American group.  They found that CFS people had much lower rates of oxygen delivery than healthy controls.   This could result in "reduced exercise capacity...because oxygen delivery is a major determinant of muscle exercise capacity."

  However they did not explain WHY the rate of oxygen delivery was reduced. This is what is important about the recognition of red cell shape in determining the rate of blood flow in capillaries and thus determining the rate of delivery of oxygen.

Capillaries

Capillaries are fine, hair-like vessels which have porous walls through which food, oxygen and water pass from the blood to the tissues. The size of the capillaries’ diameter explains why one individual becomes symptomatic of ME/CFS/FM and another individual does not.

Also why another individual does not and why there is a variation in the intensity of the symptoms between individuals, showing  similar abnormal Red Blood Cell shapes. The person with the narrow capillary diameter  having the more severe symptoms.

Cases with high values for cup forms may obtain relief by an injection of vitamin B12 as hydroxocobalamin. Those who respond feel better within 24 hours and cup forms reduced. Relief is temporary and further injections may be needed at weekly or fortnightly intervals when symptoms recur.

Where there are increased flat cells, or cells with surface changes or altered margins, evening primrose oil may provide benefit. The recommended dose for those under 50 years should take 8x 500 mg capsules with food, (3,2,3)-daily while the over 50s should take 9 x 500 mg capsules daily

                                           ————————

  Professor Campbell Murdoch MB, ChB, MD, PhD, FRCGP, FRNZCGP.

Professor and Head, Rural Clinical School, University of Western Australia, Kalgoorlie, WA.

  Chronic Fatigue Syndrome/Myalgic Encephalomyelitis  is a real physical disease.

According to the criteria for diagnosis a person must wait six months before a diagnosis can officially be made.

  Now as a doctor on duty, you are called out to an emergency on the local highway. There has been a head-on collision by a motorist into the concrete pillar of a bridge. When you arrive the fire and ambulance personnel have located the badly injured driver hanging upside down in the cab with her legs trapped by the steering wheel. There is a hysterical passenger in the front seat and a baby and little boy luckily well strapped in the back seat.

Do you:

·                take a full history and physical from the driver, arrange a few blood tests and ask her to see you next week?

·                Insist that before the driver is removed from the car, a full investigation of the cause of the accident should be completed?

·                Suggest that the accident might never have happened if the couple had organised their life better?

You may think these questions are all ridiculous. The doctor who has been called to the scene is just as dangerous and ineffective as the untrained bumbler at the scene of the accident. What is required is the equivalent of immediate care for this person whose life has fallen apart and the principles are very similar.

1. What is the greatest threat here?

2.  Don’t let lack of a definitive diagnosis impede the application of an indicated treatment.

3. A detailed history is not necessary to begin the evaluation.

 It is if we go to the crashed wreck of a life and say “Hello in there, are you okay?”

  Being patient-centred involves just as much diagnostic acumen on the part of the doctor as being doctor-centred. However, the agenda is shared and at each point the doctor discusses with the patient her or his view on the possibilities of diagnosis. This means that the healing can start before embarking on the search for a cause, and means that the time spent in searching in not wasted.

  “For the modern doctor, this is a difficult if not intolerable situation to be in, and the discomfort intrudes upon our consultations, with these patients. To protect ourselves we call these people “heartsink” patients, choosing to blame the victim rather than admit diagnostic defeat.

 The people who have the symptoms are in an even worse predicament because not only do they have symptoms which have shattered their whole lives, they also have to endure the indignity of not being believed or they have to spend a lot of energy finding a Doctor who does believe in them and their symptoms.  Everyone finds it very difficult to suffer from something which does not exist and they have tended to go from doctor to doctor for a name if not a diagnosis or to join support groups whose purpose seems to be not only mutual support but also action to force the medical profession and researchers into authenticating the symptoms through a proven diagnosis.”

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