Can physical assessment techniques aid diagnosis in people with CFS/ME? A diagnostic accuracy study, 2017, Perrin et al

[Andy]

Seems to be an attempt to prove the worth of the Perrin technique? I've put this in the biomed forum for now but obviously it can be moved if need be.

Can physical assessment techniques aid diagnosis in people with chronic fatigue syndrome/myalgic encephalomyelitis? A diagnostic accuracy study

Hives, Lucy, Bradley, Alice, Richards, James, Sutton, Chris J, Selfe, James, Basu, Bhaskar, Maguire, Kerry, Sumner, Gail, Gaber, Tarek et al


Objective: To assess 5 physical signs to see whether they can assist in the screening of patients with CFS/ME, and potentially lead to quicker treatment.

Methods: This was a diagnostic accuracy study with inter-rater agreement assessment. Participants recruited from 2 NHS hospitals, local CFS/ME support groups and the community were examined by three practitioners on the same day in a randomized order. Two Allied Health Professionals (AHPs) performed independent examinations of physical signs including; postural/mechanical disturbances of the thoracic spine, breast varicosities, tender Perrin’s Point, tender coeliac plexus and dampened cranial flow. A physician conducted a standard clinical neurological and rheumatological assessment, whilst looking for patterns of illness behaviour. Each examination lasted approximately 20 minutes.

Results: Ninety-four participants were assessed, 52 CFS/ME patients and 42 non-CFS/ME controls, aged 18-60. Cohen’s kappa revealed agreement between the AHPs was substantial for presence of the tender coeliac plexus (κ=0.65, p<0.001) and moderate for postural/mechanical disturbance of the thoracic spine (κ=0.57, p<0.001) and Perrin’s point (κ=0.56, p<0.001). A McNemar’s test found no statistically significant bias in the diagnosis by the experienced AHP relative to actual diagnosis, (p=1.0) and a marginally non-significant bias by the newly trained AHP, p=0.052. There was however, a significant bias in the diagnosis made by the physician relative to actual diagnosis, (p<0.001), indicating poor diagnostic utility of the clinical neurological and rheumatological assessment.

Conclusions: Using the physical signs appears to improve the accuracy of identifying people with CFS/ME and shows agreement with current diagnostic techniques, however the present study concludes that only 2 of these may be needed. Examining for physical signs is both quick and simple for the AHP and may be used as an efficient screening tool for CFS/ME. This is a small single centre study and therefore further validation in other centres and larger populations is needed.

Restricted access at http://clok.uclan.ac.uk/20386/

ETA: Open access now available at http://bmjopen.bmj.com/content/7/11/e017521

 

[Invisible Woman]

Participants recruited from 2 NHS hospitals, local CFS/ME support groups and the community were examined by three practitioners on the same day in a randomized order.

and

A physician conducted a standard clinical neurological and rheumatological assessment, whilst looking for patterns of illness behaviour. Each examination lasted approximately 20 minutes.

Perrin technique aside - we have no way of knowing what criteria were actually used to diagnose these patients. If the second quote literally means that a single physician was used to confirm the diagnosis it just means that they fit this individual's idea of what ME is.

Conclusions: Using the physical signs appears to improve the accuracy of identifying people with CFS/ME and shows agreement with current diagnostic techniques

Bolding is mine - Showing agreement with current diagnostic techniques doesn't inspire me with confidence. As far as I am aware the current diagnostic techniques aren't that great and this piece doesn't mention any tests to rule out other conditions. I don't have a whole lot of faith who don't understand that accurate diagnosis is a major issue with this disease.

 

[Trish]

''A physician conducted a standard clinical neurological and rheumatological assessment, whilst looking for patterns of illness behaviour. Each examination lasted approximately 20 minutes.''

''There was however, a significant bias in the diagnosis made by the physician relative to actual diagnosis, (p<0.001), indicating poor diagnostic utility of the clinical neurological and rheumatological assessment. ''

Am I reading this correctly. Is this saying the physician's diagnoses didn't fit with the 'actual diagnosis'.

Since diagnosis of ME is normally done by listening to the patient's description of history and symptoms, I'm not surprised the physician didn't get the diagnosis from examining and observing the patient - it sounds like they weren't allowed to ask any questions, just do some irrelevant observations. No wonder they got the diagnosis wrong.

Was this all designed to make the Perrin technique look good by comparison? Does anyone know what the coeliac plexus or the Perrin point are? And is there any theoretical basis that might lead to them being useful diagnostically?

 

[Andy]

Does anyone know what the coeliac plexus or the Perrin point are?

https://en.wikipedia.org/wiki/Celiac_plexus

Varicose lymphatic vessels and tenderness at ‘Perrin’s Point’ in the left breast area (the point is where the thoracic duct turns to the left to enter the subclavian vein, and where two sets of sensory nerves join).

https://www.edmesh.org.uk/the-perrin-technique-report-on-talk-by-raymond-perrin-march-2010/

 

[Snowdrop]

The coeliac plexus is for the rest of us --the solar plexus and one of the four Perrin points.
The other three are: left breast area where two sensory nerves join
mid point of the spine
top of head

https://www.edmesh.org.uk/the-perrin-technique-report-on-talk-by-raymond-perrin-march-2010/

 

[Invisible Woman]

Since diagnosis of ME is normally done by listening to the patient's description of history and symptoms, I'm not surprised the physician didn't get the diagnosis from examining and observing the patient - it sounds like they weren't allowed to ask any questions, just do some irrelevant observations. No wonder they got the diagnosis wrong.

Well they do say:

A physician conducted a standard clinical neurological and rheumatological assessment, whilst looking for patterns of illness behaviour. Each examination lasted approximately 20 minutes.

Bolding mine - what does that mean?
A) the patient says "Ouch" when I press this area
or
B) in answer to the physician's questions the patient clearly exhibits illness behaviour

Very vague. Which is why we need adherence to properly defined criteria. I suspect it suits many a "researcher" not to have to bother with tightly defined criteria.

 

[Trish]

Bolding mine - what does that mean?
A) the patient says "Ouch" when I press this area
or
B) in answer to the physician's questions the patient clearly exhibits illness behaviour

I'd guess that in order to test the Perrin diagnostic techniques which don't involve talking (except possibly ouch), they decided to use as a control a physician carrying out irrelevant rheumatology and neurology tests without talking to the patient. In both groups they could at the same time observe 'illness behaviour'.

The 'actual diagnosis' used to check validity would have been the diagnosis they entered the study with, presumably from the CFS clinic that referred them, so could be anything.

 

[Scarecrow]

Since diagnosis of ME is normally done by listening to the patient's description of history and symptoms, I'm not surprised the physician didn't get the diagnosis from examining and observing the patient - it sounds like they weren't allowed to ask any questions, just do some irrelevant observations. No wonder they got the diagnosis wrong.

I'd guess that in order to test the Perrin diagnostic techniques which don't involve talking (except possibly ouch), they decided to use as a control a physician carrying out irrelevant rheumatology and neurology tests without talking to the patient. In both groups they could at the same time observe 'illness behaviour'.

Your second quote more or less answers the first but also, bear in mind that in normal practice the AHPs would take an extensive verbal history in addition to the physical examination.

Edited to add: as someone who has been to a Perrin practitioner, I always wondered what weight was given to the physical examination versus history. I'm looking forward to seeing the full details of this study.

 

[Andy]

Should anybody feel the need to read the whole thing, it's now open access at http://bmjopen.bmj.com/content/7/11/e017521

I'll also add that to the original post.

 

[Andy]

And Ray Perrin has been promoting this https://news.sky.com/story/massage-...agnosis-of-chronic-fatigue-illnesses-11125556

 

[Scarecrow]

Inclusion criteria for CFS/ME group
To be included, patients with CFS/ME needed to have a prior formal diagnosis of CFS/ME5 at a National Health Service (NHS) hospital specialised clinic, persistent or recurrent fatigue for at least the past 6 months, a clear starting point to the fatigue, the fatigue should be unexplained by any other conditions, the fatigue should reduce the amount of physical activity each person could do and the fatigue should feel worse after physical activity.

Additionally, patients with CFS/ME needed to have at least one of the following symptoms: difficulty sleeping or insomnia, joint pain without swelling, headaches, painful lymph nodes that are not enlarged, recurrent sore throats, muscle pain without swelling, poor mental function (eg, difficulty thinking), symptoms getting worse after physical or mental exertion, feeling unwell or having flu-like symptoms, dizziness or nausea or heart palpitations.

Exclusion criteria for both CFS/ME and control groups
The following were excluded from taking part: people needing to use a wheelchair and pregnant and lactating women. In addition: comorbidities including: anaemias, autoimmune diseases, cardiac disease, endocrine disorders, infectious diseases, intestinal diseases, malignancies, neurological disorders, primary psychiatric disorders, significant pulmonary disease and primary sleep disorders. Additional exclusion criteria for control group included: a diagnosis of CFS/ME or a family history of CFS/ME.

Each participant was allocated a participant ID number with the clinical team being blinded to the groupings.

 

[Scarecrow]

Rheumatological assessment
A standard clinical neurological and rheumatological assessment was performed by a physician while observing the participant for any signs of illness behaviour, but no clinical history was taken. The neurological examination included muscle strength testing, examination of muscle tone in arms and legs, coordination including the finger nose test, heel-shin test, heel-toe walking, reflexes and sensation with eyes closed. The rheumatological examination examined joint swelling, wasting of regional muscles, deformity of joint, redness in joints or tendons and the palpation of the margin of joints in hands and feet.

If all the tests were normal with no observed illness behaviour, the patient was classified as not having CFS/ME, whereas if abnormal observations were made, the physician used their clinical experience to decide if the participant had CFS/ME. The physician performing these assessments had experience of working in NHS clinics for CFS/ME but had no experience of the Perrin technique (physician).

 

[Scarecrow]

Additional exclusion criteria for control group included: a diagnosis of CFS/ME or a family history of CFS/ME.

I haven't found any reason for this yet in the paper and I'm not able to read all of it just now but, anecdotally, I know that Dr Perrin believes that people who develop ME (or CFS, as he himself prefers) do so in part because they are anatomically susceptible and that relatives are likely to exhibit the same anatomical features, even if they currently show no signs of the illness.

 

[Valentijn]

So it is completely focused on the Perrin stuff, which gives it a rather promotional slant:

The first aim of this study was to see whether the five physical signs of the Perrin technique can assist in the screening of patients with CFS/ME, which could then subsequently lead to quicker treatment. Second, the study aimed to see whether the diagnostic accuracy was similar for a newly trained allied health professional (AHP) with no prior experience of CFS/ME compared with an experienced AHP.

They used NICE criteria for diagnosis, so it's not particularly clear if PEM was a mandatory symptom. Patients were also "assessed" for ICC criteria, but it doesn't sound like it was mandatory to qualify for an ICC diagnosis. Some of the exclusionary criteria are a bit questionable, such as autoimmunity and especially neurological disorders. It would imply that they are approaching ME as being a vague fatigue disorder instead of something which has been categorized as a neurological disease.

The assessment process sounds pretty vague and quackish, basically looking for an abnormal posture and tender points. I'd imagine those are present in many diseases. Cranial Rhythmic Impulse seems to be something also quite vague regarding how to assess it, though it's claimed that it "expresses unresolved conditional forces and patterns within the system", such as from "unresolved trauma or toxins":

The examination comprised the following four assessments:

1. Participant standing: observation and palpation of thoracic spine for any postural defects; regions of redness, temperature change or skin rashes or eruptions, for example, acne/boils.
   
   
2. Participant lying supine: observation and palpation of breast tissue for varicosities in the surface lymphatics and abnormal breast tenderness at ‘Perrin’s point’, which is a superficial tender area found at around 2–3 cm lateral and superior to the left nipple.15
   
   
3. With the participant remaining supine, palpation of the region of the coeliac plexus just below the xiphoid in the upper central area of the abdomen for any abnormal tenderness with possible temperature change in the region.
   
   
4. With the participant remaining in a supine position, cradle the head and examine the quality of the cranial rhythmic impulse.16

These assessments resulted in identification of the following signs as present or not present: (1) postural/mechanical disturbances of the thoracic spine (assessment A); (2) breast varicosities (assessment B); (3) tender Perrin’s point (assessment B); (4) tender coeliac plexus (assessment C); and (5) dampened cranial flow (assessment D).

If all five signs were present, then the participant is classified as having CFS/ME. If one or more of the signs was absent, then the participant is classified as not having CFS/ME.16

Lack of training is very relevant, since it probably takes some time to understand how to apply the bullshit:

The examination was performed by two AHPs. One had 10 years of experience of using the Perrin technique and working with patients with CFS/ME (experienced AHP); the other was newly trained in the Perrin technique with no prior experience of CFS/ME (newly trained AHP). The newly trained AHP received training, especially for this study, which involved being taught how to examine patients for the five physical signs and having hand-on experience of practising the technique.

They're comparing their method to something quite useless, presumably to make the Perrin stuff look better:

A standard clinical neurological and rheumatological assessment was performed by a physician while observing the participant for any signs of illness behaviour, but no clinical history was taken. The neurological examination included muscle strength testing, examination of muscle tone in arms and legs, coordination including the finger nose test, heel-shin test, heel-toe walking, reflexes and sensation with eyes closed. The rheumatological examination examined joint swelling, wasting of regional muscles, deformity of joint, redness in joints or tendons and the palpation of the margin of joints in hands and feet.

If all the tests were normal with no observed illness behaviour, the patient was classified as not having CFS/ME, whereas if abnormal observations were made, the physician used their clinical experience to decide if the participant had CFS/ME. The physician performing these assessments had experience of working in NHS clinics for CFS/ME but had no experience of the Perrin technique (physician).

83% of patients were female, but only 40% of controls. So diagnosis could be guessed with a decent rate of accuracy simply based on gender. Perrin practitioners in general correctly "diagnosed" more patients, but had a false positive rate of 14-17%. The physician had no false positives. I suspect the Perrin rate of a false positive misdiagnosis would be astronomical if the controls were another group of patients with a different diseases, though it's already very high is this study to begin with.

It's also difficult to generalize the diagnostic capabilities of the three groups, since there was only one member from each:

Only three practitioners (one in each category) were used. We therefore have very limited information on agreement between practitioners and whether diagnostic accuracy is substantially affected by experience; we have no information on within-category variation.

This is research quackery on par with the SMILE trial, just a bit less offensive because it doesn't assume ME is psychosomatic. I'd rate it 4 ducks out of 5:

 

[Trish]

They're comparing their method to something quite useless, presumably to make the Perrin stuff look better:

83% of patients were female, but only 40% of controls. So diagnosis could be guessed with a decent rate of accuracy simply based on gender.

I noticed both these factors too.

And the patients were recruited by volunteering. So who's to say Perrin himself or one of his minions didn't prompt their own patients, who they would recognise, to volunteer. Not saying they did...

And they assessed by 5 'techniques', but since the same assessor did all 5, what they decided for one technique would have influenced their assessment on the others. One of the techniques of the Perrin people was feeling for swelling (Edit:and tenderness) in lymphatics, and a well known recognised symptom of ME in many patients is swollen tender lymph nodes, so maybe that's all they were finding.

Not good science.

 

[Scarecrow]

They used NICE criteria for diagnosis, so it's not particularly clear if PEM was a mandatory symptom.

It's at worse "the fatigue should reduce the amount of physical activity each person could do and the fatigue should feel worse after physical activity" or at best "symptoms getting worse after physical or mental exertion". NICE diagnostic criteria certainly aren't ideal but they could be lot worse.

Lack of training is very relevant, since it probably takes some time to understand how to apply the bullshit:

As always, say what you really think!

They're comparing their method to something quite useless, presumably to make the Perrin stuff look better:

But the NHS physician has experience of ME/CFS, too. Don't they control for 'validity' of the Perrin Technique?

83% of patients were female, but only 40% of controls. So diagnosis could be guessed with a decent rate of accuracy simply based on gender.

Yes, but that's true for the NHS physician, too.

This is research quackery on par with the SMILE trial, just a bit less offensive because it doesn't assume ME is psychosomatic. I'd rate it 4 ducks out of 5:

That's harsh, isn't it? There aren't any magic circles in this one.

 

[Valentijn]

But the NHS physician has experience of ME/CFS, too. Don't they control for 'validity' of the Perrin Technique?

The limitations on the physician were pretty silly, limiting them to a brief physical exam. That isn't how the NHS diagnoses ME/CFS.

Yes, but that's true for the NHS physician, too.

The Perrin practitioners were probably involved in running the study, so likely knew a lot more about what was going on.

 

[Scarecrow]

The limitations on the physician were pretty silly, limiting them to a brief physical exam. That isn't how the NHS diagnoses ME/CFS.

No, but surely that isn't the point. It isn't the accuracy of NHS physical examinations that were being tested.

The Perrin practitioners were probably involved in running the study, so likely knew a lot more about what was going on.

Isn't that the point. The NHS were involved in it too and knew what was going on.

 

[Scarecrow]

Isn't that the point. The NHS were involved in it too and knew what was going on.

I'm not arguing that there was no bias. I bet the NHS expected a null result for the Perrin Technique and that's why they agreed to be involved.

Which sort of does bring us back to SMILE. Did Crawley ever imagine that there would be a 'positive' result for SMILE? Does she realise that it was due to study design?

 

[John Mac]

I was one of the ME patients in this study and was very impressed by how the Perrin practitioner was able to quickly home in on the sore lymph nodes that they say is characteristic of ME. I already knew of one of the points from attending a lecture by Dr Perrin about 5 years earlier however the other 4 sore lymph nodes I didn't even know I had until she pressed on them.

The NHS Physical Therapist who examined me and was presumably given some training in the technique was pretty useless, I had to ask her to go over areas again until she found the same sore lymph nodes.

I know a lot of people think this is all quackery but I think you should separate the treatment (and possibly a money making scheme) from this which is a physical examination to screen for ME.
Does anybody know of any other physical exam or blood test to diagnose ME?
I think there is a danger of throwing the baby out with the bath water.