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

[Scarecrow]

And I still can't get away from the problem that the AHPs appear to have this advantage of seeing self-selecting patients who likely have higher than typical incidence of swollen/sore lymph nodes compared to a more reflective population of ME/CFS patients.

Yes it is a shame about the recruitment method. On the plus side, they recruited from two hospital clinics (good) as well as from the local support groups and by social media and posters.

I don't agree with you about the patients being more likely to have sore lymph nodes (and, by the way, those with swollen nodes were excluded).

Would a pwME who heard about this study really be more likely to volunteer if they have sore lymph nodes? I consulted an osteopath for actual treatment because the Perrin Technique came up quite highly on an MEA survey of treatments. I never gave any thought to my lymph nodes (which for the record are rarely tender and when they are, its my armpits and groin that are sore - I'm not aware of the others until they are pressed).

My suspicion is that current methods would outperform these techniques if you tested against a typical method, and perhaps much much better if the technique had to pick out those with ME/CFS from other disease states which is what it'd have to do in a real clinical setting.

Yes, I'd like to have seen another disease incorporated into this study.

So I just can't see any value in this, certainly not enough to claim that all doctors in the world could benefit from this diagnostic technique.

To be fair, Perrin hasn't made such a claim.

 

[Scarecrow]

I'm uncomfortable with this being a commercially unproven treatment that's getting national media coverage despite the fact the study tells us nothing about the treatment at all, along with an anecdotal report in the media that the treatment can transform a person's life.

Sky also describe the 44% as 'standard examinations' which will lead the reader to believe it's been compared to standard diagnosis methods which it's not.

It's such a shame that the Science Media Centre has lost all credibility. Now it's open season again.

 

[Joel]

To be fair, Perrin hasn't made such a claim.

He has, in the media coverage:

Dr Ray Perrin...

He said: "Every GP in the world could potentially benefit from this to speed up diagnosis - currently it can be very slow and frustrating."

 

[Scarecrow]

He has, in the media coverage:

Sorry I missed that. I haven't read the coverage properly. I'm trying to make my way through the study paper.

That's concerning. And it's also bit odd because the practitioners don't diagnose without a full history, which takes considerably longer than your average GP appointment.

 

[Joel]

Sorry I missed that. I haven't read the coverage properly. I'm trying to make my way through the study paper.

That's concerning. And it's also bit odd because the practitioners don't diagnose without a full history, which takes considerably longer than your average GP appointment.

No worries, yeah it looks to me like he's just promoting his technique but the findings don't justify it. I find his other comment in the media even more concerning though, the one about treatment, because that isn't even what this study is looking at. This is serious because patients have to part with their own money for this treatment and seeing a reputable media outlet publishing these claims in association with a related paper published in a journal that they don't necessarily understand or even know how to access is likely to misinform people. Where is the evidence for the treatment working? That ME is due to poisons in the brain?

edit: those questions aren't aimed at you Scarecrow, or anyone else, they're just rhetorical

 

[Scarecrow]

No worries, yeah it looks to me like he's just promoting his technique but the findings don't justify it. I find his other comment in the media even more concerning though, the one about treatment, because that isn't even what this study is looking at. This is serious because patients have to part with their own money for this treatment and seeing a reputable media outlet publishing these claims in association with a related paper published in a journal that they don't necessarily understand or even know how to access is likely to misinform people.

I can't disagree with any of that. It does look bad.

Where is the evidence for the treatment working?

I talked to my own Perrin practitioner about this. It was the same year of the first PACE paper. At that time, they weren't sure how you could design a trial when you cannot blind the treatment and you have to reply on subjective reports. (Hey, that sounds like the same flaw identified by someone we know!). I don't know if they have made any progress since then but I wonder if Perrin thinks that if he can get the NHS to take him seriously, then it might make it easier to get funding for a treatment trial.

That ME is due to poisons in the brain?

I used the word 'arcane' the other day referring to osteopathy generally. There were elements of the PT treatment that I found quite bizarre (and it was the 'head' section) but it was relaxing and I just went with it. I've read someone else's account where they told their therapist not to bother with that part because they thought it was stupid since there was no evidence of the lymphatic system in the skull. "Poisons in the brain"? I dunno but since my treatment, we've seen the Kipnis brain lymphatics paper.

OT: Perrin is a very approachable man. Like @John Mac, I went to one of his talks but, in my case, long after I'd started treatment. I emailed him a while ago when the brain lymphatics paper was published. He wrote back and thanked me. There was a suggestion elsewhere on the forum that we invite scientists here for a Q&A session. I'd be happy to ask Perrin if we decide to do anything like that. Put questions to him directly if he'll give us the opportunity. Don't assume the worst possible motives at all possible times.

 

[Scarecrow]

A few sections from the paper that touches on some of the points raised above.

The physician was able to correctly identify 100% of the healthy controls using the standard clinical neurological and rheumatological examination. However, they were only able to correctly identify 44% of patients with CFS/ME, and the tendency to underdiagnose CFS/ME was highly statistically significant (p<0.001). This affirms the current approach used in CFS diagnostics based on NICE guidance in that clinical examination is most useful in identifying alternative diagnoses and to exclude the diagnosis of CFS/ME, but that clinical examination is not a useful modality for confirming diagnosis of CFS/ME.

Although this study shows clearly that diagnostic accuracy for CFS/ME increases using the physical signs of the Perrin technique, there are some limitations, which should be highlighted. First, this study recruited two groups of participants, people with a prior diagnosis of CFS/ME and healthy controls with no symptoms of the condition, as the purpose was to establish ‘proof of concept’ of the Perrin technique. Therefore, the study did not explore how accurate the Perrin technique physical signs would be, when presented with patients with different conditions with similar presenting symptoms such as fibromyalgia. However, in a clinical setting, knowing the history and symptoms together with the physical signs would help to differentially diagnose CFS/ME from other possible illnesses.

The gender balance in the patients with CFS/ME was similar to that of previously published work,17 although the healthy volunteers were recruited as a convenience sample, which was not gender matched. Therefore, any prior knowledge of the expected male to female ratio among patients with CFS/ME could have influenced the results. It should be noted, however, that none of the practitioners knew if the control group was matched or not for gender and that the AHP with no prior experience of CFS/ME was unaware of the gender balance.

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. Future research should involve a study design whereby there are multiple experienced AHPs, newly trained AHPs and physicians.

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 study did not include patient/family history or the patient talking about their symptoms, which should increase accuracy in clinical practice.

 

[Scarecrow]

edit: those questions aren't aimed at you Scarecrow, or anyone else, they're just rhetorical

Hey, your p.s. came too late! I couldn't see while I was typing my reply.

 

[Cheshire]

Massage technique 'speeds up' diagnosis of chronic fatigue illnesses

In tests, 86% of patients with ME were diagnosed using the technique, compared with 44% in standard examinations.

However, the ME Association told Sky News it still could not endorse the technique pioneered by Dr Perrin.

In a statement, it said: "With no current drug treatments available, patients are often desperate and will do anything, pay anything for treatments which are at best scientifically unproven and at worst, damaging."

https://news.sky.com/story/massage-...agnosis-of-chronic-fatigue-illnesses-11125556

 

[Valentijn]

Raymond Perrin is rather overstating the reality of the study, since no standard diagnostic process was used as a comparison:

Dr Ray Perrin, an osteopath and neuroscientist based in north Manchester, told Sky News he had spent 28 years pursuing his theory and was delighted to have seen the first signs of evidence-based recognition.

He said: "Every GP in the world could potentially benefit from this to speed up diagnosis - currently it can be very slow and frustrating."

And this sounds like outright bullshit with absolutely no evidence supporting it:

"Eventually, with no poisons affecting the brain, the sympathetic nervous system begins to function correctly and health is restored," Dr Perrin said.

He needs to do some real research and prove that 1) there are "poisons" affecting the brains of ME patients, 2) that the sympathetic nervous system is the root cause of ME, and 3) that a nice massage will remove poisons, affect the sympathetic nervous system, and "restore" health. I don't doubt that he's a nice guy, and might even have good intention, but the approach he's taking is pure quackery and has no scientific basis.

And the sad thing is that it's still miles better than the "evidence based" NHS treatments recommended for ME/CFS. At least you get a nice massage and no psychological abuse

 

[Scarecrow]

And the sad thing is that it's still miles better than the "evidence based" NHS treatments recommended for ME/CFS. At least you get a nice massage and no psychological abuse

Indeed and that's the initial attraction of it.

It's a lot more than can be said for just about any doctor who routinely prescribes pwME anything stronger than a pain killer or a sleeping tablet.

 

[Esther12]

And the sad thing is that it's still miles better than the "evidence based" NHS treatments recommended for ME/CFS. At least you get a nice massage and no psychological abuse

I got some free reflexology for a while. Probably the most useful medical intervention I've ever had for CFS, just because it was quite a pleasant thing to do.

[edit: In no way am I saying that I think providing reflexology would be a good use of resources!]

 

[arewenearlythereyet]

Raymond Perrin is rather overstating the reality of the study, since no standard diagnostic process was used as a comparison:


And this sounds like outright bullshit with absolutely no evidence supporting it:


He needs to do some real research and prove that 1) there are "poisons" affecting the brains of ME patients, 2) that the sympathetic nervous system is the root cause of ME, and 3) that a nice massage will remove poisons, affect the sympathetic nervous system, and "restore" health. I don't doubt that he's a nice guy, and might even have good intention, but the approach he's taking is pure quackery and has no scientific basis.

And the sad thing is that it's still miles better than the "evidence based" NHS treatments recommended for ME/CFS. At least you get a nice massage and no psychological abuse

given my personal space issues, I think I would prefer not to receive a free massage given by some strange person groping my nodes.

 

[Perrier]

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.

Were you given the treatment? Did it really Help? Has anyone else been helped?

 

[John Mac]

Were you given the treatment? Did it really Help? Has anyone else been helped?

No I wasn't given any treatment it was just a physical examination from a Perrin practitioner, an NHS physiotherapist trained in the Perrin examination and a doctor. All in all it took about 1 hour.

 

[chrisb]

I have followed this thread with the degree of scepticism which would be expected. (Sometimes I am sceptical about scepticism.) But having an enquiring disposition I thought that the least one should do is give "Perrin's Point" a prod. Totally unexpectedly it was slightly tender in a way which the corresponding position on the other side was not.

Now I just need to find some healthy controls, and people with similar but different illness. I may be absent for 2 years....with remission....for good behaviour.

But I remain sceptical about the "treatment".

 

[Scarecrow]

But I remain sceptical about the "treatment".

Nothing wrong with a bit of open-minded scepticism.

 

[Valentijn]

Now I just need to find some healthy controls, and people with similar but different illness. I may be absent for 2 years....with remission....for good behaviour.

My main concern is that he seems to be going about it backwards, as the BPS practitioners do. He starts with the premise that his particular specialty is the cure for multiple diseases, and the explanation of pathology to support that cure is then invented with little or no evidence.

Why is there no evidence of these toxins existing? Which toxins are they supposed to be? Where is the evidence that these toxins "overstrain" the sympathetic nervous system? Where is the evidence that the sympathetic nervous system is "overstrained"? WTF does "overstraining" the sympathetic nervous system even mean? Where is the evidence that the lymph nodes are blocked from normal drainage?

The organizational similarities between LP and the Perrin Technique are a bit eerie. Aside from the Perrin Technique being based on largely biological causation (but also emotional), they're organized and marketed in nearly identical manners. A 430 euro weekend course is all that's needed to become a Perrin practitioner - though the applicant at least has to have a background in osteopathy, chiropractics, or physiotherapy. That's a slight improvement over the apparent LP requirement of being susceptible enough to believe they were cured by LP in the past.

And I think Perrin's actual interest in patient accounts is limited to a similar extent as it is in the BPS framework. Why does he call it CFS/ME like they do, when it pisses off most ME patients? Why describe ME/CFS as "a clinically defined condition characterized by severe disabling fatigue and a combination of symptoms including disturbance in concentration and loss of short-term memory, disturbed sleep, and musculoskeletal pain."? Much like the BPS practice, he's framing it in terms which are most relevant to his cure, and which severely downplay the overwhelming loss of physical functionality which patients experience.

My general impression is that Perrin's explanation of causation and basis for treatment is as flimsy as the BPS basis for CBT/GET, combined with the financially exploitative approach of Lightning Process or similar. The Perrin Technique is just more palatable to patients because we aren't being explicitly or implicitly told that it's our fault that we're sick.

 

[NelliePledge]

I have followed this thread with the degree of scepticism which would be expected. (Sometimes I am sceptical about scepticism.) But having an enquiring disposition I thought that the least one should do is give "Perrin's Point" a prod. Totally unexpectedly it was slightly tender in a way which the corresponding position on the other side was not.

Now I just need to find some healthy controls, and people with similar but different illness. I may be absent for 2 years....with remission....for good behaviour.

But I remain sceptical about the "treatment".

This is where I have to admit that I have had Perrin sessions- not from him.
It attracted me fairly soon after I got diagnosed when I hadn’t even been referred to the NHS clinic. The sessions were the same price as the chiropractor I had occasional treatments from for my painful “hunching over computer” neck and shoulder.
I had bad sore throat and swollen neck glands as an issue for several years before diagnosis so the lymph thing did seem plausible. I had an initial session where I talked thro my history and the practitioner checked me over physically. Despite sore throat swollen gland issue I did not get a physical exam of any part of my body by any GP I saw about this. I suspect due to having previously had mild situational depression I am down on record as Medically Unexplained symptoms. I have requested a copy of all available records

So I was only aware of neck lymph nodes and occasionally armpit being sore. When I was checked over the Perrin practitioner pressed the Perrin point which was t terribly pleasant having someone prodding a finger into your boob however gently. And it was indeed pretty sore which I was totally unaware of. I don’t own a copy of the book so didn’t know about the specifics.
I found going for the sessions helpful in the sense I was being dealt with by someone who saw ME as physical I was advised to take omega 3 supplements- the same ones used by Basant Puri in his approach. And I did feel like I was benefiting physically although could well have been placebo. I didn’t find the massage very pleasant not exactly vigorous but it it is more challenging I think for a woman if you’re having a massage of boobs and they are tender than it would be for a guy.

I’m not good on sticking to a routine so didn’t do the self massage as often as I should have been doing. And I have had gaps as well when I’ve not been able to go for sessions so I didn’t do it regularly other than the first 3 months. I have also had other more gentle physical therapies from the practitioner which I prefer and have just started going again after a big gap just for the other stuff.

I wouldn’t cope with Perrin massage at the moment as I’ve been a fair bit worse since July - more Moderate than mild and my torso feels sore all over and I feel like I have tender lymph nodes round my rib cage a lot of the time.

Anyway that’s my experience

 

[Inara]

I agree that they would be unlikely to be specialists in those areas but the rheumatology and neurology examinations that you listed above are pretty standard doctoring tests. I dare say that even most psychiatrists wouldn't have too much trouble.

In Germany (well, my experience), these tests are only performed by neurologists. Don't know exactly why.