THE EFFICACY OF MULTI-CONVERGENT THERAPY Marie Thomas Funded by The Gatsby Foundation and HMAW

MCT MCT Developed in Cardiff by a Physiotherapist Michael Sadlier Chronic Fatigue Syndrome,IBS, tinnitus, vertigo, hyperventilation syndrome and anxiety to provide service for patients whose condition did not respond to first-line medical interventions

MCT Reflects a bio-psychosocial and philosophical approach to health outcome2 Advocates more active integrative role for therapists in the assessment and management of beliefs and emotions 2 Engle, 1997 The multi-convergent treatment regime described in the current study reflects Engel’s bio-psychosocial and philosophical approach to health outcome [13]. The therapy also mirrors the work of physiotherapists in the field of chronic pain management who advocate a more active integrative role for therapists in the assessment and management of beliefs and emotions [14, 15].

MCT Combines CBT and GET CBT Aims to identify factors – predisposing, precipitating and perpetuating Improve sleep quality Restructuring of beliefs, thoughts and behavioural patterns Multi Convergent Therapy (MCT) combines aspects of behavioural therapy and fitness training along with, in some cases, pharmacological intervention in an attempt to address the many co-existing clinical features of the condition simultaneously. An added benefit of this multi-dimensional approach was that a single therapist could conduct all components of the technique. Other aspects such as behaviour modification, breathing and relaxation techniques, connective tissue massage and brief focused psychodynamic counselling were combined in a tailored therapy programme. The approach aimed to re-focus the patient by emphasising mechanisms of internal control and therapy was adapted constantly to reflect the needs of the patient. The number of therapy sessions attended by each patient was not restricted; instead, the requirements of each patient were assessed on a regular basis. Elements were adapted to differences within the presented condition, which proved essential in heterogeneous groups like CFS. The therapeutic approach blends different aspects of MCT; no one patient received exactly the same service as another, instead, they received a slightly different approach. This meant that for certain patients exercise was stressed, with others CBT etc. The patient and therapist would, during this process, work through the following stages: (a) exploration of the predisposing precipitating and perpetuating factors, psychological, physiological and social, (b) exploration of model of illness as well as neurophysiological model of neuroplasticity, (c) introduction of behaviour modification in relation to cognitions, (d) exploration of anxiety/depression (if any existed), (e) identifying positive and negative patterns of behaviour pertaining to fatigue etc., (f) coping strategies, (g) exploration of sleep problems and rectification where problems existed (sleep hygiene) and (h) application of techniques (meditation etc.) regarding behaviour modification. Overall, the technique conforms to the type of individualised therapy programme suggested by the Working Party on CFS/ME, namely a combination of CBT, pacing and GET (the Working Party on CFS/ME, 2001).

GET Introduction to planned activity and rest (pacing) Is introduced after exploration of relationship between fatigue and cognitions Follows the rationale suggested by Noakes et al (2005) The graded exercise phase of the therapy involves the introduction of planned activity and rest (referred to as pacing). Non-prescriptive graded exercise is introduced after the patient has explored the relationship between fatigue and cognitions. The rationale follows a model similar to that suggested by Noakes et al. who hypothesised that physical activity and the recruitment of skeletal muscle units is controlled by a continuous pacing strategy within the central nervous system based on its feedback from physiological as well as psychological systems [19]. Gentle walking is introduced every second day at a level appropriate for each person in order to prevent post-exertional malaise. The distance and time walked is increased as the patient’s confidence grows. The patients themselves are responsible for building up the level of exercise and providing feedback at the therapy sessions.

MCT Also included: Mindfulness meditation Heart Rate Monitors Mindfulness (or insight) meditation is also blended with the Cognitive Behaviour Therapy/Graded Exercise Therapy approach. Patients are encouraged to fix their thoughts in the present without being distracted by the associations attached to those thoughts or sensations (such as pain) and, as a result, are able to reduce the suffering associated with physical somatic disorders [21, 22, 23]. Patients can then use the technique during times associated with heightened awareness of pain or fatigue (such as during exercise). In addition, this method can also be further used to reduce any intrusive thought patterns experienced at night which prevent the patient from falling asleep [24]. This technique has proved useful in other conditions associated with pain, immune function, sports and cardiopulmonary function [25, 26, 27, 28]. Heart rate monitors are used during the sessions to act as a symbol of fitness and wellness, to help vulnerable patients from deteriorating into a ‘boom and bust’ scenario and to asses the relaxation response [24]. The monitors enable the identification of the average peak heart rate for each patient whilst exercising at a sustainable level and also to establish cardiac rhythm. The monitors are not used to promote exercise within a given range for a number of reasons: (1) recent studies on exercise in fibromyalgia (a condition which overlaps substantially with CFS) show little correlation between cardiovascular improvement and improvement in the condition [29, 30]; (2) the effect of stress on some patients with CFS may lead to chronic over breathing (PaCO2<30mg CO2) during exercise (unpublished data from the CFS clinic); (3) although improvements in patients with CFS have been observed in previous Graded Exercise Therapy trials, exercise should not be insisted upon in all cases [11].

MCT Treatment trial conducted to formally evaluate MCT in severe disability (CFS) 35 patients 12 MCT 14 Relaxation 9 non-intervention controls Thirty-five participants, fitting the Centre for Disease Control criteria for Chronic Fatigue Syndrome, were recruited from two outpatient clinics and an existing patient panel. The active treatment took place at a clinic within the physiotherapy outpatient unit. Relaxation therapy and all assessments were conducted at the psychology unit. Patients were assigned to either Multi-Convergent Therapy (N=12) or Relaxation Therapy (N=14). Nine participants who received general medical care were used as a comparison group.

MCT for CFS Primary outcome measure3 Secondary outcomes4 Above 80% Functional performance Above 80% Secondary outcomes4 Improvements in overall illness condition Improvements in fatigue Improvements in disability 3 Sharpe et al., 1996 4 Deale et al., 1997 Main outcome measures: The Karnofsky Performance scale was used as the primary outcome measure of function. The scale ranges from 0 to 100% functionality; patients included in the study had scores of less than 70% which meant that their disability was bad enough to prevent them from working. A range of secondary outcome measures assessing overall improvement in their condition, fatigue, and disability levels were also administered.

MCT for CFS Improvement in overall condition – post-therapy and 6 months post-therapy

MCT for CFS Reduced disability – post-therapy and 6 months post-therapy

MCT for CFS Reduction in fatigue – post-therapy and 6 months post-therapy

MCT for CFS Other improvements in the MCT group included: Improved sleep quality Improved activity levels Lower symptom scores Improved cognition

MCT for CFS A recent follow-up assessment of MCT participants, 3 years post-therapy: Continued improved functioning Lower levels of fatigue Lower levels of disability Continued improved sleep Continued improved activity Lower symptom scores Data were collected for 10 of the 12 patients who had taken part in the original study. These data suggested that patients attending the therapy continued to show improvements in functioning, had lower levels of fatigue and disability, improved sleep quality and levels of activity and lower symptom scores at a three-year follow-up.

MCT To summarise: Improves physical functioning Improves overall illness condition Reduces fatigue Reduces disability Improves sleep quality Improves activity levels Improves the chance of return to work