Norwegian researchers have tested music therapy for chronic fatigue
Young people who developed chronic fatigue after having mononucleosis were treated using a combination of music therapy and cognitive behavioural therapy in a small Norwegian study. The results give no clear answers.
The study involved young people with mononucleosis. Previous research has shown that a percentage of mono patients experience chronic fatigue afterwards.
And a number of this subset of patients also develop other symptoms, such as chronic pain, memory and processing problems, and especially exertion-triggered aggravation. This means that an increase in the level of activity can cause a major worsening of their symptoms.
Taken together, these symptoms can lead to a diagnosis of chronic fatigue syndrome – also called ME (myalgic encephalomyelitis).
Music therapy and cognitive behavioural therapy
We still have a lot to learn about the causes of fatigue and chronic fatigue syndrome/ME and we lack effective treatment. When it comes to ME, there is considerable disagreement about how the disease and the research around it should be understood.
Some studies have suggested that cognitive behavioural therapy may improve some people’s fatigue symptoms. This treatment aims to change patients' thinking patterns and behaviours.
Researchers at the University of Oslo wanted to test whether combining music therapy and cognitive behavioural therapy could help youth with fatigue or chronic fatigue syndrome after mononucleosis.
"A majority of patients with post-infectious fatigue spontaneously improve on their own, but of course it’s important to find out if something can be done to shorten the period of illness," said Vegard Bruun Wyller, who led the study.
Hard to get enough participants
The researchers followed a group of 200 young people between the ages of 12 and 20 who had seen a doctor with an acute infection of the Epstein-Barr virus, the virus that causes mono.
After six months, 91 of the participants had developed chronic fatigue and were eligible to participate in the trials of music therapy and cognitive therapy. However, many refused and only 43 were included in the study.
This was not enough participants to carry out the planned study, where the aim was to investigate whether the treatment had a positive effect on activity level, symptoms and markers of disease activity in the adolescents.
Instead, the researchers chose to conduct the study as a feasibility study, to assess whether there was a basis for initiating a larger investigation.
The 43 participants were randomly divided into two groups – a treatment group and a control group. In the next three months, the treatment group received ten therapy sessions. Four of the sessions were music therapy, which included listening, improvising, writing songs and learning to play an instrument.
The control group received no treatment.
The researchers took several measurements before the treatment started, after three months and after 15 months. The main goal was to see if the treatment altered participants’ activity level, which was measured with a pedometer.
Participants also answered a questionnaire measuring fatigue, pain, quality of sleep, quality of life, and signs of anxiety or depression.
Walked fewer steps
The results generally showed little difference between the treatment group and the control group. None of the differences were clear enough to be statistically significant, that is, above the threshold where the impact is so great that it can hardly be due to chance.
However, certain measurements tended to be different between the groups.
With regard to the main objective of the study – the activity level of the participants – the results showed that the treatment group actually fared worse than the control group.
Those who received therapy walked fewer steps than those who did not receive treatment, both at three months and 15 months.
Reported slightly less fatigue after exertion
Nevertheless, participants in the treatment group reported slightly less fatigue after exertion at 15 months.
After 15 months, Wyller and colleagues categorized 62 per cent of the treatment group as healthy, which they defined as scoring below a certain number on the fatigue questionnaire. The same was true of 37 per cent of participants in the control group.
“The treatment is feasible and seems acceptable to the participants. The trend toward positive effects on patients' symptoms and recovery may justify a full-scale clinical trial,” the researchers write in an article now published in the BMJ Pediatrics Open journal.
Rasmus Goll at UiT Norway's Arctic University is also researching ME. He is not convinced.
“It’s a pretty optimistic assessment of the treatment,” he writes in an email to sciencenorway.no.
“I’m not immediately convinced of the feasibility or efficacy of the treatment.”
Goll points out that the measurement of activity – how many steps participants walked each day – actually suggests that the treatment has a negative effect.
This was the main mode of measurement of the study and is also the only objective measurement: objectively counting how many steps the participants walked.
The other measures – like fatigue and pain – were subjective, based on self-reporting. They thus measure the participant's perception of their own symptoms.
These measurements are common and necessary in studies of chronic fatigue, because the disease is defined by symptoms. However, the subjective measurements are more vulnerable to errors, because the responses can be influenced by what the patient thinks the researcher wants to hear, for example.
May be coincidence
The researchers write that they were surprised that the treatment group was less active. Wyller believes the tendency may be due to chance.
“This is a really small study. But the tendency could also be because the mental training method wasn’t aiming for increased physical activity – on the contrary, the patients learned relaxation exercises, which may have led them to rest more", he says.
In this case, the treatment worked against the intention, which was to make the participants more active.
Many dropped out of treatment group
Another issue was that six of the 21 participants in the treatment group dropped out of the study during the treatment period. Only one dropped out of the control group.
Wyller and colleagues believe that the dropouts were probably due to schools introducing a new absenteeism scheme at just this time.
“There was a lot of uncertainty about what would count as an excusable absence,” Wyller writes.
The researchers note that the majority of those who quit stated this as a reason. This included both individuals who declined to join the study in the first place, and those who dropped out along the way.
Results could have been worse
However, this doesn’t explain why more people dropped out of the treatment group compared to the control group. It shouldn’t be ruled out that something about the treatment itself caused them to drop out.
Goll wonders if the intervention might have made participants’ condition worse.
“Of course we don't know, but that should be considered,” he says.
If those who dropped out actually responded poorly to treatment, the number of healthy participants at 15 months would be much lower than 62 per cent. In fact, it would be just as low as in the control group.
Goll writes that the way the figures are shown presents the result as very positive, because the participants who dropped out are removed from the calculation.
If the results for recovery were instead calculated as "intention-to-treat" – where everyone is included – there would be no difference between the treatment group and the control group.
Overall, the study cannot say with any certainty what effect the combination of music therapy and cognitive therapy has on adolescents with chronic fatigue or ME.
But if an effect exists, it would appear to be a modest one, whether in a negative or a positive direction.
Most of the measurements in the study showed minimal differences between the treatment group and the control group. And the indications of differences that did arise were small and contradictory.
According to Wyller, some variation existed from patient to patient, but there was no evidence that the treatment had a very strong effect on any of the patients. Participants in both groups reported very few adverse effects.
Wyller believes that a larger study employing the same treatments would most likely show a moderate effect similar to the feasibility study.
Translated by Ingrid P. Nuse
Sadaf Malik et.al: Cognitive-Behavioral Therapy Combined With Music Therapy for Chronic Fatigue Following Epstein-Barr Virus Infection in Adolescents : A Feasibility Study, BMJ Pediatric Open, April 2020. doi:10.1136/bmjpo-2019-000620
Read the Norwegian version of this article at forskning.no