Fatigue, distress, mental health, and mental ability all improved after three months of low-impact exercise, weekly group sessions of cognitive behavioral therapy (CBT), or both together. The gains were significantly greater than those made by veterans who were given usual care. Physical function improved more in those who had CBT than in those who didn't.
The randomized study of 1,092 veterans at 18 hospitals is being presented Saturday at the annual meeting of the American College of Rheumatology by a team led by University of Michigan Health System rheumatologist Daniel Clauw, M.D., as well as researchers from the Department of Veterans Affairs and the Department of Defense.
"These findings suggest a real potential to improve the quality of life for those still suffering from the cluster of physical and mental symptoms often considered to be characteristic of Gulf War veterans' illness," says Clauw. "Veterans showed improvement no matter whether they received one or both of the study's interventions. We're encouraged that these simple steps appear to help some."
Clauw notes that those with Gulf War veterans' illness have many symptoms that overlap with fibromyalgia and chronic fatigue syndrome. Both of those disorders, which are more generally accepted as a distinct illness by physicians than the collection of illnesses formerly known as Gulf War syndrome, have been shown to respond to exercise and supportive interactions with others.
According to those who experience it, the overwhelming fatigue, mental distress and overall mental and cognitive effects of Gulf War veterans' illnesses often combine with physical pain and tenderness. Clauw and his colleagues from VA and military hospitals set out to see if exercise and CBT could help veterans with two or more characteristic symptoms. Their study was called CSP #470.
The study's participants all had fatigue that limited their usual activities, pain in two or more body regions, and symptoms involving their thinking and learning abilities.
All had served in the Gulf War between August 1990 and August 1991, and all had started experiencing symptoms after deployment to the Persian Gulf. They could not have a clearly defined disease that accounted for their symptoms, or physical abilities similar to the general population.
Gulf War veterans' illnesses is a term used to describe illnesses affecting veterans who served throughout the Persian Gulf region during the war with Iraq in 1990 and 1991. According to the American Legion, thousands of Gulf War veterans suffer from chronic symptoms of fatigue, joint and muscle pain, headaches, memory loss, respiratory symptoms, and gastrointestinal symptoms.
Taken together, these are now described as Gulf War veterans' illnesses, not Gulf War Syndrome. The National Institutes of Health, the Institute of Medicine, and other panels have all concluded that the illnesses observed in Gulf War veterans do not constitute a unique disease.
The participants were randomized to four groups: those who were included in weekly CBT group sessions, those who began low-impact exercise three to four times a week with the help of an exercise therapist once a week, those who followed both the CBT and exercise regimens, and those who stayed on usual treatment.
More than 80 percent of the participants had all three chief symptoms -- fatigue, pain and neurocognitive problems -- commonly attributed to Gulf War syndrome, and many had depression, an anxiety disorder or posttraumatic stress disorder. Those with severe psychiatric illnesses could not take part.
The participants were assessed before the study began, and again at 3, 6 and 12 months afterward, using standard evaluation surveys for physical function, pain, fatigue, cognitive symptoms, distress and mental health. The exercise and CBT interventions lasted three months. Eighty-five percent of the participants were men, with a mean age of 40.7 years.
The results showed that all the participants, including those who received usual care, had improved in physical function after one year. But when those who had CBT were compared with those who hadn't, those who had been in talk therapy had significant physical improvements. Eleven percent of patients who had usual care improved in their physical function, as opposed to 11.7 percent of those who exercised, 18.4 percent for those who had CBT, and 18.5 percent for those receiving both CBT and exercise.
The results for mental measures were even more compelling. Highly significant improvements in fatigue, distress, mental health function and the ability to think and understand were seen with exercise alone, and with exercise plus CBT. Those who only had CBT showed improvement in mental health function and thinking/understanding.
Intriguingly, those participants with tenderness at multiple points on their bodies improved more than those who didn't -- and the higher the number of tender points, the more responsive to treatment they were. But other measures of pain did not respond to treatment. Veterans with disabilities, mood disorders and personality disorders did not improve as well as others.
While Gulf War veterans illnesses are not well-defined, or even accepted by many experts, Clauw stresses the importance of trying to address veterans' symptoms with effective therapies, no matter what the origin of the symptoms.
In addition to Clauw, the report's authors include researchers from the Walter Reed Army Medical Center; the Veterans Affairs Medical Center in Boston; the Oregon Health Sciences University; Indiana University, the VA Cooperative Trials Coordinating Center; the White River Junction VA in White River Junction, Vermont; the VAMC in Bedford, MA; and the Office of Research and Development in the VA Veterans Health Administration.