The Perrin Technique

edmesh Open Meeting Talk on 25 March 2010

From edmesh newsletter 72, Summer 2010

The Speaker

Dr. Raymond Perrin is a Registered Osteopath who trained with the British School of Osteopathy. He has been a specialist in the study and treatment of ME since 1989 when he cured a cyclist patient of ME without intending to, and has a Ph.D. in the involvement of cerebrospinal fluid and lymphatic drainage in CFS/ME.

The Perrin Technique for CFS/ME was carefully researched and tested by academic staff in the Universities of Salford and Manchester between 1994 and 2005. Dr. Perrin personally trains and licences all practitioners of his technique at the Perrin Clinic in Manchester.

The Importance of the Lymphatic System

Dr Perrin explained that every part of the body from cells to organs must be nourished and purified to function healthily. The role of the blood and circulatory system is well known in this regard; less understood is the function of the lymphatic system.

The major functions of the body are controlled by the brain. Cerebrospinal fluid surrounds the brain, supplying nutrients to it. The fluid also draws poisons from the brain, which flow through the capillaries into the bloodstream and from there go to be detoxified in the liver.

However, blood capillaries can only deal with small molecules. Large molecules of toxins must go into the lymphatic system, which is a network of tubes which carry lymph, a clear fluid, around the body. This system provides a drainage method that backs up the blood flow. The large particles enter the system at the terminal lymph vessels or terminal lymphatics, through openings like gills in a fish. The particles break down into smaller molecules in the lymph nodes on the way to the two large subclavian veins under the collar bones. The breakdown products flow into the bloodstream and then make for the liver for final detoxification.

How CFS/ME Develops

Patients all seem to have a predisposing history of sympathetic nervous system overload, either physically, chemically, immunologically or emotionally:

• through  overactivity or injury
• because of environmental pollution
• by chronic infections or allergens
• from family or work stress.

An important function of the sympathetic nervous system is to control the pumping mechanism in the walls of the thoracic duct in the chest, which is the central system for draining lymph fluid into the bloodstream. Dr. Perrin explained that the pumping mechanism was discovered in the 1960s by Professor John Kinmonth, a London chest surgeon. However, even today, this is not generally recognised and taught in medical schools.

Diagram of the normal lymph flow through a lymphatic vessel with open valves.

If the sympathetic nervous system is hyperactive, the pump may push the lymph fluid in the wrong direction and lead to a further build-up of toxins in the body.

The lymphatic system extends from the head to the feet, with main lymph nodes in the chest as well as subsidiary lymph nodes in clusters under the chin, at the shoulders, under the arms and in the groin. It includes the lymphatic vessels through which the lymph travels in a one-way system only towards the heart.

In a disease state, toxins can actually be pumped back into the central nervous system, e.g. into the brain or breast tissue. The valves of the lymph vessels may become damaged as the lymph flows in both directions, creating congestion.

This gives rise to varicose lymph vessels or varicose lymphatics, as seen by Professor Kinmonth in surgery, with their typical beaded, colourless appearance on the skin. Dr Perrin says that they can be felt by a specially trained osteopath and that every ME patient has them.

Diagram showing development of varicose lymphatics, with reverse flow of lymph

The Role of the Hypothalamus

The hypothalamus, a small region low in the front of the brain, controls several hormones and the sympathetic nerves, which spread out in twelve pairs from the thoracic section of the spine, extending down the main part of the back.

The hypothalamus is one of the few sites in the brain allowing large molecules from the blood to enter: the blood-brain barrier acts as a filter elsewhere. The function of the hypothalamus is to sample the hormones that pass to it from the blood, and signal to the organs to rebalance if necessary. Unfortunately, large toxic molecules may also enter the brain at this point, or may already be there because of the chemical changes going on in the brain all the time, especially when stress is present.

Fortunately there is a drainage mechanism from the brain into the lymphatic system, discovered in the 1870s by the American founder of osteopathy, Dr. A. T. Still. He wrote that “the lymphatics are closely and universally connected with the spinal cord and all other nerves, and all drink from the waters of the brain.

Dr Perrin explained that there are four drainage points in the brain. The main one is the cribriform plate, part of the ethmoid bone, which separates the nasal cavity from the brain. Two rows of small holes in the plate allow the passage of blood vessels, nerves and cerebrospinal fluid to the nasal passages. The three further drainage points in the skull are situated at the auditory nerve, at the optic nerve and at the part of the trigeminal nerve in the cheek. If, however, the plate or another point is damaged, there will be a build-up of toxins in the lymph and damage to the sympathetic nervous system’s control of the thoracic duct, setting up a vicious circle. Damage can occur through causes such as congenital defect, birth trauma, emotional upset, infection, postural strain or environmental pollution.

Most of the medical profession are ignorant of these drainage points and their function, said Dr Perrin.

The Four Physical Signs of CFS/ME

Having examined over a thousand CFS/ME patients over 21 years, Dr Perrin (and now his trained practitioners) can identify four signs to confirm the diagnosis. These are:

1. 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).
2. Tenderness at the coeliac or solar plexus, at the front of the upper abdomen, where adjacent sensory and
   sympathetic nerves connect.
3. Structural problems at the mid-point of the spine, which may be flattened or restricted and tender to the touch.
4. Slow, shallow, erratic cranial rhythm to be felt in the upper part of the head, caused by lymphatic pump reversal.

Other signs include yeast patches on the skin; stretch marks (striae) due to collagen damage caused by backflow of lymph; swellings and cysts; acne; and overdilation of pupils from overstimulation of the sympathetic nervous system.

Treatment

Dr Perrin explained briefly that treatment by his technique involves gentle stimulation of the lymphatic system through stroking to drain the offending toxins from the central nervous system. This induces relaxation, soothes irritation and clears congestion from the cranium and also from the spine and surrounding soft tissue. Treatment may take between three months and three years depending on how severe the symptoms and signs are, and involves some self-massage.

In two recent clinical trials, patients with varying degrees of illness severity showed an overall 40% improvement in a year. Dr Perrin said that 90% of his personal patients are helped, and that 30% get to the 100% functioning level.

Publications and Presentations

Dr Perrin has been having articles about his work published in medical journals since 1993, and has also written a book, The Perrin Technique: how to beat Chronic Fatigue Syndrome/ME. His latest article appeared in the British Journal of Radiology in May 2010.

He was asked to make a presentation to the Group on Scientific Research (the Gibson Inquiry) at the House of Commons in 2006. The final report recommended that his methods would be “cost effective”. As a result, Dr Perrin will be presenting a research project that will take five years to prepare to the NHS and NICE.

He presented three papers at the International Association for CFS/ME’s Research and Clinical Conference at Reno, Nevada, in March 2009, and was invited to address the World Congress of Psychosomatic Medicine in 2009 as well as the European Association of Psychiatrists.

Questions

In response to questions, Dr Perrin explained that stresses of all kinds cause chemical changes in the brain and that toxins could remain in the body for years. When they are drained out by his methods, they will hit the body’s pain receptors, and may cause varying degrees of pain, although usually the more pain, the more gain. Standard lymphatic drainage techniques do not work for CFS/ME as they simply move the lymph faster the wrong way.

Dr Perrin believes that the drainage pathway is compromised mechanically as part of the root of CFS/ME. The main problem is that the toxins are affecting brain function, and metabolism. There is chronic hyperactivity of the sympathetic nervous system. He conceded that other treatments may be needed to complement his work; some of these come under the heading of “Wellbeing Therapy”.

Commenting on the XMRV virus debate, Dr Perrin quoted Dr Judy Mikovits herself as saying that it is “a consequence of impaired immunity”, and not a cause of CFS/ME. This ties in with his own belief that CFS/ME is more often a pre-viral, not a post-viral condition.

Alcohol can be difficult to tolerate because it is yet another toxin that the liver must struggle with, and because it triggers NMDA receptors, which have heightened sensitivity.

Dr Perrin concluded by warning that the World Health Organisation and the American Psychiatric Association are thinking of reclassifying CFS/ME as a psychiatric disease, and that his work is one of the main things that could stand in the way.

Follow-up

edmesh members may obtain your own free copy of the DVD of Dr Perrin’s talk by emailing jack@edmesh.org.uk. The DVD is also available to borrow from the edmesh library.

The book “The Perrin Technique”, published by Hammersmith Press Ltd in 2007, was kindly presented to the edmesh library by Dr Perrin in 2008.

Dr Perrin’s website is www.theperrinclinic.com and a documentary illustrating how patients have benefited may be viewed at www.forme-cfs.co.uk.

© edmesh 2010.

Please contact the newsletter editor (editor@edmesh.org.uk) if you wish to republish this article.

The recently funded AfME/LTCAS project will look at the potential of Skype to be used in a group setting by people with M.E.  Many people with M.E. are too ill to attend their local group meetings or don’t have a support group near them.  The project would like to find out if Skype could be used to allow such people with M.E. the opportunity to take part in a type of virtual support group meeting.

AfME would like to hold small and simple test pilots in Edinburgh and the Highland and Islands. Ideally, some of those taking part would not normally be able to attend meetings.

edmesh would like to invite members who are interested in taking part to contact us via info@edmesh.org.uk, or to pass this info on to anyone with M.E. who may be interested.

More information here:

http://www.actionforme.org.uk/get-informed/news/scottish-hub-news/funds-awarded-for-skype-feasibility-project

Date: Wednesday 1st February
Time: 2.30pm
Venue: Bisque Bar and Brasserie, 69 Bruntsfield Place, Edinburgh

Map:

We meet in the brasserie, which is a part of the Bruntsfield Hotel. It also has access to a lovely outdoor garden. There is table service so no queuing with trays and no struggling not to spill anything in getting to your seat. Prices are reasonable with a good range of refreshments and snacks.

There is ample parking (Pay & Display) along Bruntsfield Place on the opposite side of the road and also some specific blue badge spaces.

The nearest bus stops are:
From town – at the bottom of Bruntsfield Links (just after BP garage/Whitehouse Loan) which involves a short walk uphill and crossing the road OR the next stop is on the corner of Forbes Road (outside Nippers) – a slightly further walk but flat then downhill and easier access to cross the road at a Pelican crossing.
Into town – just after Costa Coffee outside Bay Tree Company/Hallibut & Herring with a short downhill walk on the same side of the road.
Lothian Buses: 11, 15, 16 and 23.

The cafe meetings are informal get-togethers for company, conversation, support, entertainment, information sharing, and refreshment. Please look out for the Newsletter on our table, or ask the staff if you can’t see us. All welcome to join us – you don’t have to be a member.

The project was awarded a small grant at the beginning of September to pay for running costs. Funded by Comic Relief, through the Scottish Community Foundation. Comic Relief spends money raised by its fundraising campaigns, Red Nose Day and Sport Relief.

This will allow the therapists to continue treating edmesh members meantime.

edmesh will be joining the rally – look out for us under the Action for ME banner.

The event will start at 11am at the Ross Bandstand in Princes St Gardens (link to map) and last about 2 hours. People with disabilities and politicians will speak about the effect of the proposed cuts.

All those interesting in attending are asked to register for the event in advance. For information on how to do so, visit The Hardest Hit website (click on Action this October ->Scotland).

If you cannot attend the rally, or prefer to protest online, go to their website and follow the link at the top.

You must be over 18 to take part. There is no obligation to fill in the survey, and you don’t have to answer any questions you prefer not to. You can have a carer or friend fill it out on your behalf as long as the answers are from you. All data will be kept confidential.

The survey should take about 15 minutes to complete.

The survey is available online at http://www.surveymonkey.com/s/scotneuroalliancehealth1. We will also have printed copies to fill in at our next cafe meeting on 5 October. Surveys can be sent freepost.

Update: you can now download the survey and cover letter (as PDF files) from this page: http://www.scottishneurological.org.uk/blogs/alliance_news/. These can be printed off and returned to the address given.

The closing date for completed surveys is 14 October 2011.

edmesh Open Meeting Talk on 2nd October 2010

by Professor Julia Newton MBBS, FRCP, PhD

From edmesh Newsletter Issue 74 (Winter 2010)

A large audience gathered to hear Dr Newton, who is Clinical Professor of Ageing and Medicine at Newcastle University. She began by explaining that her primary interest is in the autonomic nervous system (ANS), which controls all the bodily functions that the conscious mind does not, including heart output, blood pressure and circulation.

How circulation works

In accordance with the body’s needs, the heart’s rate of pumping can quicken or slow, blood pressure may rise or fall, and blood vessels can constrict or dilate. People with fatigue are more
likely to have problems such as faintness, blackouts and lack of blood going to the muscles.

Measuring and scoring

In Professor Newton’s cardiovascular laboratory, one of the largest autonomic testing labs in Europe, various skilfully contrived assessment scales and ingenious measuring devices are used
in the study of the ANS in people with various medical conditions, including ME/CFS. The Orthostatic Grading Scale measures the number of symptoms people have on standing up, such as light-headedness, palpitations, tremulousness, fatigue, nausea etc. It has been found that 89% of those with ME/CFS have a score of over 4. The more symptoms patients have, the more fatigued they are. The Composite Autonomic Symptom Scale (COMPASS), devised in the USA, which measures symptoms of autonomic dysfunction, was used with ME/CFS patients fulfilling the Fukuda diagnostic criteria, and matched controls. Symptoms are scored on the basis of presence, severity, distribution, frequency and progression, and are grouped into 8 domains ranging from orthostatic intolerance (problems on standing up) through gastrointestinal symptoms to sleep disorders. A score of 32·5 or over on the symptom scale is abnormal: ME/CFS patients had readings of 48 on average, the highest individual reading being about 70. The degree of fatigue rose steadily with the number of symptoms. Autonomic dysfunction was present in three-quarters of ME/CFS patients, a most unexpected finding. 

Those magnificent machines

The 24-hour blood pressure machine takes a measurement every 15 minutes. This has been done with over 100 ME/CFS patients and matched controls. It showed that the patients’ average blood pressure was significantly lower than in the controls. Heart rate variability (the ability to adapt cardiac output to meet the body’s energy needs) is clearly less in ME/CFS. The Tilt Table is the most specialised piece of equipment in Professor Newton’s laboratory. It is basically a bed that can be raised at the head from a horizontal to a
vertical position while the “victim’s” blood pressure is measured in the fingers. Continuous beat-to-beat pressure must be recorded by a cardiac technician supervised by a consultant (not Count Dracula). There are only two centres in Britain that provide this. The equipment is primarily used to investigate syncope (blackouts). So far 64 people with ME/CFS have been tested for Postural Orthopaedic Tachycardia Syndrome (POTS), which is an increase in heart rate from the supine to the upright position of more than 30 beats per minute, or to a heart rate greater than 120 beats per minute within 12 minutes of head-up tilt. It has been found that 27% of ME/CFS patients have POTS.

The Impedance Cardiograph

Cardiac MRIs (magnetic resonance imaging) show that the structure of ME/CFS patients’ hearts is normal, so impedance cardiography, a NASA technology, is used to assess cardiac function.
Electrodes at the back of the neck and base of the spine monitor an electric current as it travels down the aorta, showing how hard the heart is pumping. The hearts of CFS/ME patients are working harder to cope with the stress of standing up compared to the control group, some to the point of being at risk of heart failure.

Can this be seen? Yes – it is known that a beating heart is rotating at top and base as it pumps (this is called torsion) but in patients with another fatigue condition, primary biliary cirrhosis (a liver disease) torsion and rotation are dramatically impaired. Studies are now being done on ME/CFS patients to see if their hearts’ torsion and rotation are affected by high fatigue.

Down memory lane

Memory problems have been described by 85-95% of ME/CFS patients. Laboratory tests using the MRI (magnetic resonance imaging) brain scanner and tilt table reveal that:

• the more the blood pressure drops on standing upright (orthostatic intolerance), the worse the memory is;
• the more fatigued a person is, the worse the memory is;
• the more fatigued, the more white matter lesions (damaged areas) there are in the brain.

(White matter is the 45% of the brain which acts as wiring, delivering instructions to the nerve cells.)

 The valsalva (not quite a vuvuzela!)

Would you like to spend an hour blowing 15 times into a “valsalva” tube and having the results analysed in a scanner? Three pints of blood flow through the brain every minute, and blowing
causes a drop in blood pressure – the lower it goes, the likelier a swinging change in blood flow into the brain, when there should be a steady change.

What is “fatigue” all about?

The Newcastle Unit had 260 referrals from GPs of people with fatigue symptoms in 14 months. After thorough medical assessments, it was discovered that only 60% actually had ME/CFS. Of the rest,

47% had other chronic diseases such as fibromyalgia, non-alcoholic liver disease or primary biliary cirrhosis;
20% had a sleep disorder;
15% had primary depression or anxiety;
13% had non-ME fatigue;
5% other conditions.

Careful assessment is needed, for example to ensure that patients receive the right drug treatment.

Everyday tasks

There can be a dramatic drop-off in functional ability in ME/CFS, so the Newcastle team use the Patient-Reported Outcome Measure Health Assessment Questionnaire to look at getting in and out of the bath, reaching to a cupboard, cooking with pans and so on. This is a highly important area to work on, and it is closely associated with greater cognitive impairment (brain fog), fatigue and orthostatic symptoms.

Treatments

What can be done to help patients, even at this early stage of research?

Tilt Training

A technique called Tilt Training has been used successfully in Newcastle. It simply involves leaning against a wall at home day after day at a certain angle. This resets the baro-receptors for
people with problems on standing, but don’t try this without specialist authorisation! A study the team published in 2009 in a small trial on 59 people showed:

• significant improvements in the working of the autonomic nervous system;
• a trend towards improvement in fatigue.

This is very good news, but a bigger study is needed!

Exercise

As regards the thorny question of exercise, Professor Newton explained that it causes acid to build up in the muscles. ME/CFS people accumulate more acid on exercise, and struggle to get rid of it. Studies need to be done to identify which acid or acids are involved (thought to be lactic acid); the muscles and acid-transporting system need to be looked at in detail too. Certain types of exercise are very good at clearing acid and other types make it worse, because they increase the heart rate and push people beyond their anaerobic (lactic acid) thresholds, which they mustn’t go above – up to 80% is enough. The Newcastle team offer “Individualised Activity Management” (avoiding the dreaded e-word!) believing that, as with prescribing a medical drug, the choice, dose and duration of activity needs to be carefully worked out and agreed on to suit each patient.

Other treatments

Additional treatments prescribed for some include drugs to reduce tachycardia (fast heart rate), drinking up to 5 cups of coffee a day to increase blood volume (luckily “5-a-day” is already a familiar phrase!) and raising salt intake to increase blood pressure.

Questions

At the question and answer session, Professor Newton explained that MRI scans are done for research purposes, and are not available for diagnosis of individuals. Pilot MRI scans have been done on 27 ME/CFS patients, to assess brain structure, blood flow, acid movement, evidence of strokes, bleeding or white matter lesions. A lot of tests have been done on the same people to provide comprehensive information, at a cost of £100, 000 altogether, funded by MERUK. People who have had a muscle MRI scan have had a muscle biopsy after exercise, looking for acid in the cells and of what type, and for what enzymes are defective. Muscle cells can even be grown and analysed in the laboratory!

The team at Newcastle have 3 cohorts of ME/CFS patients they have been following for up to 10 years, as well as groups with other conditions involving the autonomic nervous system – the
common link is inflammation. Julia Newton keeps up with the work of Dr Jo Nijs, of the Free University, Brussels, and Professor Myra Nimmo of Loughborough University in this respect.

Professor Newton recommended that ME patients who have had blackouts, or who think they have POTS, and those who have symptoms on standing up, should see their GPs to ask for a referral to the Newcastle clinic.

She explained that her team were very grateful to ME Research UK, who had funded most of this work, and to patients from ME North East, the local self-help group, who had been very cooperative.

Conclusions

1. ME/CFS is closely associated with autonomic nervous system dysfunction.
2. A COMPASS score of over 32·5 could clearly diagnose ME/CFS in the large proportion of patients with ANS dysfunction.
3. Measurements of orthostatic intolerance, low heart rate variability and autonomic dysfunction in ME reinforce one another and their degrees of intensity correlate with fatigue severity.
4. More work needs to be done on larger numbers of people to identify the mechanisms and causes underlying ME/CFS symptoms before appropriate treatments can be devised.

Comment

Professor Newton and her colleagues are clearly doing highly original research into the autonomic nervous system and making important discoveries about the physical symptoms of ME/CFS. They are working towards making explainable connections between the different biological systems involved in the cascade of effects produced by this condition, so that it can be diagnosed and demonstrated to be an illness of the human body.

It seems probable that when the ultimate causes are figured out, they will include a kaleidoscope of influences, including genetic sensitivity, innate or acquired defects, toxic overloads, accidents, illnesses, stressful life events or situations, and negative unconscious beliefs. Then maybe those in science, medicine and alternative therapies as well as the patients themselves will be able to pool their healing resources, and we will at last see TS Eliot’s vision of “the whole consort dancing together.”

References

Newton JL et al. Symptoms of autonomic dysfunction in chronic fatigue syndrome. Quarterly Journal of Medicine 2007; 100: 519-526.

Sutcliffe K et al. Home orthostatic training in chronic fatigue syndrome – a randomised placebo-controlled feasibility study. European Journal of Clinical Investigation 2010; 40.1: 18 -24. (link to abstract)

POTS – A Personal Experience. edmesh Newsletter 69: Autumn 2009

Websites

Julia Newton:

http://www.ncl.ac.uk/biomedicine/research/brc/profile/julia.newton

MERUK:

http://tinyurl.com/atmeruk

DVD of talk

Members may obtain their own free copy of the DVD of Professor Newton’s talk by emailing jack@edmesh.org.uk. A copy of the DVD is also available from the edmesh library.

© edmesh 2010.

Please contact the newsletter editor (editor@edmesh.org.uk) if you wish to republish this article.

The campaign has been launched by the charity Invest in ME, who announced their intention to set up a research centre at their 5th Annual International Conference on Biomedical ME Research in 2010.

The centre would aim to give people with ME an early and accurate diagnosis, effective treatment and advice. A database of research is also planned. The centre will have links with other biomedical research centres such as the Whittemore Peterson Institute in Reno, Nevada.

13-year old ME sufferer Jessie Williams has started off the fundraising effort by raising £600 with a sponsored walk/wheelchair push.

To read more about the campaign and/or contribute to it, visit the blog page – http://letsdoitforme.blogspot.com/.

You can help raise awareness by liking their Facebook page or following them on Twitter.

Just an update to say that our newest therapists have now completed their training in reflexology and Reiki level 2.

If you are a member would like to take advantage of their services for free, please contact us. If you’re not a member, why not consider joining edmesh?