more likely to report pain in the symmetrically opposite limb rather than a second limb on the same side of the body; the authors found this suggestive of “systemic pain” rather than pain from an injury. Although the sample was large, the study is limited by a lack of physical examination and a lack of indication as to whether the veterans had sustained injuries during deployment or were using pain medication at the time of the survey.

Using data from a self-report questionnaire, Proctor et al. (1998) compared health problems of 252 Gulf War deployed veterans from Fort Devens, Massachusetts, and New Orleans, Louisiana, with those of 48 era veterans who had been deployed to Germany. Among the musculoskeletal symptoms reported more frequently by the Fort Devens deployed veterans were joint pains (OR 2.6) and neck aches or stiffness (OR 2.7), and among the neurological symptoms with greater prevalence in both cohorts of deployed veterans were headaches (OR 4.2); all confidence intervals excluded 1.0. About 30% of the Gulf War veterans and 11% of the comparison group reported an inability to fall asleep (OR 3.4-3.6, 95% CI excludes 1.0).

Horn et al. (2006) compared the frequency of symptom reporting between deployed and era UK veterans of Gulf War and Iraq War. Iraq War veterans did not show the difference in symptom reporting between deployed (n = 3284) and nondeployed (n = 2408) male military personnel that had been seen for Gulf War veterans. The prevalence of each of the 15 most frequently reported symptoms for Gulf War veterans was significantly greater than for era veterans (ORs 1.9-3.9, all 95% CIs exclude 1.0). Compared with era veterans, more than 50% of the Gulf War deployed veterans reported feeling unrefreshed after sleep (OR 2.8, 95% CI 2.5-3.1), irritability or outbursts of anger (OR 3.5, 95% CI 3.2-4.0), headaches (OR 2.1, 95% CI 1.9-2.3), and fatigue (OR 2.7, 95% CI 2.4-3.0). Compared with era veterans, deployed veterans were three times more likely to be a fatigue case (based on a validated 13-item fatigue scale; OR 3.39, 95% CI 3.00-3.83) and twice as likely to report fair or poor general health (OR 2.00, 95% CI 1.70-2.35). UK Iraq war veterans showed no increase in fatigue or reports of poor or fair general health compared with their nondeployed counterparts.

Summary and Conclusions

There is increased reporting of multisymptom illness among those deployed in the Gulf War as seen in most of the studies conducted on Gulf War veterans. The phenomenon, which recurs in multiple studies from several countries, is predominantly subjective, without a consistent accompanying pattern of findings on physical examination or laboratory testing. The basis for this problem remains elusive but merits further analysis, along the lines of the investigations summarized in Chapter 5.

The committee concludes that there is sufficient evidence of association between deployment to Gulf War and chronic multisymptom illness.

Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) is marked by severe and persistent fatigue with a cluster of other symptoms that have long been the focus of considerable controversy (Straus, 1991; Wessely, 1998). The study of unexplained fatiguing illnesses was greatly facilitated and legitimized in the last decade with the development of a case definition sponsored by the CDC (Box 4-1). CDC’s case definition requires fatigue and related impairment in function, and the occurrence of four of eight other defining symptoms over at least 6 months (Fukuda et al., 1994;



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