Tag: graded exercise

Chronic fatigue syndrome: an update

Abstract:

The chronic fatigue syndrome is characterised by a fatigue that is disproportionate to the intensity of effort that is undertaken, has persisted for 6 months or longer, and has no obvious cause. Unless there has been a long period of patient- or physician-imposed inactivity, objective data may show little reduction in muscle strength or peak aerobic power, but the affected individual avoids heavy activity.

The study of aetiology and treatment has been hampered by the low disease prevalence (probably <0.1% of the general population), and (until recently) by a lack of clear and standardised diagnostic criteria. It is unclear how far the aetiology is similar for athletes and nonathletes. It appears that in top competitors, overtraining and/or a negative energy balance can be precipitating factors. A wide variety of other possible causes and/or precipitating factors have been cited in the general population, including psychological stress, disorders of personality and affect, dysfunction of the hypothalamic-pituitary-adrenal axis, hormonal imbalance, nutritional deficits, immune suppression or activation and chronic infection. However, none of these factors have been observed consistently. The prognosis is poor; often disability and impairment of athletic performance are prolonged.

Prevention of overtraining by careful monitoring seems the most effective approach in athletes. In those where the condition is established, treatment should aim at breaking the vicious cycle of effort avoidance, deterioration in physical condition and an increase in fatigue through a combination of encouragement and a progressive exercise programme.

 

Source: Shephard RJ. Chronic fatigue syndrome: an update. Sports Med. 2001;31(3):167-94. http://www.ncbi.nlm.nih.gov/pubmed/11286355

 

Recovery from chronic fatigue syndrome associated with changes in neuroendocrine function

[This is a case study on graded exercise. You can read the full report here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1280066/pdf/11220065.pdf]

 

Source: Sharma A, Oyebode F, Kendall MJ, Jones DA. Recovery from chronic fatigue syndrome associated with changes in neuroendocrine function. J R Soc Med. 2001 Jan;94(1):26-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1280066/ (Full article)

 

Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome

Abstract:

OBJECTIVE: To assess the efficacy of an educational intervention explaining symptoms to encourage graded exercise in patients with chronic fatigue syndrome.

DESIGN: Randomised controlled trial.

SETTING: Chronic fatigue clinic and infectious diseases outpatient clinic.

SUBJECTS: 148 consecutively referred patients fulfilling Oxford criteria for chronic fatigue syndrome.

INTERVENTIONS: Patients randomised to the control group received standardised medical care. Patients randomised to intervention received two individual treatment sessions and two telephone follow up calls, supported by a comprehensive educational pack, describing the role of disrupted physiological regulation in fatigue symptoms and encouraging home based graded exercise. The minimum intervention group had no further treatment, but the telephone intervention group received an additional seven follow up calls and the maximum intervention group an additional seven face to face sessions over four months.

MAIN OUTCOME MEASURE: A score of >/=25 or an increase of >/=10 on the SF-36 physical functioning subscale (range 10 to 30) 12 months after randomisation.

RESULTS: 21 patients dropped out, mainly from the intervention groups. Intention to treat analysis showed 79 (69%) of patients in the intervention groups achieved a satisfactory outcome in physical functioning compared with two (6%) of controls, who received standardised medical care (P<0.0001). Similar improvements were observed in fatigue, sleep, disability, and mood. No significant differences were found between the three intervention groups.

CONCLUSIONS: Treatment incorporating evidence based physiological explanations for symptoms was effective in encouraging self managed graded exercise. This resulted in substantial improvement compared with standardised medical care.

Comment in:

Patient education to encourage graded exercise in chronic fatigue syndrome. Trial has too many shortcomings. [BMJ. 2001]

ACP J Club. 2001 Sep-Oct;135(2):46.

 

Source: Powell P, Bentall RP, Nye FJ, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ. 2001 Feb 17;322(7283):387-90. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC26565/ (Full article)

Chronic fatigue syndrome: is it physical?

Comment on: Strength and physiological response to exercise in patients with chronic fatigue syndrome. [J Neurol Neurosurg Psychiatry. 2000]

 

It is increasingly recognised that chronic fatigue syndrome (CFS) is heterogeneous. A significant proportion of patients fulfilling operative criteria for a diagnosis of CFS will also fulfill criteria for a psychiatric disorder, such as depression or somatisation. Failure to recognise this heterogeneity prejudices attempts to understand CFS in cross sectional studies. In this issue (pp 302–307) Fulcher et al report a study of muscle strength, aerobic exercise capacity, and functional incapacity in a group of patients with CFS without concurrent psychiatric disorder, compared with patients with major depression and a group of normal but sedentary subjects.1 In an incremental treadmill exercise test, patients with CFS and depressed patients had lower peak oxygen consumption rates, maximal heart rates, and plasma lactate concentrations than the sedentary controls; but this reflected the shorter duration of exercise tolerated by these patients. At submaximal work rates, patients with CFS and depressed patients experienced greater perception of eVort than sedentary controls at the same level of work. This is in keeping with the finding that such patients show greater sensitivity to bodily sensations than normal subjects. Overall, there was little difference between the patients with CFS and the depressed patients in exercise characteristics, yet the patients with CFS reported significantly greater degrees of physical fatigue and physical incapacity.

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1737076/pdf/v069p00289.pdf

 

Source: Lane R. Chronic fatigue syndrome: is it physical? J Neurol Neurosurg Psychiatry. 2000 Sep;69(3):289. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1737076/

 

Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome

Erratum in: Br J Psychiatry 1998 Jul;173:89.

 

Abstract:

BACKGROUND: The Joint Working Group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners (1996) recommended graded exercise and antidepressants for patients with chronic fatigue syndrome. We assessed efficacy and acceptability of these treatments.

METHOD: Six-month prospective randomised placebo and therapist contact time controlled trial with allocation to one of four treatment cells: exercise and 20 mg fluoxetine, exercise and placebo drug, appointments only and 20 mg fluoxetine, appointments and placebo drug. Drug treatment was double blind and patients were blind to assignment to exercise or appointments.

RESULTS: Ninety-six (71%) of 136 patients completed the trial. Patients were more likely to drop out of exercise than non-exercise treatment (P = 0.05). In an intention to treat analysis, exercise resulted in fewer patients with case level fatigue than appointments only at 26 weeks (12 (18%) v. 4 (6%) respectively P = 0.025) and improvement in functional work capacity at 12 (P = 0.005) and 26 weeks (P = 0.03). Fluoxetine had a significant effect on depression at week 12 only (P = 0.04). Exercise significantly improved health perception (P = 0.012) and fatigue (P = 0.028) at 28 weeks.

CONCLUSIONS: Graded exercise produced improvements in functional work capacity and fatigue, while fluoxetine improved depression only.

Comment in:

Commentary on: randomised, double-blind, placebo-controlled trial of fluoxetine and graded exercise for chronic fatigue syndrome. [Br J Psychiatry. 1998]

Analysis of drop-out data in treatment trials. [Br J Psychiatry. 1998]

Fluoxetine and graded exercise in chronic fatigue syndrome. [Br J Psychiatry. 1998]

 

Source: Wearden AJ, Morriss RK, Mullis R, Strickland PL, Pearson DJ, Appleby L, Campbell IT, Morris JA. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. Br J Psychiatry. 1998 Jun;172:485-90. http://www.ncbi.nlm.nih.gov/pubmed/9828987

 

Treating chronic fatigue with exercise. Exercise, and rest, should be tailored to individual needs

Comment on: Putting the rest cure to rest–again. BMJ. 1998

 

 

Editor – While I welcome Sharpe and Wessely’s reminder about the dangers of bed rest,1 I am concerned about the blanket advice regarding activity levels for patients with chronic fatigue. Chronic fatigue syndrome is now generally acknowledged to be a heterogeneous condition, not a single entity with a single cause. Accordingly, what may suit one person may be totally inappropriate for another. As research has shown, most patients with chronic fatigue syndrome remain ambulant, spend relatively few daytime hours resting, are no more inactive than people with mild multiple sclerosis, and tend to perform at or near their activity ceiling.2 What these patients need is not a strict programme in which rest is allowed according to a predetermined plan but a flexible approach that does not ignore current energy levels or make people feel guilty if they increase rest periods when they consider this to be right for them.

From a theoretical perspective, inactivity may well be an important factor in chronic fatigue syndrome, but I note that Sharpe and Wessely did not provide a single reference to back their claim that many patients simply “go home and rest,” let alone that most resort to “excessive rest.” Does this mean that the theory that “excessive inactivity” perpetuates chronic fatigue syndrome is based largely on anecdotal reports and articles in magazines? Moreover, in this age of evidence based medicine, discussions of a treatment should mention the negative reports of its efficacy as well as the positive.3,4

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113801/

 

Source: Goudsmit E. Treating chronic fatigue with exercise. Exercise, and rest, should be tailored to individual needs. BMJ. 1998 Aug 29;317(7158):599; author reply 600. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113801/

 

Putting the rest cure to rest—again

Go home and rest” is still the advice given to many patients who complain of chronic fatigue. The refrain is echoed in self help books and magazines and adopted by many patients. What are the origins of rest as a treatment, does it work, and what evidence is there on which to base our advice to patients?

Victorian physicians diagnosed them as neurasthenia and routinely prescribed rest. This approach was typified by Silas Weir Mitchell’s “rest cure,” which was so popular as to be described as “the greatest advance of which practical medicine can boast in the last quarter of the century.” Despite such accolades, the popularity of the rest cure was short lived. By the turn of the century the same private clinics that once provided it were changing to more active treatments and to the newer psychotherapies. The years that followed saw the end of the rest cure; Karl Menninger poured scorn on the lack of psychological sophistication shown by its proponents, while Richard Asher drew attention to the “the dangers of going to bed.”

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112768/

Comment in:

Treating chronic fatigue with exercise. Exercise improves mood and sleep. [BMJ. 1998]

Treating chronic fatigue with exercise. Exercise, and rest, should be tailored to individual needs. [BMJ. 1998]

Treating chronic fatigue with exercise. Results are contradictory for patients meeting different diagnostic criteria. [BMJ. 1998]

 

Source: Sharpe M, Wessely S. Putting the rest cure to rest—again. BMJ. 1998 Mar 14;316(7134):796. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112768/ (Full article)

 

Graded exercise in chronic fatigue syndrome. Chronic fatigue syndrome is heterogeneous condition

Comment on: Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. [BMJ. 1997]

 

Editor—The study reported by Kathy Y Fulcher and Peter D White will provide new hope to many patients diagnosed as having the chronic fatigue syndrome.1 Before exercise regimens become the treatment of choice, however, it is worth noting that over two fifths of the patients in the study reported no or little improvement. It is a pity that the researchers did not compare those who were “very much better” with those who were not, in terms of variables such as the onset of illness (acute or gradual, history of infection) 2 and the presence of additional symptoms frequently associated with the syndrome—for example, cognitive difficulties, nausea, and malaise after exercise. This might have shown whether one particular subgroup fared better than another, allowing doctors to tailor their advice and further improve patients’ care.3

The possibility that subgroups may have different prognoses also deserves consideration. For instance, a recent study found that 70% of patients diagnosed as having epidemic neuromyasthenia recovered within two years.4 If two thirds of the subjects studied by Fulcher and White also had disease of acute onset linked to infection, one could argue that the exercise regimen reflected the natural course of the illness while the flexibility training made patients worse.

A final point concerns the 20 subjects taking full dose antidepressants. The authors do not specify why these drugs were being taken by people who did not have clinical depression or sleep disorders. Moreover, since many patients with the chronic fatigue syndrome cannot tolerate therapeutic doses of antidepressants,5 some of the reported fatigue and malaise may have been drug induced.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127599/pdf/9361552.pdf

 

Source: Goudsmit EM. Graded exercise in chronic fatigue syndrome. Chronic fatigue syndrome is heterogeneous condition. BMJ. 1997 Oct 11;315(7113):948. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127599/

 

Graded exercise in chronic fatigue syndrome. Patients were selected group

Comment on: Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. [BMJ. 1997]

 

Editor—Kathy Y Fulcher and Peter D White conclude that their findings support the use of graded aerobic exercise in the management of the chronic fatigue syndrome.1 Those readers who delve no further than the abstract and key points may welcome this “take home message.”

Several flaws in the paper, however, make accurate interpretation of the findings difficult and greatly limit its applicability. Firstly, less than two fifths of those screened for the trial actually entered it. Many of those who did not enter it were excluded on the basis of current psychiatric disorder, even though the Oxford criteria used by the authors do not specifically exclude patients with anxiety and depression.2 Given that this is already a subgroup selected by their referral to psychiatric outpatient departments, to select out those with a current psychiatric disorder makes them an unusual group indeed.

Secondly, successful randomisation should make the intervention and control groups similar. Such comparability should enable the problem of confounders, known or unknown, to be accounted for. Evidence of the comparability of cases and controls should be presented.3 Age and sex are almost universal confounders. In this study one might also add body mass index, duration of illness, and even previous athletic training as other possible confounders. The paper does not break down the age and sex of the two groups to enable comparison.

Thirdly, the main outcome measure is the self rated clinical global impression change score. This score is a validated measure of overall change.4 However, the validity of the subsequent categorisation of patients into those with a score of 1 or 2 and those with a score of 3-7, and whether this was a post hoc categorisation, is not stated. A categorisation into 1-3 (all scores representing an improvement) and 4-7 (the rest) would not have produced a significant change. Numerous other physiological outcome measures are provided, but more clinically relevant would have been consultation rates, use of drug treatment, and time off work (time off work was measured only at one year, after the crossover). In short, for those considering the options for managing this condition, especially those who commission services, the message should be that we need more information before we can tell if graded exercise will help most patients with the chronic fatigue syndrome.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127633/pdf/9361551.pdf

 

Source: Sadler M. Graded exercise in chronic fatigue syndrome. Patients were selected group. BMJ. 1997 Oct 11;315(7113):947-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127633/

 

Graded exercise in chronic fatigue syndrome. Including patients who rated themselves as a little better would have altered results

Comment on:

Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. [BMJ. 1997]

Managing chronic fatigue syndrome in children. [BMJ. 1997]

 

Editor—“Editor’s choice” in the issue of 7 June states, “we agree that myalgic encephalomyelitis (or chronic fatigue syndrome) is a serious condition” and “all conditions have a mental and physical component.” This is the stance of the patient organisations supporting patients with this condition. Unfortunately, some doctors have trivialised this illness; ridiculed patients and their supporters; and subjected a few of them, including children, to oppressive, perhaps even abusive, forms of treatment. Hopefully, this is now a thing of the past. We need, as Harvey Marcovitch says, to explore what might be done to help them.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127632/pdf/9361550.pdf

 

Source: Franklin AJ. Graded exercise in chronic fatigue syndrome. Including patients who rated themselves as a little better would have altered results. BMJ. 1997 Oct 11;315(7113):947; author reply 948. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127632/