EXERCISE & CFS

The triggering event is frequently an infec- tion, particularly of viral origin, but other factors may potentiate the disease. There are numerous reports on the coexistence of chronic fatigue and depression and other psychiatric disorders, and some CFS patients have a history of psychiatric dis- orders prior to the fatigue. An alternative view is that depression is a secondary effect of the disability caused by CFS. Patients can then enter into a vicious cir- cle of symptoms, avoidance, inactivity, fatigue and depression.

Treatment Pharmacological approaches have included the use of antidepressants. Sleep distur- bance is also a common symptom of CFS and some have had success with tricyclic antidepressants such as amitriptyline or imipramine, acting as sleep modulators (3).

Cognitive behavioural therapy (CBT) focus- es on the theory that the disability seen in CFS patients is aggravated by cognitive distortions and is perpetuated by maladap- tive behaviour. A small number of studies have observed a significant improvement in symptoms and functioning using CBT alone or combined with occupational ther- apy (4,5).

Treatments aimed at modulating a pro- posed chronic activation of the immune system, such as immunoglobulins, as well

in these patients. As a result those dealing with this particular group may have found it ‘safer’ and less contradictory to recom- mend rest and relaxation.

Rest has com-

monly been the mainstay of this treatment, with work and physical activity approached with caution (6).

Patients are frequently told to rest until symptoms subside or to modify their lifestyle and live within their own individ- ual limits. The most successful treatments for CFS to date have been those incorpo- rating graded exercise therapy (7,8) or cognitive behavioural therapy (4). On the CBT trial 73% of CFS patients achieved a satisfactory outcome, assessed by the Karnofsky scale, compared with 27% given only medical care, one year after trial entry. Following three months of graded aerobic exercise, 55% of patients rated themselves “much” or “very much better”, compared to only 27% on the control (flex- ibility) treatment, which increased to 74%, one year after trial entry.

as anti-viral treatments have also produced inconsistent results.

Only a few studies have attempted to treat the effects of deconditioning and inactivi- ty in CFS. This may be due, in part, to the lack of agreement on the physical aetiolo- gy of the syndrome, as well as the resur- gence of symptoms observed after activity

Benefits of exercise The avoidant behaviour and inactivity, characteristic of CFS, is known to have a detrimental effect on muscle, as well as on respiratory and cardiovascular functions. The evidence to date shows no abnormali- ties in cardiovascular or peripheral muscle response, other than what would be expected as a result of deconditioning. In addition, CFS patients tend to have an

EXERCISE PROGRAMME

Improvements rely initially on introduc- ing patients to a regular pattern of activity that may or may not be consid- ered of sufficient intensity to stimulate increases in maximum aerobic capacity. However the longer term aim should be to gradually increase the intensity over time as confidence, self-esteem and a sense of control over physical symptoms are achieved.

Exercise treatment follows the basic principles of exercise prescription for healthy individuals (10) adapted to the patient’s current capacity. Regular patient contact is recommended, ideally twice but at least once per month, as

12 SportEX

patients need regular encouragement and the exercise programme itself needs more gradual and regular progression. Exercise intensity and duration should be individu- ally tailored, but most patients can begin at an intensity of about 40% of their max- imum aerobic capacity which equates to approximately 50% of their individual peak heart rate reserve (HRR), reached in the walking or cycle test.

To calculate:

HRR = peak test HR - resting HR Exercise HR (50%) = RHR + (0.5 x HRR)

If measuring heart rate is not appropriate, use of the Borg RPE scale is recommended

with clear instruction, aiming for a target rating of 11-13 on the scale (this may not correspond to HR). Some patients may wish to buy a heart rate monitor.

Progression is determined by individual ability.

regular pattern of exercise, regardless of duration, such that patients are encour- aged to exercise daily, at least five days per week. They are encouraged to sched- ule their exercise session into their day, setting aside the time and planning in advance, particularly with regard to the best time of day to exercise.

Sessions

should initially last 5 to 15 minutes, depending on ability, and are progressed

The initial aim is to establish a