Chronic Fatigue Syndrome

ASHTON JEPPESEN

Chronic Fatigue Syndrome

WHY Chronic Fatigue??

• I got MONO when I was 19, and still suffer from chronic fatigue

• Thought it would be interesting to find out current research.

• How set up an exercise plan

OVERVIEW

DefinitionEpidemiologySymptomsDiagnosisComplicationsTreatmentsEffects of Disease & Medicine on

ExerciseEffects of Bout of exercise on Patient

vs. Effects of Training Exercise PrescriptionSummary

Define: Chronic Fatigue Syndrome CFS

Also known as Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS)

CFS is a puzzling & complex idiopathic condition defined only by symptoms

Persistent debilitating fatigue, not relieved by rest, and not accounted by any specific identified medical or psychiatric conditions

Definition Continued…

Criteria for CFS (Chronic Fatigue Syndrome)

Severe chronic fatigue lasting 6 months 4 or more of the following symptoms

• Substantial impairment in short-term memory or concentration• Sore throat• Tender lymph nodes• Muscle pain• Multi-joint pain without swelling or redness• Headaches of a new type, patter, or severity• Un-refreshing sleep• Post-exertional malaise lasting at least 24 hrs.

Incidence or Prevalence

Prevalence is between 400 to 2,500 adults per 100,00 population

Just under 1 million peoplemore common in women, white majority,

middle classRecently, show CFS is higher in lower

socioeconomic status and minority cultural or ethic groups

CFS is associated with social strain, negative aspects of social support, physical inactivity, anxiety & depression.

Causes???

Causes of CFS is still unknown but possible causes include:

1. Viral infection (MONO)2. Immunologic dysfunction

3. Abnormal hypothalamic-pituitary-adrenal (HPA) axis activity

4. Neurally mediated hypotension5. Nutritional deficiency

6. Profound psychological stress

SymptomsOn-going fatigue-not relieved

by restHeadachesSleep disturbanceMuscle painFrequent sore throatPainful lymph nodesDifficulty concentration &

memoryLow-grade feverAches

Symptoms inhibit day to day activities

Diagnosis & Test

According to the Centers for Disease Control (CDC)If someone has substantial reduction in previous levels of

occupational, educational, social, and or personal activities.If there is an occurrence of 4 or more of the following

symptoms: impairment in short-term memory

sore throat, tender lymph nodes,

muscle pain, multi-joint pain,

headaches, sleep is not refreshing,

post-exertional malaise (more than 24hrs)

Diagnosis……….

A physician must exclude all other conditions that may precipitate similar symptoms

To exclude all conditions, a person with CFS must endure countless laboratory test and procedures

***Thus a fitness professional must appreciate the long, exhausting, and frustrating journey their client has to take before receiving the diagnosis of CFS

Diagnosis & Test

Since the diagnosis of CFS is based solely on symptoms, there are no recommended specific lab test.

Lab test should be focused on confirming or excluding other possible conditions

***White blood cell count……any monocytes or

granulocytes ?

Typical Treatments

1.Pharmacological therapy2.Sleep hygiene

3.Dietary management & nutritional supplements

4.Activity management5.Cognitive Behavioral

Therapy/Graded Exercise 6.Alternative approaches

Treatments

Click icon to add picture2 COMMON TREATMENTS (for exercise)

1. 1.Cognitive-behavioral treatment

2. 2. Graded Exercise Therapy

3.

Treatments

Cognitive Behavioral Therapy (CBT) :is a psychotherapeutic approach: a talking therapy.

CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present. FEAR OF EXERCISE

Graded Exercise Therapy : improving physiological exercise capacity and exercise tolerance by gradually increasing exercise intensity and duration.

Graded Exercise Therapy (GET)

Main goal is to 1st increase duration and 2nd to increase intensity.

DurationPatients need to start at a low

baseline for 2 weeks, exercising at least for 5 days

Then incrementally increase daily exercise on duration until they are doing 30 min of exercise for 5 days

Can be done in sessions of 10 to 15 mins

Graded Exercise Therapy

IntensityOnce 30 minutes of daily exercise is achieved,

intensity should be increased.10-20%, but no more than 20% weekly.If patient develops symptoms as a response to

increased intensity, they should KEEP exercising at that level, rather than stop

The body with start to adapt and the symptoms should subside

Let your patient/client chose what kind of exercise and dosage they will preform because they will be more likely to continue exercising

ResearchOne study from Journal of

Pediatrics and Child Health, 2009 showed:

GET had a significant effect in aerobic capacity on CFS

Increase in exercise duration by 18% Also increase in time to fatigue, exercise

intensity (METs) and peak oxygen uptake Upper body muscular strength and

endurance through a 70% increase in # of pushups

Overall concluded that GET is effective in improving quality of

life and depressive feelings

Educating Clients

Providing information about home exercise programs, their illness & treatment, is considered an important part of the therapy process.

Early research has shown that if patients recognize the benefits from exercise ,on their chronic disease, than they are more likely to continue physical activity.

In the general population, ½ of all who participate in supervised exercise programs stop within 3-6 months…

Common Effects of Disease on Ability to Exercise

Post-exertion malaise /more than 24hrs

Musculoskeletal pain- in vigorous exercise

Worsening symptoms So, it is important for patients to learn

how to estimate their current physical capability, prior to exercise.

When exercise, patients need lots of breaks, with the lengths of the breaks equaling duration of activity

Patients can’t just work out when they want to work out. They need to be in the “RIGHT” mind!

Medicines For CFS

Medicine Effects on exercise

Antidepressants (TCA) Increase heart rate, decrease blood pressure, & ECG changes

Anti-arrhythmic agent Increase heart rate & ECG Changes

Carisoprodol/ cyclobenzaprine Reduce blood pressure and cause dizziness

Anxiolytic Reduce heart rate & blood pressure

Alprazolam & lorazepam Muscular in-coordination

Beta Blockers Decrease heart rate and blood pressure, reducing exercise capacity in patients without angina

Acute Effects of Chronic Fatigue on Exercise

Higher RPE at every work load compared to healthy controls

Slower hear rate acceleration as workloads increase

Some may have 10 to 50% lower maximal power output compared to controls

Expect to experience an increase in symptoms after completion of a single bout of exercise

Chronic Effects of Exercise with CFS clients

• One study showed that those who participated in a low impact aerobic dance session 2x per week (20 weeks) had significant decrease in exercise induced pain.

• In the long run, exercise programs have shown to improve pain, fatigue, and/or anxiety/depression.

• Overall it was not shown improvements with strength, but more the ability to tolerate pain without symptoms getting worse!!

• Prevent deconditioning

Commonly used

Exercise tests

Submaximal test using the Balke & Naugton Treadmill protocols

Cycle ergometer protocols Start slow, go slow

Primary concern is an adequate warm-up and tolerable rate of increase to minimize premature local muscle failure and fatigue

6 min walk test- better used as functional test, rather than measurement of cardiorespiratory fitness.

Exercise Testing

Incremental exercise testing with monitoring of standard cardiovascular & ventilatory responses.

electrocardiogram, blood pressure, heart rate monitor, respiratory gas exchange and ventilation may be indicated as a screening test for individuals whose diagnosis is not yet established.

Remember , individuals with long-standing symptoms are very likely to have a low level exercise activity & have undergone significant DECONDITIONING.

Exercise Testing

Work rates will therefore usually start out low relative to standard protocol. Based on predicted age, size, and gender.

Work rates below 2 METs and increase .5 to 1 MET per stage.

NOTE Testing should be scheduled for a day when

the client does not have other activities scheduled

Exercise Goals/Programming

Goals1st- prevent further

deconditioningResist the temptation to

adopt a traditional method of training aimed at aerobic capacity

Instead focus on modest goals for preventing deconditioning

Focus on increasing duration not intensity.

ProgrammingRPE should be the

primary goal to determine exercise intensity of the client

Aerobic exercise should be one that is familiar to them.

For strength training stay away from delayed onset muscle soreness (DOMS). Eccentric exercises!!

PRESCRIPTIONMODE GOAL

Aerobic: large muscle activities (walking, rowing, cycling, swimming)

Prevent deconditioningMaintain functional abilitiesReturn to desired occupation/social activities

Resistive: Large muscle groups (theraband, light dumbbells)

Similar to aerobic exercise

Intensity/Duration/ Frequency Progression

Aerobic: RPE 9-12*Intensity not main focus

5 Min per session up to 60 Min

3 to 5 days per week Be prepared for set backs

1 to 2 times per day

Resistive: Below point of muscle to fatigue

As toleratedExpect a slower rate of progression

3 to 5 days per week Avoid symptoms of muscle soreness

Once per day

Dose

Response

Maximal Tolerated Dose

Therapeutic Range

Pharmacotherapy model

Summary & Conclusion

CFS is defined by symptoms, therefore there isn’t any diagnosis test

Chronic Fatigue is fatigue lasting at least 6 monthsExercise is one of the common treatments for CFSThe goals for exercise are 1st duration 2nd intensityRPE is the primary key for intensityWhen testing CF patients remember their

workloads are going to be lower than the norms and to increase slower than normal

Encourage client to not stop if symptoms resume, to just continue to exercise and the body will adapt

BE PATIENT

References

Bailey, S. P. T. ,. D. ,. F. (2011). Exercise as a treatment for chronic fatigue syndrome. ACSM Health & Fitness Journal, 15(1), 20-25. Clark, L., & White, P. (2005). The role of deconditioning and therapeutic exercise in chronic fatigue syndrome (CFS). Journal Of Mental Health, 14(3), 237-252doi:10.1080/09638230500136308Darcy, P., Napora, L., DeMarco, C., & Remsber, C. (2002). Acsm's resources for clinical exercise

physiology. (1 ed., pp. 111-120). Baltimore: Lippincott Williams & Wilkins.Durstine, J. L., Moore, G. E., Painter, P. L., & Roberts, S. O. (2009). Acsm's exercise management for persons with chronic diseases and disabilities. (3rd ed., pp. 233-237). Champaign, IL: Human Kinetics.Gordon, B. A., Knapman, L. M., & Lubitz, L. (2010). Graduated exercise training and progressive resistance training in adolescents with chronic fatigue syndrome: a randomized controlled pilot study. Clinical Rehabilitation, 24(12), 1072-1079. doi:10.1177/0269215510371429Gordon, B. and Lubitz, L. (2009), Promising outcomes of an adolescent chronic fatigue syndrome inpatient programme. Journal of Paediatrics and Child Health, 45: 286–290. doi: 10.1111/j.1440-1754.2009.01493.xNijs, J., Paul, L., & Wallman, K. (2008). Chronic fatigue syndrome: an approach combining self-

management with graded exercise to avoid exacerbations. Journal Of Rehabilitation Medicine: Official Journal Of The UEMS European Board Of Physical And

Rehabilitation Medicine, 40(4), 241-247. Skinner S., J. (2005). Exercise testing and exercise prescription for special cases. (3rd ed. ed., pp. 188- 199). Baltimore: Lippincott Williams & Wilkins.