Chronic Fatigue
Syndrome
ASHTON
JEPPESEN
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
Definition
Epidemiology
Symptoms
Diagnosis
Complications
Treatments
Effects of Disease & Medicine on Exercise
Effects of Bout of exercise on Patient vs.
Effects of Training
Exercise Prescription
Summary
OVERVIEW
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 people
more common in women, white majority, middle
class
Recently, 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 hypotension
5. Nutritional deficiency
6. Profound psychological stress
On-going fatigue-not relieved by
Symptoms rest
Headaches
Sleep disturbance
Muscle pain
Frequent sore throat
Painful lymph nodes
Difficulty concentration &
memory
Low-grade fever
Aches
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 therapy
[Link] hygiene
[Link] management & nutritional
supplements
[Link] management
[Link] Behavioral Therapy/Graded
Exercise
[Link] approaches
2 COMMON
TREATMENTS
(for exercise)
1. [Link]-
behavioral
treatment
2. 2. Graded
Exercise
Therapy
3.
Treatments
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.
Duration
Patients 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
Intensity
Once 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
One study from Journal of
Research 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
Goals Programming
1st- prevent further RPE should be the
deconditioning primary goal to
Resist the temptation to determine exercise
adopt a traditional intensity of the client
method of training aimed Aerobic exercise should
at aerobic capacity be one that is familiar to
Instead focus on modest them.
goals for preventing For strength training stay
deconditioning away from delayed onset
Focus on increasing muscle soreness
duration not intensity. (DOMS). Eccentric
exercises!!
PRESCRIPTION
MODE GOAL
Aerobic: large muscle activities (walking, Prevent deconditioning
rowing, cycling, swimming) Maintain functional abilities
Return to desired occupation/social
activities
Resistive: Large muscle groups Similar to aerobic exercise
(theraband, light dumbbells)
Intensity/Duration/ Frequency Progression
Aerobic: RPE 9-12 5 Min per session up to 60 Min
*Intensity not main focus
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 tolerated
Expect a slower rate of progression
3 to 5 days per week Avoid symptoms of muscle soreness
Once per day
Therapeutic Range
Maximal Tolerated
Dose
Response
Dose
Pharmacotherapy model
Summary & Conclusion
CFS is defined by symptoms, therefore there isn’t any
diagnosis test
Chronic Fatigue is fatigue lasting at least 6 months
Exercise is one of the common treatments for CFS
The goals for exercise are 1st duration 2nd intensity
RPE is the primary key for intensity
When 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), 237-252
doi:10.1080/09638230500136308
Darcy, 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:10.1177/0269215510371429
Gordon, 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.x
Nijs, 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.
