# Exercise as it relates to Disease/Chronic Fatigue Syndrome Benefits from Aerobic Exercise

This is an analysis of the article “Randomised controlled trial of graded exercise in patients with chronic fatigue syndrome” by Fulcher and White

## What is the background to this research?

Myalgic Encephalomyelitis also known as Chronic Fatigue Syndrome is a severe and complex illness, which can not be cured with rest. Chronic Fatigue Syndrome is primarily an illness which causes an individual to consistently feel fatigued. Individuals with CFS suffer from muscular skeletal pain whether they have participated in exercise or not, sleep deprivation, psychological distress and regular headaches. CFS affects between 0.006% and 3% of the population depending on the criteria of definition used, with women being at a higher risk than men. It is usually developed in children between the ages of 12–15 years and in adults between their 20s and mid 40s.
The causes of CFS are still not completely well understood, although some theories suggest that viruses, hypotension, a weakened immune system, and hormonal imbalances could all contribute to the onset of CFS. Researchers also speculate that some individuals are genetically predisposed to develop CFS. The challenges of defining the causes of CFS is due to no single cause being identified, and many other illnesses producing similar symptoms, therefore making it very difficult for medical professionals to diagnose CFS. The U.S. Centers for Disease Control and Prevention (CDC) have proposed that CFS may be the result of multiple varying conditions, rather than one unique symptom. Statistics show that 10 to 12 percent of people with Epstein-Barr virus, Ross River virus, and Coxiella burnetti develop a condition that meets the criteria for a CFS diagnosis. Peter D White is a professor of Psychological Medicine, honorary consultant liaison psychiatrist at St Bartholomew's hospital and co-leader of the chronic fatigue syndrome (CFS) service there. Kathy Y Fulcher is an exercise physiologist and was laboratory director of the National Sports Medicine Institute, London. This study is a reflection of the expertise provided by both authors.
There are three stages of CFS:
Mild: Capable of taking care of oneself but may need the occasional day to rest.
Moderate: Reduced mobility, headaches, body aches and pains, sleep deprivation and may feel the need to have afternoon naps.
Severe: Difficulty concentrating, minimal ability to perform daily tasks such as brushing hair or teeth and significantly reduced mobility.
Treatments for CFS include medications, nutritional supplements, cognitive behavioural therapy, lifestyle changes and graded exercise therapy. This particular study by Kathy Y Fulcher and Peter D White perform a randomised controlled trial of graded exercise in patients with CFS, determining whether exercise successfully relieves symptoms.

## Where is the research from?

The study was supported by a grant from the Linbury Trust, a sainsbury charitable trust. The tests were undertaken in a CFS clinic in a general hospital department of psychiatry.

## What kind of research was this?

This research is a qualitative analysis. This type of research is used to provide in-depth information, objectives and outcomes of the control trial performed. Data was collected through self reports, questionnaires and individual results from physiological testing.

## What did the research involve?

Fulcher and White conducted a 12-week study with 66 patients with CFS who had neither a psychiatric disorder nor sleep deprivation. Patients participated in either graded aerobic exercise or flexibility exercises and relaxation therapy. Those patients who participated in the flexibility exercises were allowed to cross over to aerobic exercise afterwards.
Once the 12 week period was complete there was a three-month and one year follow up on patients.

## What were the basic results?

According to The Centers for Disease Control and Prevention no exercise is bad, some is good and too much is not helpful. Graded exercise programs consist of light to moderate intensities depending on the individual and what level of CFS they have. The results from the study supports this statement by showing that a graded exercise program improved physical function and general health of patients. Improvement was maintained or exceeded at both the three month and one year follow up, hence the results from the study are unlikely to be spontaneous.
| Exercise | Information Collected |
| Exercise treatment | 16/29 patients rated themselves as 'better' |
| Flexibility treatment | 08/30 patients rated themselves as 'better' |
| Cross over | 12/22 patients rated themselves as 'better' |

## What conclusions can we take from this research?

The results present in this study determine that the findings support the use of appropriately prescribed graded aerobic exercise in the management of patients with CFS. The level of CFS determines how much exercise an individual should be prescribed and whether or not they should participate in aerobic exercise or flexibility programs. It is evident from this study that participating in aerobic exercise, individuals can relieve fatigue, functional capacity and increase fitness.
Although CFS can cause individuals to feel constantly fatigued, it is proven that exercise is necessary in order to reduce symptoms of the disease. Exercise is used to recondition the body both physically and mentally.

## Practical advice

Results from the study suggests that the following practical advice should be considered when participating in either exercise or flexibility programs:
* Gradual, careful increase in exercise
* Understanding the benefits of specific exercises such as aerobic and flexibility
* Avoiding additional physical activity other than the prescribed program
* Being able to continue exercise after the 12 week study
Although a prolonged lack of exercise can deteriorate CFS, increased rest is not recommended and patients should continue to maintain a level of bearable exercise.

## Limitations of study

Although the study shows evidence that both aerobic exercise and flexibility are successful in relieving fatigue in individuals with CFS, bias may have been present by exercise physiologists, especially during reassessments due to encouragement. The self rating of the overall outcomes could potentially hinder the accuracy of the results.
To enable researchers to gain a more thorough appreciation of the topic, examples of aerobic exercise programs should be included.

## Further resources

For further information regarding the benefits aerobic exercise has on chronic fatigue syndrome; click on the links below.
1. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial: http://www.bmj.com/content/325/7357/185.1?trendmd-shared=0
2. Graded exercise helps patients with chronic fatigue syndrome: http://www.bmj.com/content/314/7095/0.2?trendmd-shared=0
3. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome: http://www.bmj.com/content/322/7283/387?trendmd-shared=0
4. Strength and physiological response to exercise in patients with chronic fatigue syndrome: http://jnnp.bmj.com/content/69/3/302.short

## References

* 1 2 3 4 Kathy Y Fulcher, Peter D White, 1997. 'Randomised controlled trial of graded exercise in patients with chronic fatigue syndrome'. BMJ, pp1-3
* 1 2 Cleare AJ, Reid S, Chalder T, Hotopf M, Wessely S, 2015. 'Chronic fatigue syndrome'. BMJ Clinical Evidence. Systematic review 1101.
* ↑ Anthony J. Cleare, Steven Reid, Trudie Chalder, Matthew Hotopf and Simon Wessely, 2015. 'Chronic Fatigue Syndrome'. BMJ clinical evidence 1-1.
* 1 2 Unknown, 2015.'Chronic Fatigue Syndrome'. NHS Choices, pp 1-1
* 1 2 Steven Kim, 2015. 'Chronic Fatigue Syndrome: Causes, Symptoms and Treatment'. Health line Media, 1-7.
* ↑ 2016. 'Peter D White, BSc, MBBS, MD, FRCP, FRCPsych'. Wolfs Institute of Preventative Medicine. Queen Mary University of London, internet
* 1 2 2013. 'Chronic Fatigue Syndrome'. Centre for Disease Control and Prevention, pp 1-1
* 1 2 3 Bavinton J, Darbishire L, White PD, 2015. PACE manual for therapists: graded exercise therapy for CSF/ME. Final trial version: version 7 (internet), p.27.