# Graded Exercise Therapy In CFS?



## M&M (Jan 20, 2002)

This was posted to the Co-Cure list:****************************************************DOES GRADED EXERCISE THERAPY IMPROVE POST-EXERTIONAL MALAISE IN CFS?*_Susanna Agardy_People with CFS/ME are being increasingly urged to exercise to improvefunctioning. For example, in the Medical Journal of Australia, Prof. AndrewLloyd has announced that 'one can safely conclude ...that graded physicalexercise should become a cornerstone of the management for patients withCFS'1 unless they are severely ill.8In the same editorial the problem of post-exertional malaise isacknowledged: 'â€¦the cardinal phenomenon of fatigue in CFS is characterisedby a marked and prolonged exacerbation of symptoms following minor physicalactivityâ€¦'1. As CFS/ME people with this problem know, this exacerbation isoften delayed and brings into play many symptoms. This should be enough toindicate that there is something extraordinary, rather than justexacerbated fatigue happening here. It can be serious enough to stopsufferers from entering exercise experiments or to cause dropping out of them.Three studies, two of them British2, 3 and one Australian4, have been citedas providing evidence for the benefits of GET. All of the studies foundsignificant improvements in fatigue and functioning of a large proportionof CFS participants who completed a graded exercise program compared withcontrols who did stretching or relaxation or received medical care.Patients' beliefs about the physical cause of their illness were found tochange with their improvements in fatigue when used together with CBT2, ortheir improvement was interpreted in this light 4.To what extent can the results of these studies be generalised to peoplewith post-exertional malaise?1. Two of the studies, which are often quoted, show no evidence of directlyaddressing what we know as post-exertional malaise and do not even mentionit.2, 3 These studies used the Oxford Criteria of 1991 for CFS formulatedby the Oxford Consensus Meeting.5The syndrome definition in the Oxford Criteria for CFS does not includepost-exertional malaise. Another section of the Oxford Criteria mentionsthat 'â€¦it should be stated whether the fatigue is greatly increased byminor exertionâ€¦'5, but there is no requirement to include subjects who havethis problem. There is no mention of 'increased fatigue' in thestudies. In any case, this amorphous and confusing term fails to dojustice to the phenomenon of post-exertional malaise.Only Wallman seems to refer to the problem in stating that there was 'norelapse' during the course of treatment.4 Wallman required doctors'certificates to state that patients met the Fukuda Criteria6. Althoughthese criteria include post-exertional malaise it is not an essentialcriterion.None of the authors show evidence of having ascertained whether thesubjects in fact suffered from post-exertional malaise prior to thetreatments. Therefore, these studies leave themselves open to theinterpretation that at least some subjects in the studies did not sufferfrom post-exertional malaise to begin with.2. Fulcher3 excluded people with sleep disorders, a well-recognisedfeature of CFS/ME according to the Oxford5, Fukuda6 and Canadian7 Criteria.This could have further excluded CFS/ME sufferers who have post-exertionalmalaise as part of the syndrome.3. The studies by Fulcher3 and Wallman4 began with pre-treatmentassessments including aerobic capacity and target heart rates involvingtreadmill or cycle testing. These tests would be likely to cause a degreeof relapse in most people with post- exertional malaise, for many of whomaerobic exercise is having a shower, or even less activity. The authorsseem oblivious to the contradiction of giving CFS sufferers sustainedaerobic exercise, maximal or submaximal, before they underwent thecarefully designed graded exercise program. Yet, no complaint or problemis reported.4. The studies are subject to volunteer bias, that is, people who feelwell enough to do exercise or think they can perform in such a study willparticipate and those who are more severely affected will excludethemselves. This may be unavoidable, but the conclusions able to be drawnwill be limited.These studies do not justify claims which imply that graded exerciseassists in overcoming the effects of post-exertional malaise. They alsocast no light on the problem of sufferers who fail to improve or get worsefollowing exercise. They cannot be generalised to the population of CFS/MEsufferers.Perhaps the experimenters have not paid attention to post-exertionalmalaise because they subscribe to the belief system which dictates thatmost of the limitations to CFS/ME people doing exercise reside within their'dysfunctional' belief systems and the consequent assumed deconditioning.Where selection of subjects ignores and excludes post-exertional malaise(as with the use of the Oxford Criteria), the experimenters' belief systemis perpetuated and remains unchallenged.For GET studies to have credibility for sufferers of post-exertionalmalaise they need to demonstrate that the subjects suffered from thisproblem before and not after the study. This would mean using the CanadianCriteria7, which requires the presence of post-exertional malaise for adiagnosis of CFS/ME. The studies would also need to take into accountvariables such as stage and severity of illness and correlate the responsesto exercise with some of the physical abnormalities which have beendiscovered. While there is any ambiguity about this crucial issue peoplewith post-exertional malaise cannot but reject the generalisations fromthese studies.References:1. Lloyd AR. To exercise or not to exercise in chronic fatiguesyndrome? No longer a question [editorial]. Med J Aust 2004; 180: 437-438.2. Powell P, Bentall RP, Nye FJ, Edwards RHT. Randomised controlledtrial of patient education to encourage graded exercise in chronic fatiguesyndrome. BMJ 2001; 322: 1-5.3. Fulcher KY, White PD. Randomised controlled trial of gradedexercise in patients with the chronic fatigue syndrome. BMJ 1997; 314:1647-1652.4. Wallman KE, Morton AR, Goodman C, et al. Randomised controlledtrial of graded exercise in chronic fatigue. Med J Aust 2004; 180: 444-448.5. Sharpe MC, Archard LC, Banatvala JE, Borysiewicz LK, Clare AW,David A, et al. A report-chronic fatigue syndrome: guidelines for researchJR Soc Med 1991;84:118-21.6. Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome:a comprehensive approach to its definition and study. Ann Intern Med 1994;121: 953-959.7. Carruthers BM, Jain AK, De Meirlier K, et al. Myalgicencephalomyelitis/chronic fatigue syndrome: clinical working casedefinition, diagnostic and treatment protocols. J Chronic Fatigue Syndr2003; 11: 7-116. Available at: www.mefmaction.net/documents/journal.pdf (accessed Sep 2004).8. Lloyd AR, To exercise or not to exercise in chronic fatiguesyndrome? [Letter] Med J Aust 2004; 181 (10): 578-580.


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