CASE NOTES: Try con­trolled ac­tiv­ity for chronic fa­tigue

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EW disor­ders present as much mys­tery and con­tro­versy as chronic fa­tigue syn­drome (CFS). Al­though there is grow­ing ev­i­dence that the con­di­tion can be trig­gered by cer­tain types of in­fec­tions, the ex­act cause re­mains un­known.

CFS is closely com­pa­ra­ble to pro­longed fa­tigue which may fol­low suc­cess­ful can­cer treat­ment (post-can­cer fa­tigue), and also the syn­drome in which mus­cle and joint pain pre­dom­i­nates — known as fi­bromyal­gia.

Al­though there are no ex­ter­nal signs of th­ese con­di­tions, and no lab­o­ra­tory tests to make the di­ag­no­sis, for the pa­tients the symp­toms of the con­di­tion are very real. Whilst pro­longed and un­ex­plain­able fa­tigue presents as the pri­mary symp­tom, it is of­ten ac­com­pa­nied by sleep dis­tur­bance, mus­cle and joint pain as well as psy­cho­log­i­cal dis­tur­bance — some­times man­i­fest­ing as de­pres­sion. This dis­tress is com­pounded not only by the frus­tra­tion of deal­ing with a con­di­tion that has no iden­ti­fi­able cause, but the anx­i­ety aris­ing from the un­pre­dictable time­frame that the pa­tient can ex­pect to live with the dis­or­der and en­dure its neg­a­tive im­pact to their qual­ity of life.

Since there are no med­i­ca­tions to re­duce the symp­tom of fa­tigue, a num­ber of other treat­ment op­tions have been in­ves­ti­gated. To date, the most promis­ing re­sults have been achieved with cog­ni­tive be­havioural ther­apy (CBT) or graded ex­er­cise ther­apy (GET). Re­search pub­lished in the jour­nal Psy­cho­log­i­cal Medicine con­cluded that a mul­tidis­ci­plinary approach in­cor­po­rat­ing both strate­gies is most ef­fec­tive (2004;34(6):991-999).

The CBT approach in­cludes sleep­wake cy­cle man­age­ment, ad­vice re­gard­ing per­sonal con­cerns and mis­con­cep­tions sur­round­ing the con­di­tion, and sup­port strate­gies to ad­dress emo­tional is­sues. The ma­jor prin­ci­ple of graded ex­er­cise ther­apy is to ad­dress the over­ac­tiv­ity-un­der­ac­tiv­ity cy­cle com­monly ob­served among peo­ple with chronic fa­tigue, as well as to pro­gres­sively im­prove their tol­er­ance to ac­tiv­i­ties which may have pre­vi­ously ex­ac­er­bated their symp­toms.

Nei­ther treat­ment is a cure, but it does im­prove phys­i­cal and cog­ni­tive func­tion, as well as over­all qual­ity of life.

Peo­ple with chronic fa­tigue of­ten have a poor gauge of their ‘‘ fa­tigue thresh­old’’ — the point at which their symp­toms may be ex­ac­er­bated by ex­cess or in­ap­pro­pri­ate phys­i­cal ac­tiv­ity. This of­ten leads to an in­ten­si­fied and pro­longed pe­riod of fa­tigue, of­ten con­fin­ing the per­son to se­verely re­duced ac­tiv­ity or bedrest. Con­se­quently, this re­cur­ring cy­cle pro­vokes anx­i­ety and in­creased vul­ner­a­bil­ity to pain and fa­tigue. By avoid­ing ac­tiv­ity for fear of a re­cur­rence, the per­son be­comes phys­i­cally de­con­di­tioned and grad­u­ally ex­pe­ri­ences in­creased fa­tigue and pain symp­toms.

Hence, peo­ple with fa­tigue-re­lated disor­ders ben­e­fit from care­ful su­per­vi­sion of an ac­tiv­ity pro­gram. Graded ex­er­cise ther­apy is a multi-stage process that be­gins with ‘‘ ac­tiv­ity pac­ing’’. In this approach, daily ac­tiv­ity lev­els and symp­toms are mon­i­tored to de­ter­mine a base­line. The base­line en­sures that the per­son main­tains ac­tiv­ity lev­els just be­low their symp­tom thresh­old. Their lev­els of ac­tiv­ity are pro­gres­sively in­creased to im­prove the per­son’s daily func­tion, in­clud­ing their cop­ing mech­a­nisms.

The Univer­sity of NSW has es­tab­lished the Fa­tigue Clinic — the first to pro­vide multi-dis­ci­plinary treat­ment for fa­tigue and its as­so­ci­ated disor­ders, in­clud­ing pain and sleep dis­tur­bances. Lo­cated within the Lifestyle Clinic, the fa­cil­ity also serves as a re­search cen­tre in fa­tigue-re­lated con­di­tions.

One on­go­ing study is in­ves­ti­gat­ing the ben­e­fits of GET and CBT in can­cer sur­vivors ex­pe­ri­enc­ing fa­tigue af­ter treat­ment. Pro­fes­sor Andrew Lloyd — an in­ter­na­tion­ally recog­nised ex­pert in fa­tigue-re­lated disor­ders and a chief in­ves­ti­ga­tor in the Fa­tigue Clinic study — says the clinic is ‘‘ long over­due’’.

‘‘ Pro­grams like this will help pa­tients and their GPs to ac­tively man­age the ill­ness. Un­til we can find a cure, this re­mains the most ef­fec­tive treat­ment for this con­di­tion.’’ Tips to pace ac­tiv­ity: Keep an ac­tiv­ity diary, record­ing both cog­ni­tive tasks (eg work­ing at a com­puter; writ­ing an es­say or study­ing etc) as well as phys­i­cal ac­tiv­i­ties (in­clud­ing walk­ing and house­hold du­ties).

Record the du­ra­tion of each task, and note your en­ergy lev­els dur­ing the day. A pe­dome­ter may help as­sess phys­i­cal ac­tiv­ity lev­els

Re­view a 10-day sam­ple of the diary, and iden­tify your pat­terns of ac­tiv­ity — both cog­ni­tive and phys­i­cal.

De­ter­mine your base­line: if 40 min­utes of phys­i­cal ac­tiv­ity seems to ag­gra­vate your symp­toms, re­duce the ac­tiv­ity to 30 min­utes be­fore tak­ing a break. Al­though it may seem you’re go­ing back­wards, keep in mind that the strat­egy is to pro­gres­sively in­crease the amount of ac­tiv­ity with­out trig­ger­ing the symp­toms. The trick to ac­tiv­ity pac­ing is to have the dis­ci­pline to do no more ac­tiv­ity than was planned — even if you feel quite able to.

Re­mem­ber — graded ex­er­cise is safe, and rest is not a cure. Even dur­ing higher lev­els of fa­tigue, try to main­tain some level of ac­tiv­ity. Chris Tzar is an ex­er­cise phys­i­ol­o­gist and di­rec­tor of the Lifestyle Clinic, Fac­ulty of Medicine, Univer­sity of NSW

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