CASE NOTES: Try controlled activity for chronic fatigue
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