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Benefits of Exercise Therapy

We were interested to read in the report by Clapp et al (August 1999) that 30 minutes of intermittent walking did not exacerbate symptoms or cause any abnormal physiological response to exercise in subjects with chronic fatigue syndrome (CFS). Clapp and colleagues go on to suggest that "some individuals with CFS may be able to use low-level, intermittent exercise without exacerbating their symptoms." They also write that "there are no data suggesting that exercises are effective as a primary treatment for patients with CFS."

These authors do not go far enough in their recommendation and are quite wrong in their assumption regarding exercise as a primary treatment. Our group has published a randomized controlled trial showing that graded aerobic exercise therapy, properly supervised, is a significantly more effective treatment than the same amount of therapist input using only stretching and relaxation exercises.¹ This study showed that 52 % of patients rated themselves as "much" or "very much" better after 3 months of treatment, analyzed by intention to treat, compared with 27% of those treated with a control treatment. At the 1-year follow-up, the proportion of those who rated themselves as "much" better increased to 63% by intention-to-treat analysis (74% by completed patients' analysis). Only 1 patient out of 33 patients rated himself "worse" after treatment, the same proportion as in the control treatment. Four patients dropped out of exercise therapy, and 3 patients dropped out of the control treatment. We excluded patients with a comorbid psychiatric disorder. We concluded that "these findings support the use of appropriate prescribed graded aerobic exercise in the management of patients with chronic fatigue syndrome."¹

A further study, without any patients excluded on the basis of comorbid psychiatric disorder, has also been published. Wearden and colleagues² reported less impressive results with graded exercise therapy, primarily due to one third of the patients dropping out before the end of therapy. Even so, those who completed exercise therapy made significant improvement in fatigue and aerobic work capacity 6 months after starting treatment. The amount of supervised graded exercise therapy was less than in our own study, and the way the exercise was graded was different as well.

We have gone on to publish a description of how to deliver a graded exercise therapy program to patients with CFS.³ We suggest that graded exercise therapy is a beneficial treatment for the majority of patients with CFS, particularly in those who do not have a comorbid psychiatric disorder. Continuous exercise seems helpful, provided patients start at a short duration of exercise appropriate to their baseline ability.

Dr Peter White

Senior Lecturer and Honorary Consultant
Queen Mary and Westfield College
University of London

Kathy Fulcher

National Sports Medicine Institute
St Bartholomew's
London

References

1. Fulcher KY, White PD. Randomised control led trial of graded exercise in patients with the chronic fatigue syndrome. BMJ.1997; 314:1647–1652.[Abstract/Free Full Text]
2. Wearden AJ, Morriss RK, Mullis SR, et al. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. Br J Psychiatry.1998; 172:485–490.[Abstract/Free Full Text]
3. Fulcher KY, White PD. Chronic fatigue syndrome: a description of graded exercise treatment. Physiotherapy.1998; 84:223–226.

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