[Letter from Joan Crawford: In the February 2015 edition of Therapy Today (News, p6) there is a short report on exercise and CFS.
Uncritically your report states, ‘Both [CBT aimed at increasing patients activity and GET (graded exercise therapy)] have been shown to be beneficial to people with CFS.’ The evidence base does not support this bold assertion.
In a recent Cochrane Review (1) of the eight clinical trials of GET (n=1518) 85 per cent of the patients (n=1287) were recruited into five of these trials based on one symptom – fatigue. (2) This is a common symptom of many health problems, including major depression, making generalisation of the findings problematic.
The high percentage of patients included in these trials with elevated levels of distress perhaps indicating a depressive state, (1) which may be their primary condition, confounds the results. Exercise, through behavioural activation programmes, has a moderately positive impact on patients with depression. (3)
It is unclear whether the modest improvement seen in some of these trials can be accounted for by an improvement in low mood caused by depression. Moreover, where there are data, there is a high usage of antidepressants in patients included in trials. Three further trials used the CDC (4) CFS criteria (n=231). While these criteria purport to be more selective, they do not necessarily include patients whose primary difficulties include post-exertion weakness and debility beyond broadly defined fatigue and other general symptoms, that could be attributed to CFS or major depression.
There is also an issue with lack of evidence of patients’ fidelity to exercise programmes using objective measures. Without using monitoring devices such as actimeters or pedometers to track daily activity levels, we have no accurate way of assessing whether an increase in activity occurred and whether this helps.
Black and McCully’s study (5) demonstrates the difficulties CFS patients face when trying to increase activity and concluded that they were exercise intolerant, unable to sustain activity targets.
Many patient surveys from across the world report numerous instances of harm and worsening of symptoms from taking part in exercise programmes. For a summary of the difficulties and limitations of the reporting of harms, in and outside of clinical trials, and why these might be underestimated, please see Kindlon. (6)
[Joan Crawford MA, MSc, CSci, MBPS, MBABCP; Chair, Chester ME self help (MESH); humanistic counsellor, CBT therapist and trainee counselling psychologist]
1. Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy for chronic fatigue syndrome. Cochrane Database Systematic Review 2015.
2. Sharpe M, Archard L, Banatvala J et al. Chronic fatigue syndrome: guidelines for research. Journal of the Royal Society of Medicine 1991; 84(2):118–121.
3. Cooney GM, Dwan K, Greig CA et al. Exercise for depression. The Cochrane Library 2013.
4. Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Annals of Internal Medicine 1994; 121(12): 953–959.
5. Black CD, McCully KK. Time course of exercise induced alterations in daily activity in chronic fatigue syndrome. Dynamic Medicine 2005; 28(4):10.
6. Kindlon T. Reporting of harms associated with graded exercise therapy and cognitive behavioural therapy in Myalgic Encephalomyelitis/chronic fatigue syndrome. Bulletin of the IACFS/ME 2011; 19(2): 59–111.
Activity and chronic fatigue syndrome, by Joan Crawford in Therapy today vol 26, no. 2, March 2015 [letters]