From the Cochrane Library, 10 February 2015.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003200.pub3/abstract (full text available).
Exercise therapy for chronic fatigue syndrome
Lillebeth Larun(1,*), Kjetil G. Brurberg(1), Jan Odgaard-Jensen(2), Jonathan R Price(3)
1) Norwegian Knowledge Centre for the Health Services, Primary Health Care Unit, Oslo, Norway
2) Norwegian Knowledge Centre for the Health Services, Global Health Unit, Oslo, Norway
3) University of Oxford, Department of Psychiatry, Oxford, UK
*Lillebeth Larun, Primary Health Care Unit, Norwegian Knowledge Centre for the Health Services, PO Box 7004, St Olav’s plass, Oslo, N-0130, Norway. Lillebeth.Larun@kunnskapssenteret.no.
Chronic fatigue syndrome (CFS) is characterised by persistent, medically unexplained fatigue, as well as symptoms such as musculoskeletal pain, sleep disturbance, headaches and impaired concentration and short-term memory. CFS presents as a common, debilitating and serious health problem. Treatment may include physical interventions, such as exercise therapy, which was last reviewed in 2004.
The objective of this review was to determine the effects of exercise therapy (ET) for patients with CFS as compared with any other intervention or control.
• Exercise therapy versus ‘passive control’ (e.g. treatment as usual, waiting-list control, relaxation, flexibility).
• Exercise therapy versus other active treatment (e.g. cognitive-behavioural therapy (CBT), cognitive treatment, supportive therapy, pacing, pharmacological therapy such as antidepressants).
• Exercise therapy in combination with other specified treatment strategies versus other specified treatment strategies (e.g. exercise combined with pharmacological treatment vs pharmacological treatment alone).
We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL) and SPORTDiscus up to May 2014 using a comprehensive list of free-text terms for CFS and exercise. We located unpublished or ongoing trials through the World Health Organization (WHO) International Clinical Trials Registry Platform (to May 2014). We screened reference lists of retrieved articles and contacted experts in the field for additional studies
Randomised controlled trials involving adults with a primary diagnosis of CFS who were able to participate in exercise therapy. Studies had to compare exercise therapy with passive control, psychological therapies, adaptive pacing therapy or pharmacological therapy.
DATA COLLECTION AND ANALYSIS
Two review authors independently performed study selection, risk of bias assessments and data extraction. We combined continuous measures of outcomes using mean differences (MDs) and standardised mean differences (SMDs). We combined serious adverse reactions and drop-outs using risk ratios (RRs). We calculated an overall effect size with 95% confidence intervals (CIs) for each outcome.
We have included eight randomised controlled studies and have reported data from 1518 participants in this review. Three studies diagnosed individuals with CFS using the 1994 criteria of the Centers for Disease Control and Prevention (CDC); five used the Oxford criteria. Exercise therapy lasted from 12 to 26 weeks. Seven studies used variations of aerobic exercise therapy such as walking, swimming, cycling or dancing provided at mixed levels in terms of intensity of the aerobic exercise from very low to quite rigorous, whilst one study used anaerobic exercise. Control groups consisted of passive control (eight studies; e.g. treatment as usual, relaxation, flexibility) or CBT (two studies), cognitive therapy (one study), supportive listening (one study), pacing (one study), pharmacological treatment (one study) and combination treatment (one study). Risk of bias varied across studies, but within each study, little variation was found in the risk of bias across our primary and secondary outcome measures.
Investigators compared exercise therapy with ‘passive’ control in eight trials, which enrolled 971 participants. Seven studies consistently showed a reduction in fatigue following exercise therapy at end of treatment, even though the fatigue scales used different scoring systems: an 11-item scale with a scoring system of 0 to 11 points (MD -6.06, 95% CI -6.95 to -5.17; one study, 148 participants; low-quality evidence); the same 11-item scale with a scoring system of 0 to 33 points (MD -2.82, 95% CI -4.07 to -1.57; three studies, 540 participants; moderate-quality evidence); and a 14-item scale with a scoring system of 0 to 42 points (MD -6.80, 95% CI -10.31 to -3.28; three studies, 152 participants; moderate-quality evidence). Serious adverse reactions were rare in both groups (RR 0.99, 95% CI 0.14 to 6.97; one study, 319 participants; moderate-quality evidence), but sparse data made it impossible for review authors to draw conclusions. Study authors reported a positive effect of exercise therapy at end of treatment with respect to sleep (MD -1.49, 95% CI -2.95 to -0.02; two studies, 323 participants), physical functioning (MD 13.10, 95% CI 1.98 to 24.22; five studies, 725 participants) and self-perceived changes in overall health (RR 1.83, 95% CI 1.39 to 2.40; four studies, 489 participants). It was not possible for review authors to draw conclusions regarding the remaining outcomes.
Investigators compared exercise therapy with CBT in two trials (351 participants). One trial (298 participants) reported little or no difference in fatigue at end of treatment between the two groups using an 11-item scale with a scoring system of 0 to 33 points (MD 0.20, 95% CI -1.49 to 1.89). Both studies measured differences in fatigue at follow-up, but neither found differences between the two groups using an 11-item fatigue scale with a scoring system of 0 to 33 points (MD 0.30, 95% CI -1.45 to 2.05) and a nine-item Fatigue Severity Scale with a scoring system of 1 to 7 points (MD 0.40, 95% CI -0.34 to 1.14). Serious adverse reactions were rare in both groups (RR 0.67, 95% CI 0.11 to 3.96). We observed little or no difference in physical functioning, depression, anxiety and sleep, and we were not able to draw any conclusions with regard to pain, self-perceived changes in overall health, use of health service resources and drop-out rate.
With regard to other comparisons, one study (320 participants) suggested a general benefit of exercise over adaptive pacing, and another study (183 participants) a benefit of exercise over supportive listening. The available evidence was too sparse to draw conclusions about the effect of pharmaceutical interventions.
Patients with CFS may generally benefit and feel less fatigued following exercise therapy, and no evidence suggests that exercise therapy may worsen outcomes. A positive effect with respect to sleep, physical function and self-perceived general health has been observed, but no conclusions for the outcomes of pain, quality of life, anxiety, depression, drop-out rate and health service resources were possible. The effectiveness of exercise therapy seems greater than that of pacing but similar to that of CBT. Randomised trials with low risk of bias are needed to investigate the type, duration and intensity of the most beneficial exercise intervention.
From the Journal of Sports Medicine and Physical Fitness, 18 February 2015 (published ahead of print).
Physical effects of a reconditioning programme in a group of chronic fatigue syndrome patients.
Guillamó E, Barbany JR, Blazquez A, Delicado MC, Ventura-Farré JL, Javierre C.
Department of Physiological Sciences II, Exercise Physiology Unit, School of Medicine, University of Barcelona, Barcelona, Spain – email@example.com
Physical exercise can be part of treatment in patients with chronic fatigue syndrome (CFS), where the aim would be to improve strength and endurance through increasing physical exercise (intensity and time) without aggravating symptomatology. The present study examines the effectiveness of a reconditioning programme (focusing on strength, endurance, balance and propioception) for achieving maximum functional capacity according to the clinical status of CFS patients.
Sixty-eight patients with CFS were randomly assigned to two groups: a control group (CG) comprising 22 patients and an active group (AG) of 46 patients, the latter being invited to take part in a functional reconditioning programme based on 12 weeks of laboratory training followed by a further 12-week home training period. Functional assessments were as follows: before (I) and after (II) the laboratory training and after (III) the home training.
In the AG, 22 patients (67%) completed the intervention (laboratory) stage and 20 finished the whole protocol (61%). Patients in the AG showed improved static and dynamic balance, as well as significantly greater maximum strength (F=7.059, p<0.05). Differences in resistance strength were also observed, with the AG showing a 19.9% improvement between functional assessments I and II (p=0.04). We don't found changes in the CG. CONCLUSION A physical exercise programme of this kind might offer CFS patients the opportunity to improve their strength, balance and quality of life, there being only a very small risk of relapse and none of the adverse effects of other treatments.