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BMJ No 7113 Volume 315 Letters Saturday 11 October 1997 Graded exercise in chronic fatigue syndrome Patients should have initial period of rest before gradual increase in activity Editor, We remain firmly opposed to exercise programmes that encourage patients with the chronic fatigue syndrome to increase their levels of physical activity progressively without making allowance for fluctuating levels of disablement. Nevertheless, we welcome Kathy Y Fulcher and Peter D White's finding that an individually tailored programme can produce benefits in a carefully selected subset.(1) We have concerns, however, about the way in which these results have been oversimplified in the media and may now be put into practice by health professionals with no experience of this approach to management. Our first concern is whether the results are as impressive as they seem. We find it surprising that patients in the exercise group who rated themselves as better showed no significantly greater improvement in either peak oxygen consumption or muscle strength than did the other patients. In addition, it would have been useful to know what percentage of both groups had stopped claiming long term sickness benefits - perhaps the most objective assessment of improvement. Secondly, we are concerned that all the patients had been ill for a considerable period (median 2.7 years). Definitions of the chronic fatigue syndrome state that symptoms must have been present for at least six months before a diagnosis can be made. As a result no similar research study has been done into the most appropriate advice regarding rest and activity during the first few months of this illness. Until this has been done, our guidelines will continue to advise an initial period of rest followed by a gradual increase in activity. Thirdly, severely affected patients were excluded from the study. A small but important minority are either wheelchair-bound or even bedbound, and for this group any type of activity programme must inevitably be structured at an entirely different level. Fourthly, the authors seem to dismiss the possibility that fatigue could involve an underlying physiological or biochemical defect. Although considerable uncertainty surrounds the role of persistent viral infection and immunological dysfunction in the chronic fatigue syndrome, evidence links the condition with hypothalamic dysfunction, particularly hypocortisolaemia,(2) and other disturbances of the central nervous system.(3) Finally, in this heterogeneous disorder, the role of disordered oxidative metabolism in skeletal muscle cannot be ruled out as an explanation for fatigue in a subset of patients.(4) Charles Shepherd Medical director Anne Macintyre Medical adviser ME Association, High Street, Stanford le Hope, Essex SS17 0HA References 1 Fulcher K Y, White P D. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ 1997;314:1647-52. (7 June.) 2 Demitrack M A, Dale J K, Straus S E, Laue L, Listwak S J, Kruesi M J P, et al. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab 1991;73:1224-34. 3 Chaudhuri A, Majeed T, Dinan T, Behan P O. Chronic fatigue syndrome: a disorder of central cholinergic transmission. J Chronic Fatigue Syndrome 1997;3:3-16. 4 McCully K K, Natelson B H, Iotti S, Sisto S, Leigh J S. Reduced oxidative muscle metabolism in chronic fatigue syndrome. Muscle Nerve 1996;19:621-5. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline