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BMJ No 7113 Volume 315 Letters Saturday 11 October 1997
Graded exercise in chronic fatigue syndromeChronic fatigue syndrome is heterogeneous conditionEditor,The study reported by Kathy Y Fulcher and Peter D White will provide new hope to many patients diagnosed as having the chronic fatigue syndrome.(1) Before exercise regimens become the treatment of choice, however, it is worth noting that over two fifths of the patients in the study reported no or little improvement. It is a pity that the researchers did not compare those who were 'very much better' with those who were not, in terms of variables such as the onset of illness (acute or gradual, history of infection)(2) and the presence of additional symptoms frequently associated with the syndrome - for example, cognitive difficulties, nausea, and malaise after exercise. This might have shown whether one particular subgroup fared better than another, allowing doctors to tailor their advice and further improve patients' care.(3) The possibility that subgroups may have different prognoses also deserves consideration. For instance, a recent study found that 70% of patients diagnosed as having epidemic neuromyasthenia recovered within two years.(4) If two thirds of the subjects studied by Fulcher and White also had disease of acute onset linked to infection, one could argue that the exercise regimen reflected the natural course of the illness while the flexibility training made patients worse. A final point concerns the 20 subjects taking full dose antidepressants. The authors do not specify why these drugs were being taken by people who did not have clinical depression or sleep disorders. Moreover, since many patients with the chronic fatigue syndrome cannot tolerate therapeutic doses of antidepressants,(5) some of the reported fatigue and malaise may have been drug induced. While treatments linked to behaviour seem to benefit many patients with chronic fatigue, further research is needed to characterise the minority in whom they do not. If studies fail to acknowledge the heterogeneity of the chronic fatigue syndrome, subgroups with different needs may be overlooked.(2) Ellen M Goudsmit Editor,
ME and CFS Medical
Update
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 Fukuda K, Straus S, Hickie I, Sharpe M, Dobbins JC, Komaroff A, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121:953-9. 3 Lerner A M, Zervos M, Dworkin H J, Chang C H, Fitzgerald J T, Goldstein J, et al. New cardiomyopathy: pilot study of intravenous ganciclovir in a subset of the chronic fatigue syndrome. Infect Dis Clin Pract 1997;6:110-7. 4 Levine P H, Snow P G, Ranum B A, Paul C, Holmes M J. Epidemic neuromyasthenia and chronic fatigue syndrome in West Otago, New Zealand: a 10-year follow-up. Arch Intern Med 1997;157:750-4. 5 Weir W R C. PVFS in an infectious diseases clinic. In: Jenkins R, Mowbray J, eds. Post-viral fatigue syndrome. Chichester: Wiley, 1991.
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