New British research suggests that people with chronic fatigue syndrome may be helped the most when standard treatment is coupled with cognitive behaviour therapy or exercise therapy.
The condition is a complex one characterized by profound tiredness, impaired concentration, diminished memory, sleep difficulties and muscle and joint pain. Authors suggest use of cognitive behaviour therapy and “graded exercise therapy”. The findings also support the somewhat controversial notion that incremental adjustments in physical behaviour and/or mental attitude can ultimately have a positive impact on the disorder, the authors said. At present the traditional therapy includes giving patients information about their condition, advice on how to manage symptoms and assistance with coping approaches.
The new approach found little appreciable benefit with a third alternate therapeutic approach that focuses on helping patients strictly structure their activity and relaxation routines to match their severely reduced energy levels. This strategy, known as “adaptive pacing therapy,” assumes that chronic fatigue syndrome is not, in fact, reversible with behavioural changes. Study author Dr. Peter D. White, a professor of psychological medicine at Barts and the London School of Medicine, and a psychiatrist at St Bartholomew's Hospital in London said, “Patients who received either graded exercise therapy or cognitive behaviour therapy reported less fatigue and better function than those who received either adaptive pacing therapy or specialist medical care alone.”
White and his colleagues report their findings in the Feb. 18 online edition of The Lancet. They write that the exact cause of the disease is not known yet. However they found that cognitive behavioural therapy targets the building fear and avoidance of activity that can exacerbate CFS. In effect, it seeks to break a vicious cycle in which mental inhibitions actually perpetuate and aggravate the underlying chronic fatigue.
Graded exercise therapy, known as “GET” tries to reduce fatigue and disability by gradually helping patients increase their activity levels to improve their overall physical fitness. The team involved 641 chronic fatigue patients from four different rehabilitation centres in Britain. They were divided up into one of four groups. Over the course of a year, all got standard specialist medical care, while three of the groups received one additional treatment: pacing therapy, cognitive therapy or exercise therapy.
Results showed that the greatest improvements in terms of both fatigue levels and physical function were experienced by those patients who were treated with standard therapy in combination with either cognitive therapy or exercise therapy. Also patients who got a combination of standard treatment and pacing therapy fared no better than those who got standard treatment alone. Specifically, 60 percent of the standard/cognitive or standard/GET patients experienced fatigue and function improvements, while 30 percent reported “normal levels” of fatigue and function. Half as many of the standard therapy alone or standard/pacing patients reported normal fatigue and function levels.
White noted that all the treatments were equally safe, and serious reactions were rare. “Patients now have a choice of two moderately effective and safe treatments that can help them towards a healthier life,” he said.
Dr. Nancy Klimas, chief medical officer at the Chronic Fatigue Centre at the University of Miami Miller School of Medicine, noted that the merits of various therapeutic approaches to chronic fatigue syndrome are still a matter of debate. She added, “But here Dr. White is saying that cognitive behavioural therapy and graded exercise are moderately helpful, but not curative… And I would agree with that… On the other hand, it’s also important to note that when we talk about helping patients increase their activity levels, we’re talking about people who have very limited amounts of energy…And you have to work within this ‘energy envelope,’ because if you push beyond the threshold they will relapse. So often, what we’re talking about is about five minutes of exercise before taking a rest.” “In any case, I look at this as a first step,” she said, “and anticipate more effective therapies, based on a better understanding of the biology of the illness, in the future.”
The study however has triggered a debate since many patients do not accept that this disease could have a psychological basis. Patient groups and some researchers have challenged the criteria used by the British investigators as likely to include many people with depression, which often causes severe fatigue. They also note that the study excluded patients who could not get to treatment centres, most likely ruling out some of the sickest patients. And at least one survey has found that exercise therapy can significantly worsen many patients’ symptoms they report.
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