reprinted with permission of Yale University Press and Benjamin H. Natelson, MD. This section is from Chapter 7.
Arguments rage over whether patients with severe and chronic fatigue should exercise or not. One of the elements that adds to the confusion is that a common complaint of CFS patients is that exertion, even when quite mild, produces a flare-up of their symptoms. The problem is the interplay between the illness and the drop in fitness that inactivity brings. Certainly if you are in the phase of the illness where you have fever and extreme malaise that keeps you in bed, you should not consider exercise. The timing would make as much sense as exercising while you have the flu. But many of my patients experience different phases in their CFS. For instance, it is not at all uncommon for the fever and sore throat to go away. Even if these do not disappear, many patients find that they can spend a substantial period of time out of bed. They may still be disabled and unable to work because of their symptoms, but they will be able to exercise — at least a little.
Stress testing We have done research on twenty-two CFS patients of this sort. We did actual exercise stress testing, consisting of walking at a fast rate until the patients could not walk further. We compared these results to those of healthy people who did not exercise regularly. Not surprisingly, the CFS group (who all said that their activity level was substantially reduced compared to levels before their illness) were less fit than the healthy group. However, the difference was relatively small. Had we found a comparison group of people who were extremely sedentary, we suspect we would not have found any difference between the group.
This extreme exercise challenge produced serious flare-ups in only a few patients. But the exercise did have a measurable negative effect on the CFS patients’ ability to do mental work after the stress test. A check with our patients and with our healthy comparison subjects about their fatigue following the stress test revealed that the healthy people felt less fatigue. The patients’ fatigue did get worse, but not strikingly so. That surprised us, because a common complaint of the CFS patient is that even mild exercise produces a worsening of overall condition and fatigues them sufficiently that they often have to go to bed. It is possible that the short burst of high-intensity exertion demanded in our stress test is not the type of exertion that produces this pattern of worsening. Learning exactly what kind of exertion produces symptom flare-ups will take research. Since a maximal stress test did not produce serious flare-ups of illness, we believe that less intensive physical exertion will not do so either. That is why we are beginning to prescribe gentle fitness training for patients with CFS.
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Fitness training for CFS The exertion we induced was of an experimental nature and is not what we would suggest to a patient. All the same, it makes the point that [gentle] fitness training is a possibility for patients with severe fatigue. Indeed, several groups have shown that fitness training makes fibromyalgia patients feel better; since patients with fibromyalgia plus fatigue probably have CFS, these studies auger well for the CFS patient. In fact, my colleagues in our rehabilitation department have done fitness training on nearly a hundred CFS patients with encouraging results. Furthermore, a recent Australian study reported the results of a treatment trial of gentle conditioning in CFS and concluded that it is not only effective but that it continues to reduce CFS symptoms many months later. The totality of these experiences tells us that fitness training, monitored by a trained physical therapist and individually tailored for the patient, should be part of the management of CFS for appropriate patients.
The goal of the exercise regimen depends on the person. If you have been unable to walk at all, five minutes of walking is a major achievement. But I try to ask everyone to aim for 20 minutes of walking at a quick pace. If a person can attain this goal, then I raise it to 30 minutes at the same quick pace. Achievement of the 20-minute goal of course depends on the person. If you are in good health but have been extremely sedentary, you can attain this goal in about a month, but it will take much longer if you have a fatiguing illness such as CFS. And disappointments will come. For the CFS patient, there is often a narrow line between being able to exercise at all and the worsening of symptoms that too much exercise brings. Indeed, I have a few male CFS patients who are fine as long as they can remain sedentary. These patients are the exception: they can work and have a normal life as long as they can live a verytranquil life with no physical demands. If they have to meet even as mild a demand as walking a long distance from office to car, by the time they reach the car they begin to feel feverish and achy. Obviously the kind of exercise that I am recommending here will not work for them.
Tai chi Two other forms of exercise may be helpful in combating fatigue. The first is a very gentle muscular conditioning, used for millennia in China, called tai chi. It consists of a series of exercises that are easy to perform and can be done daily. I have been impressed that some of my sickest CFS patients are able to do the tai chi exercises, and they report less fatigue and pain thereafter. Although we know nothing of how such exercise works, it certainly must counteract the biological effects of inactivity. One can learn the exercises either at one of the many courses on tai chi taught at local colleges or at a fitness center. Another alternative is to buy a videotape that demonstrates the exercises.
Kundalini yoga Our knowledge about the final form of exercise that I want to mention is even more rudimentary, but it is logical that it might be helpful in the treatment of fatigue. The system of exercises called kundalini yoga is more diverse and usually more active than the stretching and static posture form of hatha yoga that is more common in the United States. Kundalini yoga uses various combinations of patterns of breathing and muscular exertion. Breathing as regularly as a metronome has a major influence on the heart. If you check the pulse in your neck or wrist while you breathe slowly and regularly, you will feel your pulse rate increase while you breathe in and decrease while you breathe out.
Regular breathing has this effect on the heart via a nerve called the vagus. When firing of the vagus nerve diminishes, heart rate increases; when firing increases, heart rate slows. In addition to these effects on the heart, the vagus nerve plays an important role in hastening digestion. Slowing of the heart and turning on digestive processes are what happens in the absence of stress; when stress exists, vagal firing stops, and heart rate increases while digestion stops. Thus one way of viewing the vagus is as a nerve whose function it is to combat arousal or stress. We have learned that it works at subnormal levels in CFS. This fact may explain, at least in part, why the CFS patient is so often stress sensitive.
In addition to the possible stress-relieving effects of paced breathing, these sorts of breathing exercises may be specifically useful for the CFS patient by increasing the function of their vagus nerves.