Pacing and Energy Management
Pacing, an energy management technique, can be especially beneficial for CFS patients[74,69] and should be considered for most CFS patients. Pacing involves moderating activity to minimize the push-crash cycle and reduce the stress and frustration that occur with relapse.[75]
* Encourage patients to be aware of their own personal threshold of relapse, even when it seems like a moving target, and learn to avoid triggering relapse symptoms by keeping activity within a safe limit. Patients who learn to adapt to a changing threshold of activity and pace activity accordingly will be more successful at managing the illness and increasing function.
* Advise patients to consider all the movement and activity they engage in, including personal grooming, grocery shopping, household chores, tasks performed during full- or part-time employment, anaerobic exercise, and aerobic exercise, when developing an energy management program.
* Instruct patients to pace activity, performing specific activities, such as household tasks, in small, manageable chunks with rest breaks, rather than in a single energy-depleting effort. Activity should be spread evenly throughout the day, and it should not exacerbate fatigue or other symptoms. Once patients are stabilized, activity is incrementally increased.[76]
* Instruct patients to view their available energy as if it were a bank account. If they overexert themselves, it is like being overdrawn at the bank, and they have to pay it back by resting more the next day. As time passes, patients learn how much energy they can expend without experiencing the characteristic postexertional malaise.[77]
Strength and Conditioning
A strengthening and conditioning program can reduce pain, prevent muscle spasms, increase strength and flexibility, improve balance, reduce falls, and enhance stamina and function in CFS patients.[78] Low-level exercise, including stretching, strength training, and simple resistance training, appears to be reasonably well tolerated by most patients, as long as they learn to avoid overexertion.
* Encourage patients to start with simple stretching and strengthening exercise, using only body weight for resistance. Gradually add wall push-ups, modified chair dips, and toe raises to the routine. Increase repetitions gradually. Patients can begin with a set of 2-4 repetitions and build to a maximum of 8.
* Add resistance exercise as strength improves. Exercise bands or light weights are both good options for simple resistance training that increases muscle mass and metabolic rate without overtaxing CFS patients.
* Add a focus on strengthening core abdominal muscles to relieve back pain and improve overall circulation.
* Advise patients who do not tolerate an upright position to use other positions rather than standing. Stretching and strengthening exercises can be performed on a floor mat or in water.
* Be aware that for patients who are severely deconditioned, it may be advisable to begin with a physical conditioning program, which is primarily anaerobic exercise, before introducing aerobic activities.
* Encourage patients who can tolerate greater levels of exercise to engage in movement therapies like yoga, tai chi, and qigong and light aerobic activity like short walks and swimming.
* Educate patients about the role that even modest strength-building exercise can play in increasing muscle mass and setting metabolic rate. Since many CFS patients have a very low metabolic rate, and metabolic syndrome is a common comorbid condition, building muscle mass is important.
Graded Activity and Exercise
Graded activity refers to movement and exercise that is started slowly and increased slowly, gradually increasing both the level of activity and the duration. Graded exercise may include both anaerobic and aerobic activities and can be effective in improving function and decreasing fatigue.[79,74] Functional capacity varies greatly from patient to patient, so exercise plans must be tailored accordingly.[80,81]
* Teach CFS patients that all exercise needs to be followed by a rest period at a 1:3 ratio, resting 3 minutes for each minute of exercise. Some patients can exercise for only short periods, just 2 to 5 minutes, without risking a relapse. This kind of interval activity -- exertion followed by rest -- can enable patients to gradually increase activity levels over a period of weeks or months.
* Advise deconditioned patients to limit themselves to the basic activities of daily living until they have stabilized. Several daily sessions of brief, low-impact activity can then be added, such as a few minutes of stretching, strength exercises, or light activity like walking or cycling. These sessions are increased by 1 to 5 minutes a week as tolerance develops.
* Instruct patients to return to the most recent manageable level of activity if they report that exercise is worsening symptoms.[76] Daily exercise may be divided into 2 or more sessions to avoid symptom flare-ups; some patients, however, cannot exercise daily early in the course of their rehabilitation.
* Advise patients to adapt their exercise program to allow maximum mat time. Alternating a short session of standing exercise with a short session of mat work may enable patients to tolerate more exercise without precipitating a crash.
* Encourage patients to consider aerobic activities they can do close to home, like walking for short intervals or swimming in a backyard pool. Going to the gym can involve showering, dressing, driving, and other exertion, exhausting a patient's energy envelope before aerobic activity even begins. And it may make some patients inadvertently overexert to "keep up with" other gym patrons.
* Write physical therapy referrals that are quite specific in outlining appropriate physical conditioning and graded exercise programs for CFS patients.