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Physical activity intensity but not sedentary activity is reduced in CFS (Newton, 11)

Dolphin

Senior Member
Messages
17,567
Latest paper by Julia Newton

Physical activity intensity but not sedentary activity is reduced in chronic fatigue syndrome and is associated with autonomic regulation.

QJM. 2011 Mar 7. [Epub ahead of print]

Newton JL, Pairman J, Hallsworth K, Moore S, Pltz T, Trenell MI.

From the UK National Institute for Health Research Biomedical Research Centre in Ageing & Age-related Disease, Institute for Ageing and Health, Newcastle University, Newcastle, UK, MRC Centre for Brain Ageing & Vitality, Newcastle University, Newcastle upon Tyne and School of Computing Science, Newcastle University, Newcastle upon Tyne, UK.

Abstract
BACKGROUND: Chronic fatigue syndrome (CFS) is a common debilitating condition associated with reduced function and impaired quality of life. The cause is unknown and treatments limited. Studies confirm that CFS is associated with impaired autonomic regulation and impaired muscle function.

AIM: Define the relationship between sedentary behaviour, physical activity and autonomic regulation in people with CFS.

DESIGN: Cohort study.

METHODS: Physical activity was assessed objectively in 107 CFS patients (Fukuda) and age, sex and body mass index (BMI)-matched sedentary controls (n = 107). Fatigue severity was determined using the Fatigue Impact Scale in all participants and heart rate variability performed in the CFS group.

RESULTS: The CFS group had levels and patterns of sedentary behaviour similar to non-fatigue controls (P > 0.05). Seventy-nine percent of the CFS group did not achieve the WHO recommended 10 000 steps per day. Active energy expenditure [time >3 METs (metabolic equivalents)] was reduced in CFS when compared with controls (P < 0.0001). Physical activity duration was inversely associated with resting heart rate (P = 0.04; r(2) = 0.03), with reduced activity significantly associating with reduced heart rate variability in CFS. There were no relationships between fatigue severity and any parameter of activity. Thirty-seven percent of the CFS group were overweight (BMI 25-29.9) and 20% obese (BMI ≥30).

CONCLUSION: Low levels of physical activity reported in CFS represent a significant and potentially modifiable perpetuating factor in CFS and are not attributable to high levels of sedentary activity, rather a decrease in physical activity intensity. The reduction in physical activity can in part be explained by autonomic dysfunction but not fatigue severity.

PMID: 21382927 [PubMed - as supplied by publisher]
 

Dolphin

Senior Member
Messages
17,567
Seventy-nine percent of the CFS group did not achieve the WHO recommended 10 000 steps per day.
So 21% did.

One hundred
and seven age-, gender- and BMI-matched
control individuals (n = 107) who did not take part
in regular exercise (<30 min exercise three times per
week) and did not have CFS were also recruited.
I think I've seen more sedentary groups.

Steps (per day) Controls: 10270 (3999) CFS: 7089 (3096) <0.0001


This is the most detailed/best I've seen in ME/CFS research
Objective habitual physical activity assessment

Habitual physical activity was measured objectively
using a validated25 multi-sensor array (SenseWear
Pro3, Bodymedia Inc., PA, USA) worn over 7 days.
The multi-sensor array measures four key metrics:
skin temperature, galvanic skin response, heat flux
and motion via a 3-axis accelerometer. The sensors
combined with algorithms, calculate the average
daily energy expenditure relative to baseline metabolism
[metabolic equivalent: MET per day (1 MET =
resting metabolic rate)], total energy expenditure
(calories per day), active energy expenditure (total
calories expended over 3 METS per day), physical
activity duration (minutes >3 METS per day) and
average daily number of steps walked. Patterns of
sedentary behaviour were assessed by power law
analyses of the lengths of sedentary bouts fitted from
raw sedentary data as described in more detail previously.
26 Probabilities of bout lengths were plotted
against the fraction of total sedentary time. Activity
patterns were also assessed by assessing transitions
from active to inactive period, termed ‘zero-crossing
rate’ and normalized by the length of the recording.

The following is interesting:
Compared to the age-, sex- and BMI-matched
controls; the CFS group had significantly reduced
physical activity duration, steps, average METS (all
P < 0.0001; Table 1 and Figure 1). Total energy
expenditure (EE) was significantly lower in CFS compared
with controls (P < 0.0001; Table 1); however,
there was no significant difference in the time spent
in sedentary activity (Table 1). A further analysis of
the pattern of sedentary behaviour also shows that
there are no differences in the transition from being
sedentary to being active (termed zero-crossing rate)
or in the duration of sedentary bout length (Figure 2).
Importantly the reduction physical activity was
related to significantly lower levels of moderate
and vigorous activity in the CFS group compared
to controls (Table 1).
The CBT School of thought say we spend too much time resting/in bed. This shows we spend no more time being sedentary than others (it's just that for the rest of the time, our activities are less intense).

They talk about this in the discussion section:
Our data on well-matched individuals
shows clearly that people with CFS do not
have increased periods of sedentary activity, in contrast
to previous observations.20 The similar level of
sedentary behaviour between CFS and controls is of
clinical relevance as sedentary behaviour is acknowledged
to have a strong adverse influence upon
healthy living, compounding metabolic diseases
and reducing life expectancy.13,14,17,32 Recent studies
report that the breaks in sedentary time provide
an even stronger indicator of metabolic risk than
total sedentary duration alone.32 The breaks in sedentary
time, the transition from being sedentary to
being active (zero-crossing rate), provides a physiological
stimulus which increases peripheral blood
flow maintains cellular signalling.34

In contrast to the sedentary data, when comparing
levels of active energy expenditure, patients with
CFS show a 30% reduction in moderate energy
expenditure and a 50% reduction in time spent performing vigorous activity. Combined with the
sedentary behaviour data, this observation suggests
that people with CFS move the same amount as
people without CFS. However, the intensity of the
activity is reduced in CFS. It is possible that the
reduction in physical activity intensity relates not
to motivation to be physically active, rather a functional
deregulation in the muscle or autonomic
function. Recent observations from our group and
others suggest that muscle metabolism is impaired
in CFS, with a rapid accumulation of acid inside
of skeletal muscle in CFS.9,10 Furthermore, subtle
abnormalities in cardiac bioenergetic function in
CFS suggest changes in autonomic function, possibly
relating to altered autonomic function.35 The
combined effect of metabolic and autonomic deregulation
observed in these studies would be a
decreased exercise tolerance, a possible explanation
for the decreased intensity of physical activity
in the present study. Alternatively, it may be that
patients with CFS avoid increased activity because
of perceived negative consequences such as
post-exertional malaise or increased pain.36

We were surprised to find that there was no relationship
between increased fatigue and reduced habitual
physical activity, which is in contrast to other
studies.20 We would suggest that this is explained by
a ceiling affect in the symptom assessment tools i.e.
a relatively low symptom burden leads to significant
impact upon physical activity levels. Previous studies
have also reported mixed groups of patients
with CFS and multiple sclerosis making comparison
difficult.
I'm not sure what they are getting at here. I wonder is the ceiling effect in the fatigue scale i.e. the moderate and severe patients score similar (high) scores.

I find this bit annoying:
However, individualized programmes targeting increases in habitual physical
activity at often initially a very low level of intensity
can lead to benefits for patients.39 It is vital that
those with CFS are encouraged to increase their habitual
physical activity, as this is a significant environmental
factor influencing physical fitness and
well-being. Evidence suggests that physical activity
helps maintain physical function, delays the onset
of disability, reduces mortality and extends life expectancy
in normal ageing.14–16 In other fatigue
associated diseases (multiple sclerosis), those who
participate in regular physical exercise report better
fatigue, depression and quality of life scores.40
Combined, the present study highlights the importance
of targeting sedentary behaviour and exercise
tolerance in CFS. Other studies suggest a benefit of
increasing physical activity. The challenge ahead
is to understand how these observations can be
incorporated into clinical care.
I think the evidence from other programs is weak. For example, Wiborg et al. (2010) found that there was no increase in activity levels over the control group from the three supposedly-successful CBT programs involving CBT.

And I don't like them using "sedentary behaviour" here when their own study found the CFS patients weren't anymore sedentary.
 

ixchelkali

Senior Member
Messages
1,107
Location
Long Beach, CA
News flash: ME/CFS patients have reduced levels of physical activity. No duh.

Low levels of physical activity reported in CFS represent a significant and potentially modifiable perpetuating factor in CFS and are not attributable to high levels of sedentary activity, rather a decrease in physical activity intensity.

So their research demonstrates that low levels of physical activity are attributable to a decrease in physical activity intensity. Brilliant.:rolleyes:

This is what they're spending precious research dollars on.
 

*GG*

senior member
Messages
6,389
Location
Concord, NH
News flash: ME/CFS patients have reduced levels of physical activity. No duh.



So their research demonstrates that low levels of physical activity are attributable to a decrease in physical activity intensity. Brilliant.:rolleyes:

This is what they're spending precious research dollars on.

I concur!

GG
 

xchocoholic

Senior Member
Messages
2,947
Location
Florida
News flash: ME/CFS patients have reduced levels of physical activity. No duh.



So their research demonstrates that low levels of physical activity are attributable to a decrease in physical activity intensity. Brilliant.:rolleyes:

This is what they're spending precious research dollars on.

Geesh ... Why do they keep doing ridiculous studies like this ? I'd like to have access to their bank accounts for just one day .... ugh .... x
 

SOC

Senior Member
Messages
7,849
Did they test another bunch of non-PWCs? Maybe a group of poorly managed depressives?
 

oceanblue

Guest
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1,383
Location
UK
This is the most detailed/best I've seen in ME/CFS research

The following is interesting:

The CBT School of thought say we spend too much time resting/in bed. This shows we spend no more time being sedentary than others (it's just that for the rest of the time, our activities are less intense).
Agreed, I think that overall the findings are interesting and important, despite some of the unsubtantiated conclusions. As they say, the fact that they used large and well matched sample as well as control groups make these findings more reliable than those from other studies:

Physical activity has been theoretically linked to
symptom presentation,33 with patients suggested to
relate physical activity to fatigue and myalgia. This
in turn produces an avoidance of physical activity as
patients attempt to reduce symptoms. Despite this
hypothetical link, there is very limited data to support
this in CFS.20 Our data on well-matched individuals
shows clearly that people with CFS do not
have increased periods of sedentary activity, in contrast
to previous observations
.

...suggests that people with CFS move the same amount as
people without CFS. However, the intensity of the
activity is reduced in CFS. It is possible that the
reduction in physical activity intensity relates not
to motivation to be physically activ
e, rather a functional
deregulation in the muscle or autonomic function.
As Dolphin implies, this undoes the 'pervasively inactive' theory of the biopsychosocialists.

My once concern is that this study found no correlation between fatigue and activity levels, which is suprising. One possiblility is that the CFS particpants were all Pacing, modifying their activity levels to control fatigue.
 

ixchelkali

Senior Member
Messages
1,107
Location
Long Beach, CA
My once concern is that this study found no correlation between fatigue and activity levels, which is suprising. One possiblility is that the CFS particpants were all Pacing, modifying their activity levels to control fatigue.

Another possibility is that few, if any, of their subjects had CFS, but instead their cohort was a mixed bag of idiopathic fatigue and depression patients.
 

oceanblue

Guest
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Location
UK
Another possibility is that few, if any, of their subjects had CFS, but instead their cohort was a mixed bag of idiopathic fatigue and depression patients.
the paper states that the patients were all diagnosed according to Fukuda criteria so it would be suprising if 'few, if any' had CFS, but the fact that 21% met the WHO guidelines for 10,000 steps a day suggests that as a group they were not exactly severely affected.
 

Dolphin

Senior Member
Messages
17,567
I'm curious as to what this citation 20 is.
20. Vercoulen JHMM, Bazelmans E, Swanink CMA, Fennis JFM,
Galama JMD, Jongen PJH, et al. Physical activity in chronic
fatigue syndrome: assessment and its role in fatigue. J of
Psychiatric Research 1997; 31:66173.
 

biophile

Places I'd rather be.
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8,977
oceanblue wrote: My one concern is that this study found no correlation between fatigue and activity levels, which is surprising. One possiblility is that the CFS particpants were all Pacing, modifying their activity levels to control fatigue. [...] The paper states that the patients were all diagnosed according to Fukuda criteria so it would be suprising if 'few, if any' had CFS, but the fact that 21% met the WHO guidelines for 10,000 steps a day suggests that as a group they were not exactly severely affected.

My post was inspired by oceanblue's comments rather than a direct response to them. Newton et al 2011 found that low levels of overall physical activity are attributed to a decrease in physical activity intensity rather than high levels of sedentary activity. Like others here, I don't like how the findings refuted one piece of behaviour-babble (patients spend way too much time resting or in bed) only for the authors to replace it with another ("potentially modifiable perpetuating factor" = CFS patients just need GET to successfully increase the intensity of physical activity).

There are good reasons why patients avoid physical activity of higher intensity. Years ago I wondered if low intensity GET didn't work then maybe I just needed to do shorter bursts of more intense activity, let's just say it didn't work out either. ;-) The authors themselves mention a few possibilities, a "functional deregulation in the muscle or autonomic function" or patients avoid activity because of "perceived negative consequences such as post-exertional malaise or increased pain".

Recently however, another group of researchers (Meeus et al 2011) not only found their CFS patients to be more sedentary than healthy sedentary controls but found that patients who were less active and more sedentary with better "activity dispersion" reported fewer symptoms and variations on the same and next day. Here is the results in the abstract, some but not all of the findings seem to be opposite of Newton et al 2011:

RESULTS: Patients with CFS were less active, spent more time sedentary, and less time lightly active (P<.05). The course of the activity level during the registration period (P interaction>.05), peak activity, and the staggering of activities (ratio peak/average) on 1 day were not different between groups (P>.05). Negative correlations (-.242 varying to -.307) were observed for sedentary activity and the ratio with symptom severity and variation on the same and the next day. Light, moderate, and vigorous, as well as the average activity and the peak activity, were positively correlated (.242 varying to .421) with symptom severity and variation.

CONCLUSIONS: The more patients with CFS are sedentary and the better activity is dispersed, the fewer symptoms and variations they experience on the same and next day. Inversely, more symptoms and variability is experienced when patients were more active that day or the previous day. The direction of these relations cannot be determined in a cross-sectional study and requires further study.

http://www.ncbi.nlm.nih.gov/pubmed/22032215

As for the lack of correlation between fatigue severity and physical activity in Newton et al 2011, it may depend on how fatigue is measured, perhaps it is the decades of researchers' overemphasis on fatigue which may make this finding surprising if we are used to the paradigm that ME/CFS is primarily about fatigue, but I'm not that surprised and there are a number of possible explanations.

In my own experience a later decline of function compared to the earlier years has been less about baseline fatigue and more about other symptoms or complications and the body's inability to sustain normal output without worse consequences, especially at higher intensities of activity. I also remember reading an article about the stages of ME (from Cheney or Ramsay?) where baseline fatigue or whatever often improving but long-term patients often remain even more impaired than before because of the toll on the body and additional symptoms etc.

As oceanblue's comments suggest, those with more severe illness leading to lower physical activity may have already adapted their activity pattern to control the fatigue. Whereas some high functioning patients in the earlier stages of illness may have higher than expected levels of fatigue because they are in a constant state of post-exertional fatigue due to pushing through symptoms to attempt normal living while their body still can. There are countless anecdotes of such patients who were able to do this in the beginning (contrary to all the simplistic decondition-babble) only for it to eventually take a massive toll on them in the long-term.

Newton et al 2011 wrote on the lack of correlation: "We would suggest that this is explained by a ceiling affect in the symptom assessment tools i.e. a relatively low symptom burden leads to significant impact upon physical activity levels." Are they saying, as Dolphin suggested "the moderate and severe patients score similar (high) scores", or are they saying patients are just over sensitive to minor increases in symptoms?

There is also two recent systematic reviews to consider:

* "Tired of being inactive: a systematic literature review of physical activity, physiological exercise capacity and muscle strength in patients with chronic fatigue syndrome." (Nijs et al 2011) http://www.ncbi.nlm.nih.gov/pubmed/21166613

* "Daily physical activity of patients with the chronic fatigue syndrome; a systematic review." (Evering et al 2011) http://www.ncbi.nlm.nih.gov/pubmed/20943713
 

Wonko

Senior Member
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1,467
Location
The other side.
i for one take on board that my percieved risk of negative consequences has limited my physical activities in a detrematal manner, so I'm off to hold a picnic in the fast lane of a motorway, after all how many people actually suffer harm doing this, the risk is clearly totally imaginary.
 

alex3619

Senior Member
Messages
13,810
Location
Logan, Queensland, Australia
I have not read the full paper, but again it appears that issues with severe and very severe patients are ignored. Most studies appear to be for mild patients with a few moderate patients thrown in. Severe or worse would require the study to be done in their own homes. So again how relevant is this to severe ME? If it is not relevant for severe ME, how can we be sure its relevant for mild ME and not erroneous?

From my own experience I am as active as I can be without crashing. It took many years for me to learn to pace myself, but mostly I can succeed now. Ummm, scratch that, I am a stubborn cuss and believed in the value of exercise for a very long time, it took way over a decade from the commencement of mild symptoms (less than 50% functional capacity) before I finally realized I was never going to make it work.

Bye, Alex
 

Dolphin

Senior Member
Messages
17,567
There are good reasons why patients avoid physical activity of higher intensity. Years ago I wondered if low intensity GET didn't work then maybe I just needed to do shorter bursts of more intense activity, let's just say it didn't work out either. ;-)
Sorry to hear that.

I remember reading (I think it was in a book by Dr. Anne Macintyre or Charles Shepherd) about somebody sprinting for a bus and "knocking themselves out" for 3 months.
I managed for five years undiagnosed - four years fairly highly functioning (full-time education, high level). How I think I survived was a bit fortuitous: I sprained my hamstring early in the (undiagnosed) illness (hamstring is muscle/tendon at back of leg). I was sports mad before the illness so after occasionally playing and finding it would flare up, I tried to nurse it, lots of stretches, etc. - I would "beat myself up" if I have started sprinting or even going fast as my hamstring would flair up. So by avoiding sprinting, I think it enabled me function at a high level (I even got my exercise up to a level of 6 mile cycle/1000m swimming every two days for a year (before relapsing) (swimming did involve 30 second break every 50m - I found I got out of breath). Anyway, my experience along with the anecdote in the book, etc. makes me thinking high intensity activities don't suit this illness.
 
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My ergotherapist told me to do less when I'm consistently doing activities that I perceive to be of moderate intensity, such as cooking or brushing my teeth, or occasionally doing high intensity activities like cleaning.

Then two weeks later, my physiotherapist looked at my activity results from a SenseWear arm band (coincidentally taken during a crash brought on by briefly tensing muscles as a relaxation exercise), and said I'm not doing enough moderate intensity exercise when I was consistently doing brief light intensity activities (included in the same category as not moving at all) to avoid another crash.

Depending on how the next visits go, I'm thinking of locking them in a room together until they sort it out. Possibly with the relaxation therapist and psychologist thrown into the mix for good measure :p
 

WillowJ

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WA, USA
Whereas some high functioning patients in the earlier stages of illness may have higher than expected levels of fatigue because they are in a constant state of post-exertional fatigue due to pushing through symptoms to attempt normal living while their body still can. There are countless anecdotes of such patients who were able to do this in the beginning (contrary to all the simplistic decondition-babble) only for it to eventually take a massive toll on them in the long-term.

& that would include me. i didn't know. Even now that I know, I still may do more than I "should", because I need to (to perform basic self-care, to be minimally responsible towards my family, and to better the situation of myself and my compatriots with ME & similarly neglected/maligned conditions; I refuse to sit by and allow the status quo to continue unchallenged).

Whoever thinks we are underperforming, fleeing the pressures of the work-a-day world, seeking secondary gains from illness, etc., has never carefully considered us without an a priori determination of what they would find.
 

Dolphin

Senior Member
Messages
17,567
biophile said:
Whereas some high functioning patients in the earlier stages of illness may have higher than expected levels of fatigue because they are in a constant state of post-exertional fatigue due to pushing through symptoms to attempt normal living while their body still can. There are countless anecdotes of such patients who were able to do this in the beginning (contrary to all the simplistic decondition-babble) only for it to eventually take a massive toll on them in the long-term.

& that would include me. i didn't know. Even now that I know, I still may do more than I "should", because I need to (to perform basic self-care, to be minimally responsible towards my family, and to better the situation of myself and my compatriots with ME & similarly neglected/maligned conditions; I refuse to sit by and allow the status quo to continue unchallenged).

Whoever thinks we are underperforming, fleeing the pressures of the work-a-day world, seeking secondary gains from illness, etc., has never carefully considered us without an a priori determination of what they would find.
Of course, we seem to be in a no-win situation: some say we are action-prone while then we supposedly under do it. Wessely (?) said something like 2 star ability, 5 star ambition - yet he was one of the people most pushing the CBT model largely based on us underdoing it.