Symptom fluctuations and daily physical activity in CFS (Meeus et al, 2011)

[Dolphin]

I read the full text of this today. I'll post some comments below.

Symptom fluctuations and daily physical activity in patients with chronic fatigue syndrome: a case-control study.

Arch Phys Med Rehabil. 2011 Nov;92(11):1820-6.

Meeus M, van Eupen I, van Baarle E, De Boeck V, Luyckx A, Kos D, Nijs J.

Source
Division of Musculoskeletal Physiotherapy, Department of Health Sciences, Artesis University College Antwerp, Antwerp, Belgium; Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium.

Abstract

Meeus M, van Eupen I, van Baarle E, De Boeck V, Luyckx A, Kos D, Nijs J. Symptom fluctuations and daily physical activity in patients with chronic fatigue syndrome: a case-control study.

OBJECTIVES:
To compare the activity pattern of patients with chronic fatigue syndrome (CFS) with healthy sedentary subjects and examine the relationship between the different parameters of performed activity (registered by an accelerometer device) and symptom severity and fluctuation (registered by questionnaires) in patients with CFS.

DESIGN:
Case-control study. Participants were asked to wear an accelerometer device on the nondominant hand for 6 consecutive days. Every morning, afternoon, and evening patients scored the intensity of their pain, fatigue, and concentration difficulties on a visual analog scale.

SETTING:
Patients were recruited from a specialized chronic fatigue clinic in the university hospital, where all subjects were invited for 2 appointments (for questionnaire and accelerometer adjustments). In between, activity data were collected in the subject's normal home environment.

PARTICIPANTS:
Female patients (n=67) with CFS and female age-matched healthy sedentary controls.

INTERVENTIONS:
Not applicable.

MAIN OUTCOME MEASURES:
Accelerometry (average activity counts, peak activity counts, ratio peak/average, minutes spent per activity category) and symptom severity (intensity of pain, fatigue, and concentration difficulties).

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.

 

[Dolphin]

Two extracts from introduction

From introduction:

Based on their behavior, patients with CFS can be
categorized in 2 subgroups: those who feel helpless and avoid
activity, resulting in extremely passive behavior and those who
are characterized by a highly variable activity pattern. On good
moments, they try to move mountains, leading to exhaustion
and longer periods of recovery. It is suspected that both types
of physical behavior are maladaptive.9

- patients can't win!

On the other hand (not directly after), for CFS, typical postexertional malaise or symptom exacerbation after
physical activity should be taken onto account.1 This is a primary
characteristic evident in up to 95% of patients with CFS 13 and is
not present in other disorders where fatigue is a predominant
symptom such as depression or rheumatoid arthritis.14,15 Postexertional
malaise is one of the best predictors of the differential
diagnosis of CFS and major depressive disorder.16 After a maximal
effort, patients with CFS stay exhausted for a longer period
(up to 2d), compared with controls, experiencing fatigue up to 2
hours after the effort.17,18 There is evidence of impaired pain
inhibition19 and further immune deregulation after exaggerated
physical activity in patients with CFS.14,20 The reported increase
in oxidative stress20 and the complement activation14 after exercise
may explain the postexertional malaise and the typical exacerbation
in symptoms.

 

[Dolphin]

Control group

Control group:

Sedentary was defined as a sedentary job and less than 3 hours of
moderate physical activity/week (activity demanding at least
the threefold of the energy spent passively).22

Participants did not differ significantly concerning age, weight, or minutes
of sports or exercise per week. The majority of the patients
with CFS (n=43 or 64.2%) were not professionally active, compared
with 11 subjects of the control group (16.7%).

"professionally active" = in employment (I presume)

 

[Dolphin]

Comparison of CFS and Controls

Compared with the sedentary controls, patients with CFS
displayed an overall lower activity level, with more time spent
sedentary and less time spent lightly active. We found that the
average ACs were 17.8% lower during the weekdays and
19.5% lower during the weekend. This is in line with other
studies reporting that patients with CFS are 15% to 45% less
active compared with sedentary controls.5-7 The peak values
were not significantly lower in patients with CFS. These results
are contradictory to the results of van der Werf et al,6 who
found less active activity peaks in patients with CFS.

6. van der Werf SP, Prins JB, Vercoulen JH, van der Meer JW,
Bleijenberg G. Identifying physical activity patterns in chronic
fatigue syndrome using actigraphic assessment. J Psychosom Res
2000;49:373-9.

They are also in contrast to

Physical activity intensity but not sedentary activity is reduced in chronic fatigue syndrome and is associated with autonomic regulation.
QJM. 2011 Aug;104(8):681-7. Epub 2011 Mar 7.
Newton JL, Pairman J, Hallsworth K, Moore S, Pltz T, Trenell MI.
Discussed here: http://forums.phoenixrising.me/show...entary-activity-is-reduced-in-CFS-(Newton-11)

The amount of time sedentary in the two studies is hugely different:

Meeus:

Time sedentary (min)
CFS Weekday: 680.70(113.66) .000* Week end day: 720.69(131.07)
CON Weekday: 587.97(95.95) Week end day: 644.83(120.19)

p-values:
Weekday: .000*
Week end day: .001*

versus

Newton: Sedentary time (min) CON: 1213 (262) CFS: 1262 (177) (not statistically different)

Definition of sedentary in Meeus:

Besides generating the total amount of ACs and the average
amount of ACs per minute for each day, the Actical is able to
subdivide the daily activity in 4 activity levels: sedentary
activity (1metabolic equivalents [METs]), light activity
(3METs), moderate activity (36METs), and vigorous activity
(6METs).

I think sedentary in Newton might include anything under 3 METs; alternatively, they use a fancier technique:

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

26. Chastin SFM, Granat MH. Methods for objective measure,
quantification and analysis of sedentary behaviour and inactivity.
Gait Posture 2009; 31:826.

For light activity in Meeus, the controls did more of it:

Time light activity (min)
CFS 624.6585.03 .000*
CON 692.3969.57 634.8986.26
CFS Weekday: 624.65(85.03) Week end day: 592.57(100.65)
CON Weekday: 692.39(69.57) Week end day: 634.89(86.26)

p-values:
Weekday: .000*
Week end day: .010*

If on adds the two types of activity together:

CFS Weekday: 1325.35 Week end day: 1313.26
CON Weekday: 1280.36 Week end day: 1279.72

one sees results which are not that different for sedentary in the Newton group:

Newton: Sedentary time (min) CON: 1213 (262) CFS: 1262 (177) (in Newton, these figures were not statistically different)

Note: judging by the minutes in both studies, sleep time is counted within the total minutes (I have seen other studies that excluded it). So for example if people with CFS simply slept longer, that could potentially explain the difference in sedentary time between the CFS patients and controls.

 

[Dolphin]

CFS activity levels don't fluctuate any more than controls within a day or day-to-day

The present study is the first to compare the fluctuations in daily
physical activity between patients with CFS and healthy sedentary
controls. We hypothesized that patients with CFS would present a
more fluctuating activity pattern, with greater variations and a bad
staggering of activities during the day. Concerning the staggering
of activities during the day, we found higher ratios (peak activity
on average activity) in patients with CFS (not statistically significant - see next sentence). So, they tended to
concentrate their activities more in peaks (probably on their better
moments), instead of dispersing them, but the difference was not
statistically significant. Additionally, the fluctuations in the activity
pattern during the complete registration period were not significantly
different between patients and controls.
[..] the present study was not able to confirm the hypothesis of a more fluctuating
activity pattern in patients with CFS, nor during the day, nor
during the registration period.

"during the day" means within any one day.

Note, van der Werf found something similar on daily changes:

"there were no significant group, gender or interaction effects for the number of absolute large or relatively large day-to-day fluctuations (Table 2 and Table 3)." "The day-to-day fluctuation measures were based on somewhat arbitrary criteria (1 S.D. and 33% activity change). However, when we post hoc tested alternative criteria (50% or 66% activity change), again no significant group differences between controls and CFS patients emerged."

van der Werf SP, Prins JB, Vercoulen JH, van der Meer JW, Bleijenberg G. Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. J Psychosom Res. 2000 Nov;49(5):373-9.

This is interesting because part of the rationale of many behavioural interventions in CFS patients is said to be to reduce "boom and bust" (Deary & Chalder). However, it may be the case that the frequency of this activity pattern in CFS has been exaggerated. [ref: Deary V, Chalder T: Chapter 11, "Conceptualisation in Chronic Fatigue Syndrome" in Formulation and Treatment in Clinical Health Psychology Edited by Ana V. Nikcevic, Andrzej R. Kuczmierczyk, Michael Bruch]

 

[Dolphin]

Here's a bit more (trying not to copy and paste too much):

Regarding the associations with the activity pattern of the
previous day (they also looked at within the same day), similar results were found (to within the same day), indicative of the postexertional
malaise lasting for more than 24 hours. More physical
activity results in more complaints and more fluctuation, even the
day after. These results suggest that any physical activity leads to
more complaints, while the literature is rather shaded.

This is interesting:

Clinical Implications
Considering the present results, it may be hard to achieve the
right balance in the clinical approach of patients with CFS. It is
important to manage the activity pattern of patients with CFS,
aiming at a more functional level and avoiding deconditioning.
But it seems to be a very delicate assignment, to find a balance
between rest and activity.

A lot of psychs would give the management approach required would be fairly straightforward.

Prudence is called, and further study regarding the rehabilitation
of patients with CFS is warranted.

CONCLUSIONS
Patients with CFS were far more passive that healthy sedentary
control subjects. We found no evidence for important variations in
the activity pattern of patients with CFS during the day, or day by
day. But we did find correlations between symptom intensity and
the activity pattern, suggesting the close link between symptom
exacerbation and physical activity. Sedentary activity and staggering
of the activity (ratio) were negatively correlated to symptom
severity and variation on the same day and the next day. Light,
moderate, and vigorous activity, as well as average activity and
the activity peak, were positively correlated to symptom severity
and variation on the same day and the subsequent day. In consequence,
the present results require caution concerning physical
activity in patients with CFS.

 

[livingwithcfids]

Dolphin, nothing against you but this study sucks in that nothing was accomplished; just repetitive information known for the last 30 years. This study seemed like it could have been done in 2001, not 2011. I like how they used ALL females in the study with no explanation as to why.

Of course patients with CFS were less active
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."

They can't be serious. Exercise induces symptoms? Who would have guessed? Brainless Belgians!

 

[oceanblue]

Thanks for the helpful analysis, Dolphin. I only had the energy to skim it but you've highlighted some very important findings:

CONCLUSIONS
Patients with CFS were far more passive that healthy sedentary
control subjects. We found no evidence for important variations in
the activity pattern of patients with CFS during the day, or day by
day. But we did find correlations between symptom intensity and
the activity pattern, suggesting the close link between symptom
exacerbation and physical activity. Sedentary activity and staggering
of the activity (ratio) were negatively correlated to symptom
severity and variation on the same day and the next day. Light,
moderate, and vigorous activity, as well as average activity and
the activity peak, were positively correlated to symptom severity
and variation on the same day and the subsequent day. In consequence,
the present results require caution concerning physical
activity in patients with CFS.

Maybe the tide is finally turning.


This is odd though:

The peak values were not significantly lower in patients with CFS.

I would expect CFS patients to have less high-intensity activity (unless peak was defined relative to each participant's average activity) and this anomaly might cast doubt on some of the other findings.

 

[taniaaust1]

I havent been able to read this whole thread or whole first post but I certainly agree with what they come up with here. It supports what most of us say about pacing ourselves. Pacing is the only way I think we have any chance of getting stability with our illness.

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.

 

[Dolphin]

This is odd though:

The peak values were not significantly lower in patients with CFS.

I would expect CFS patients to have less high-intensity activity (unless peak was defined relative to each participant's average activity) and this anomaly might cast doubt on some of the other findings.

I think this bit relates to length of very vigorous activity. Neither group did very much of this.

Time very vigorous (min)

CFS Weekday: 0.65(2.30) Week end day: 0.66(2.00)
CON Weekday: 1.46(3.91) Week end day: 2.16(7.91)

p-values:
Weekday: .148
Week end day: .141

So there was a numerical difference, with the length of time more than double during the week and triple at week ends, on average, but there was a big variation (SD) in the control values meaning it wasn't statistically significant.

Perhaps if there were male controls rather sedentary female controls, there would be a difference.

So don't think the study would/should be dismissed for this finding.

 

[oceanblue]

I think this bit relates to length of very vigorous activity. Neither group did very much of this.

Time very vigorous (min)

CFS Weekday: 0.65(2.30) Week end day: 0.66(2.00)
CON Weekday: 1.46(3.91) Week end day: 2.16(7.91)

p-values:
Weekday: .148
Week end day: .141

So there was a numerical difference, with the length of time more than double during the week and triple at week ends, on average, but there was a big variation (SD) in the control values meaning it wasn't statistically significant.

Perhaps if there were male controls rather sedentary female controls, there would be a difference.

So don't think the study would/should be dismissed for this finding.

I'm reassured. There wasn't really enough data to draw any conclusion on vigorous activity levels at all (encouraging though that patients were numercially less active) so it seems reasonable to ignore it.

 

[Esther12]

Just posting to mark this thread for future reading... it looks interesting, but I've not had a chance today. Ta.

 

[Dolphin]

Just posting to mark this thread for future reading... it looks interesting, but I've not had a chance today. Ta.

I'm not sure what system you use - not sure if you know that under "thread tools" you can subscribe to a thread. I sometimes do that for some threads where I have read them but not posted a message.

 

[BEG]

I am appreciative, Dolphin, that you posted this article. Not only that, you posted it in a manner that made it easy to read and understand (for those of us whose fatigue can be measured also in brain activity.) Personally, I don't think this type of information can ever be overdone. We're fighting a very ignorant public . . . still. Lazy 'n crazy anyone?

A take away point for me: An exacerbation of symptoms with even light activity is not something to dismiss. It can be harmful. Who needs more oxidative stress?

I like that the authors used METS to define activity level. I believe that term is underused. During cardiopulmonary excercise terting, I learned the number of METS I can't exceed without symptoms. Believe me when I say that I shouldn't put my book down and get out of a chair, and a stroll around a mall is out of the question.

So thanks again, for painstakingly presenting this article, to reinforce what we already know, and to inform those who don't know.

 

[Dolphin]

I am appreciative, Dolphin, that you posted this article. Not only that, you posted it in a manner that made it easy to read and understand (for those of us whose fatigue can be measured also in brain activity.) Personally, I don't think this type of information can ever be overdone. We're fighting a very ignorant public . . . still. Lazy 'n crazy anyone?

A take away point for me: An exacerbation of symptoms with even light activity is not something to dismiss. It can be harmful. Who needs more oxidative stress?

I like that the authors used METS to define activity level. I believe that term is underused. During cardiopulmonary excercise terting, I learned the number of METS I can't exceed without symptoms. Believe me when I say that I shouldn't put my book down and get out of a chair, and a stroll around a mall is out of the question.

So thanks again, for painstakingly presenting this article, to reinforce what we already know, and to inform those who don't know.

Cheers Brown-eyed Girl. An earlier poster did say it was nothing against me personally so I didn't take it personally as post really directed at the whole research project rather than what I wrote. But useful to know somebody found it useful also. I partly write things like this for myself and my goldfish memory.

 

[Snow Leopard]

Hi Dolphin, I appreciate your analysis too, because you tend to report things in a similar way to what I'd think is important. So reading your analyses saves me a lot of time!

 

[WillowJ]

Thanks for this, Dolphin.

Archives of Physical Medicine and Rehabilitation... so the normal audience would be a journal for, occupational therapists, physical therapists, and the like, yes? that would be a good audience to educate. maybe also, social services might read it? would that be too much to hope for?

 

[barbc56]

What does subscribe to post mean? I usually bookmark things but sometimes on boards it will only save the front page of the board.

Obviously, not computer literate here. :>)

 

[Esther12]

What does subscribe to post mean?

I've got to admit - I'm not sure either. I had assumed it e-mailed you about updates, but this could be totally wrong. We could always just click on it, and find out!

 

[Dolphin]

I've got to admit - I'm not sure either. I had assumed it e-mailed you about updates, but this could be totally wrong. We could always just click on it, and find out!

Yes, you get updates. Some people may not like getting updates. I have updates sent to my E-mail* (but it doesn't have to be like that).

*Unless it's urgent, I then copy them in to a particular E-mail folder I have and follow the link when it suits better (well, that's the theory - I can't always restrain myself!).