Testing for Post-Exertional Malaise

Dolphin

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Moderator Note - this thread was split from http://forums.phoenixrising.me/inde...sical-activity-in-cfs-meeus-et-al-2011.13139/

mtnbibliophile - perhaps this might be of value in some way:

Postexertional malaise in women with chronic fatigue syndrome.

J Womens Health (Larchmt). 2010 Feb;19(2):239-44.
VanNess JM, Stevens SR, Bateman L, Stiles TL, Snell CR.
Source

Pacific Fatigue Laboratory, University of the Pacific, Stockton, California 95211, USA. mvanness@pacific.edu

Abstract

OBJECTIVE:

Postexertional malaise (PEM) is a defining characteristic of chronic fatigue syndrome (CFS) that remains a source of some controversy. The purpose of this study was to explore the effects of an exercise challenge on CFS symptoms from a patient perspective.

METHODS:

This study included 25 female CFS patients and 23 age-matched sedentary controls. All participants underwent a maximal cardiopulmonary exercise test. Subjects completed a health and well-being survey (SF-36) 7 days postexercise. Subjects also provided, approximately 7 days after testing, written answers to open-ended questions pertaining to physical and cognitive responses to the test and length of recovery. SF-36 data were compared using multivariate analyses. Written questionnaire responses were used to determine recovery time as well as number andtype of symptoms experienced.
RESULTS:

Written questionnaires revealed that within 24 hours of the test, 85% of controls indicated full recovery, in contrast to 0 CFS patients. The remaining 15% of controls recovered within 48 hours of the test. In contrast, only 1 CFS patient recovered within 48 hours. Symptoms reported after the exercise test included fatigue, light-headedness, muscular/joint pain, cognitive dysfunction, headache, nausea, physical weakness, trembling/instability, insomnia, and sore throat/glands. A significant multivariate effect for the SF-36 responses (p < 0.001) indicated lower functioning among the CFS patients, which was most pronounced for items measuring physiological function.

CONCLUSIONS:

The results of this study suggest that PEM is both a real and an incapacitating condition for women with CFS and thattheir responses to exercise are distinctively different from those of sedentary controls.
PMID:

20095909

[PubMed - indexed for MEDLINE]
 
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Dolphin, in addition to the Stevens study on post-exertional malaise you cited above, I recommend Dr. Keller's presentation, Exercise Testing to Quantify Effects of Fatigue on Functional Capacity in Patients With CFS by Keller, B.A., Micale, FG, Ithaca College, which I have lost the url for (Sorry!) Furthermore, I STRONGLY recommend that anyone who needs to provide documented evidence of the extent of their CFS fatigue or existence of PEM make their way to Ithaca for Dr. Keller's two-day exercise tolerance test. Unfortunately, Ithaca is not easily accessible from most places, but it was worth the trip for me (9 hrs to get home via bus). It provided terrific evidence for my disability appeal, plus I have never had any other doctor so generous with her time in explaining my test results as Dr. Keller was. She's a PhD physiologist, not an MD, which might explain some of her willingness to devote time to me, but she's also simply a very caring as well as very intelligent person. Her entire staff demonstrated a real concern for her patients.
 

Dolphin

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Dolphin, in addition to the Stevens study on post-exertional malaise you cited above, I recommend Dr. Keller's presentation, Exercise Testing to Quantify Effects of Fatigue on Functional Capacity in Patients With CFS by Keller, B.A., Micale, FG, Ithaca College, which I have lost the url for (Sorry!) Furthermore, I STRONGLY recommend that anyone who needs to provide documented evidence of the extent of their CFS fatigue or existence of PEM make their way to Ithaca for Dr. Keller's two-day exercise tolerance test. Unfortunately, Ithaca is not easily accessible from most places, but it was worth the trip for me (9 hrs to get home via bus). It provided terrific evidence for my disability appeal, plus I have never had any other doctor so generous with her time in explaining my test results as Dr. Keller was. She's a PhD physiologist, not an MD, which might explain some of her willingness to devote time to me, but she's also simply a very caring as well as very intelligent person. Her entire staff demonstrated a real concern for her patients.
The only time I came across her that I recall was at the IACFS/ME 2011 conference. I hope she publishes.

http://www.iacfsme.org/LinkClick.aspx?fileticket=+G6GTkbP33I=&tabid=499

Session: IDENTIFYING ABNORMALITIES IN CFS/ME: THE IMPORTANCE OF EXERCISE CHALLENGE
Chair Staci R. Stevens, M.A.

Exercise Testing to Quantify Effects of Fatigue on Functional Capacity in Patients With CFS

Betsy A. Keller, B.A.
Micale, FG Ithaca College

Objective:
The purpose of this study was to assess the effects of post-exertional malaise (PEM) on functional capacity and anaerobic threshold in subjects diagnosed with chronic fatigue syndrome (CFS).

Methods:

Subjects were 10 females and 2 males (41.3+1.11 yrs) diagnosed with CFS by a physician experienced in the diagnosis of CFS.

To induce PEM, each subject completed a maximum exercise test on a cycle ergometer.

A second maximum exercise test was performed 24 hrs later to assess the effects of exercise-induced PEM on functional capacity.

Maximum oxygen consumption (VO2max), maximum heart rate (HRmax), anaerobic threshold (AT), maximum workload (Wmax), workload at AT (ATwork), and respiratory exchange ratio (RER) were measured.

RER is an objective indicator of substrate utilization and subject effort during exercise.

Results:

Significant decreases from test 1 to test 2 were 13.5% for VO2max (21.5 to 18.6 ml.kg-1.min-1; p<0.01), 8 bpm for HRmax (p<0.01), 18.8% for AT (12.0 to 9.7 ml.kg-1.min-1; p<0.05), 9.4% for Wmax (121 to 109 W, p<0.05), and 17.3% for ATwork (58.3 to 48.2 W; p<0.05).

However, there was no change in maximum RER indicating that subject effort was maximum and also comparable during both tests.

Conclusion:

Results indicate that PEM decreased maximum functional capacity by more than 13% to below 5 METS; a level at or below that which is required by many job-related activities and IADLs.

To compare, VO2max in healthy individuals is highly reproducible over days and even months (r>.95)1, with a SEM of < 6%1,2.

Thus, for subjects in this study, an expected variation between tests would be ±1.29 ml.kg-1.min-1 in contrast to the observed decrease of 2.9 ml.kg-1.min-1.

Furthermore, PEM decreased AT to below 3 METS (e.g., light-moderate speed walking), which is a level of many activities considered to be sedentary in nature.

Thus, completion of sedentary ADLs and IADLs for those with CFS requires production of energy via anaerobic processes that will further contribute to PEM and exacerbate symptoms of CFS.

Since many daily activities fall into the 3-5 MET range, individuals with CFS will exacerbate symptoms associated with PEM simply by completing normal daily activities.

1Taylor, HL, Buskirk, E & Henschel, A. (1955). Maximal oxygen intake as an objective measure of cardiorespiratory performance. J Appl Physiol, 8, 73-80.

2Katch, VL, Sady, SS & Freedson, P. (1982). Biological variability in maximum aerobic power. Med Sci Sports & Ex, 14(1), 21-25.

Betsy A. Keller, PhD, Professor, Exercise & Sport Sciences, Ithaca College, 318 Center for Health Sciences, Ithaca, NY 14850 keller@ithaca.edu

Frank G. Micale, M.S., Clinical Associate Professor, Exercise & Sport Sciences, Ithaca College, 317 Center for Health Sciences, Ithaca, NY 14850 fmicale@ithaca.edu
 
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Thank you - that's exactly the study I meant. Her sample was unfortunately very small, so I hope she republishes when she has more data. Also she's starting a new (related) study which I will post more about next Tuesday after she comes by my house to do the testing for it.
 

peggy-sue

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And still the psychs say there are no tests for ME!:mad:

Dolphin, I'd really like to thank you too, for posting and analysing this paper. I was sitting here reading your work, and thinking to myself; "Dolphin's doing a better job on this than the authors did!" THANK-YOU!
 
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Unfortunately, there still is not a single definitive test, because post-exertional malaise can be caused by other things. But the number of tests that can be done to show symptoms that have a high correlation with CFS/ME is mounting, and that is making it easier to prove we're sick. Even more unfortunately, it's not just the psychs who say there are no tests for ME. The Social Security Administration, disability insurance companies, most non-CFS-ers who write about it, and most doctors and researchers still take the position that there are no tests for CFS/ME.
 
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Incidentally, when I did Keller's PEM test, it also showed that my performance on the first day of the test was way below normal, that is, my energy level was significantly below normal even before exercise. I got dynamite results from this test for my disability insurance case. If you take it, though, be prepared for a total crash for at least a couple days (I was totally bedridden for a couple weeks, didn't dare drive a car for another week after that).
 

anciendaze

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When I just repeated a search for this study, I also turned up a paper from 1995.

The use of cardiopulmonary exercise testing is not only valid and reliable, but also serves as an objective indicator for assessing disability through the evaluation of functional capacity. In
working with Dr. Daniel Peterson for the last six years, we have been very successful in ...
Apparently they have been very successful in getting ignored since 1989!

You might think this work has never been replicated, but that would be wrong.
Physiological responses to incremental exercise in patients with chronic fatigue syndrome.
http://europepmc.org/abstract/MED/11528333
Patients with chronic fatigue syndrome performed worse than controls in a controlled repeated exercise study despite a normal oxidative phosphorylation …


So when does serious consideration of CPET reach CDC attention? 2014.

Keller turns up in two other papers,
A diagnostic test for the identification of metabolic dysfunction

Snell, Christopher R., J. Mark VanNess, Staci R. Stevens, Lucinda Bateman, and Betsy Keller. "Intravenous Saline Administration Improves Physical Functioning in a Patient with Chronic Fatigue Syndrome: 2064: Board# 1 2: 00 PM–3: 00 PM." Medicine & Science in Sports & Exercise 38, no. 5 (2006): S359.

What I find most curious here is that the effect of a liter of IV saline on patients, and the vulnerability to episodic dehydration and hypovolemia, are part of the folklore of this disease, but virtually never taken seriously.

(A friend of mine just spent some thousands of dollars on an ambulance ride to get 1 liter of IV saline, after which nobody could find anything wrong.)


Since everyone "important" seems to know in advance that we are all wimps, it is interesting to read of a case involving an "ultra-endurance" cyclist. The problem with this paper is that, because a muscle biopsy showed no defect, the problem was assumed to be merely a matter of perception, though possibly neurological. Can anyone explain how perceptual defects are able to lower anaerobic threshold?

Forget that last, there are people with advanced degrees who can explain any result. This should be a prime indication that they are no longer connected with science.
 

Dolphin

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Yes, I'm on researchgate but I signed out before and was able to get downloads when somebody said they had difficulty. I think the trick, for want of a better word, was to click "download" when one got the preview of the paper. But Bob has shown how to do it above in this case.