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Review
. 2016 Dec 20;12(12):CD003200.
doi: 10.1002/14651858.CD003200.pub6.

Exercise Therapy for Chronic Fatigue Syndrome

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Free PMC article
Review

Exercise Therapy for Chronic Fatigue Syndrome

Lillebeth Larun et al. Cochrane Database Syst Rev. .
Free PMC article

Update in

  • Exercise therapy for chronic fatigue syndrome.
    Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Larun L, et al. Cochrane Database Syst Rev. 2017 Apr 25;4(4):CD003200. doi: 10.1002/14651858.CD003200.pub7. Cochrane Database Syst Rev. 2017. PMID: 28444695 Free PMC article. Updated. Review.

Abstract

Background: Chronic fatigue syndrome (CFS) is characterised by persistent, medically unexplained fatigue, as well as symptoms such as musculoskeletal pain, sleep disturbance, headaches and impaired concentration and short-term memory. CFS presents as a common, debilitating and serious health problem. Treatment may include physical interventions, such as exercise therapy, which was last reviewed in 2004.

Objectives: The objective of this review was to determine the effects of exercise therapy (ET) for patients with CFS as compared with any other intervention or control.• Exercise therapy versus 'passive control' (e.g. treatment as usual, waiting-list control, relaxation, flexibility).• Exercise therapy versus other active treatment (e.g. cognitive-behavioural therapy (CBT), cognitive treatment, supportive therapy, pacing, pharmacological therapy such as antidepressants).• Exercise therapy in combination with other specified treatment strategies versus other specified treatment strategies (e.g. exercise combined with pharmacological treatment vs pharmacological treatment alone).

Search methods: We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL) and SPORTDiscus up to May 2014 using a comprehensive list of free-text terms for CFS and exercise. We located unpublished or ongoing trials through the World Health Organization (WHO) International Clinical Trials Registry Platform (to May 2014). We screened reference lists of retrieved articles and contacted experts in the field for additional studies SELECTION CRITERIA: Randomised controlled trials involving adults with a primary diagnosis of CFS who were able to participate in exercise therapy. Studies had to compare exercise therapy with passive control, psychological therapies, adaptive pacing therapy or pharmacological therapy.

Data collection and analysis: Two review authors independently performed study selection, risk of bias assessments and data extraction. We combined continuous measures of outcomes using mean differences (MDs) and standardised mean differences (SMDs). We combined serious adverse reactions and drop-outs using risk ratios (RRs). We calculated an overall effect size with 95% confidence intervals (CIs) for each outcome.

Main results: We have included eight randomised controlled studies and have reported data from 1518 participants in this review. Three studies diagnosed individuals with CFS using the 1994 criteria of the Centers for Disease Control and Prevention (CDC); five used the Oxford criteria. Exercise therapy lasted from 12 to 26 weeks. Seven studies used variations of aerobic exercise therapy such as walking, swimming, cycling or dancing provided at mixed levels in terms of intensity of the aerobic exercise from very low to quite rigorous, whilst one study used anaerobic exercise. Control groups consisted of passive control (eight studies; e.g. treatment as usual, relaxation, flexibility) or CBT (two studies), cognitive therapy (one study), supportive listening (one study), pacing (one study), pharmacological treatment (one study) and combination treatment (one study). Risk of bias varied across studies, but within each study, little variation was found in the risk of bias across our primary and secondary outcome measures.Investigators compared exercise therapy with 'passive' control in eight trials, which enrolled 971 participants. Seven studies consistently showed a reduction in fatigue following exercise therapy at end of treatment, even though the fatigue scales used different scoring systems: an 11-item scale with a scoring system of 0 to 11 points (MD -6.06, 95% CI -6.95 to -5.17; one study, 148 participants; low-quality evidence); the same 11-item scale with a scoring system of 0 to 33 points (MD -2.82, 95% CI -4.07 to -1.57; three studies, 540 participants; moderate-quality evidence); and a 14-item scale with a scoring system of 0 to 42 points (MD -6.80, 95% CI -10.31 to -3.28; three studies, 152 participants; moderate-quality evidence). Serious adverse reactions were rare in both groups (RR 0.99, 95% CI 0.14 to 6.97; one study, 319 participants; moderate-quality evidence), but sparse data made it impossible for review authors to draw conclusions. Study authors reported a positive effect of exercise therapy at end of treatment with respect to sleep (MD -1.49, 95% CI -2.95 to -0.02; two studies, 323 participants), physical functioning (MD 13.10, 95% CI 1.98 to 24.22; five studies, 725 participants) and self-perceived changes in overall health (RR 1.83, 95% CI 1.39 to 2.40; four studies, 489 participants). It was not possible for review authors to draw conclusions regarding the remaining outcomes.Investigators compared exercise therapy with CBT in two trials (351 participants). One trial (298 participants) reported little or no difference in fatigue at end of treatment between the two groups using an 11-item scale with a scoring system of 0 to 33 points (MD 0.20, 95% CI -1.49 to 1.89). Both studies measured differences in fatigue at follow-up, but neither found differences between the two groups using an 11-item fatigue scale with a scoring system of 0 to 33 points (MD 0.30, 95% CI -1.45 to 2.05) and a nine-item Fatigue Severity Scale with a scoring system of 1 to 7 points (MD 0.40, 95% CI -0.34 to 1.14). Serious adverse reactions were rare in both groups (RR 0.67, 95% CI 0.11 to 3.96). We observed little or no difference in physical functioning, depression, anxiety and sleep, and we were not able to draw any conclusions with regard to pain, self-perceived changes in overall health, use of health service resources and drop-out rate.With regard to other comparisons, one study (320 participants) suggested a general benefit of exercise over adaptive pacing, and another study (183 participants) a benefit of exercise over supportive listening. The available evidence was too sparse to draw conclusions about the effect of pharmaceutical interventions.

Authors' conclusions: Patients with CFS may generally benefit and feel less fatigued following exercise therapy, and no evidence suggests that exercise therapy may worsen outcomes. A positive effect with respect to sleep, physical function and self-perceived general health has been observed, but no conclusions for the outcomes of pain, quality of life, anxiety, depression, drop-out rate and health service resources were possible. The effectiveness of exercise therapy seems greater than that of pacing but similar to that of CBT. Randomised trials with low risk of bias are needed to investigate the type, duration and intensity of the most beneficial exercise intervention.

Conflict of interest statement

LL: nothing to declare. KGB: nothing to declare. JO‐J: nothing to declare. JRP: nothing to declare.

Figures

Figure 1
Figure 1
PRISMA flow diagram.
Figure 2
Figure 2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 3
Figure 3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Analysis 1.1
Analysis 1.1
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 1 Fatigue (end of treatment).
Analysis 1.2
Analysis 1.2
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 2 Fatigue (follow‐up).
Analysis 1.3
Analysis 1.3
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 3 Participants with serious adverse reactions.
Analysis 1.4
Analysis 1.4
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 4 Pain (follow‐up).
Analysis 1.5
Analysis 1.5
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 5 Physical functioning (end of treatment).
Analysis 1.6
Analysis 1.6
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 6 Physical functioning (follow‐up).
Analysis 1.7
Analysis 1.7
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 7 Quality of life (follow‐up).
Analysis 1.8
Analysis 1.8
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 8 Depression (end of treatment).
Analysis 1.9
Analysis 1.9
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 9 Depression (follow‐up).
Analysis 1.10
Analysis 1.10
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 10 Anxiety (end of treatment).
Analysis 1.11
Analysis 1.11
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 11 Anxiety (follow‐up).
Analysis 1.12
Analysis 1.12
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 12 Sleep (end of treatment).
Analysis 1.13
Analysis 1.13
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 13 Sleep (follow‐up).
Analysis 1.14
Analysis 1.14
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 14 Self‐perceived changes in overall health (end of treatment).
Analysis 1.15
Analysis 1.15
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 15 Self‐perceived changes in overall health (follow‐up).
Analysis 1.16
Analysis 1.16
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 16 Health resource use (follow‐up) [Mean no. of contacts].
Analysis 1.17
Analysis 1.17
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 17 Health resource use (follow‐up) [No. of users].
Analysis 1.18
Analysis 1.18
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 18 Drop‐out.
Analysis 1.19
Analysis 1.19
Comparison 1 Exercise therapy versus treatment as usual, relaxation or flexibility, Outcome 19 Subgroup analysis for fatigue.
Analysis 2.1
Analysis 2.1
Comparison 2 Exercise therapy versus psychological treatment, Outcome 1 Fatigue at end of treatment (FS; 11 items/0 to 33 points).
Analysis 2.2
Analysis 2.2
Comparison 2 Exercise therapy versus psychological treatment, Outcome 2 Fatigue at follow‐up (FSS; 1 to 7 points).
Analysis 2.3
Analysis 2.3
Comparison 2 Exercise therapy versus psychological treatment, Outcome 3 Fatigue at follow‐up (FS; 11 items/0 to 33 points).
Analysis 2.4
Analysis 2.4
Comparison 2 Exercise therapy versus psychological treatment, Outcome 4 Participants with serious adverse reactions.
Analysis 2.5
Analysis 2.5
Comparison 2 Exercise therapy versus psychological treatment, Outcome 5 Pain at follow‐up (BPI, pain severity subscale; 0 to 10 points).
Analysis 2.6
Analysis 2.6
Comparison 2 Exercise therapy versus psychological treatment, Outcome 6 Pain at follow‐up (BPI, pain interference subscale; 0 to 10 points).
Analysis 2.7
Analysis 2.7
Comparison 2 Exercise therapy versus psychological treatment, Outcome 7 Physical functioning at end of treatment (SF‐36, physical functioning subscale; 0 to 100 points).
Analysis 2.8
Analysis 2.8
Comparison 2 Exercise therapy versus psychological treatment, Outcome 8 Physical functioning at follow‐up (SF‐36, physical functioning subscale; 0 to 100 points).
Analysis 2.9
Analysis 2.9
Comparison 2 Exercise therapy versus psychological treatment, Outcome 9 Depression at end of treatment (HADS depression score; 7 items/21 points).
Analysis 2.10
Analysis 2.10
Comparison 2 Exercise therapy versus psychological treatment, Outcome 10 Depression at follow‐up (BDI; 0 to 63 points).
Analysis 2.11
Analysis 2.11
Comparison 2 Exercise therapy versus psychological treatment, Outcome 11 Depression at follow‐up (HADS depression score; 7 items/21 points).
Analysis 2.12
Analysis 2.12
Comparison 2 Exercise therapy versus psychological treatment, Outcome 12 Anxiety at end of treatment (HADS anxiety; 7 items/21 points).
Analysis 2.13
Analysis 2.13
Comparison 2 Exercise therapy versus psychological treatment, Outcome 13 Anxiety at follow‐up (BAI; 0 to 63 points).
Analysis 2.14
Analysis 2.14
Comparison 2 Exercise therapy versus psychological treatment, Outcome 14 Anxiety at follow‐up (HADS anxiety; 7 items/21 points).
Analysis 2.15
Analysis 2.15
Comparison 2 Exercise therapy versus psychological treatment, Outcome 15 Sleep at end of treatment (Jenkins Sleep Scale; 0 to 20 points).
Analysis 2.16
Analysis 2.16
Comparison 2 Exercise therapy versus psychological treatment, Outcome 16 Sleep at follow‐up (Jenkins Sleep Scale; 0 to 20 points).
Analysis 2.17
Analysis 2.17
Comparison 2 Exercise therapy versus psychological treatment, Outcome 17 Self‐perceived changes in overall health at end of treatment.
Analysis 2.18
Analysis 2.18
Comparison 2 Exercise therapy versus psychological treatment, Outcome 18 Self‐perceived changes in overall health at follow‐up.
Analysis 2.19
Analysis 2.19
Comparison 2 Exercise therapy versus psychological treatment, Outcome 19 Health resource use (follow‐up) [Mean no. of contacts].
Analysis 2.20
Analysis 2.20
Comparison 2 Exercise therapy versus psychological treatment, Outcome 20 Health resource use (follow‐up) [No. of users].
Analysis 2.21
Analysis 2.21
Comparison 2 Exercise therapy versus psychological treatment, Outcome 21 Drop‐out.
Analysis 3.1
Analysis 3.1
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 1 Fatigue.
Analysis 3.2
Analysis 3.2
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 2 Participants with serious adverse reactions.
Analysis 3.3
Analysis 3.3
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 3 Physical functioning.
Analysis 3.4
Analysis 3.4
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 4 Depression.
Analysis 3.5
Analysis 3.5
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 5 Anxiety.
Analysis 3.6
Analysis 3.6
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 6 Sleep.
Analysis 3.7
Analysis 3.7
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 7 Self‐perceived changes in overall health.
Analysis 3.8
Analysis 3.8
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 8 Health resource use (follow‐up) [Mean no. of contacts].
Analysis 3.9
Analysis 3.9
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 9 Health resource use (follow‐up) [No. of users].
Analysis 3.10
Analysis 3.10
Comparison 3 Exercise therapy versus adaptive pacing, Outcome 10 Drop‐out.
Analysis 4.1
Analysis 4.1
Comparison 4 Exercise therapy + antidepressant placebo versus antidepressant + exercise placebo, Outcome 1 Fatigue.
Analysis 4.2
Analysis 4.2
Comparison 4 Exercise therapy + antidepressant placebo versus antidepressant + exercise placebo, Outcome 2 Depression.
Analysis 4.3
Analysis 4.3
Comparison 4 Exercise therapy + antidepressant placebo versus antidepressant + exercise placebo, Outcome 3 Drop‐out.
Analysis 5.1
Analysis 5.1
Comparison 5 Exercise therapy + antidepressant versus antidepressant + exercise placebo, Outcome 1 Fatigue.
Analysis 5.2
Analysis 5.2
Comparison 5 Exercise therapy + antidepressant versus antidepressant + exercise placebo, Outcome 2 Depression.
Analysis 5.3
Analysis 5.3
Comparison 5 Exercise therapy + antidepressant versus antidepressant + exercise placebo, Outcome 3 Drop‐out.

Update of

  • Exercise therapy for chronic fatigue syndrome.
    Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Larun L, et al. Cochrane Database Syst Rev. 2016 Jun 24;(6):CD003200. doi: 10.1002/14651858.CD003200.pub5. Cochrane Database Syst Rev. 2016. PMID: 27339435 Updated. Review.

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