Chronic Fatigue Syndrome (CFS) Occupational Therapy Practice

Introduction

Chronic fatigue syndrome (CFS) is characterized by persistent unexplained symptoms of fatigue for more than 6 months in duration. People with CFS may experience disability and decreased participation in occupations. Occupational therapy can play a role in this not-well understood pathology by promoting therapeutic interventions such as exercise, mobilization, awareness, coping strategies for patients to achieve an increase in activity level and to regain their ability to lead productive and healthy lives.

Etiology

CFS is often called myalgic encephalomyelitis (ME). The etiology is controversial and not completely understood. Potential causations may involve infections, the immune system, genetics, or a combination of these factors.[1]Sapra A, Bhandari P. Chronic Fatigue Syndrome. [Updated 2021 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: … Reference List

Epidemiology

The prevalence of ME/CFS is believed to range from 0.007% to 2.8% of the general adult population.[2]Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S. A community-based study of chronic fatigue syndrome. Arch Intern Med. 1999 Oct … Reference List[3]Steele L, Dobbins JG, Fukuda K, Reyes M, Randall B, Koppelman M, Reeves WC. The epidemiology of chronic fatigue in San Francisco. Am J Med. 1998 Sep 28;105(3A):83S-90S.[4]Fukuda K, Dobbins JG, Wilson LJ, Dunn RA, Wilcox K, Smallwood D. An epidemiologic study of fatigue with relevance for the chronic fatigue syndrome. J Psychiatr Res. 1997 Jan-Feb;31(1):19-29.[5]Wessely S, Chalder T, Hirsch S, Wallace P, Wright D. The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study. Am J Public Health. 1997 … Reference List CFS has been found to be higher in age groups 40-70 years with more women affected than men. It seems to be higher in the white population compared to the non-white population. Social risk factors such as stress have been suspected to cause CFS.[6]Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S. A community-based study of chronic fatigue syndrome. Arch Intern Med. 1999 Oct … Reference List[7]Lawrie SM, Pelosi AJ. Chronic fatigue syndrome in the community. Prevalence and associations. Br J Psychiatry. 1995 Jun;166(6):793-7.[8]Bierl C, Nisenbaum R, Hoaglin DC, Randall B, Jones AB, Unger ER, Reeves WC. Regional distribution of fatiguing illnesses in the United States: a pilot study. Popul Health Metr. 2004 Feb 04;2(1):1.[9]Vincent A, Brimmer DJ, Whipple MO, Jones JF, Boneva R, Lahr BD, Maloney E, St Sauver JL, Reeves WC. Prevalence, incidence, and classification of chronic fatigue syndrome in Olmsted County, Minnesota, … Reference List

Pathophysiology

The pathophysiology is not completely understood, but there may be a change in the immune system, increased oxidative stress, and CNS changes such as neuroinflammation, neuronal sensitivity, and neuroendocrine changes (e.g., excess serotonin levels).[10]Lorusso L, Mikhaylova SV, Capelli E, Ferrari D, Ngonga GK, Ricevuti G. Immunological aspects of chronic fatigue syndrome. Autoimmun Rev. 2009 Feb;8(4):287-91.[11]Marshall-Gradisnik S, Huth T, Chacko A, Johnston S, Smith P, Staines D. Natural killer cells and single nucleotide polymorphisms of specific ion channels and receptor genes in myalgic … Reference List

Diagnosis

In 2015, the Institute of Medicine (IOM) diagnostic criteria for CFS requires the presence of 3 following systems for more than six months for at least 50% of the time.

  • Fatigue
  • Malaise
  • Poor sleep

Plus at least one symptom of:

  • Cognitive impairment
  • Orthostatic intolerance

Risks and Contraindications

  • No evidence suggests that exercise may worsen symptoms or outcomes.[12]The effect of physiotherapy on fatigue and physical functioning in chronic fatigue syndrome patients: A systematic review G. Galeoto1, J. Sansoni1, D. Valenti2, R. Mollica 3, D. Valente4, M. … Reference List
  • Resumption of exercise may cause initial discomfort.
  • Avoid overexertion to minimize flare-ups and relapses.

Outcome Measures

  • Beck Depression Inventory
  • Life Satisfaction Questionnaire
  • Self-Efficacy Scale
  • Health Assessment Questionnaire
  • Visual Analogue Scale
  • Metabolic Equivalent (METs)
  • Mindfulness Attention Awareness Scale
  • Hospital Anxiety and Depression Scale
  • Fatigue Severity Scale; Fatigue Impact Scale[13]The effect of physiotherapy on fatigue and physical functioning in chronic fatigue syndrome patients: A systematic review. G. Galeoto1, J. Sansoni1, D. Valenti2, R. Mollica 3, D. Valente4, M. … Reference List

CFS Occupational Therapy Treatment

  1. Education of CFS
  2. Cognitive-behavioral therapy (CBT)
  3. Graded exercise therapy[14]Wilshire CE, Kindlon T, Courtney R, Matthees A, Tuller D, Geraghty K, Levin B. Rethinking the treatment of chronic fatigue syndrome-a reanalysis and evaluation of findings from a recent major trial … Reference List
  4. Pacing Therapy was not found to be significant.
  5. Lifestyle management
  6. Comorbid condition and symptom management[15]Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study … Reference List[16]National Collaborating Centre for Primary Care (UK). Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy): Diagnosis and Management of Chronic Fatigue Syndrome/Myalgic … Reference List

Cognitive-Behavioral Therapy

CBT has been shown to help patients recognize behaviors that may make them more tired. This, in turn, enables patients to help minimize symptoms through their thoughts and feelings. Multiple studies have shown positive effects from CBT on mood and fatigue on adolescent and adult participants.[17]White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O’Dowd H, Wilks D, McCrone P, Chalder T, … Reference List[18]National Collaborating Centre for Primary Care (UK). Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy): Diagnosis and Management of Chronic Fatigue Syndrome/Myalgic … Reference List[19]O’Dowd H, Gladwell P, Rogers CA, Hollinghurst S, Gregory A. Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme. Health … Reference List

Graded Exercise Therapy

GET involves a gradual increase of physical activity with an increase in intensity and duration. It has been shown to be effective for addressing fatigue and functional impairment.[20]White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O’Dowd H, Wilks D, McCrone P, Chalder T, … Reference List An example of a program may include a final goal of 30 minutes of physical activity five days per week. Aerobic exercise has been appropriately used with CFS. Walking has been shown to be more effective than running in studies. Other exercises include swimming, cycling, and rowing as they employ large muscle groups and promote an increase in heart rate. Psychological factors should be addressed to maximize the benefits of exercises. OTs should collaborate with patients to promote more meaningful exercises compared to generally prescribed ones. Patients should keep to a consistent program and be encouraged not to over-exert themselves to speed up recovery. One goal is to empower patients to make them direct themselves in exercise and be in control of the recovery process.

Lifestyle Management

A lifestyle management may be helpful to address symptoms of CFS such as sleep distrubance and pain. LM may help to promote behavioral patterns needed to manage CFS in a structured and habitual manner. Recovery through collaboration with the therapist may address occupations beyond the commonly addressed ADLs and also address occupations such as return to work training. LM has been shown to support the management of other chronic conditions such as obstructive sleep apnea.[21]Thomasouli, M. A., Brady, E. M., Davies, M. J., Hall, A., Khunti, K., Morris, D. H., & Gray, L. J. (2013). The impact of diet and lifestyle management strategies for obstructive sleep apnoea in … Reference List The aims of LM include: evaluation, investigating relationships of the illness and outcome measures, and establishing a plan to manage and improve symptoms as reported by patients. Experimental groups who received LM for return to work reported improvements in stamina, ambulation, fatigue, headaches, and muscle pain. 42% who participated in LM had returned to work in paid and voluntary work after 18-month follow-up.[22]McDermott, C., Richards, S. C. M., Ankers, S., Selby, M., Harmer, J., & Moran, C. J. (2004). An evaluation of a chronic fatigue lifestyle management programme focusing on the outcome of return to … Reference List

Comorbid condition and symptom management

As comorbidities may be any underlying condition that co-exists with CFS, occupational therapy may provide secondary interventions to manage other symptoms that may co-exist with those of CFS. This includes mental health conditions such as depression and anxiety. Bottom-up approach areas that may address include pain, weakness, poor endurance as reported by the patient and observed by the therapist. Comorbidities may affect any occupation from social participation to sleep and the therapist plays an important role in addressing these occupations using evidence-based practice.

Discussion

The symptoms of LFS can be debilitating for patients and affect any occupation. From sleep to pain to fatigue, CFS can also take a psychological toll on patients due to its persistence of symptoms for over 6 months+. A client-centered, collaborative, holistic approach that integrates CBT, GET, and LM as well as other coping techniques such as pacing and energy conservation may be effective in stabilizing and minimizing symptoms. There seems to be little risk and harm from commonly used OT approaches for LFS as long as the patients are made aware of their symptoms and when to slow-down or stop, as well as continue with their program and not quit. While much remains unknown regarding the disease of CFS, occupational therapy has many tools, measures, and approaches to help patients with CFS lead fulfilling and meaningful lives from returning to work, going to school, leisure, to spiritual activities.

References

References
1 Sapra A, Bhandari P. Chronic Fatigue Syndrome. [Updated 2021 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557676/
2, 6 Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S. A community-based study of chronic fatigue syndrome. Arch Intern Med. 1999 Oct 11;159(18):2129-37.
3 Steele L, Dobbins JG, Fukuda K, Reyes M, Randall B, Koppelman M, Reeves WC. The epidemiology of chronic fatigue in San Francisco. Am J Med. 1998 Sep 28;105(3A):83S-90S.
4 Fukuda K, Dobbins JG, Wilson LJ, Dunn RA, Wilcox K, Smallwood D. An epidemiologic study of fatigue with relevance for the chronic fatigue syndrome. J Psychiatr Res. 1997 Jan-Feb;31(1):19-29.
5 Wessely S, Chalder T, Hirsch S, Wallace P, Wright D. The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study. Am J Public Health. 1997 Sep;87(9):1449-55.
7 Lawrie SM, Pelosi AJ. Chronic fatigue syndrome in the community. Prevalence and associations. Br J Psychiatry. 1995 Jun;166(6):793-7.
8 Bierl C, Nisenbaum R, Hoaglin DC, Randall B, Jones AB, Unger ER, Reeves WC. Regional distribution of fatiguing illnesses in the United States: a pilot study. Popul Health Metr. 2004 Feb 04;2(1):1.
9 Vincent A, Brimmer DJ, Whipple MO, Jones JF, Boneva R, Lahr BD, Maloney E, St Sauver JL, Reeves WC. Prevalence, incidence, and classification of chronic fatigue syndrome in Olmsted County, Minnesota, as estimated using the Rochester Epidemiology Project. Mayo Clin Proc. 2012 Dec;87(12):1145-52.
10 Lorusso L, Mikhaylova SV, Capelli E, Ferrari D, Ngonga GK, Ricevuti G. Immunological aspects of chronic fatigue syndrome. Autoimmun Rev. 2009 Feb;8(4):287-91.
11 Marshall-Gradisnik S, Huth T, Chacko A, Johnston S, Smith P, Staines D. Natural killer cells and single nucleotide polymorphisms of specific ion channels and receptor genes in myalgic encephalomyelitis/chronic fatigue syndrome. Appl Clin Genet. 2016;9:39-47.
12 The effect of physiotherapy on fatigue and physical functioning in chronic fatigue syndrome patients: A systematic review G. Galeoto1, J. Sansoni1, D. Valenti2, R. Mollica 3, D. Valente4, M. Parente5, A. Servadio
13 The effect of physiotherapy on fatigue and physical functioning in chronic fatigue syndrome patients: A systematic review. G. Galeoto1, J. Sansoni1, D. Valenti2, R. Mollica 3, D. Valente4, M. Parente5, A. Servadio
14 Wilshire CE, Kindlon T, Courtney R, Matthees A, Tuller D, Geraghty K, Levin B. Rethinking the treatment of chronic fatigue syndrome-a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT. BMC Psychol. 2018 Mar 22;6(1):6.
15 Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994 Dec 15;121(12):953-9.
16, 18 National Collaborating Centre for Primary Care (UK). Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy): Diagnosis and Management of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy) in Adults and Children [Internet]. Royal College of General Practitioners (UK); London: Aug, 2007.
17, 20 White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O’Dowd H, Wilks D, McCrone P, Chalder T, Sharpe M., PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011 Mar 05;377(9768):823-36.
19 O’Dowd H, Gladwell P, Rogers CA, Hollinghurst S, Gregory A. Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme. Health Technol Assess. 2006 Oct;10(37):iii-iv, ix-x, 1-121.
21 Thomasouli, M. A., Brady, E. M., Davies, M. J., Hall, A., Khunti, K., Morris, D. H., & Gray, L. J. (2013). The impact of diet and lifestyle management strategies for obstructive sleep apnoea in adults: a systematic review and meta-analysis of randomised controlled trials. Sleep and Breathing, 17(3), 925-935.
22 McDermott, C., Richards, S. C. M., Ankers, S., Selby, M., Harmer, J., & Moran, C. J. (2004). An evaluation of a chronic fatigue lifestyle management programme focusing on the outcome of return to work or training. British Journal of Occupational Therapy, 67(6), 269-273.
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