Chronic Fatigue Syndrome (CFS) Occupational Therapy Practice


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.


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.


The prevalence of ME/CFS is believed to range from 0.007% to 2.8% of the general adult population. 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.


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 


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.11 
  • 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 Scale12 

CFS Occupational Therapy Treatment

  1. Education of CFS
  2. Cognitive-behavioral therapy (CBT)
  3. (Inconclusive) Graded exercise therapy13 
  4. Pacing Therapy was not found to be significant.
  5. Lifestyle management
  6. Comorbid condition and symptom management14 15 

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.16 15 17 

Graded Exercise Therapy

Update: There had been conflicting evidence making GET controversial for this condition. The British National Institute for Health and Care Excellence (NICE) recently published its updated guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). NICE concluded, after an extensive review of the literature, that graded exercise therapy (GET) is harmful and should not be used, and that cognitive behavioural therapy (CBT) is only an adjunctive and not a curative treatment.18 

GET involves a gradual increase of physical activity with an increase in intensity and duration. It has been shown to be effective at one point for addressing fatigue and functional impairment.16  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.19  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.20 

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.


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.


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