COMMENTARY

Chronic Fatigue Syndrome: Right Name, Real Treatments

Peter D. White, MD

Disclosures

March 12, 2015

In This Article

Is "CFS" Safely Treatable?

So, is CFS an area of therapeutic nihilism that awaits scientific breakthroughs before we can help patients? Or are treatments available that can help today? Systematic reviews and meta-analyses of trials have consistently concluded that two treatments show the best evidence of efficacy: cognitive-behavioral therapy (CBT) and graded exercise therapy (GET).[5,6] This conclusion was reinforced by the latest Cochrane review of eight trials of exercise therapy, published this month, which concludes that "Patients with CFS may generally benefit and feel less fatigued following exercise therapy, and no evidence suggests that exercise therapy may worsen outcomes."[6]

The more recent reviews include the largest trial of rehabilitative therapies for CFS (the PACE trial), which I helped lead. In the PACE trial, 640 patients with CFS were recruited, defined using the Oxford criteria (which require fatigue to be the primary complaint),[7] from six secondary care clinics in the United Kingdom. They were randomly assigned to one of four treatments: standard medical care alone (SMC), and SMC supplemented by one of three therapies: CBT, GET, and adaptive pacing therapy (APT).[8] All therapies were delivered individually. Follow-up lasted up to 52 weeks after randomization. We found that both CBT and GET were most effective at reducing fatigue and improving physical disability, the two primary outcomes. This was true however we defined CFS, including the subgroup that met criteria for ME. To our surprise, the pacing intervention of APT was no more effective than specialist medical care alone, in spite of these patients receiving up to 15 sessions of therapy; there was even some evidence that pacing was associated with worse physical function.[9] CBT and GET were also as safe as the others in some six measures of adverse outcomes.[8,9] Both treatments were cost-effective, particularly when considering societal costs.[10]

The most recent paper from the trial showed that the main mediator of the effect of both CBT and GET was reduction in fear avoidance, explaining up to 60% of the variance.[11] We found that physical reconditioning did not mediate treatment effects, even with GET, although increased speed of walking in the 6-minute timed walking test did help to mediate the effect of GET. These findings suggest that both GET and CBT primarily work by graded exposure to the avoided stimulus of physical activity; they are essentially behavior therapies.

It seems that there are effective and safe treatments for CFS. Why aren't clinicians and patients using these more? Some people demonstrate a strong drive to legitimize CFS through finding associated physical biomarkers. Some believe the idea that behavioral therapy does not fit well with a biomedical etiology. In fact, of course, it does; rehabilitative approaches such as CBT and GET are effective in improving both symptoms and disability of many chronic conditions of known pathology.[12,13,14] It is also no surprise to learn that behavioral treatments change our pathophysiology.[15] Because it can be argued in any case that the dualistic categorization of medical conditions into "organic" and "functional" is inconsistent with our present knowledge of the indivisibility of mind and body,[16] this should not be a problem, but beliefs based on outmoded dualism are sometimes hard to shift.[17]

Some clinicians are concerned about the safety of an exercise therapy in a condition made worse by exercise.[18] Repeated surveys of members of patient groups report that as many as a half say that they have been harmed by exercise therapy.[19] This is in direct contrast to research trials of exercise therapy,[6] in which only 1 of 8 trials showed an increased proportion of participants stopping treatment prematurely.[20] The difference in this trial is probably explained by the exercise therapy being designed as a physical training program, with a high initial intensity and duration of exercise, which took no account of symptoms. There is a world of difference between GET and being told to join a gym. The other problem with generalizing from surveys of patient group members is that one cannot be sure of the form and content of treatment received, nor of whether respondents really had CFS. One American survey showed that only a third of such patients had CFS.[21]

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