1. September 15(C) Exact T & R Chronic Fatigue and physical activity

2. Outline September 15(C) Exact T & R  What are chronic fatigue syndrome (CFS) and fibromyalgia (FM)?  How do those with CFS or FM respond to exercise?  What are the considerations for exercise in those with CFS or FM?  Summarise an appropriate exercise prescription for those with CFS or FM  Outline the changes that might be expected to the condition/symptoms with exercise.

3. What is CFS? September 15(C) Exact T & R  Also been known as Royal Free disease, Iceland disease, neurasthenia, myalgic encephalomyelitis (‘ME’), and post-viral fatigue syndrome. However, chronic fatigue syndrome (CFS) is the term that has been adopted and clearly defined for the purpose of research in this area.  Diagnosis of CFS  Unexplained onset of fatigue  Fatigue present > 6months  Fatigue limits daily activity  Fatigue not resolved by rest  4+ of the following symptoms: muscle pain, joint pain, sore throat, tender lymph nodes, cognitive dysfunction, sleep disturbance, post exercise discomfort lasting >24 hours.

4. What is FM? September 15(C) Exact T & R  Fibromyalgia is a syndrome of persistent widespread pain and tenderness. Individuals may also experience a wide range of other symptoms such as difficulty sleeping, fatigue, stiffness, and depression.  No underlying inflammation.  Diagnosis of FM  Chronic widespread pain in all four body quadrants  Pain in 11 out of 18 tender points  Other symptoms: fatigue, morning stiffness, weakness, attention and memory disturbances (‘fibro fog’), heat and cold intolerance, weight fluctuations, sleep disturbance, depression.

5. September 15(C) Exact T & R FM tender points

6. September 15(C) Exact T & R Other related conditions  Lupus  Temporomandibular disorder

7. Exercise response in CFS and FM For many patients, minimal exertion i.e. less than others might consider exercise can exacerbate symptoms from 6 hours to 5 days  Response to aerobic activity  Studies with cycle ergometer show no difference in VO 2 at same power output for patients vs controls  Similar, higher or lower heart rates – reflecting different fitness levels  RPE usually higher - ? Reflects de- conditioning, increased fatigue, pain and anxiety.  Response to strength training  Weaker - ? Due to lower motivation, de-conditioning and more fatigue and pain  No difference in muscle structure or metabolism. September 15(C) Exact T & R

8. September 15(C) Exact T & R Exercise responses in CFS and FM  No difference in basic physiology involved in performing aerobic or strength training  Different reactions in patients with CFS or FM to exercise probably associated with:-  Fitness  Habitual physical activity  Perception of effort involved.

9. September 15(C) Exact T & R Considerations for exercise  Fatigue and pain  Symptoms vary from day to day  Patients may reduce or avoid physical activity to avoid symptoms  Rest longer after exercise  Exercise may provoke feelings of anxiety and increased vulnerability to pain and fatigue  Increased pain and fatigue may be associated with or exaggerated by de-conditioning.

10.  Suggested primary goals :  Increase physical tolerance  Promote long term compliance  Transient increase in symptoms will occur when starting new activity or increasing activity  Start slowly and progress gradually. September 15(C) Exact T & R Exercise Prescription Overview

11.  Frequency: 3 or more per week  Intensity: Generally low or moderate intensity tolerated better than high intensity. RPE 12 -14  Time: Brief exercise better tolerated than prolonged and intermittent rather than continuous. 10-15 minutes or more  Type: Low impact, walking, swimming, aqua, stationary cycling. September 15(C) Exact T & R FITT

12.  Establish a sustainable baseline of activity  Extend duration  Extend intensity. September 15(C) Exact T & R Graded Exercise Therapy

13.  Frequency: 3-5/week  Intensity: RPE 12 -14  Time & Type:  Warm up - 5 mins water walking  Work out 1 – 5 mins bounding/jumping  Workout 2 – 10 mins ROM stretching  Cooldown – 8 mins relaxation and swimming September 15(C) Exact T & R Just one example……

14. WeekRPEHR maxFrequencyTime 1 - 210-1140-50%3/week10 mins 310-1140-50%3/week12 mins 410-1140-50%3-4/week12 mins 5 - 610-1140-50%3-4/week14 mins 710-1140-50%3-4/week18 mins 810-1140-50%3-5/week20 mins 9 - 1010-1140-50%3-5/week24 mins 11 - 12 45-55%3-5/week28 mins September 15(C) Exact T & R Getting the right grade

15. Exercise Outcomes September 15(C) Exact T & R  Aerobic activity  Increased fitness  Decreased fatigue and pain  Decreased heart rate  Decreased RPE  Increased functional capacity  Fewer symptoms.  Strength training  Improvements similar to healthy sedentary subjects  No change in pain or tenderness  Improved perceptions of mood and fatigue.

16. September 15(C) Exact T & R Thank you!

17. Your turn….. September 15(C) Exact T & R The goal: Frequency: 3/week Intensity: RPE 12 -14 Time: 30 minutes Type: Cycling, Walking How would you get there?...... How long will it take?..........